Life after all that mess…

Finally, researchers of snoring problems found a solution for those who suffer from this alarming issue. This Good Morning Snore Solution review affirms that this solution for snore is very easy to use and very comfortable. It is an innovative mouthpiece that can be worn while you sleep. This review finds that this device is non intrusive and very manageable; the final solution to all snoring problems. People with snoring problems who are not comfortable with using other anti snoring products like pillows, spray, head straps and other devices will find this product a very good alternative.

The Good Morning Snore Solution.

The Good Morning Snore Solution.

This product is very easy to use. The mouthpiece needs to be placed just right of your tongue’s tip. Once inserted you just move it slightly forward. You will feel that this anti snore mouthpiece will comfortably settle between your bottom and top jaw line. This product will keep your tongue still free to move around without any difficulty. It will not restrict its movements or goes down at the back of your throat. It will not block your airways either. And what’s surprising is, the annoying sound of your snore will be gone for good. What this product does is reverse what happens when you snore which is keeping the air that passes your esophagus from vibrating. The company virtually guarantees that the product will effectively eliminate the noise that your esophagus is making, guaranteeing you a good night of rest.

The Good Morning Snore Solution: Pros And Cons
The Good Morning Snore Solution inventor assures you that this product is Food and Drug Administration (FDA) approved. Another thing is that its effectiveness has been scientifically proven so it means a lot to those who have snoring problems. Dr. Leslie Dort conducted studies which have been published in the Sleep Breathing Journal that show that the snoring problems of patients who used this product have minimized their snores by 70 percent.

tvmpConsidering the fact that snoring is one of the most common problems today, it is no wonder that statistics have shown that snorers can rarely be found among healthy people. Devices like VitalSleep can be very helpful for this problem, but it is always better to change everyday habits, and start with changing the eating and exercise routines.

Meanwhile, Let’s Talk VitalSleep

Yoga is well known for its miraculous effects on snoring. Simply put, some postures can successfully remove the nasal blockages, and help everyone find the natural anti-snoring solution. Snoring and weight are related, so any type of exercise that can reduce the weight can stop the snoring, as well. The best thing about exercises is that they can be done at home, and thanks to many DVD specially created for this purpose, everyone can get in shape quickly. Nonetheless, exercising is nothing without proper diet, and although there is no “stop-snoring meal plan”, one can learn what types of food can ease the symptoms. The most important thing is what one eats before a bedtime, and it is recommended to avoid spicy food, and even dairy products in some cases. Top choices of food are fresh vegetables, lean meat, and natural spices. If that is not enough, the Vitalsleep can always be a great complement to a proper lifestyle.

How Snoring Can Cause Emotional Pain?

After some time, snoring can become a serious problem, which can affect even the strongest relationship between bed partners. The lack of quality sleep causes nervousness and anxiety, so the snorer should take care of the problem as soon as possible, and try out some of the stop snoring mouthpiece products designed for this purpose.

The lack of sleep is not the only trouble the bed partners can experience. The snorer may feel guilty for not letting the bed partner rest, so that may create the chain reaction and lead to bitterness. The next stage usually involves fights between bed partners because the snorer feels helpless, and the bed partner feels ignored. The biggest problem begins when bed partners decide to sleep in separate rooms because of snoring. That usually decreases the intimacy, so they become nothing but strangers living in the same house. It is not rare to find out that people got divorced because of snoring, and although this cannot be the only problem, it certainly is a trigger. Even with this problem the bed partners can improve the relationship by finding out what causes snoring and how can that be stopped. In many cases, a lifestyle change can solve the issue, and sometimes the patient needs stop snoring mouthpiece or the nasal strap.

It is even recommended highly by many dentists and medical practitioners. This anti snoring product has a very sleek design. It is completely non intrusive, natural, comfortable and an effective mouthpiece roll into one. The manufacturer assured you can be sure of its effectiveness that’s why they offer each customer with a 30 day money back guarantee. It might not be as good as the SnoreRX or Good Morning Snore Solution (read reviews here), but it is a quality stop snoring mouthpiece.

Only two side effects have been noted when using this product. First, the user may experience a tender tongue. It is very common for those who use it for the first few days. But when your tongue gets used to it, the tenderness will be gone automatically. Also, you may salivate or drool when you use this product. This will happen also only during the first few days. But after several days, these symptoms will be gone for good as well as your mouth gets used to it.

hombFor several decades, medical billing was done almost entirely on paper. However, with the advent of medical practice management software, also known as health information systems, it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market. Several companies also offer full portal solutions through their own web-interfaces, which negates the cost of individually licensed software packages. Due to the rapidly changing requirements by U.S. health insurance companies, several aspects of medical billing and medical office management have created the necessity for specialized training. Medical office personnel may obtain certification in the field of medical billing training through various institutions.

