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The Future of Rural Rheumatology

Robert Jackson, DO, is a practicing rheumatologist and president of Premier Specialty Network. His company works with more than 30 rheumatologists, who provide services to more than 60 rural hospitals in six states. The Rheumatologist recently asked Dr. Jackson to comment on the future of rheumatology in rural areas.

Q: What do you see as the future of rural rheumatology between now and 2021?
A: I don’t think that the need for our specialty in rural areas is going to lessen. Instead it will increase. This demand will, likely, keep reimbursement levels competitive and make it a good business model to go outside the city.

Q: There is a concern that government healthcare reform was not favorable to rural locations, and a number of rural hospitals have closed. How does that fit in with the scenario you seem to see?
A: [That has been] unfortunate. … There are many areas with only one hospital left. Losing that facility can have a [devastating] impact on communities both immediately, as one of the area’s largest employers, and longer term [because the] lack of a hospital can make it harder to bring in new employers.

Because of this, I think political pressure on, and by, both parties will [create] an incentive for Congress to keep small hospitals alive even as the rest of the government seems to be applying pressure to close them.

In some areas, they may be lost as a provider of in-patient acute care services, but in most cases, they will still be providing outpatient and urgent care [services]—some of which can be provided by rheumatology specialists.

Q: What are some of the other pluses you see in this area of practice going forward?
A: Technology is likely to get better in rural areas. This [fact] will mean top-level care is available quicker and easier in rural and suburban areas and increase the ability of practitioners to make good professional decisions. It should also help with concerns about professional isolation.

Q: Speaking of technology, you seem to suggest that electronic medical records(EMRs) are somewhat of a two-edged sword.
A: The old way of closing down your office, grabbing your paper records and driving down the road to another community is not all that productive. On the other hand, it isn’t unusual for a rheumatologist to practice at more than one hospital, with limited ability to exchange information between them, and each may have different ways of entering information.

We also have the same problems that our colleagues in urban areas do. Most EMRs were made with primary care physicians in mind and don’t work well with the needs of specialists.

Q: What are some of the things you are concerned about?
A: I am worried about healthcare reform and its impact on the pipeline for new graduates in all specialties. Those of us already in the business talk about the economic impact, grumble about lifestyles and dissatisfaction at work. Will that affect whether people choose the healthcare field as a profession? It may be that medicine in general, and rheumatology in particular, is not viewed as a job with a future.


How To Get Rid Of Bed Bugs

Bed bugs, known scientifically as Cimex lectularius (Cimicidae) are small wingless insects that feed by hematophagy – exclusively on the blood of warm blooded-animals. As we are warm-blooded animals, we are ideal hosts for them.

Over millions of years, bed bugs have evolved as nest parasites – inhabiting the nests of birds and the roosts of bats. Some of them have learnt to adapt to the human environment and live in our nests, i.e. our homes, and more specifically, our beds. Newborns, called hatchlings or nymphs, are tiny, about the size of a poppy seed, while adults grow to about ¼ of an inch long. Their shape is oval and flattened. Both nymphs, eggs and adults are visible to the naked eye.

They are called bed bugs because of their preferred habitat in human homes: sofas, bed mattresses and other soft furnishings.

Bed bugs are seen as a growing problem within all types of dwellings, including private homes, dormitories, cruise ships, army barracks, and shelters.

Bed bugs breed successfully in various environments and circumstances. On 12th December, 2011, experts at SRI International reported that bed bugs can inbreed and still produce healthy offspring.

When seen close up they may have a white, light tan to a deep brown or burnt orange color. Just after molting, most of them are plain white. When they have had their feed a dark red or black blob may be observed within their body. They will instinctively seek shelter in dark cracks and crevices when disturbed.

