Young adults, in a period of transition, are often reluctant to seek treatment for mental health problems because of the stigma, inadequate insurance coverage and difficulty finding a mental health care provider.

But a new preliminary study by researchers at Case Western Reserve University suggests that depression symptoms may be significantly reduced when 18- to 25-year-olds interact with computerized avatars—virtual 3D images of a healthcare provider like a nurse practitioner or physician —as a way to rehearse office visits ahead of time and learn self-management skills.

Study results were published in the current Applied Nursing Research journal article (http://www.appliednursingresearch.org/), "Avatar-based depression self-management technology: promising approach to improve depression symptoms among young adults."

Melissa Pinto, PhD, RN, a KL2 Clinical Research Scholar and instructor at Case Western Reserve's Frances Payne Bolton School of Nursing, collaborated with developers of the Electronic Self-Management Resource Training (eSMART) team: Ronald Hickman Jr., PhD, ACNP-BC, and John Clochesy, PhD, RN, FAAN (now at University of Southern Florida) from the nursing school, and Marc Buchner, PhD, from the Virtual Gaming Lab at Case Western Reserve's engineering school.

Pinto said the study was the first to her knowledge to use an avatar-based intervention for this age group to improve depressive symptoms.

The researcher used a Case Western Reserve-designed virtual program, called eSMART-MH. eSMART-MH was adapted from a previous platform (eSMART-HD) designed by the team to help adults with chronic health problems manage their health.

The interactive avatar program, eSMART-MH, was designed in Buchner's Virtual Gaming Lab and tailored for young adults with depressive symptoms. eSMART-MH walks young adults through healthcare appointments with an avatar healthcare provider in virtual primary care office setting. During these visits, young adults practice talking about depression, ask avatar healthcare providers questions and learn self-managements skills to help manage depressive symptoms.

At this age, a majority of young people do not make contact with mental health providers until years after they first experience depressive symptoms. And those who do seek professional help may go to their first few appointments, but stop going soon after, said Pinto, who has studied mental health interventions in adolescents and young adults for six years.

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At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.

This Big Brother-ish approach is one of a panoply of efforts to promote a basic tenet of infection prevention, hand-washing, or as it is more clinically known in the hospital industry, hand-hygiene. With drug-resistant superbugs on the rise, according to a recent report by the federal Centers for Disease Control and Prevention, and with hospital-acquired infections costing $30 billion and leading to nearly 100,000 patient deaths a year, hospitals are willing to try almost anything to reduce the risk of transmission.

Studies have shown that without encouragement, hospital workers wash their hands as little as 30 percent of the time that they interact with patients. So in addition to the video snooping, hospitals across the country are training hand-washing coaches, handing out rewards like free pizza and coffee coupons, and admonishing with “red cards.” They are using radio-frequency ID chips that note when a doctor has passed by a sink, and undercover monitors, who blend in with the other white coats, to watch whether their colleagues are washing their hands for the requisite 15 seconds, as long as it takes to sing the “Happy Birthday” song.

All this effort is to coax workers into using more soap and water, or alcohol-based sanitizers like Purell.

“This is not a quick fix; this is a war,” said Dr. Bruce Farber, chief of infectious disease at North Shore.

But the incentive to do something is strong: under new federal rules, hospitals will lose Medicare money when patients get preventable infections.

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A study released today by George Washington University School of Public Health and Health Services (SPHHS) researchers offers an in-depth look at hospitals nationwide and admissions to intensive care units (ICU). The study, published in the journal Academic Emergency Medicine, finds a sharp increase—nearly 50 percent—in ICU admissions coming from U.S. emergency departments.

"These findings suggest that emergency physicians are sending more patients on to the ICU," said SPHHS researcher and lead author Peter Mullins. "The increase might be the result of an older, sicker population that needs more care." The larger question, one that this study couldn't answer, is whether there will be enough ICU capacity in the future to accommodate the growing number of patients, particularly the oldest of the old, the authors said.

Mullins and his colleagues conducted the study by using data from the National Hospital Ambulatory Care Survey, a sample of U.S. hospital-based emergency departments during a seven-year period. They found that ICU admissions jumped from 2.79 million in 2002-2003 to 4.14 million in 2008-2009. The study also shows that during the same time frame overall emergency department admissions grew by only 5.8 percent.

Other key findings of the study:
- ICU admissions grew the most among patients aged 85 and older—increasing 25 percent every two years.
- Utilization of tests and services provided to emergency department patients on their way to the ICU also jumped during the study period, with the largest rise occurring in computerized tomography (CT) or magnetic resonance imaging (MRI) tests. In fact, CT and MRI tests provided while still in the emergency department increased from 16.8 percent to 37.4 percent.
- The most common reasons for ICU admissions were symptoms such as chest pain or shortness of breath that can signal life-threatening conditions like heart attacks.
- On average, patients had to wait five hours in the emergency department before getting into the ICU.