The Certified Medical Reimbursement Specialist (CMRS) accreditation by the American Medical Billing Association is one of the most recognized of specialized certification for medical billing professionals. Steps have been taken in recent years to make the billing process clearer for patients. The Healthcare Financial Management Association (HFMA) unveiled a “Patient-Friendly Billing” project to help healthcare providers create more informative and simpler bills for patients. Additionally, as the Consumer-Driven Health movement gains momentum, payers and providers are exploring new ways to integrate patients into the billing process in a clearer, more straightforward manner.

Having been married for a couple of years to a snorer is not a joke. There were times when I got so worried that I chose not to sleep just to make sure he breathes well. He gasped and choked while asleep and having that in sight was just so disturbing. I suffered from hearing that sound, too. For two years, I had to cope up with his startling snores. The first few snoring-husbandmonths were the worst. I couldn’t sleep without taking sleeping pills. That was so stressful that getting pregnant was close to impossible. But surprisingly, my husband has gotten me pregnant. This prompted him that he had to do something about it or our child might be the one to put up with my lack of sleep. He made use of some good anti snoring devices. The first two gadgets that he tried were a failure. But when he tried an item that his doctor recommended to him, and it worked magically. Now, our child is about to be born. My doctor assured me that he’s a healthy baby. If my husband did not address his habitual snoring, my pregnancy would have been unwholesome. It seems like my husband did it not for his own sake, but for the sake of our child.

The Impact of Snoring On One’s Confidence and Social Life

My friends paid me a visit last week. They asked me to go with them as they plan to take a vacation in Hong Kong. They told me that I should not worry about the expenses. The hotel accommodation has been paid and all of us will be housed in the same hotel room for two nights. Although the invitation sounded great, I had to turn it down. It is not actually the expenses that I was worried about. I just did not like the idea that we will all be sleeping in the same room. None of my friends knows about my snoring. I know them too well and they will only tease me if they find out that I snore like a guy. It is sad that just because of my snoring, I cannot join in this fun summer getaway. But at least I have read up on anti snoring pillows to at least reduce the distracting sound that I produce when I am asleep. Maybe I should start locating a doctor that specializes on this medical condition, too. My social life is becoming affected by my snoring. It is also beginning to have negative impact on my confidence that’s why I really have to put an end to it.

Snoring Pillows Can Help

spIt has been discovered that the number of people with snoring problems keep rising every day. In America alone, those with this sleep disorder is approximated to be between 12 to 20 million, and the number is thought to be rising steadily. Meaning that at night, those who have sleep disturbances from snoring partners or siblings is more than triple that figure. This therefore gives a funny trend. Since lack of sleep has lots of demerits, then some causes of poor work and abnormal tempers at the work place is due to fatigue which is common for those who cannot have enough sleep due to snoring problems. The remedy came in the form of a snoring pillow.

The snoring pillows have been developed by medics to help alleviate the problem of snoring. This product was developed specifically to help in keeping open the airwaves which are known to be blocked during sleep thereby causing expulsion of air with difficulty which finally leads to the abnormal sound that a snorer produces. The snoring pillow has a unique shape which promotes healthier side sleeping. It is strong enough to keep the head in the right position that keeps the airwaves open. At the same time, it is soft enough to give the user a comfortable feeling while sleeping. Some manufacturers of the pillow provide a pillowcase as well as an after sales service.

Why Does Snoring Annoy Someone So Much?

Snoring from a roommate can be so annoying when one is struggling to fall asleep. It can get very irritating when someone keeps waking you up every hour from their snoring. Snoring is a problem that should be addressed as it affects a recipient and the victim too. Snoring pillows should be used to support the head and neck for a snore free rest. Repetitive sounds can stress a light sleeper who wakes up at the slightest interruption. Large alcohol intake relaxes the neck muscle obstructing free breathing resulting in loud snores, which can disturb the rest of the residents in a home.

A snoring person looks selfish to the one who is getting disturbed, as they are fast asleep and keeping them awake. A person who snores should agree to use snoring pillows for the benefit of all. There are cases of people who have kicked their roommates to wake them up due to snoring. A married couple may have separate bedrooms when one partner keeps the other awake because of snoring. The snoring partner may be forced to sleep on the couch if another bedroom is not available; snoring may cause reduced intimacy in marriage and hurt it in the process.

bmostrThe skin tone tags are generally small ample epidermis increase that will cause no hurting as well as is usually harmless. Some individuals adopt information on how to remove skin tags yet medically authorized procedures are typically best applications for handling. You have to distinguish that it happens to be not essential to eliminate epidermis tags other than in cases reveal before. Several people decide to eradicate tags on account of ugly physical emergence. They generally grow in your neck, nasal, eyelids, face along with the armpits although they will grow somewhere in your body part.