Spotting signs of bed bugs

The biggest sign of bed bugs is people complaining of bites that occurred while they were asleep. If this happens, you should examine the bedrooms for bed bugs and signs of bed bug activity. Look carefully into the creases in the bed linen, and seams and tufts of mattresses and box springs for bugs or eggs. The eggs will look like tiny pale poppy seeds.

Signs of bed bug activity may exist beneath loose areas of wallpaper near beds, in the corner of desks and dressers, in the laundry, and in drawers.

Look out for dark brown or reddish fecal spots (bed bug droppings, excrement). If the area is very infested you may sense a coriander-like odor. The excrement is a liquid that looks either light brown or black that can either bead up or be absorbed by the material around it.

Dogs can be trained to sniff out live bed bugs or past infestations. A dog’s sense of smell is so acute that it can pick up the scent of a single bed bug

For more information click here.

Paving The Way For Virus-Like Nanodevices That Diagnose Disease And Make Drugs

Mimicking viruses to target specific cells

Nanotechnology is a relatively new, but rapidly expanding field, where tiny devices and molecular-scale tools offer exciting possibilities for manipulating cells and their components. Now researchers, copying the tactics used by viruses to evade the immune system, have created the first nanodevices that survive the body’s immune defenses. The achievement supplies a missing piece to the puzzle of how to use nanodevices at the cellular level.

Scientists at Harvard’s Wyss Institute for Biologically Inspired Engineering in Boston, MA, say their DNA nanodevice has successfully completed its first pilot mission.

Writing in ACS Nano, they conclude the accomplishment provides “a platform for the engineering of sophisticated, translation-ready DNA nanodevices.”

Such “smart DNA nanorobots” could use logic to diagnose diseases like cancer earlier than current approaches can. They could also target drugs directly to chosen tumors, or even manufacture them on the spot.

Mimicking viruses to target specific cells
Senior author William Shih, an associate professor of Biological Chemistry and Molecular Pharmacology at Harvard Medical School, says:

“We’re mimicking virus functionality to eventually build therapeutics that specifically target cells.”

The researchers believe the same cloaking method could be used to make artificial containers or “protocells” that could detect toxins in drinking water, or pathogens in food.

DNA is mostly known for its role as a conveyor of genetic information. But the researchers behind this latest study are looking at it differently – they see DNA as a 3D building material. They take strands of DNA and program them to fold into shapes, reminiscent of the Japanese paper-folding art of origami.

Specifically, they use their nanoscale origami skills to create DNA devices that are increasingly complex in shape, and approaching the intricacy of the molecular machinery found in cells.

The team is effectively building tiny robots out of DNA. These DNA nanorobots are capable of several functions: they can sense their environment, work out how to respond, then do something useful like trigger a chemical reaction, perform a movement or generate a mechanical force.

Such devices are not new. For example, in 2012, researchers at the Wyss Institute reported how they devised origami DNA nanorobots that target cancer cells and deliver instructions that make them commit suicide.

Also that year, scientists at Massachusetts Institute of Technology revealed how they devised nano-factories that could make drugs at tumor sites. Their nanoparticles produce proteins when ultraviolet light shines on them.

How to make DNA nanorobots invisible to immune system?

However, what has been missing is a way for nanorobots to evade the immune system – or at least hide from it long enough to be able to do their job. When Prof. Shih and colleagues injected nanorobots into the bloodstream of mice, their immune systems quickly found and digested them.

Prof. Shih, who is also an associate professor of Cancer Biology at the Dana-Farber Cancer Institute, says, that led them to ask, “How could we protect our particles from getting chewed up?”

They found the answer in nature. A virus hides from the host immune system with the help of a cloaking device. The virus protects its genome inside a solid protein coat covered in an oily protein – a double layer of phospholipid – identical to that contained in membranes surrounding the host’s living cells.

Prof. Shih says they wondered if enclosing their nanodevice inside such an envelope would have a similar effect.

To arrive at such a solution they first folded the DNA into a virus-sized octahedron, then built in handles on which to hang lipids, which then directed the double-layer membrane to assemble around the octahedron.