Additional research must be done to find ways to keep critically ill patients from facing long waits in crowded emergency departments, said co-author Jesse Pines, MD, MBA, MSCE, a practicing emergency physician and an associate professor of emergency medicine and health policy at SPHHS.

"Studies have shown that the longer ICU patients stay in the emergency department, the more likely they are to die in the hospital," Pines said. "Better coordination between the emergency department and ICU staff might help speed transfers and prevent complications caused by long emergency department waits," he said.

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For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work.

Not anymore. Radiologists still make twice as much as family doctors, but are high on the list of specialists whose incomes are in steepest decline. Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees. On Internet forums, younger radiology residents agonize about whether it is too late to switch tracks.

At St. Barnabas Hospital in the Bronx, a dozen radiologists in training, including Dr. Luke Gerges, 28, are suddenly stranded on an expensive road to nowhere. All received termination notices recently because their hospital is ending their residency program next year as part of a plan to replace its radiologists with a teleradiology company that reads diagnostic images remotely.

“Those days of raking in the dough with radiology are gone,” said Dr. Gerges, who is four years beyond medical school and $300,000 in debt. He said he chose a specialty he loves without caring that big salaries were waning, but never imagined it would be this hard to finish his postgraduate training and get a job.

“No one is going to hire me to be a radiologist without my training,” he said.

Few specialties have been immune to the same factors depressing radiology: deep Medicare cuts, cut-rate competition driven by technology, doubts about the health value of many tests and procedures and new measures to tilt public money to primary care.

The case of St. Barnabas may be extreme, said Dr. Paul H. Ellenbogen, chairman of the American College of Radiology, the principal organization of the nation’s 30,000 radiologists, who called the hospital’s treatment of the residents “unconscionable.” But it is part of a larger pattern that has made radiology the target of a dozen cuts in Medicare reimbursement since 2006, he said, totaling $6 billion.

“We were somewhat victims of our success,” said Dr. Ellenbogen, in Dallas, whose career spans what radiologists call the golden years, when the cost of diagnostic imaging grew faster than other items in health care.

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In a Spanish study, nurses trained specifically to resolve acute health problems of low complexity provided care of comparable quality to that of general practitioners.

The findings, published March 21 on the website of the Journal of Advanced Nursing, suggest nurses may be able to take on some of the care generally provided by physicians, the researchers said.

Mireia Fàbregas, MD, of the Institut Català de la Salut, in Barcelona, and her colleagues randomized 1,461 adult patients who requested same-day appointments to see either nurses trained to respond to problems with low complexity or to see general practitioners. The study was conducted in 38 general practices in Catalonia, Spain, with 142 general practitioners and 155 nurses participating. The investigators measured how well patients' symptoms resolved and how satisfied patients were two weeks after the visit.

The investigators found that nurses successfully solved 86.3% of the cases. The health problem that nurses solved with greatest ease was burns, followed by injuries and acute diarrhea. Nurses were less successful at resolving low back pain, acute mild upper respiratory symptoms and urinary discomfort. “This lower resolution could be explained by the fact that these problems require more complex physical examinations that are not usual in a nurse’s daily work,” Fàbregas said.

Patients who saw nurses were as satisfied with their visit as those who saw doctors. When patients were asked about their preferences regarding which professional they would like to visit if a similar health problem arose again, more than 40% of patients in each group expressed indifference.

The study abstract is available at http://onlinelibrary.wiley.com/doi/10.1111/jan.12120/abstract.

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A bipartisan House bill reintroduced Thursday would create 15,000 more medical residency positions under Medicare in a move to alleviate the looming U.S. doctor shortage.

The measure from Reps. Allyson Schwartz (D-Pa.) and Aaron Schock (R-Ill.) would mandate that 50 percent of the positions train residents in primary care.

It would also require federal health officials to study the specialty needs of the U.S. healthcare system as they evolve and allocate residencies accordingly.

"It's not a problem of people going into medicine," Schock told a press conference. "It's a problem of having the hands-on training at the teaching hospitals available."

The number of Medicare-sponsored residencies has not increased in 15 years, he said.

Groups like the Association of American Medical Colleges (AAMC) estimate that the U.S. healthcare system will be short tens if not hundreds of thousands of doctors in the coming decades.

Thursday's bill would cost an estimated $9 billion to $10 billion over 10 years, Schwartz said. The 15,000 new positions would be added over a five-year period.

“Because it takes seven to 10 years to train a doctor, Congress must act now to increase Medicare’s support for graduate medical education," AAMC president Darrell Kirch said in a statement.

