Maintaining Medical Competence

“I am free, no matter what rules surround me…because I know that I alone am morally responsible for everything I do.”― Robert A. Heinlein

I recently renewed my Arizona medical license and meet all the requirements. I far exceed the required CME hours and have no Medical Board actions, removal of hospital privileges, lawsuits, or felonies. None of the bad things are likely since I have not seen patients since July 1, 2011 and I no longer have hospital privileges. However, this caused me to pause when I came to the question of “Actively practicing”? A quick check of the status of several who do not see patients but are administrators, retired or full time editors of other medical journals revealed they were all listed as “active”. I guess that “medical journalism” is probably as much a medical activity as “administrative medicine” which is recognized by the Arizona Medical Board. This got me to thinking about competence and the Medical Board’s obligation to ensure competent physicians.

Medical boards focused on preventing the unlicensed practice of medicine by “quacks” and “charlatans” in the first half of the Twentieth Century. The Boards evolved over time to promote higher standards for undergraduate medical education; require assessment of knowledge and skills to qualify for initial licensure; and develop and enforce standards for professional practice. Beginning with New Mexico in 1971, nearly all state medical boards require a prescribed number of continued medical education (CME) hours with Colorado being a notable exception. Colorado’s lack of CME requirements goes against the recent trends. In 2010 the Federation of State Medical Boards (FSMB) House of Delegates voted to adopt a framework for maintenance of licensure to address concerns among policymakers and regulators (1). The FSMB’s framework contains three components: 1. reflective self assessment; 2. assessment of knowledge and skills; and 3. performance in practice.

Self-reflection has long been a mainstay of good medical practice. However, the requirement is vague and most evidence suggests that physicians are not very good at it (2). Assessment and reassessment of knowledge and skills has been present in most medical specialty and subspecialty boards for some time. Furthermore, actively practicing physicians are required to undergo periodic peer review and reapplication for hospital privileges. Further testing and assessment seems costly and largely unneeded. However, medical licensure is above all about seeing and treating patients. What is new is FSMB’s recognition of the importance of active medical practice in determining medical competence. In many instances, policymakers such as chiefs of staff, hospital board members, administrators or members of guideline writing committees have been non- or very limited practicing physicians. Their decisions have often been fundamentally flawed. Quality has been frequently politically defined rather than patient centered and evidence based. In too many cases, hastily adopted guidelines are proven wrong and even potentially dangerous to patients (3).

A physician who directs care should be subject to the “Continued Competency Rule” which is used in Colorado (4). This rule requires that a physician, “if not having engaged in active practice for two or more years…be able to demonstrate continued competency”. It needs to be recognized that those who meet this standard are only competent in their own area of practice. For example, a pulmonary and critical care physician has no business directing neurosurgical care or formulating orthopedic guidelines. Administrative medicine, and for that matter, medical journalism, would do not meet this standard of competency since neither involves taking responsibility for the care of patients. The requirement for physician administrators to be really active in the practice of medicine may be one key to improved medical care and competence. At least it should make them think about directing care or mandating a guideline that they, themselves have to follow.

Richard A. Robbins, MD*

References

1. Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician's commitment to lifelong learning. Ann Intern Med 2012;157:287-9.
2. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094-102.
3. Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37.
4. http://www.dora.state.co.us/medical/ (accessed 11/5/12).

* The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Maintaining medical competence. Southwest J Pulm Crit Care 2012;5:266-7. PDF

Interference with the Patient–Physician Relationship

“Life is like a boomerang. Our thoughts, deeds and words return to us sooner or later, with astounding accuracy.”-Brant M. Bright, former project leader with IBM

A recent sounding board in the New England Journal of Medicine discussed legislative interference with the patient-physician relationship (1).  The authors, the executive staff leadership of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Surgeons believe that legislators should abide by principles that put patients’ best interests first. Critical to achieving this goal is respect for the importance of scientific evidence, patient autonomy, and the patient-physician relationship. According to the authors, lawmakers are increasingly intruding into the realm of medical practice, often to satisfy political agendas without regard to established, evidence-based guidelines for care.