Nanodevice coated with lipid bilayer looked just like enveloped virus

The coated nanodevice looked just like an enveloped virus when seen through an electron microscope.

The next stage was to show the enveloped device could evade the immune system and survive in the body. To do this the devices were first loaded with dye, then injected into mice. Using whole body imaging, the researchers could track the nanodevices by seeing which parts of the mice glowed.

They also dyed and injected uncoated devices into another group of mice. These only glowed in the bladder area, showing that their immune systems had broken them down quickly and their bodies were ready to excrete their remnants.

But the mice that were injected with enveloped nanodevices told a different story. Their whole bodies glowed for hours, showing that the nanodevices stayed in the bloodstream for about the same length of time as effective drugs.

To show that the enveloped devices had also evaded the immune system, the researchers measured levels of two immune-activating molecules. The levels were 100 times higher in the mice that received uncoated nanodevices compared to the ones that received coated ones.

The researchers foresee cloaked nanorobots doing things like activating the immune system to fight cancer, or suppressing it to stop it rejecting transplanted tissue. They say that the main point is being able to control the immune system.

The National Institutes of Health, the US Army Research Laboratory’s Army Research Office, and the Wyss Institute at Harvard University contributed funds for the study.

In February 2014, Medical News Today reported on a study that used nanoparticles to target inflammation-causing immune cells. Researchers at the University of Illinois at Chicago have developed a system for precisely targeting out-of-control immune cells without interfering with correctly functioning immune cells.

Gout Isn’t Always Easy to Prove: CT Scans Help Catch Cases Traditional Test Misses

Gout Isn’t Always Easy to Prove: CT Scans Help Catch Cases Traditional Test Misses

Gout is on the rise among U.S. men and women, and this piercingly painful and most common form of inflammatory arthritis is turning out to be more complicated than had been thought. The standard way to check for gout is by drawing fluid or tissue from an affected joint and looking for uric acid crystals, a test known as a needle aspiration. That usually works, but not always: In a new Mayo Clinic study, X-rays known as dual-energy CT scans found gout in one-third of patients whose aspirates tested negative for the disease. The CT scans allowed rheumatologists to diagnose gout and treat those patients with the proper medication.

The results are published in the Annals of the Rheumatic Diseases, the European League Against Rheumatism journal.

The study tested the usefulness of CT scans in finding uric acid crystals around joints across a wide spectrum of gout manifestations. The researchers found CT scans worked particularly well in detecting gout in patients who had experienced several gout-like flares but whose previous needle aspirates came back negative. After CT scans found what appeared to be uric acid crystals, ultrasound-guided aspirates were taken in those areas and tested for urate crystals.

“These were in part patients that had been falsely diagnosed with diseases like rheumatoid arthritis or labeled with a different type of inflammatory arthritis, resulting in a completely different and often not effective treatment approach,” says first author Tim Bongartz, M.D., a Mayo Clinic rheumatologist. “And there were patients who remained undiagnosed for several years with, for example, unexplained chronic elbow or Achilles tendinitis, where the CT scan then helped us to pick up uric acid deposits.”

The study isn’t meant to suggest that CT scans should be the first test used to look for gout, Dr. Bongartz says. Needle aspirates work well in most cases, and the research showed CT scans weren’t as effective a diagnostic tool among patients having their first gout flare-up, he says. In some of those acute gout cases, needle aspirates found uric acid crystals, but CT scans didn’t.


Five percent of adult African-Americans and 4 percent of whites in the U.S. have gout. The nation’s obesity CT Scan Gout2epidemic is thought to be a factor behind the increase in gout cases.

Gout is often thought of as a man’s disease and associated with sudden sharp, burning pain in the big toe. It’s true that until middle age, more men than women get gout, but after menopause, women catch up in the statistics. And gout can hit more than the big toe: Other joints including parts of the feet, ankles, knees, fingers, wrists and elbows can be affected.

