quarta-feira, 11 de janeiro de 2012

Exposições em Museu

Prezados amigos(as), dando continuidade ao que está acontecendo em termos de cultura no mundo, estou colocando alguns avisos sobre visitas em museus.
 No Brasil acontecerá no final do mês Um dos mais importantes eventos do calendário oficial do Momento Itália - Brasil, a exposição “Modigliani: Imagens de uma vida” será inaugurada em 31 de janeiro no MNBA, com  obras nunca antes expostas na America Latina. Para o público a mostra abre dia 1º de fevereiro.
Serão exibidas 12 pinturas e 5 esculturas originais, além de obras e documentos, fotos,  desenhos, diários e manuscritos de Modigliani e de importantes artistas da sua época, num total de 230 peças. Com isso o público vai ter acesso a um rico panorama da vida artística parisiense e italiana do século XX, distribuídas em cinco salas do MNBA

aproveitem as férias e divirtam-se.










No The Metropolitan Museum of Art, New York, está acontecendo a  exposição  "retrato renascentista de Donatello para Bellini "

21 de dezembro de 2011 - 18 de março, 2012

 
Tem sido dito que a Renascença testemunhou a redescoberta do indivíduo. De acordo com esta noção, no início da Renascença a Itália também sediou a primeira era grande do retrato na Europa. Retrato assumiu uma nova importância, se era para gravar as características de um membro da família para as gerações futuras, celebrar um príncipe ou um guerreiro, exaltar a beleza de uma mulher, ou tornar possível a troca de uma semelhança entre amigos. Esta exposição reunirá cerca de 160 obras, de artistas como Donatello, Filippo Lippi, Botticelli, Verrocchio, Ghirlandaio, Pisanello, Mantegna, Bellini Giovanni, e da Antonello de Messina, e nos meios de comunicação que vão desde iluminação e pintura manuscrito a escultura em mármore e bronze , atestando a nova moda e usa do retrato no século XV na Itália.
Durante o Renascimento, os artistas que trabalham em Florença, Veneza, e os tribunais da Itália criou retratos magníficos das pessoas ao seu redor, desde chefes de Estado e igreja para patronos, acadêmicos, poetas e artistas, concentrando-se pela primeira vez na produção reconhecíveis semelhanças e as expressões da personalidade. O rápido desenvolvimento do retrato estava ligado intimamente ao Renascimento a sociedade ea política, os ideais do indivíduo, e conceitos de beleza. O objeto pode ter sido para comemorar um evento-a significativa casamento, a morte, a adesão a uma posição de poder ou pode ter sido para gravar as características de um membro estimado da família para as gerações futuras.
Apresentando muitos raros empréstimos internacionais, esta exposição irá apresentar um levantamento inédito do período e fornecer novas pesquisas e insights sobre o início da história do retrato. Será dividido em três seções e terá uma duração de um período de oito décadas. Início em Florença, onde os retratos independente apareceu pela primeira vez em abundância, ela move-se para os tribunais de Ferrara, Mântua, Bolonha, Milão, Urbino, Nápoles e Roma papal, e termina em Veneza, onde a tradição do retrato afirmou-se surpreendentemente no final do século .

Quem tem dinheiro e disponibilidade é uma boa pedida.



 

 

 

Vesalius, Andreas

Prezados amigos, como o meu blog é bem diversificado, estou abrindo um espaço para divulgar as grandes obras de artes de vários artistas de varias épocas e séculos.
Estou começando com um grande artista  Sr. Andreas Vesalius, que contribuiu muito para o ensino na área da Anatomia.
Ao lado estamos vendo uma de suas obras publicada em 1543 " Dissecação do corpo humano em pose alegórica".
Obra Renascentista.



