The article goes on to cite examples including:

1. The Florida Firearm Owners’ Privacy Act, which substantially impaired physicians’ ability to deliver gun-safety messages to patients.
2. New York legislation requiring physicians to offer terminally ill patients information and counseling regarding palliative care and end-of-life options.
3. A Virginia bill requiring women to undergo ultrasonography before an abortion including mandated transvaginal ultrasonography in some instances.
4. Pennsylvania, Ohio, Colorado, and Texas legislation limiting a physician’s ability to disclose information about exposure to chemicals such as benzene, toluene, ethylbenzene, and xylene used in the process of hydraulic fracturing (“fracking”).

The authors condemn these actions that undermine physician autonomy and the fundamental principles of respect for patient autonomy, beneficence, nonmaleficence, and justice that shape physicians’ actions and behavior. The authors go on to state that “laws and regulations are blunt instruments… that reduce health care decisions to a series of mandates …for political or other reasons unrelated to the scientific evidence and counter to the health care needs of patients”. However, these legislative actions are an extension of the trend where multiple individuals and groups have increasingly dictated patient care.

It would be remiss not to point out that those clinician groups have been as guilty of dictating healthcare as some of the politicians by publishing or endorsing mandates for care. As the authors state mandates “do not allow for the infinite array of exceptions-cases in which the mandate may be unnecessary, inappropriate, or even harmful to an individual patient”. Although the authors would likely argue that they publish guidelines rather than mandates, their guidelines have as much authority as laws given that both threaten a physician’s ability to practice. Penalties for noncompliance with guidelines such as removing hospital privileges, reducing payments or listing physicians in the National Practioner Database are as much a threat to physicians as legislative action.

These clinician groups would also likely argue that their guidelines are evidence-based and in the patient’s best interests. However, there are multiple instances where the mandates are not evidence based and ineffective (e.g., pneumococcal 23 polyvalent vaccine in adults) (2-4) or even harmful (e.g., tight control of glucose in the ICU) (5). Patient autonomy and individual needs, values, and preferences must be respected. Physicians must have the ability and freedom to treat their patients “freely and confidentially, to provide patients with factual information relevant to their health, to fully answer their patients’ questions, and to advise them on the course of best care without the fear of penalty” (1).

These clinician groups should speak out against political mandates or when the scientific evidence is premature, weak or contradictory regardless of the source. Medical guidelines should have patients' best interests at heart and not political agendas whether from politicians or others. Importantly, these clinician groups should “recognize the infinite array of exceptions” to each mandate or guideline. Finally, they should condemn the practice of allowing regulatory agencies to promote a political or financial agenda by threatening physicians to conform to the ever increasing numbers of mandates and guidelines that are based on poor quality evidence. Those that are members of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, or the American College of Surgeons who agree that mandates undermine the physician-patient relationship and ultimately adversely affect patient care should speak loudly to their executive staff leaders to ensure their voices are heard. Better ways of informing clinicians of best current practice are needed, but also needed are ways of making the accomplishment of best practices easy and rewarding, rather than punitive.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med 2012;367:1557-9.t
2. Fine MJ, Smith MA, Carson CA, Meffe F, Sankey SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Int Med 1994;154:2666-77.
3. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Sys Rev 2003:CD000422.
4. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009;180:48-58.
5. Robbins RA, Singarajah CU. Critical care review: the high price of sugar. Southwest J Pulm Crit Care 2011;3:78-86

The views expressed in this editorial are those of the author and not necessarily the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Interference with the patient-physician relationship. Southwest J Pulm Crit Care 2012;5:253-5. PDF 

Guidelines for Starting Today’s Private Practice

Starting a new practice may seem like a daunting task. The purpose of this editorial is to demystify the process of creating a new practice from the beginning. The cardinal rule is to keep costs low and not to outsource work that can easily be performed by any competent physician and staff. You do not need a manager, lawyer, business partner, coder or biller individually; you may be able to perform many of these services yourself. What you do need is a commitment to making your practice a success. 

Do not spend too much on your office space, furnishings or equipment. Start with the bare essentials. Immediately start applying to all insurance companies especially Medicare. Request an employer identification number. Set up a basic business banking account and submit the account number to the insurance companies you plan to work with.