“The first flare of gout most commonly occurs in the big toe, but gout can affect pretty much every joint in the body, and the more gout flares you have the more likelihood that other joint areas will be affected,” Dr. Bongartz says.

An accurate and early gout diagnosis is crucial because gout patients are treated with different medication than people with other forms of inflammatory arthritis, and proper medication and dietary changes can help prevent further gout attacks and the spread of the disease to other joints.

“What we are learning from the dual-energy CT scans has really changed our perception of where gout can occur and how it can manifest,” Dr. Bongartz says. “The ability to visualize those deposits clearly broadens our perspective on gout.”

The study co-authors included researchers from Mayo Clinic radiology, rheumatology, orthopedic surgery, family medicine and biomedical statistics and informatics.

Plan to Limit Some Drugs in Medicare Is Criticized

Opponents warn that the proposal, if enacted, could harm patients. Federal officials say it would lower costs and reduce overuse of the drugs.

An alliance of drug companies and patient advocates, joined by Democrats and Republicans in Congress, is fiercely opposing an Obama administration proposal that would allow insurers to limit Medicare coverage for certain classes of drugs, including those used to treat depression and schizophrenia.

The proposed rule, which would lift a requirement that insurers cover “all or substantially all” drugs in certain treatment areas, is just one of a series of changes to the drug program that are being opposed by the unlikely alliance. Even insurers and drug benefit managers, who have previously supported added limits on drug coverage, oppose the rule. They object to provisions including changes to so-called preferred pharmacy networks, where consumers are steered toward a limited network of pharmacies, and to reducing the number of plans that insurers can offer in any one region.

A House subcommittee plans to hold a hearing on the proposal next week, and the rule is open for public comment until March 7.

“We’ve been scratching our heads over this,” said John J. Castellani, the chief executive of the Pharmaceutical Research and Manufacturers of America, the drug-industry trade group. Medicare Part D, he noted, is the rare government program that not only gets high marks from consumers but also has cost taxpayers billions of dollars less than originally expected. “Why is the administration trying to make such extensive changes to a program that isn’t broken?”

Mr. Castellani’s organization was one of more than 200 groups that signed a letter this week asking that the rule be withdrawn. Earlier this month, Republican and Democratic members of the Senate Finance Committee warned that the proposal could “diminish access to needed medication” without saving much money.

The administration’s proposal would remove the protected status from three classes of drugs that has been in place since the program’s inception in 2006: immunosuppressant drugs used in transplant patients, antidepressants and antipsychotic medicines. They include many well-known drugs, such as Wellbutrin, Paxil and Prozac to treat depression, and Abilify and Seroquel to treat schizophrenia.

Three other categories — cancer, H.I.V. and anti-seizure drugs — would retain their status as protected classes and insurance companies would be required to continue covering nearly all drugs in those treatment areas. Medicare has traditionally required the broad coverage because patients with these conditions must often try several drugs before finding one that works.

In proposing the change last month, the administration said that the policy was envisioned as a temporary measure to help ease patients’ transition to the new Medicare drug program, and that since then, insurers had lost their leverage in negotiating with drug companies because the drug companies knew the insurers were required to cover their drug costs and were therefore less willing to offer lower prices.

In its proposal, the Obama administration cited a 2008 study by the actuarial and consulting firm Milliman that showed that the six protected classes accounted for anywhere from 17 to 33 percent of total outpatient drug spending under Part D of Medicare. In addition, it said that the costs of those drugs were on average 10 percent higher than they would be without the requirement to cover substantially all drugs in these classes.

The administration predicted savings for both beneficiaries and the Medicare program if prescription drug plans could remove some currently covered drugs from their formularies. It could also give insurers additional tools to limit overuse of certain drugs, such as the prescribing of antipsychotic drugs to nursing-home patients with dementia, a common practice that is widely viewed as inappropriate.