The Cauterization is one of the procedures regarding burning the skin cell. It is the most frequent answer to the difficulty with how to remove skin tags. The expansion is burned through apply of a metallic probe that is heated through electric current. Another method is excision, practically, which implies cutting off. It is usually a surgical method the place that the expansion is removed fully through cutting it from the outside of your skin. Some tags are usually unintentionally cut off whilst shaving. Several tags have been traced when bleeders removed. For situation, ensure that the cutting edge you utilize is appropriately sanitized along with the immediate part across the tag to avoid infection.

Advantages Of Learning Traditional Methods Of Removing Skin Tags

Why should you spend your hard-earned money in the hospital on removing skin tags when you can do it by yourself? Skin tags can look like a big issue to any kind of person who has them. Sometimes, their size could be a discouragement especially for you who want to get rid of them. You should not be discouraged anymore. You can learn how to remove skin tags so easily through different means and try them on yourself.

Information is all over presently. In fact, the internet has made it easier for us. You can access information anywhere and at any time. Instead of spending much money going to the hospital to have your skin tag removed, you can simply get to the internet and acquire information that will help you. Learning traditional methods of removing skin tags through the internet will save you a lot of time. This is because you can go on with your work while at the same time dealing with the skin tag. For example, tying a knot on the skin tag using dental floss or a piece of thread will not hinder you from pursuing your daily chores. Going to the hospital to have them removed will cost much of your time since you will have to wait maybe for long queues in the hospital before you are attended to.

anti-aging-creams-01The beauty industry is packed with various anti-aging remedies such as anti-wrinkle creams. Many people use anti-wrinkle creams because these products promise to give a youthful-looking skin. But the effectiveness of these products is still being debated. It is hard to measure the effectives of anti-wrinkle creams because there are a number of factors that should be taken into account. Consumers have different skin types so they can have different reactions to anti-wrinkle creams. Usually, the effects of anti-wrinkle creams may be evident after two months or more. It is crucial to consider that type of active ingredients that make up the cream and their concentration can influence the results. If you had been using a particular anti-wrinkle cream for many months already and still cannot find satisfactory results, you should consider switching to another brand. If you had just started using a particular product and you had observed undesirable effects that you were not warned about, you should stop using the product. You can avoid these types of situations by scrutinizing the product before buying it. Find the 10 anti-wrinkle creams with the highest ratings and study each of them. It is better to ask for the professional opinion of a dermatologist before using any cosmetic skin care product. Read more

The Secrets to a Healthy Skin

You may search for the 10 anti-wrinkle creams that are best-rated by consumers but it is better to start the improvements from within. If you really want to have a healthy-looking skin, there is a need for lifestyle modification. These anti-wrinkle creams may reduce the signs of aging on your face but it is better to prevent their premature appearance.  There are a number of things that you can do to prevent early onset of wrinkles, pigmentation and discoloration. Wearing sunscreen can be beneficial to your skin. It will protect your skin from the harmful effects of UV rays. It is recommended to use sunscreen with higher SPF if you are staying on a sunny area. You should also drink plenty of water to replenish the moisture that is lost through sweating. You can maintain your skin´s healthy appearance by consuming plenty of fruits and vegetables. These contain vitamins and minerals that are essential for your skin´s health. You should also stay away from smoking and drinking because these can inflict awful effects on to your skin. If you are planning to use any type of cosmetic skin care product, it is encouraged to consult a dermatologist first. The doctor can give a suitable recommendation for your skin type and skin condition.

How Your Lifestyle Can Affect Your Skin

life-style-01You have to be prepared for the early onset of wrinkles if you are fond of sun bathing without wearing sunscreen. This is because the UV rays can cause wrinkles. And if your skin is constantly exposed to UV rays, it will acquire wrinkles before their due. If your activities require sun exposure for long hours, you should wear sunscreen with higher SPF. Your skin will significantly benefit from this practice. The food that you eat can also affect your skin´ s health. You have to consume fruits and vegetables because they contain essential nutrients that are not only good for your skin but to your overall health as well. It is also encouraged to get enough sleep and learn to relax. You should not smoke if you do not want to have a youthful-looking skin. Cigarette smoking can make wrinkles appear earlier by constricting the blood vessels. If you have visible lines already, you should use a reliable anti-wrinkle cream. There are many options in the market. But you can narrow your options by searching the 10 anti-wrinkle creams with best results according to consumer reviews. You should be careful with any skin care product that you are using. It is crucial to be certain that it is suitable for your skin type and skin condition.