You can purchase an entire electronic healthcare record (EHR) system or you can create your own EHR using basic word processing software, a free electronic prescription account and inexpensive billing software. Purchase malpractice, business and personal health insurance. Consider using a temp agency for staffing. 

High quality notes and good physician communication is paramount to success. Give community lectures and grand rounds at local hospitals. Introduce yourself to physicians by joining the local medical society, visiting other practices, applying for medical staff privileges and mailing an introduction letter. With the help of this paper you will be able to create your own private practice without delay.

Evan D. Schmitz, MD (evandschmitz@gmail.com)*

April Y. Schmitz, RN*

Hoan P. Tran, MD**

* The authors are in private practice in Richland, Washington and have no conflict of interest to declare.

** The author is in private practice in Yakima, Washington and has no conflict of interest to declare.

The views expressed are those of the authors and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Socieities.

Reference as: Schmitz ED, Schmitz AY, Tran HP. Guidelines for starting today's private practice. Southwest J Pulm Crit Care 2012;5:229. PDF

The Emperor Has No Clothes: The Accuracy of Hospital Performance Data

Several studies were announced within the past month dealing with performance measurement. One was the Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission, JCAHO) 2012 annual report on Quality and Safety (1). This includes the JCAHO’s “best” hospital list. Ten hospitals from Arizona and New Mexico made the 2012 list (Table 1).

Table 1. JCAHO list of “best” hospitals in Arizona and New Mexico for 2011 and 2012.

This compares to 2011 when only six hospitals from Arizona and New Mexico were listed. Notably underrepresented are the large urban and academic medical centers. A quick perusal of the entire list reveals that this is true for most of the US, despite larger and academic medical centers generally having better outcomes (2,3).

This raises the question of what criteria are used to measure quality. The JCAHO criteria are listed in Appendix 2 at the end of their report. The JCAHO criteria are not outcome based but a series of surrogate markers. The Joint Commission calls their criteria “evidence-based” and indeed some are, but some are not (2). Furthermore, many of the Joint Commission’s criteria are bundled. In other words, failure to comply with one criterion is the same as failing to comply with them all. They are also not weighted, i.e., each criterion is judged to be as important as the other. An example where this might have an important effect on outcomes might be pneumonia. Administering an appropriate antibiotic to a patient with pneumonia is clearly evidence-based. However, administering the 23-polyvalent pneumococcal vaccine in adults is not effective (4-6). By the Joint Commission’s criteria administering pneumococcal vaccine is just as important as choosing the right antibiotic and failure to do either results in their judgment of noncompliance.

Previous studies have not shown that compliance with the JCAHO criteria improves outcomes (2,3). Examination of the US Health & Human Services Hospital Compare website is consistent with these results. None of the “best” hospitals in Arizona or New Mexico were better than the US average in readmissions, complications, or deaths (7).

A second announcement was the success of the Agency for Healthcare Quality and Research’s (AHRQ) program on central line associated bloodstream infections (CLABSI) (8). According to the press release the AHRQ program has prevented more than 2,000 CLABSIs, saving more than 500 lives and avoiding more than $34 million in health care costs. This is surprising since with the possible exception of using chlorhexidine instead of betadine, the bundled criteria are not evidence-based and have not correlated with outcomes (9). Examination of the press release reveals the reduction in mortality and the savings in healthcare costs were estimated from the hospital self-reported reduction in CLABSI.

A clue to the potential source of these discrepancies came from an article published in the Annals of Internal Medicine by Meddings and colleagues (10). These authors studied urinary tract infections which were self-reported by hospitals using claims data. According to Meddings, the data were “inaccurate” and “are not valid data sets for comparing hospital acquired catheter-associated urinary tract infection rates for the purpose of public reporting or imposing financial incentives or penalties”. The authors propose that the nonpayment by Medicare for “reasonably preventable” hospital-acquired complications resulted in this discrepancy. There is no reason to assume that data reported for CLABSI or ventilator associated pneumonia (VAP) is any more accurate.