“We believe the Part D program has been a phenomenal success,” said Jonathan Blum, principal deputy administrator of the Center for Medicare and Medicaid Services, which oversees the Part D program. But, he added, “We also see vulnerabilities in the program, and we have proposed for public input into ways to improve it.”

Leaders of numerous patient advocacy groups, many of whom met last week with White House officials to express concern about the proposed rule, said they were worried that patients could be harmed if the policy changed.

“The proposal undermines a key protection for some of the sickest, most vulnerable Medicare beneficiaries,” said Andrew Sperling, a lobbyist at the National Alliance on Mental Illness.

Under the proposal, Mr. Sperling said, a Medicare drug plan could have a list of preferred drugs with just two medications to treat schizophrenia. That is inadequate, he said, because antipsychotic drugs work in different ways in the body, and have different side effects. “You get much better outcomes when a doctor can work with patients to figure out which medications will work best for them,” he said.

In a letter written by members of the Senate Finance Committee, the senators suggested that the change could raise costs in other areas. “If beneficiaries do not have access to needed medication,” the letter said, “costs will be incurred as a result of unnecessary and avoidable hospitalizations, physician visits and other medical interventions.”

The new federal health care law requires that Medicare drug plans include all drugs in certain categories and classes “of clinical concern,” and it authorized the secretary of health and human services to identify those categories.

Mr. Sperling said lawmakers had assumed that Medicare officials would keep the original six protected classes and add to them, not cut them. The administration proposal sets a high standard for designating protected classes, saying the drugs must be needed to prevent “hospitalization, persistent or significant disability or incapacity, or death” that would otherwise occur within a week.

Emily Shetty, a lobbyist for the Leukemia and Lymphoma Society, said Medicare beneficiaries, who include older and disabled Americans, should be treated with special care. “They are a more vulnerable patient population as a whole, and having access to a full range of therapies is crucial to ensure that they are able to get the care that they need,” she said.

The Medicare Part D program is unusual in that it requires broad coverage of drugs in these categories.

Commercial insurance plans, including those in the new marketplaces operating under the federal health care law, have more flexibility. Some drugs are simply not covered, and some plans require that patients and doctors go through additional steps — such as trying other drugs first, or getting approval from the insurer — before a drug will be paid for.

Insurers and the companies that manage their drug benefits argue that this arrangement has worked well for consumers, ensuring that drugs are being used properly and helping to keep prices low. But others have identified what they describe as a worrying trend toward more limited drug coverage, and higher out-of-pocket costs for the most expensive drugs.

The rule has some supporters, and many groups back some aspects of the proposal while opposing others.

“Just because a program is popular doesn’t mean that it’s being run the most efficiently, and at the best value for taxpayers and patients,” said B. Douglas Hoey, chief executive of the National Community Pharmacists Association, which supports many aspects of the rule.

This article appeared in print on , in the New York Times with the headline: Plan to Limit Some Drugs in Medicare Is Criticized.

Regional Rheumatologist Distribution Leaves Many Patients Under served

A Current Study Demonstrates That Regional Shortages Already Exist

Many areas of the United States have few or no practicing adult rheumatologists, and in some cases – particularly in smaller “micropolitan” areas – the closest practicing rheumatologist is 200 miles away, according to an analysis of U.S. Census data and information from the American College of Rheumatology membership database.  Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care.

Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care, reported Dr. John D. FitzGerald of the University of California, Los Angeles, and his colleagues. The authors are members of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues.

What do the findings show?

These findings come in the wake of an American College of Rheumatology workforce study initiated in 2005, which showed that demand for rheumatologic care at that time was in balance with the supply of adult rheumatologists (with an estimated 1.67 rheumatologists per 100,000 persons), but which predicted that demand would outstrip supply over time, leading to a shortage of 2,500 adult rheumatologists by 2025. The ACR responded to that report by increasing funding for the training of new rheumatologists by targeting programs with unfilled Accreditation Council for Graduate Medical Education slots, the investigators said.