Andreas Vesalius (1514-1564) nasceu pouco antes da meia-noite do dia 31 de dezembro de 1514. Tanto seu bisavô quanto o avô haviam sido médicos, e o pai era o boticário do imperador Maximiliano I, da família Habsburg. Incentivado pelo pai a seguir a profissão da família, Vesalius cursou primeiro a Universidade de Louvain, perto de Bruxelas, na Bélgica, e depois começou a estudar medicina na Universidade de Paris.
Nas aulas, os professores liam livros da Antigüidade sobre personagens como Galeno, o anatomista grego, enquanto seus assistentes conduziam dissecações desastradas. Vesalius dizia que conseguiria aprender mais com um açougueiro no mercado de carnes. Em 1536, ele voltou a Louvain, onde aproveitou uma chance de estudar o esqueleto humano. Encontrou o cadáver de um ladrão pendurado em uma forca nas imediações da cidade. Pássaros haviam comido toda a carne, limpando os ossos do esqueleto. Vesalius o desmembrou e estudou até conhecer todos os ossos, até mesmo com os olhos vendados.
Em 5 de dezembro de 1537, Vesalius se formou em medicina pela Universidade de Pádua, perto de Veneza e tornou-se professor de anatomia no dia seguinte. Segundo a promessa que havia feito a si mesmo, ensinava anatomia conduzindo ele próprio as dissecações. As aulas de Vesalius tornaram-se imensamente populares. Os alunos se amontoavam na sala para observar suas habilidosas dissecações. De forma a mostrar pequenos detalhes a grandes platéias e para ter alguma coisa que lhe ajudasse nas palestras quando não havia cadáveres disponíveis, Vesalius desenhou mapas dos órgãos humanos, que pendurou na sala de aula. Alguns desses mapas foram plagiados e publicados sem sua permissão. Ele publicou o restante dos mapas com um manual de anatomia para completá-los.
O sucesso do manual o incentivou a publicar De Humani Corpus Fabrica (A Matéria do Corpo Humano). Esta grande obra foi publicada em 1543 em sete volumes, com descrições detalhadas e 300 ilustrações. Vesalius escolheu Jan Stephen van Calcar, um jovem aluno do artista Ticiano, para aperfeiçoar seus esboços de forma que os pontos essenciais pudessem ser compreendidos rapidamente. Os desenhos mostravam o corpo humano em poses naturais. No livro, Vesalius detalhou suas descobertas e corrigiu mais de 200 erros que havia encontrado nos livros de Galeno. Ele também revelou que Galeno havia baseado suas teorias de anatomia em dissecações de animais.
O livro de Vesalius gerou forte oposição. O anatomista principal de Paris, Jacques Sylvius, o atacou, dizendo se um insulto a Galeno. Vesalius tinha 28 anos de idade quando publicou A Matéria do Corpo Humano. Depois de defender o livro por um ano, ele deixou o magistério e as pesquisas de anatomia. Daquele ponto em diante, trabalhou como médico na corte dos Habsburg, primeiro para o imperador Carlos V, filho de Maximiliano, e depois para o filho de Carlos, Felipe II, em Madri.
Com 50 anos de idade, Vesalius viajou a Jerusalém, não se sabe ao certo por quê. A peregrinação pode ter sido feita para calar os críticos que o acusavam de falta de piedade. Tragicamente, na viagem de volta, Vesalius morreu em um naufrágio perto da ilha grega de Zakinthos.
Fonte de pesquisa:
www.historia.com.br



Magnetic Resonance Imaging: Generating a New Pulse in the Physical Therapy Profession

Prezados colegas, a cada dia estamos sendo testados nas nossas profissões. Com as novas tecnologias de ponta, muitos dos problemas  patológicos e principalmente das dores sem causas pré- estabelecidas  que exigiam de nós um conhecimento quase que transcendental, dificultando aos profissionais de saúde em fechar um diagnóstico preciso, sendo na sua grande maioria fechado apenas com base na anamnese e no exame clínico.  Hoje com a qualidade dos aparelhos de imagens, os profissionais de saúde têm encontrado mais facilidade em confirmar o que tem encontrado na anamnese e nos exames clínicos e confirmando com os exames de imagens. A Ressonância Magnética é um bom exemplo desse tipo de exame, que hoje facilita bastante aos profissionais a fecharem um diagnóstico mais coerente, principalmente os de causas pré-estabelecidas.
Por outro lado estamos vendo cada vez mais os profissionais abandonarem a prática da avaliação seja ela clínica ou funcional; não podemos nos esquecer que os exames de imagens por natureza apresentam uma característica auxiliadora, o que isso quer dizer, é que o exame de imagem é secundário ao exame clínico ou funcional, lógico dependendo de cada caso, pode ser que eles tenham em determinados momentos um caráter primário.
O fisioterapeuta dentro das suas funções tem a total liberdade de solicitar exames que venham a elucidar  e ajudar a fechar o seu fisiodiagnóstico, porém  a dificuldade desse profissional em lidar com exames de imagem ainda é muito grande, exigindo de nós um compromisso maior em aprender a entender um exame desse porte. Acredito que neste momento e com a exigência do mercado, que tem exigido cada vez mais profissionais qualificados, as Universidades que oferecem o curso de Fisioterapia deveriam se preocupar mais com esta parte da matéria. Como é de costume, lendo um artigo na revista JOSPT encontrei um artigo que fala sobre o avanço da fisioterapia neste campo do conhecimento.
Espero que seja proveitoso para vocês.

