US Falls Short of EM Trained Physicians in Hospital Emergency Departments

"Emergency Medicine Specialists in Short Supply"

by Elizabeth Cooney, www.Boston.com

December 17, 2008

Even under the rosiest of scenarios, it's unlikely the nation's emergency rooms will be staffed with only emergency medicine specialists anytime soon, Boston researchers predict.

Writing in the journal Academic Emergency Medicine, lead author Dr. Carlos A. Camargo of Massachusetts General Hospital estimates that it would take until 2019 to find enough fully-trained, board-certified emergency physicians to work in the 4,828 emergency departments that are open 24 hours a day. And that best-case projection assumes that no current doctors who meet those qualifications die or leave their jobs.

The Institute of Medicine said in 2006 that ERs should ideally be staffed by doctors who had spent their residency training in emergency medicine and had later passed tests to become certified in the specialty. But only about 55 percent of doctors working in ERs meet that standard, Camargo and his co-authors write.

"The mismatch between the supply and demand for residency-trained, board-certified emergency physicians is a longstanding problem," Camargo said in a statement. "We probably should explore alternatives, such as giving the family physicians who currently staff many US emergency departments extra training in key emergency procedures. We might also increase our reliance on nurse practitioners and physicians assistants, who can help emergency physicians of any training background better handle the continually rising number of patients."

Visit the Boston Globe Website to read more, view comments and post your ideas about solving this issue.

EM in War Time: A True Story in Iraq

I was reading an article in the November 2008 volume of Emergency Physicians Monthly (www.EPmonthly.com) that really touched me. The article was written by CDR Mark Plaster of the Marine Corps, United States Navy. He wrote about the importance of disassociation when treating patients anywhere, and especially within a unit during war time. 

His story begins by describing his team of providers preparing to treat fellow marines who had driven  over a land mine. His providers set up equipment and IV's, divided into teams to treat each possible injury, pulled security outside the tent, and waited for their patients to arrive. 

CDR Plaster then has a flash back to another incident when he had two injured marines from a grenade going off. One Marine, which he and the rest of his crew knew well from their unit, had a horrible injury that required immediate attention; while the other Marine was left by the wayside. Over a few minutes, it became obvious that the seemingly unhurt Marine was actually hurt rather badly and required neurosurgery to stop a subdural bleed from shrapnel to the brain. Because of the relationship between the providers and the Marine whose injuries were obvious, they focused their attention on him, and almost missed a potentially fatal diagnosis on the other Marine.

The story then goes back to the present tense and describes the tension as they wait for the victims of the land mine to enter the tent. After a few moments, one of the crew members notified them that no one was injured. The vehicle they were driving took a beating, but that was all. CDR Plaster could sense the relief of his crew and, astonishingly, some disappointment that the casualty didn't happen. Their adrenaline was pumping and they were excited at the prospect of testing their skills, both individually, and as a team. 

CDR Plaster started to tell them they should be thankful the situation hadn't escalated as they thought, that none of their fellow Marines were going to die this day; but he then realized the importance of this exercise, of learning to disassociate oneself from emotion, in order to provide the best emergency care for every patient. They decided it was a day "to celebrate the victory of pushing [death] back another day."

Whether or not your personal beliefs support the war, the reality is that our EM physicians, PA's, NP's, nurses, and many other providers are serving our fellow men as they fight to keep our country, our homes, our families safe from the evils of this world. I'll use this opportunity to thank all of our servicemen, medical or other professionals, for their commitment to our nation. We should all be so thankful to their sacrifices to make the world a better place.

Does Your State Make the Grade in Emergency Medicine?

The American College of Emergency Physicians (www.ACEP.org) released a report this week that "grades"  Emergency Care in the United States. They gave the nation a C- overall, and didn't grant anything higher than a B for any state in the union. 

Click the link below to see how your state measures up.