During the first two years of medical school, students intensively study the sciences that form the basis of medical practice. These courses have traditionally been taught through lectures and laboratories and tested by rote recall of literally thousands of pieces of information. This model hearkens back to a previous era when physicians were expected to master all the scientific knowledge that then existed as the foundation of medicine. The explosion of biomedical science over the last several decades has rendered this once challenging task now frankly impossible.

THINK, AS AN EXAMPLE, of our knowledge of infectious diseases over the last 50 years. In 1944 bacteria and viruses had been discovered, but little was known about how they caused disease. The entire antibiotic armamentarium consisted of sulfa and penicillin. Medicine had nothing else to offer for a multitude of fatal infections. Today, we know about many thousands of disease-causing organisms and scientists regularly discover new ones. The hospital where I work routinely stocks 47 antibacterial agents, not counting antiviral and antifungal medications that are in their infancy and just beginning to proliferate. The latest edition of a major pediatric infectious disease textbook runs two volumes and 2,395 pages (and it just covers pediatric diseases). A lifetime of study could easily be spent on this one important but relatively small part of medicine. Yet medical students, with a crash course over a handful ‘of weeks, are presented with a vast portion of the current knowledge. Having had no clinical experience themselves (clinical rotations do not normally begin until the third year of medical school), students cannot separate out of the sea of information what is most critical for them to know. So they try to learn it all. Anywhere from two to four other courses are going on at the same time. Students often feel abject at their inability to master all the material, and these very motivated, intelligent young people flounder at their impossible yet seemingly expected task. It is an understatement to say that student morale is often devastated.

IN ADDITION to the sheer weight of modem medical knowledge, the advent of the molecular age of biomedical science adds further educational challenges. A generation ago, the basic science curriculum of medical school focused on subjects like gross anatomy, physiology and pathology, each of which had a palpable and obvious connection to real patients. The birth of molecular biology has forced these traditional disciplines into smaller segments of the curriculum, while much more abstract studies like cell biology, biochemistry and immunology make up an ever-increasing part of the course load. These newer subjects are indispensable to the modern practice of medicine and no doctor would be considered adequately trained without them, but they bring to medical education a level of abstraction and remoteness from living, breathing, whole patients unprecedented in medical history. Simply put, it was much easier to dissect a diseased lung and imagine, even empathize with, the person to whom it once belonged than it is to study the unseeable molecular mechanisms of lung tissue and feel the same connection.

In no way do I propose that medical students not learn the molecular science that has revolutionized medicine. However, our system of medical education has made no allowances for the new challenge that molecular medicine presents to students. Most who choose medicine as a career do so with the intention of one day caring for sick people, but the heavy emphasis on molecular science from the very outset of medical school without any humanizing patient-care experiences to balance it begins to drive a wedge between the physician-to-be and his or her future patients. The impersonal, sterile, unsatisfying doctor-patient relationship that many of us have experienced has its earliest roots here.

Underlying the first two influences I have discussed–the explosion of medical knowledge and the molecularization of medical science–is a philosophy of scientific materialism that dominates medical school education during the early formative years. The intense study of disease almost exclusively from a molecular, cellular and organ perspective without consideration of the intact patient reduces illness to the level of specific defects. The human being becomes nothing more than a conglomerate of molecular pathways and cellular mechanisms. In principle the whole of the human condition is supposed to be knowable in this way. Illnesses once mysterious and even spiritual, stillbirth or depression for example, are at last giving up their secrets to new technologies and modes of investigation. Why then should not all of human experience–an artist’s genius, a child’s love for her mother, the self-sacrifice of a saint-be a function of programmed molecular processes and no more?

This philosophy of scientific materialism is reinforced by the fact that almost all the first-year courses in medical school are taught by Ph.D. scientists, not physicians. Their perspective differs dramatically from that of practicing doctors and their influence, along with the seeming remoteness of the subject matter from clinical medicine, redefines the self-understanding and goals of many students. Having come to medical school to learn to care for sick people, they begin to see themselves as scientists first and caregivers second, if at all.

The only concession that most medical schools make to the humanistic aspects of the profession is a course in medical ethics taught over a few weeks sometime in the first or second year. A few schools have recently introduced more extensive courses roughly centering on the theme “The Physician and Society,” yet these offerings at most represent isolated and abstract attempts to introduce humanism into the students’ vision, coming as they do buried amid the hard science courses that dominate the students’ time.

PERHAPS EVEN MORE fundamentally, students are subtly but strongly taught in the early years of medical school that the career to which they aspire is foremost about science and only secondarily about people. They lose the sense that while science may be the indispensable foundation of modem medicine, the fundamental goals of science and those of medicine differ. Nowhere in medical school is it stated or even implied that science is about determinism–how process A inevitably leads to result B–while medicine is about freedom–striving to help individuals be as healthy as possible to live out their lives in their essential human freedom.