 
Magnetic Resonance Imaging: Generating a New Pulse in the Physical Therapy ProfessionJAMES M. ELLIOTT, PT, PhD1J Orthop Sports Phys Ther 2011;41(11):803-805. doi:10.2519/jospt.2011.0109
I
n 2003, the Board of Directors of the American Physical Therapy Association (APTA) published a position statement (BOD-P03-03-12-28) promoting the goal that all physical therapists hold the privileges of autonomous practice. In 2006, the House of Delegates of the APTA moved forward on the same topic with their position statement (HOD P06-06-18-12), reaffirming the concept from the
BOD that "Autonomous physical therapist practice is characterized by independent, self-determined professional judgment and action." The statement further defined the 4 expected privileges of the autonomous physical therapist practitioner by the year 2020:
1. Direct and unrestricted access: the physical therapist has the professional capability and ability to provide to all individuals the physical therapy services they choose without legal, regulatory, or payer restrictions.
2. Professional ability to refer to other healthcare providers: the physical therapist has the professional capability and ability to refer to others in the healthcare system for identified or possible medical needs beyond the scope of physical therapist practice.
3. Professional ability to refer to other professionals: the physical therapist has the professional capability and ability to refer to other professionals for identified patient/client needs beyond the scope of physical therapist practice.
4. Professional ability to refer for diagnostic tests: the physical therapist has the professional capability and ability to refer for diagnostic tests that would clarify the patient/client situation and enhance the provision of physical therapy services.
Professional Ability to Refer for Diagnostic Tests
While each of the 4 privileges offer an exciting, and mostly measurable, glimpse into autonomous practice, the ability to refer for diagnostic tests is particularly relevant to the topic of this special issue on magnetic resonance imaging (MRI). As a doctoring profession, one could argue that the ability to refer a patient for MRI (and other imaging applications) must be available to the direct-access physical therapist. Though the prescription for and use of MRI has not typically been considered within the scope of physical therapist practice, as others have detailed,
 READINESS: WHAT DOES THE EVIDENCE SAY?
P
hysical therapists undergo extensive didactic and clinical preparation; they possess excellent diagnostic skills, and are well versed in current best diagnostic and treatment-based evidence.4 Physical therapists are well suited to become key members of an interdisciplinary healthcare team that makes early decisions towards retarding or preventing the development of long-term physical impairments second
1
Assistant Professor, Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL; Honorary Senior Fellow, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
journal of orthopaedic
& sports physical therapy | volume 41 | number 11 | november 2011 | 803
ary to injury and/or disease processes. A system that places physical therapists as first-line providers for patients with painful neuromusculoskeletal conditions may help to realize such an outcome.22 and The University of Wisconsin Hospital and Clinics.2 It must be emphasized that the physical therapists in these settings have undergone extensive advanced training in evaluating, diagnosing, and treating patients’ conditions in a direct-access setting, and in ordering imaging to aid in diagnosis when necessary. These examples provide evidence that an advanced training program can effectively establish the primary care scope of the physical therapist. But just as importantly, we must add that the data emerging from these model centers may not yet be generalizable to our national or worldwide physical therapist communities.19 In an attempt to reduce specialty care costs (eg, ordering of imaging) for patients with low back pain, changes in the clinical decision pathway were proposed and included implementation of an evidenced-based protocol with physical therapists up front. After 1 year, the model yielded favorable results. The number of ordered MRI exams and total cost per episode of care were both reduced. Furthermore, the initiation of direct-access physical therapy resulted in fewer patients transiting to the chronic pain center. While further research is required before definitive conclusions can be drawn, this example provides strong foundation for welcoming physical therapists who are well versed in the implementation of appropriate imaging guidelines, as front-line providers.
Health systems in which physical therapists are specifically empowered to function as first-line providers include the US Military, Kaiser Permanente Northern California, the Department of Veterans Affairs Salt Lake City Health Care Systems,
Another example of physical therapists functioning under expanded primary care privileges is the 2004 pilot project from the Virginia Mason Medical Center in Seattle, WA.
 TOWARDS A NEW NORMATIVE MODEL FOR PHYSICAL THERAPIST PRACTICE
I
An important personal context for this special issue is my belief that such interdisciplinary professional collaboration, at least with respect to MRI, can be further cultivated by physical therapists who seek formal or informal opportunity to gain an improved working knowledge of (1) the complexities of MRI,
ncorporation of didactic content on diagnostic imaging (eg, radiography, computed tomography, ultrasound, MRI) has become the educational norm for entry-level and transition Doctor of Physical Therapy degree students. Additionally, there are a number of professional development opportunities offered through advanced clinical practice courses by the APTA. Clinicians and researchers in our field have published and continue to publish seminal and oftentimes multidisciplinary works related to imaging.6,8,9,12-16,23,24,26-28 Our journals continue to publish more imaging-related studies/cases, and our professional conferences encourage and accept poster and platform submissions that feature imaging. Finally, the recent development of the Special Interest Group on Imaging within the Orthopedic Section of the APTA is another important contribution to developing practice competencies, reducing practice variability, fostering imaging curriculum in physical therapist education, and promoting the role of the physical therapist, as a primary care team member, in judicious referral for imaging procedures. These all represent a great start for informing the entire physical therapist community and other stakeholders (medical practitioners, administrators, insurers, legislators, and the public) regarding the evolving important role of imaging within the scope of physical therapy practice. However, to realize the maximum potential and success of such a model, collegial collaboration with others inside and outside the physical therapy profession is imperative. This collaborative approach is consistent with the definition of professional autonomy, not deviant from it.21 (2) the issues related to patient and operator safety when working in an MRI environment,10 (3) determining the best sequences for identifying pathology,11,29,30 (4) emerging evidence that highlights advanced imaging applications,1,5 (5) continued vigilance regarding overutilization of MRI services,17 and, finally, (6) a history of physical therapy and imaging.4
This special issue contains a collection of manuscripts, authored by multidisciplinary teams, that address each of the aforementioned topics. As such, it is highly relevant for all clinicians involved in managing patients with neuromusculoskeletal disorders, because MRI may play a significant role in helping to make more informed clinical decisions. More importantly, we hope that the information presented here will inspire readers to seek and embrace opportunities for fostering and maintaining collegial collaborations inside and outside the professional boundaries of physical therapy.