They noted, however, that the national estimates did not consider regional variation in the distribution of rheumatologists. “Clustering of rheumatologists in some regions can leave other areas of the country with too few adult rheumatologists in supply,” wrote Dr. FitzGerald and his associates, who mapped all adult practicing rheumatologists’ addresses as recorded in the 2010 ACR membership database, and assessed the number of rheumatologists in Core Based Statistical Areas (CBSAs), commonly referred to as micropolitan and metropolitan areas. CBSAs are “defined by regions with a high degree of social and economic integration (determined by commute to work) around a central urban core,” they said.

Shortage in Rheumatology

Traveling Clinics Could Ease the Burden

The findings of the current study demonstrate that regional shortages already exist. “If we simply use the 1.67 number of rheumatologists per 100,000 persons as a definition of insufficient rheumatology supply, then a majority (85%) of the CBSAs would be potentially underserved,” the investigators noted.

When a definition of no practicing rheumatologists within a 50-mile travel distance is used, 24% of CBSAs – representing 18.9 million persons – would still be affected by an insufficient supply of rheumatologists; with a 100-mile cut point, 5% of CBSAs –representing 2.5 million people – would be underserved.

“While this is no surprise to affected local patients, practitioners, or policy makers, this study identifies potential target communities … that might benefit most from addition of a local rheumatologist,” the investigators noted.

One possible intervention for addressing the shortage is simply providing up-to-date information about shortages, as this could lead to migration, expansion of existing practices, or attraction of new rheumatologists. Increasing the supply of trainees in areas with unmet needs and committing additional funds to training programs in underserved areas are also possible interventions, the authors said.

Approaches such as the use of traveling clinics and e-mail or video consultation, which have previously been used to address shortages in rural areas, could also be helpful, they said, adding that it has been suggested that midlevel providers could also effectively help fill workforce shortages.

According to the ACR database, there were 3,920 practicing adult rheumatologists in 2010; 90% practiced in metropolitan areas (areas with at least 50,000 population around a central urban core), 3% practiced in micropolitan areas (areas with 10,000 to less than 50,000 population, excluding rare exceptions centered around a less dense urban cluster), and 7% practiced in rural regions.

“Notably, a greater proportion of rheumatologists were practicing in metropolitan areas (over micropolitan areas) than would be expected based on population distribution alone. While only 31 metropolitan areas (9%) did not have a practicing member rheumatologist, the majority of micropolitan areas (84%) did not have a rheumatologist,” the investigators wrote.

As for areas with no rheumatologist, the distances to the nearest practicing rheumatologist varied widely. Only 1% of metropolitan areas, compared with 16% of micropolitan areas, had a distance of more than 75 miles to the nearest rheumatologist, and CBSAs with populations over 200,000 had a travel distance as great as 94 miles, while some smaller micropolitan regions had travel distances greater than 200 miles, for example.

Many smaller micropolitan areas with populations of at least 40,000 had no practicing rheumatologists, and several more populous areas with populations of 200,000 or more also had no practicing rheumatologist.

Conversely, areas with higher population densities; greater proportions of younger, female, white, and Asian populations; and the presence of an active adult fellowship training program had greater numbers of rheumatologists.

Three Ways to Improve U.S. Healthcare

Indeed, the most pressing problem with American healthcare is that it is too wasteful.

Listening to caregivers from other countries, it’s easy to feel exasperated about U.S. healthcare. American hospitals are filled with good people trying to do good work, but at every turn the system of misplaced incentives gets in the way of good patient care.

As written in the Washington Post, two U.S. business professors, Vijay Govindarajan from Dartmouth and Ravi Ramammurti from Northeastern University tell the story of how Indian hospitals deliver better care for much less.