These and other healthcare data seem to follow a trend of bundling weakly evidence-based, non-patient centered surrogate markers with legitimate performance measures. Under threat of financial penalty the hospitals are required to improve these surrogate markers, and not surprisingly, they do. The organization mandating compliance with their outcomes joyfully reports how they have improved healthcare saving both lives and money. These reports are often accompanied by estimates, but not measurement, of patient centered outcomes such as mortality, morbidity, length of stay, readmission or cost. The result is that there is no real effect on healthcare other than an increase in costs. Furthermore, there would seem to be little incentive to question the validity of the data. The organization that mandates the program would be politically embarrassed by an ineffective program and the hospital would be financially penalized for honest reporting.

Improvement begins with the establishment of guidelines that are truly evidence-based and have a reasonable expectation of improving patient centered outcomes. Surrogate markers should be replaced by patient-centered outcomes such as mortality, morbidity, length of stay, readmission, and/or cost. The recent "pay-for-performance" ACA provision on hospital readmissions that went into effect October 1 is a step in the right direction. The guidelines should not be bundled but weighted to their importance. Lastly, the validity of the data needs to be independently confirmed and penalties for systematically reporting fraudulent data should be severe. This approach is much more likely to result in improved, evidence-based healthcare rather than the present self-serving and inaccurate programs without any benefit to patients.

Richard A. Robbins, MD*

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Available at: http://www.jointcommission.org/assets/1/18/TJC_Annual_Report_2012.pdf (accessed 9/22/12).
2. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
3. Rosenthal GE, Harper DL, Quinn LM. Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals. JAMA 1997;278:485-90.
4. Fine MJ, Smith MA, Carson CA, Meffe F, Sankey SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Int Med 1994;154:2666-77.
5. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Sys Rev 2003:CD000422.
6. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009;180:48-58.
7. http://www.hospitalcompare.hhs.gov/ (accessed 9/22/12).
8. http://www.ahrq.gov/news/press/pr2012/pspclabsipr.htm (accessed 9/22/12).
9. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
10. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12.

*The views expressed are those of the author and do not necessarily represent the views of the Arizona or New Mexico Thoracic Societies.

Reference as: Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5. PDF

Getting the Best Care at the Lowest Price

“Computers make it easier to do a lot of things, but most of the things they make it easier to do don't need to be done.”- Andy Rooney

A recent report from the IOM Institute of Medicine (IOM) claims that $750 billion, or about 30% of healthcare expenditures is wasted each year (1). This attention-grabbing statistic is reminiscent of the oft-quoted figure of 44,000-98,000 deaths attributable to medical errors annually from the 2000 IOM report titled “To Err Is Human: Building a Safer Health System” (2). The IOM estimate of deaths was based on two studies that used the Harvard Medical Practice Study methodology (3-6). Nurses reviewed charts and using preset criteria cases referred charts to physicians who had undergone a short training course. The physicians judged whether the adverse event was due to a medical error and whether the error contributed to the patient’s death. The incidence of deaths from medical errors was double in New York compared to Utah and Colorado resulting in the IOM’s high and low estimate. I remember reading the studies and thinking that both had problems. The physician reviewers were often outside the specialty area involved (e.g., nonsurgeons reviewing surgical cases); the criteria for error and whether it contributed to death were not clearly defined; and the results were inconsistent (were physicians from New York really twice as negligent as those from Utah and Colorado?). My impression was that no one would believe these flawed studies. I was very wrong. The IOM report helped spark an ongoing campaign for patient safety resulting in a number of interventions. Most were focused on physicians, some were expensive, and to date, it is unclear whether they have improved outcomes or wasted resources.

Now the IOM has published that an inefficient, extraordinarily complex, and slow-to-change US healthcare system wastes huge amounts of money (Table 1) (1).

Table 1. IOM estimates of wasted healthcare dollars.

Although the validity of the estimates is uncertain, most in healthcare would agree that a large portion of healthcare dollars are wasted. The report implies much of this inefficiency is due to clinicians because they are slow-to-change, inefficient and unable to keep up with the explosion in healthcare knowledge. Because of these limitations, physicians often mismanage the patient resulting in the waste of dollars noted above. In the healthcare system envisioned by the IOM, electronic health records (EHRs) would bring the research contained in more than 750,000 journal articles published each year to the point of care. Since it would be impossible for a clinician to read all 750,000 articles these would be communicated to the clinicians as guidelines.