POUNDING HOME THE TRUTH
I
Finally, I would like to thank all the authors for their contribution to this issue and also the multidisciplinary team of reviewers for their expertise, time, and effort in providing peer review.
 
804
| november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy
 
REFERENCES
1. Beattie PF. Diffusion-Weighted Magnetic Resonance Imaging of the Musculoskeletal System: An Emerging Technology With Potential to Impact Clinical Decision Making. J Orthop Sports Phys Ther. 2011;41:887-895. http://dx.doi.org/10.2519/jospt.2011.3744 2. Boissonnault WG, Badke MB, Powers JM. Pursuit and implementation of hospital-based outpatient direct access to physical therapy services: an administrative case report. Phys Ther. 2010;90:100-109. http://dx.doi.org/10.2522/ptj.20080244 3. Boissonnault WG, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. J Orthop Sports Phys Ther. 2006;36:351-353. http://dx.doi.org/10.2519/jospt.2006.0107 4. Boyles R, Gorman I, Pinto D, Ross M. Future physical therapist practice and the role of diagnostic imaging. J Orthop Sports Phys Ther. 2011;41:829-837. http://dx.doi.org/10.2519/jospt.2011.3556 5. Cagnie B, Elliott J, O’Leary S, D’hooge R, Dickx N, Danneels L. Muscle functional MRI as an imaging tool to evaluate muscle activity. J Orthop Sports Phys Ther. 2011;41:896-903. http://dx.doi.org/10.2519/jospt.2011.3586 6. Cagnie B, O’Leary S, Elliott J, Peeters I, Parlevliet T, Danneels L. Pain-induced changes in the activity of the cervical extensor muscles evaluated by muscle functional magnetic resonance imaging. Clin J Pain. 2010;27:392-397. http://dx.doi.org/10.1097/AJP.0b013e31820e11a2 7. Davenport TE, Kulig K, Resnik C. Diagnosing pathology to decide the appropriateness of physical therapy: what’s our role? J Orthop Sports Phys Ther. 2006;36:1-2. http://dx.doi.org/10.2519/jospt.2006.0101 8. Deyle GD. Musculoskeletal imaging in physical therapist practice. J Orthop Sports Phys Ther. 2005;35:708-721. http://dx.doi.org/10.2519/jospt.2005.2034 9. Dickx N, D’Hooge R, Cagnie B, Deschepper E, Verstraete K, Danneels L. Magnetic resonance imaging and electromyography to measure lumbar back muscle activity. Spine (Phila Pa 1976). 35:E836-842. http://dx.doi.org/10.1097/BRS.0b013e3181d79f02 10. Durbridge G. Magnetic resonance imaging: fundamental safety issues. J Orthop Sports Phys Ther. 2011;41:820-828. http://dx.doi.org/10.2519/jospt.2011.3906 11. Elliott JM, Flynn T, Press J, Al-Najjar A, Nguyen B, Noteboom J. The pearls and pitfalls of magnetic resonance imaging for the spine. J Orthop Sports Phys Ther. 2011;41:848-860. http://dx.doi.org/10.2519/jospt.2011.3636 12. Elliott JM, Jull G, Noteboom JT, Darnell R, Galloway G, Gibbon WW. Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis. Spine (Phila Pa 1976). 