Much of the depersonalizing approach to patients found in medicine today stems from this early dominance of scientific materialism in medical school. Here are sown the roots of dismissing a man with excruciating pain as “the kidney stone in Room 10″ or seeing a dying woman only as a particularly interesting case of breast cancer. Popular medical dramas always portray interactions with demanding or unsavory patients as the root of doctors’ dissatisfaction with patient care, but nothing could be further from the truth. The clinical encounter between doctor and patient remains the ultimate humanizing and empathizing moment in medicine. Unfortunately, doctors routinely reduce patients to their diagnoses and dismiss their humanity because they have been taught from the most formative beginnings of their medical education to think in strictly scientific and not humanistic terms.

The last sweeping change in American medical education came in the mid-19th century, when Dr. William Osler first brought medical students out of the laboratory and lecture hall to the patient’s bedside. Until then, there had been no hands-on clinical training in American medical schools, and caring for sick patients was learned as an apprentice after medical school had ended. Osler’s revolution in teaching formed the basis for the two-year pre-clinical and two-year clinical curriculum that makes up medical school today. As I have indicated, however, this model has become sorely outdated. A new revolution in medical education is needed that would bring the student to the patient’s bedside from the first moment of medical school to allow the humanizing effect of the clinical encounter to flourish. Immersion in the care of real patients from the outset is the only way to counterbalance the influence of the scientific materialism that now predominates. Students will also much more easily gain a sense of what is clinically relevant in the basic science curriculum and can thus direct their own learning more efficiently to deal with the overwhelming quantity of modem medical knowledge.

Some medical schools, most notably Harvard’s, have begun to move generally in this direction. Harvard’s “New Pathway” program introduces medical students to the clinics and hospitals early in their training, but as yet only in small increments. Other schools have followed suit and some may still introduce more radical changes along the same lines. These moves are encouraging and demonstrate that some influential medical educators have recognized the problem. Yet the steps so far have been modest and change slow, as change in medical education is wont to be.

In the end, though, such fundamental change must come. The vast transformation in medical knowledge since Osler’s day is too overwhelming to be taught by the same system without the inevitability of doctors drifting further and further away from their patients. Early immersion in the clinical setting–interviewing and examining patients, observing and assisting physicians, becoming involved in the lives of real patients–is the only answer to the great challenges of medical education today. Otherwise, the exploding quantity of knowledge, the further molecularization of science and the pull of scientific materialism will only more profoundly alienate doctors-to-be from the very people who seek their help.

Voco, vocare, vocatus–the Latin root of the word “vocation” means to summon, to call, to name, to call upon, to invite, to challenge. The American Heritage Dictionary of the English Language defines the word thus: 1) a regular occupation, especially one for which a person is particularly suited or qualified; 2) an inclination, as if in response to summons, to undertake a certain kind of work, especially a religious career. The phrase, “as if in response to a summons,” introduces a mystical quality. If the word “profession” is brought into the discussion, there is a degree of religious-secular conceptual crossover. One definition of that word, from the same dictionary, is: an occupation requiring considerable training and specialized study. In most religious orders and congregations the taking of final vows is referred to as “making one’s profession.” Profession is a part of vocation, but vocation suggests a higher calling, something requiring time, training and commitment, with an ineffable quality that goes beyond a job.

Vocation in Depth.

Religious have explored and developed the concept of vocation in depth and detail. Consider Your Call, a book by Dom Daniel Rees and a group of English Benedictines that examines the vocation to Benedictine monastic life, supplied much food for thought. Three passages from this book apply also to medical training:

* Vocation also means a call to service of other people at some stage in the unfolding of God’s covenant.

* A human person says yes to God in a matter that seems to affect only himself, but the repercussions of his choices are felt far. beyond his own life. He serves the economy of salvation precisely by being or doing what God is asking him to be or do and on his obedience may hinge the destinies of many in ways entirely unknown to him.

* The greatest of all Old Testament vocations is that of Abram. “Go from your country and kindred and your father’s house and to the land I will show you. These three statements suggest service, influence or role model and faith in God’s presence.

Service is a mandate and the easiest topic to discuss. In the Letter of James we read: “You have faith, and I have works. Is that it? Show me your faith without works, and I will show you the faith that underlies my works.” Service need not be as heroic or exotic as that of Dr. Albert Schweitzer or Dr. Tom Dooley. The potential for service in medicine is enormous: waiving fees, working in an inner-city clinic after hours, short-term work in foreign missions, consulting in an AIDS hospice. Only a little imagination is needed. One of the changes in medical education over the past two decades is an emphasis on community service by medical students. This can range from tutoring reading to work with the homeless or medically indigent.


The impact of the exercise of one’s vocation on the destinies of others is more mysterious. Rarely are we aware of our effect on others’ lives or how others influence our lives. Two personal examples can illustrate this.