Over the past decade, a remarkable number of laws, rules, regulations, and new ways of doing business have hit physicians (7). Each, when viewed alone, looks very reasonable, but, taken in aggregate, they are undermining the profession and medical care. Healthcare has become more expensive and physicians have shouldered this blame despite losing much of their autonomy. The IOM recommendations on computers may be another in the death by a thousand cuts that independently thinking physicians are receiving.

Although I’m resentful of the IOM report’s implications, bringing computers and EHRs to the clinic is a good idea. However, as a retired VA physician I have repeatedly heard how the “magic” of the computer can solve problems. The VA long ago installed an electronic health record with a set of guidelines that anyone could follow. Certainly improved efficiency and reduced costs would shortly follow. Unfortunately, this does not appear to be the case. When the VA EHR was instituted the numbers of physicians and nurses within the VA declined although the numbers of total employees increased (8). At least part of the increase was due to installation and maintenance of an EHR. At the same time an ever increasing number of guidelines were placed on the computer. Costs to ensure compliance and bonuses paid to administrators for compliance further escalated expenses. Furthermore, the guidelines caused a marked consumption of clinician time. According to one estimate, compliance with the source of many of the VA guidelines, the US Preventative Services Task Force, would require 4-7 hours of additional clinician time per day (9). Clearly, this was unsustainable so further money was allocated to hire healthcare technicians to comply with many of the guidelines. Compliance improved but efficiency, costs, morbidity or mortality did not (10). Furthermore, an unexpected increase in healthcare expenditures occurred outside the VA as a consequence of EHRs. A recent report from the Office of Inspector General of Health and Human Services notes an increase in higher level billing codes in Medicare patients (11). Experts say EHR technology resulted in the increase because of its super-charting capabilities (12). Therefore, it seems unlikely that EHRs as currently utilized will improve efficiency or lower costs.

Much to their credit, the IOM seems to recognize these limitations when they say, "Given such real-world impediments, initiatives that focus merely on incremental improvements and add to a clinician's daily workload are unlikely to succeed” (1). The report goes on to say that instead, the entire infrastructure and culture of healthcare must be reconfigured for significant change to occur. I would agree. Previous changes to improve healthcare have done nothing more than shift monies away from clinical care which will not improve patient outcomes (13). This occurred at the VA and will occur again if left unchecked. A meaningful partnership between clinicians and payers achieving and rewarding high-value care is needed. To do this physicians need considerable input, and perhaps more importantly, control of any EHR. Second, physicians need to be rewarded for good care which is centered on improved patient outcomes and not endless checklists that do little more than consume time. Failure to do so will result in inefficient and more costly care and not in the improvements promised by the IOM.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Smith M, Saunders R, Stuckhardt L, McGinnis JM. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academy Press. 2000. Available at: http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx (accessed 9/8/12). 
2. Kohn LT, Corrigan JM, Donaldson MS.  To Err Is Human: Building A Safer Health System.  Washington, DC: National Academy Press. 2000. Available at: http://www.nap.edu/openbook.php?isbn=0309068371 (accessed 9/8/12). 
3. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical injury and medical malpractice. N Engl J Med 1989;321:480-4.
4. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
5. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
6. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
7. Kellner KR. Physician killed by ducks. Chest 2005;127:695-6.
8. Robbins RA. Profiles in medical courage: of mice, maggots and Steve Klotz. Southwest J Pulm Crit Care 2012;4:71-7.
9. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41.
10. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
11. Office of Inspector General. Coding trends of Medicare evaluation and management services. Available at: http://oig.hhs.gov/oei/reports/oei-04-10-00180.asp (accessed 9-8-12).
12. Lowes R. Are Physicians Coding Too Many 99214s? Medscape Medical News. Available at: http://www.medscape.com/viewarticle/767732 (accessed 9-8-12).
13. Robbins RA, Gerkin R, Singarajah CU. Correlation between patient outcomes and clinical costs in the VA healthcare system. Southwest J Pulm Crit Care 2012;4:94-100.

*The views expressed in this editorial are those of the author and do not necessarily represent the views of the Arizona or New Mexico Thoracic Societies.

Reference as: Robbins RA. Getting the best care at the lowest price. Southwest J Pulm Crit Care 2012;5:145-8. (Click here for a PDF version of the editorial)