The two professors uncovered nine private hospitals in India that provide quality care at a fraction of U.S. prices. For example, cardiac surgery there costs $3,200, which is 5 to 10 percent of the cost in the United States. Outcomes are comparable and the hospitals make a profit. More striking than the ends, though, were the means. Three major innovations lie at the heart of the Indian hospitals’ success.

Hub and Spoke Design

Major hub hospitals reside in the cities, while spoke hospitals service the surrounding areas.

“This strategy concentrates the best equipment and expertise within the hub, with telecommunication links that allow hub specialists to serve spoke patients remotely. Since these specialists perform a high number of specific procedures, they quickly develop skills that improve quality,” they write.

The best results in medicine come when we allow practitioners (and their teams) to specialize in their craft. This is not what happens in the United States. Here, competing hospitals dilute the talent.

Looking at heart rhythm procedures, catheter ablation of atrial fibrillation and pacemaker/defibrillator lead extraction, as examples, are good examples because it takes hundreds of cases and years of experience to master these “feel”-dependent procedures. Experienced operators who are concentrated in a few major centers should be the only doctors doing these procedures. In most American cities, though, these two procedures are divvied up among many hospitals and many operators. However, the literature is replete with studies that correlate outcomes with operator training and experience.

The notion that building big beautiful hospitals in the suburbs for convenience—and then thinking they are good places for care—is insulting. What’s wrong with saying: I’m sorry you are facing lead extraction, but for this, you need to go to Hospital X, and it’s downtown. Sorry. It’s inconvenient and the parking stinks. But it’s best for your healthcare. At the moment, American healthcare practitioners aren’t courageous enough to say this.

Task Shifting

The authors also point out that in India, lower-level staffers perform a much wider array of medical tasks:

“The transfer of responsibility for routine tasks to lower-skilled workers leaves doctors free to focus on complicated medical procedures. Several hospitals have created a tier of paramedic workers with two years of training after high school to perform routine medical jobs. As a result, surgeons, for example, are able to perform two to three times as many surgeries as their U.S. counterparts. Compare that with the United States, where hospitals reduce costs by laying off support staff and shifting mundane tasks such as billing and transcription to doctors, who are overqualified for those duties.”

Consider my experience: After performing nearly 10,000 catheter ablations and cardiac devices over 15 years, I’ve gotten really good at these procedures. In my city of one million people, Louisville, Kentucky, there are only a handful of other doctors who do these procedures well. In an Indian system, we would be protected. We would be asked to do high-level heart procedures and little else. Yet that’s not the case in the U.S. system. I can only do these skill-dependent procedures two and a half days a week. That’s because I have other duties, like managing routine blood tests, seeing routine follow-ups, and entering clerical data on each patient. In fact, due to the burden of tasks, I’ve had to reduce the number of patients I see by nearly 50 percent over the past decade.

In the U.S., to even think about task shifting is seen as weak—or pompous. You are too good to do grunt work? Indian hospitals don’t have the luxury of worrying about such perceptions. Scarcity forces efficiency.

Another impediment to task-shifting in the U.S. is the false belief that lesser-trained caregivers, like nurse practitioners or physicians assistants, are not adequate. This is ludicrous. In my field, there is ample evidence that nurse-directed care can even be better than doctor-directed care. Why wouldn’t it be? If all you do each day is listen to and care for patients in just a couple of disease states, you become skilled, regardless of the letters that follow your name.


You don’t have to go to India to see frugality in hospitals. Germany re-sterilizes equipment that in the U.S. gets thrown away after one use, and they perform procedures with equipment that has been proven useful through evidence, not marketing.

The wastefulness of U.S. healthcare is complicated. The fee-for-service model, in which hospitals and doctors make more when they do more, contributes to the problem. The unbundling of cost and price is also a huge factor. These are big policy problems, but ignoring them keeps us behind other countries in how we deliver care.

This article was originally published on December 10th, 2013 on The Atlantic.