My twin brother and I attended a small public high school. Regina Robaczewski, the librarian, was determined that students should become self-sufficient in a library of any kind. About 17 years after finishing high school, while planning the guest list for a party to celebrate his master’s degree, Jim was adamant that Miss Robaczewski, who had been in retirement for over a decade, be invited. He responded to a quizzical look saying, “The only thing I learned in high school was how to use the library, which is how I got through this degree. If it weren’t for her, this party wouldn’t be happening.” The surprise on my face reflected that I had felt something similar years earlier upon first walking into Penn State’s sprawling Pattee Library as a freshman. “Big … but I can handle it.” During the party we were able to thank her for the influence she had on our education. She glowed.

The second passage returns to medicine. After practicing geriatric internal medicine for 10 years, I returned to residency training in psychiatry. In the interim between closing my practice and beginning residency I was able to spend three months working at St. Joseph’s Mercy Hospital in Georgetown, Guyana. Mary Liguori Cantilin, R.S.M., M.D., was one of two surgeons at the 100-plus bed hospital. She made rounds seven days a week and was on duty for stretches of up to two months. Even when she was not officially on duty, she was available to advise me on problems unique to that unfamiliar tropical setting.

Except to attend Mass, Sister Ligouri rarely left the hospital complex in which the convent was located. In her late 60’s, her stamina after two and a half decades as a missionary surgeon in India, Guam and Guyana was incredible, as was her obvious joy in what she did both as a nun and as a surgeon. One evening, a little less than a year later, I received a phone call that she had died suddenly earlier in the day. Looking out over the lights of center-city Philadelphia, where we had hoped to meet during her upcoming from leave, I realized she had, by her dedication and joy in what she did, reminded me of something I was starting to forget: It is a privilege to be a physician.

The lives of both these women, one whose vocation was to teach and the other whose religious and medical vocations were inextricably joined, have had an impact that is probably well beyond anything they could have imagined or realized.

The third text, which promises God’s presence when facing the unknown, is particularly relevant to the physician in training. Abram was asked to leave all that was familiar and trust in God. The limits of his world and existence were to be expanded. Like Abram, the physician is called to go to the limits of his or her world and existence–in this case, the limits of knowledge, ability and physical stamina–and expand them. Becoming and being a physician are not easy. Too little sleep and relaxation, coupled with too much stress and too many deaths, characterize the training of most physicians and the practice of many. Graduation from medical school marks the beginning of more severe challenges and training that continue for three or six or more years. Giving of oneself daily can siphon everything before replenishment is possible. There may be no one to comfort the comforter or heal the healer. Remembering God’s promise to Abram to show the way can take one through some very difficult moments.

Hippocrates Censored.

A tradition older than Christianity outlined the vocation of medicine in the oath attributed to Hippocrates. The oath set out the relationship between physician and student and proscribed giving deadly medicine to anyone if asked, giving a pessary to produce abortion and seducing patients. Two versions of the oath lie before me as I write. The traditional text, from which this synopsis was made, is in a frame that was propped up, along with a crucifix, inside the lid of my father’s coffin in 1974. He was a 1931 medical graduate whose life and vocation influenced many. The version of the oath administered at my graduation from the same medical school 44 years later deleted references to abortion, ignored the mandate to teach and glossed over administering deadly medicine by suggesting only that criminal considerations should stay the physician’s hand. Many schools have revised the oath and others have ceased administering it, thereby changing the ritual of profession.

Over the past few years much has been written describing changes in the business of medicine. They are too numerous to detail here. Capitated care, in which the cost of lab tests, specialty consultation or imaging studies is essentially deducted from the ordering physician’s salary, is one example. The potential for financial interests taking precedence over patient needs is obvious.

A commitment to residency training and teaching, to passing down the tradition and learning, is being questioned as something that is costly to the physicians who do the teaching. The amount of time spent teaching students and residents at the bedside has diminished over the past two decades. This is tragic. The best way, perhaps the only way, to learn medicine is at the bedside or in the clinic, watching seasoned physicians, not slightly more advanced trainees, interact with patients and having one’s own work as a trainee observed and evaluated by those same experienced practitioners.

Continuing Medical Education, or CME, remains a big advantage for the US health system.

But like nearly every other aspect of medicine, CME has undergone radical change in recent years, and there will be more dramatic changes likely to be just ahead. Sure, Dr. Brown still attends an occasional out-of-town conference, but at the core of the CME effort in the new millennium lies the concept of a multimedia CME training location – a comprehensive, local information clearinghouse using the latest technology to aid the physician in the difficult new world of medicine while providing an exciting new opportunity for marketing.