"Medical schools and teaching hospitals see these proposals as the beginning of a comprehensive strategy to improve the healthcare of all."

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New research from Indiana University has found that machine learning -- the same computer science discipline that helped create voice recognition systems, self-driving cars and credit card fraud detection systems -- can drastically improve both the cost and quality of health care in the United States.

Using an artificial intelligence framework combining Markov Decision Processes and Dynamic Decision Networks, IU School of Informatics and Computing researchers Casey Bennett and Kris Hauser show how simulation modeling that understands and predicts the outcomes of treatment could reduce health care costs by over 50 percent while also improving patient outcomes by nearly 50 percent.

The work by Hauser, an assistant professor of computer science, and Ph.D. student Bennett improves upon their earlier work that showed how machine learning could determine the best treatment at a single point in time for an individual patient.

By using a new framework that employs sequential decision-making, the previous single-decision research can be expanded into models that simulate numerous alternative treatment paths out into the future; maintain beliefs about patient health status over time even when measurements are unavailable or uncertain; and continually plan/re-plan as new information becomes available. In other words, it can "think like a doctor."

"The Markov Decision Processes and Dynamic Decision Networks enable the system to deliberate about the future, considering all the different possible sequences of actions and effects in advance, even in cases where we are unsure of the effects," Bennett said.

Moreover, the approach is non-disease-specific -- it could work for any diagnosis or disorder, simply by plugging in the relevant information.

The new work addresses three vexing issues related to health care in the U.S.: rising costs expected to reach 30 percent of the gross domestic product by 2050; a quality of care where patients receive correct diagnosis and treatment less than half the time on a first visit; and a lag time of 13 to 17 years between research and practice in clinical care.

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With hospitals buying up medical practices around the country and seeking to make the most of their investment, the American Medical Association reached out to doctors this week to remind them that patient welfare must always come first and not be overridden by the economic interests of hospitals that now employ doctors in ever-growing numbers.

“In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority,” says a policy statement adopted by the association.

“A physician’s paramount responsibility is to his or her patients,” the association said. At the same time, it added, a doctor “owes a duty of loyalty to his or her employer,” and “this divided loyalty can create conflicts of interest, such as financial incentives to over- or under-treat patients.”

The association is disseminating its policy to doctors at a time when more of them are becoming hospital employees. About one-third of new doctors say they would prefer to be employed by hospitals, rather than practice on their own. The association is urging hospitals and medical groups to adopt similar policies.

A major goal of the guidelines is to protect the professional autonomy of doctors. Hospital employment agreements often include provisions that discourage doctors from sending patients to providers of services that are not affiliated with the hospital.

The guidelines say that “physicians should always make treatment and referral decisions based on the best interests of their patients.” Moreover, the association says, patients should be told whenever a hospital provides financial incentives that encourage, discourage or restrict referrals or treatment options.

“We never want patients to worry or wonder if a decision is being made in their best interest,” said Dr. Ardis Dee Hoven, a Kentucky internist who is president-elect of the association.

From 2000 to 2010, the American Hospital Association says, the number of doctors employed by hospitals grew by 32 percent, to 212,000. The trend has accelerated since then, in part because of federal policies that encourage doctors and hospitals to band together to coordinate care.

In addition, many doctors have found that private practice on their own is no longer profitable and comes with a host of complications, so they are more receptive to the idea of hospital employment.

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In the United States, we are now short approximately 9,000 primary care doctors. These are the general internists, family doctors, geriatricians and general pediatricians, the doctors responsible for diagnosing new illnesses, managing chronic ones, advocating preventive care and protecting wellness. And health care leaders predict that that deficit will worsen dramatically in the next 15 years. Specialties like general surgery, neurosurgery and emergency medicine will also become critically understaffed; but primary care will be hardest hit, with a shortfall of more than 65,000 doctors.

While the demands from a growing and aging population and an influx of 40 million patients newly covered by insurance are considered the main drivers of this crisis, there is no shortage of issues on the physician supply side.

For starters, only 2 percent of all medical students in a recent study expressed interest in practicing primary care as a general internist. Most continue to flock to subspecialty fields like dermatology, anesthesiology, radiology and ophthalmology.

And once trained, primary care practitioners are particularly vulnerable to burnout and more likely to leave clinical practice than doctors in subspecialties like cardiology or gastroenterology.

It’s like the patient is bleeding faster than we can transfuse.

Experts have proposed several solutions to the doctor shortage. But for many worried patients and doctors, the best answer is seemingly the most obvious one: churn out more young doctors and funnel them into residency programs that train for primary care.

Unfortunately, according to a new study published in The Journal of the American Medical Association, it’s not that obvious.

Researchers asked more than 50,000 doctors training in internal medicine about their career plans. As expected, the majority of these young doctors planned on becoming subspecialists.

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