2006;31:E847-855. http://dx.doi.org/10.1097/01.brs.0000240841.07050.34 13. Elliott JM, Pedler A, Beattie P, McMahon K. Diffusion-weighted magnetic resonance imaging for the healthy cervical multifidus: a potential method for studying neck muscle physiology following spinal trauma. J Orthop Sports Phys Ther. 2010;40:722-728. http://dx.doi.org/10.2519/jospt.2010.3423 14. Elliott JM, Pedler A, Kenardy J, Galloway G, Jull G, Sterling M. The temporal development of fatty infiltrates in the neck muscles following whiplash injury: an association with pain and posttraumatic stress. PLoS One. 6:e21194. http://dx.doi.org/10.1371/journal.pone.0021194 15. Elliott JM, Sterling M, Noteboom JT, Darnell R, Galloway G, Jull G. Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain. Clin Radiol. 2008;63:681-687. http://dx.doi.org/10.1016/j.crad.2007.11.011 16. Elliott JM, Pedler AR, Cowin G, Sterling M, McMahon K. Spinal cord metabolism and muscle water diffusion in whiplash. Spinal Cord. 2011 Mar 8. Epub ahead of print. http://dx.doi.org/10.1038/sc.2011.17 17. Flynn T, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41:838-846. http://dx.doi.org/10.2519/jospt.2011.3618 18. Fritz J, Flynn TW. Autonomy in physical therapy: less is more. J Orthop Sports Phys Ther. 2005;35:696-698. http://dx.doi.org/10.2519/jospt.2005.0111 19. Fuhrmans V. A novel plan helps hospital wean itself off pricey tests. Available at: http://online.wsj.com. Accessed September 19, 2011, 2007. 20. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289:2810-2818. http://dx.doi.org/10.1001/jama.289.21.2810 21. McMahon K, Cowin G, Galloway G. Magnetic resonance imaging: the underlying principles. J Orthop Sports Phys Ther. 2011;41:806-819. http://dx.doi.org/10.2519/jospt.2011.3576 22. Murphy BP, Greathouse D, Matsui I. Primary care physical therapy practice models. J Orthop Sports Phys Ther. 2005;35:699-707. http://dx.doi.org/10.2519/jospt.2005.2167 23. O’Leary S, Cagnie B, Reeve A, Jull G, Elliott JM. Is there altered activity of the extensor muscles in chronic mechanical neck pain? A functional magnetic resonance imaging study. Arch Phys Med Rehabil. 2011;92:929-934. http://dx.doi.org/10.1016/j.apmr.2010.12.021 24. Patten C, Meyer RA, Fleckenstein JL. T2 mapping of muscle. Semin Musculoskelet Radiol. 2003;7:297-305. http://dx.doi.org/10.1055/s-2004-815677 25. Ross MD, Boissonnault WG. Red flags: to screen or not to screen? J Orthop Sports Phys Ther. 2010;40:682-684. http://dx.doi.org/10.2519/jospt.2010.0109 26. Ross MD, Cheeks JM. Clinical decision making associated with an undetected odontoid fracture in an older individual referred to physical therapy for the treatment of neck pain. J Orthop Sports Phys Ther. 2008;38:418-424. http://dx.doi.org/10.2519/jospt.2008.2687 27. Ross MD, Cheeks JM. Undetected hangman’s fracture in a patient referred for physical therapy for the treatment of neck pain following trauma. Phys Ther. 2008;88:98-104. http://dx.doi.org/10.2522/ptj.20070033 28. Segal RL. Use of imaging to assess normal and adaptive muscle function. Phys Ther. 2007;87:704-718. http://dx.doi.org/10.2522/ptj.20060169 29. Strudwick M, Anderson S, Dimmick S, Saltzman M, Hsu W. Pearls and Pitfalls of Magnetic Resonance Imaging of the Upper Extremity. J Orthop Sports Phys Ther. 2011;41:861-872. http://dx.doi.org/10.2519/jospt.2011.3833 30.

journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 805

Tall M, Thompson A, Greer B, Campbell S. The Pearls and Pitfalls of Magnetic Resonance Imaging of the Lower Extremity. J Orthop Sports Phys Ther. 2011;41:873-886. http://dx.doi.org/10.2519/jospt.2011.3713
n closing, as an old legal adage states: If you have the truth on your side, pound the truth. If you have the facts on your side, pound the facts. And if you have neither, pound the table. For today’s (and tomorrow’s) physical therapist, it is important to realize the responsibility that comes with the complex challenges of referral for imaging and other diagnostic privileges. As such, let’s work in an interdisciplinary environment towards discovering new facts that reveal new truths regarding physical therapists as front-line providers. Our field has and will continue to overcome professional challenges, but we must not be guilty of pounding the table. Let’s gather the facts and stick to the truth.t
 
3,7,8,18,22,28 this may be the perfect time to challenge the obstacles precluding the obtainment of such diagnostic privileges and to specifically provide perspective on why and how such a specialized privilege could positively impact the provision of physical therapy services and patient outcomes.8,28 Physical therapists can play a crucial primary-care role through participation in models based on diagnostic and patient management algorithms3,7,18,25 to (1) reduce practice variation,18 and (2) help to ensure that patients understand both the necessity for appropriate imaging and appreciate the potential negative consequences of unnecessary imaging.17,20 An expected obligation of such autonomy, however, is accountability. Is our entire profession adequately prepared to accept the role of, or the responsibilities associated with, referral for imaging privileges?

sábado, 7 de janeiro de 2012

Is America’s Booming Health Care Sector Actually a Bubble?



Prezados Colegas, lendo um artigo no jornal The New Repulic a respeito do crescimento de profissionais na área da saúde nos EUA, fiquei preocupado por que estou vendo este processo acontecendo no Brasil.
cada vez mais estamos colocando no mercado de trabalho, profissionais e mais profissionais na área da saúde e o nível de atendimento encontra-se cada vez pior.
Exponho este artigo para uma reflexão a respeito do que as Universidades e os Professores estão fazendo com a sociedade que recebe essas mãos de obras.

Is America’s Booming Health Care Sector Actually a Bubble?

·                                
Darius Tahir
·                      December 23, 2011 | 12:00 am



Over the last two decades, the health care sector has been a remarkable engine of job growth in the United States. Even as the economy plods along, health care has been responsible for adding an average of 22,500 jobs per month in 2011 through July. Health care jobs now represent about 11 percent of American employment, as compared to 8 percent in 2001. But rather than cheer this development, a number of health care experts are increasingly worried.
The reasoning behind wonks’ fears is that even as the health care sector has added jobs, the productivity of the average worker may have declined, indicating a labor force that is growing bloated and inefficient. As a recent paper in the New England Journal of Medicine by Bob Kocher and Nikhil Sahni showed, labor productivity growth in the health care sector actually fell by .6 percent between 1990 and 2010, a result which corroborates the findings of a 2010 paper by heath economist David Cutler. This conundrum raises an urgent question: How can we rethink health care labor to foster a more innovative, productive system? While a number of legal, cultural, and logistical hurdles remain, the most promising answer seems to lie in allowing basic medicine to be practiced in more places and by an increasingly diverse set of practitioners.