Wide-ranging materials are available on most medical subjects, to provide the information physicians need to best serve their patients, and to advance their specialty training and education. Programs can be custom-tailored for each doctor, following an initial assessment that pinpoints his or her strengths and weaknesses. The staff (or someone on-line) then designs an individual study program with precisely the materials needed to improve practice skills. Materials come in whatever format is best suited for a particular physician, taking full advantage of such new technologies as teleconferencing, electronic consulting, direct television, multimedia programs for personal computers via the Internet, or CD-ROM, video, and audiotapes. The resources of the center are always state-of-the-art.

Industry support underpins much of the activity through innovative sponsorship platforms. Some healthcare companies support the center itself; others underwrite the preparation and distribution of learning materials, sometimes on a cooperative basis.

A revolution underway

But that will be then, and this is now. The CME revolution is already underway and the opportunities for industry participation are wide open. Let us describe a current example that foreshadows the shape of things to come – taking into account that multimedia training locations are not yet up and running.

One pharmaceutical company was looking for an innovative way to introduce a new anti-androgen product for use in the treatment of prostate cancer. Specifically, they wanted to use an educational tool to attract physicians’ attention. The purpose was not to tie the educational material directly to the product, but rather to create awareness among specialty physicians that this company was going to be a major player in this field.

Together, we came up with the idea of sending videotapes that would prepare doctors for urology board examinations. We decided not to send them directly to physicians and residents – that would have been too expensive and represented considerable waste circulation – but to all 126 resident directors of urology at the nation’s medical schools.

The tapes were broken down into three primary parts: comprehensive medical content, questions and answers, and board exam simulation exercises.

In addition, new time-saving technology allowed users to pinpoint exactly the segments of the tapes they wanted to view. Within weeks, some two dozen letters from directors were received, thanking the company for making these materials available at no charge. In fact, the company was so pleased with the results that it plans to continue its educational efforts in other specialty areas, such as oncology.

Does such non-promotional education translate into sales? Not easy to say. Name recognition and goodwill are intangibles. But working in a field where companies compete fiercely to be recognized as leaders by their target audiences, a company that initiates creative programs will likely be remembered … and rewarded.

The concept of multimedia training is at least on the radar screen of the most innovative players, although no one yet knows what to call it, much less what final form it will take. It may be completely “virtual” and accessed from the physician’s home or office; it may include specified carrels in medical libraries or hospitals around the country; or it may involve freestanding multimedia centers in major population centers. Physicians may pay-per-view for satellite-borne applications, or pay “admission” or user fees in a library; or be given complimentary “memberships” by healthcare companies.

Whatever the ultimate configuration, we believe that the concept of multimedia training locations is the emerging new model for CME. Industry will discover dynamic new opportunities to reach audiences in the form of sponsorship and other forms of support through arrangements that satisfy their own marketing objectives as well as Food and Drug Administration (FDA) requirements.

The forces of change

There are many forces fueling the rapid evolution of this concept. Physicians have an expressed need to more efficiently design and manage their continuing education. The relentless squeeze on healthcare costs make the old ways of disseminating CME too expensive and time consuming. There is a glaring need for new channels of communication among industry, CME providers, physicians, and medical schools following the dramatic shift towards managed care. Changes in FDA and American Medical Association (AMA) guidelines during the first half of the 1990s have reduced industry involvement in CME. And, finally, the advance of new information technologies, which have the potential to slash CME costs overnight and to make delivery systems more efficient, have made the concept of a centralized, interactive multimedia center not only practical, but inevitable.

The most obvious manifestation of the cost-reduction pressures in healthcare, of course, is the enormous shift from private practice care to managed care organizations (MCOs) which has deprived many physicians of their autonomy in deciding how much time and money to spend on attending far-flung CME conferences.

The other key change of recent years was the publication of revised FDA (draft) and AMA guidelines. Under the new rules, industry must clearly separate its educational and promotional messages. In some cases, this has drastically limited industry participation in sponsorship programs. Finding new ways to reach its target markets has proved difficult and, often, companies simply opted to withdraw the financial support they had routinely given CME providers such as medical schools and community hospitals. Funds formerly devoted to CME were shifted to other areas of marketing and promotion, weakening the once-strong link between industry and information providers.

Despite these changes, industry’s need to reach these important audiences, coupled with doctors’ need for continuing education still remain, and so does the providers’ need for financial support. And while the role of MCO doctors in choosing specific drug brands may have diminished, their opinions still have substantial influence on therapeutic decisions. The MCOs, meanwhile, have a strong stake in keeping their doctors updated and board-certified, if only for competitive reasons.

The combination of these factors still gives industry a strong incentive to underwrite CME offerings and to use traditional CME providers as a link to physicians. Only if accredited providers sponsor CME courses and materials will doctors be able to earn CME credit, and accreditation remains a driving factor in determining which courses they will sign up for. Ultimately, the prestige of the provider will also greatly influence whether they accept the information as credible.

Finally, the FDA has suggested strongly in its draft policy on pharmaceutical-supported education that partnering with CME providers helps the company to make sure that it meets FDA criteria for objectivity, balance, independence, and scientific rigor. That means industry will usually have to partner with medical schools, accredited communication companies, hospitals, and professional associations. Only if planning and editorial control rests with these third-party sponsors can pharmaceutical companies be sure that they will be able to get word out on their products through educational media without falling afoul of the FDA.

Mutual cooperation needed

The new information technologies, meanwhile, have gone largely unexploited by traditional CME providers, mainly because they have been unable to finance these advances without industry’s support. That’s why the rationale for mutual cooperation is, if anything, stronger than ever.

The bottom line is that physicians are starting to turn away from traditional delivery systems, putting pressure on innovators to blaze new trails. Most industry players, however, are having a difficult time keeping abreast of the new opportunities, much less in deciphering where the future lies.

This is hardly surprising given the enormous amount of change that has taken place over a so short a period. Yet if our prediction is correct – that the future of CME will be focused on centralized, information-centered CME media centers, there will be a resurgence in industry-funded CME in the years immediately ahead. Those unprepared will break down on the shoulders of the information highway while more visionary players surge ahead.

Traditionally, medical schools could count on relationships with public hospitals to provide a vast number of uninsured or Medicaid patients, who would be treated by residents and medical students, under the supervision of fully qualified physicians. But, the supply of low-income patients available for medical education is drying up. No one in the profession much likes to admit it, but in many big-city hospitals today the best place to find med students and residents is the lounge or the nurses’ station, not the patients’ ward.

University of Colorado Hospital remains one of the few.

Why is this happening? One reason is that the notion of using poor patients as guinea pigs for med students has come under attack from legislators and physicians who increasingly realize that everyone is entitled to the same level of care regardless of income. But an even more important factor is the continuing revolution in health-care economics. Thanks to changes in Medicaid funding and to hospital cost-cutting efforts emphasizing treatment on an outpatient basis, many indigent patients who were once considered prime candidates for treatment by medical apprentices are now being signed up by health plans that pay health-care providers at least as much, if not more, than other third-party insurance payers.

Private insurers, such as New York’s HIP, have realized that they can provide health care to Medicaid patients at a tiny fraction of the government’s cost–and pocket the difference. Thus, Medicaid patients, once the unwashed castoffs of the health-care system, have become a hot commodity for health plans and hospitals, to the point where one plan recently was penalized for recruiting more patients than it could provide care for. The trend will probably accelerate now that the federal authorities have allowed New York State to start mandated managed care for 2.4 million Medicaid patients, most of whom live in New York City.

That will mean a significant blurring of the formerly clear distinction between “public” and “private” patients, and a drop in the number of patients available to serve as teaching cases for students and residents–especially in New York, which trains a disproportionate 15 percent of the nation’s residents. Formerly undesirable Medicaid patients are now considered lucrative private patients, and many faculty physicians now keep their residents and students as far away from them as possible. (I was recently kicked out of a delivery room by such a physician.) As a result, the number of cases in which doctors-in-training can really get involved is dwindling.

Compounding the problem is the fact that patients are perfectly happy to allow physician assistants (PAs) and nurse practitioners (NPs), rather than doctors, to perform procedures and take part in medical decision-making. An ad running in many New York newspapers and magazines touts the expertise of the Columbia Advanced Practice Nurse Associates, “a new choice in primary care”–never mind that the ad features what appears to be a fake x-ray of a broken bone. PAs and NPs get paid less than doctors, largely because their training and education is far more superficial than that of doctors. But they deliver babies, write medication orders, and manage their own patients, all with the full support of the law, and of managed-care companies, who see them as cheap medical labor.

The solution to this “volume shortage” facing medical education is not to prohibit private health plans from enrolling Medicaid patients, although this practice ought to be carefully regulated. The solution is for all patients, rich and poor, and all health-care providers, at every stage of training, to acknowledge everyone’s obligation to all patients, present and future. Insured–that is, higher-income–patients at the most private of hospitals should not consider themselves above being examined by a resident, any more than uninsured patients at Bellevue Hospital should consider themselves guinea pigs for medical students and residents.

Physicians who have admitting privileges at private teaching hospitals should explain that medical students and residents are crucial members of the health-care team–especially because it is often the student who actually has the most time to listen to the patient. This role should extend also to outpatient visits, where the focus of medical education should shift to reflect changes in medical practice wrought by managed care. Denying medical trainees the experience they need will only hurt all patients, rich and poor, in the future.