ACROSS THE FIELD, health care experts speak in unison about the need for health workers with varying credentials to take on a number of responsibilities that are currently the sole purview of doctors. In the same NEJM paper, Kocher and Sahni write that a “different quantity and mix of workers engaging in a higher value set of activities” is necessary to increase productivity, with one of their suggestions being to relax licensure and scope of practice requirements for nurse practitioners and other non-doctor health care workers. That’s a suggestion with which Joe Antos, a scholar at the American Enterprise Institute, agrees, saying “We need to make it possible for people without MD after their name to handle a richer set of tasks.” The theory behind this argument is that as technology becomes more advanced, so too should the nature of tasks that low- to medium-skilled workers are able to perform. As Ashish Jha, an associate professor at Harvard Public School of Medicine and a practicing physician, told me, “What you see in other industries is when there’s been an uptick of technology, it has allowed everybody to move up in terms of the kinds of work they do. [In health care] it [should] allow nurses do stuff only doctors could do before.”
Several obstacles stand in the way of this vision becoming a reality, however. To begin, a morass of state laws blocks nurses and other non-MDs from performing many tasks. According to a report from Kaiser Health News, Colorado recently became the 16th state to allow nurse anesthetists to work without a doctor’s oversight. The specificity of the change suggests the scope of the challenge: Each change is approved piecemeal, often over the objections of physicians’ groups. “The standard pushback [against allowing nurses to take a higher burden in health care] is it’s going to affect the quality of care,” says Jha. “My argument is it might! I don’t know that it won’t … but we can actually study that and monitor it closely. And if it starts affecting quality [negatively], we can back off. … [But] we can’t be so afraid to innovate that we’re locked into a completely unsustainable way of doing things.”
In addition, there’s another, cultural obstacle standing in the way of non-MDs taking on greater responsibilities. Kaiser Health News quotes another doctor saying that allowing nurses to take up a greater role is “exactly what people worry about” when they worry about health care reform—that is, their doctors will be taken away from them. Patients are biased in favor of physicians. As Antos asks rhetorically, “Nurses could do a lot of the work … but you look at my mother: Who does she listen to—the doctor or the nurse?”
Another popular suggestion for increasing productivity in the health care workforce is to change where health care is practiced. Recently there’s been an uptick in what’s known as “retail clinics”—that is, small health clinics being located in retail stores, often in strip malls. CVS is one big brand that’s made an investment, and it has been rumored that Wal-Mart is interested in entering the market as well. For Americans, retail clinics are a quick and convenient way to deal with urgent but not catastrophic care. In a piece titled, “And now I’m forced to like retail clinics a little,” blogger, physician, and professor Aaron Carroll waxed rhapsodic about the convenience of taking his kids into a such a clinic to see if an ordinary sore throat was strep throat: “[It] opens at 8 AM. No appointments. It would take a few minutes and everyone would be on their way. Problem solved.” And, Carroll adds, since a doctor’s clinical diagnostic skills are no better than 50 percent for determining whether a given sore throat is bacterial or viral, you need a test, for which a “mid-level practitioner is more than enough.”
Retail clinics are not without some drawbacks, however. Austin Frakt, a health economist and one of Carroll’s co-bloggers, notes that such clinics tend to poach younger and more affluent patients—meaning that measurements of their quality might be skewed by a better patient population. In addition, standalone retail clinics might well contribute to the fragmentation of care problem in the health system by creating another place generating records and care and prescriptions that’s unconnected to everything else. And yet, despite these potential pitfalls, the value proposition offered by such clinics led the majority of experts with whom I spoke to consider them a trend worth monitoring.
Of course, there is one last issue to consider before attempting to ramp up the productivity of today’s health care workforce. When academic papers attempt to gauge productivity, the measure is derived from things it can count: visits to the doctor, number of scans, etc. But it’s possible, Frakt says, “to imagine a situation where greater quality means fewer visits to the doctor.” For example, a well-done surgery might reduce readmission to the hospital; or, a timely, state-of-the-art drug intervention might head off a problem before it ever develops.
If there’s unanimity on one point, however, it’s that the health care system is stuck and needs reinventing, especially in the way it pays for health care. “The big reasons,” Jha told me, “we haven’t seen big gains in productivity and efficiency is the business model. We have new technology, people with bright ideas … but the dominant players in the market have a very specific idea of how they’re being paid.” But in the meantime, expanding the range of qualified people who can practice medicine and places where care can be accessed seems like an important first step.
Darius Tahir is an intern at The New Republic.