Click Here for the Full Report

Gasping After Cardiac Arrest Associated with Improved Survival

By Todd Neale, Staff Writer, MedPage Today

Published: November 24, 2008

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine.

TUCSON, Ariz., Nov. 24 - Out-of-hospital cardiac arrest patients who gasp or have labored breathing derive the most survival benefit from immediate chest compressions, a retrospective analysis showed.

Explain to interested patients that this study found that gasping after cardiac arrest is common and is associated with higher rates of survival to hospital discharge.

Point out that the researchers said that chest compressions should be initiated on all out-of-hospital cardiac arrest patients, even those who are gasping.

Of patients who received compressions from a bystander, those who were gasping were more likely to survive to hospital discharge than those who were not breathing at all (39% versus 9.4%; OR 5.1, 95% CI 2.7 to 9.4), Gordon Ewy, M.D., of the University of Arizona, and colleagues reported online in Circulation: Journal of the American Heart Association 

"Gasping is an indication that the brain is still alive," Dr. Ewy said, "and it tells you that if you start and continue uninterrupted chest compressions, the person has a high chance of surviving."

Witnesses to cardiac arrest sometimes interpret gasping as normal breathing and don't call 911 or start chest compressions as quickly as they should, according to the researchers.

"These results suggest that the recognition and importance of gasping should be taught to bystanders and emergency medical dispatchers so as not to dissuade them from initiating prompt resuscitation efforts when appropriate," the researchers said.

This is especially important because chest compressions may cause a patient to begin gasping, Dr. Ewy said.

"This scares many people and they stop pressing on the chest," he said. "This is bad because gasping is an indication that you're doing a good job."

To determine the occurrence of gasping after out-of-hospital cardiac arrest, the researchers examined transcripts from the Phoenix Fire Department Regional Dispatch Center.

Of 113 patients who had a witnessed or non-witnessed cardiac arrest, 38.9% gasped or had labored breathing.

In a separate analysis, the researchers looked at emergency medical services' first-care reports of 1,218 patients who had a witnessed cardiac arrest.

Overall, 191 gasped and 1,027 didn't. The two groups did not differ significantly by age, arrest location, or receipt of bystander CPR.

For those who collapsed after EMS personnel arrived, 32.8% started gasping.

Rates of gasping declined as arrival time increased. There were 20.1% who had labored breathing when the arrival time was less than seven minutes, 13.9% when it was seven to nine minutes, and 7.4% when it was greater than nine minutes.

Gasping was significantly more common in the witnessed ventricular fibrillation group than in patients who had a witnessed arrest with a different rhythm (18.4% versus 13.6%; OR 1.7, 95% CI 1.2 to 2.4).

Survival to hospital discharge was significantly higher in patients who had some residual breathing than in those who did not (28.3% versus 7.8%; OR 3.4, 95% CI 2.2 to 5.2).

Of patients who were gasping when EMS personnel arrived, those who were receiving chest compressions from a bystander were more likely to survive than those who were not (39% versus 21%, P<0.01).>

Patients who had gasping or labored breathing still had a survival advantage even if they weren't receiving CPR from a bystander (21.1% versus 6.7%; OR 2.4, 95% CI 1.2 to 4.3).

The researchers said that the results call into question the importance of rescue breathing for cardiac arrest patients, especially in light of previous findings of no survival benefit from rescue breathing.

"Interruptions for rescue breathing make CPR efforts more complicated and result in fewer compressions during this crucial period when perfusion is key to successful resuscitation," they said.

In addition, gasping is likely more beneficial than rescue breathing, Dr. Ewy said.

"When the patient gasps, there is a negative pressure in the chest, which not only sucks air into the lungs but also draws blood back to the heart," he explained.

"In contrast, mouth-to-mouth breathing creates overpressure in the chest and actually inhibits blood flow back to the heart," he continued. "Gasping during cardiac arrest is much better than mouth-to-mouth breathing."

The authors acknowledged that the study was limited by the possibility that the EMS reports did not accurately record the presence or absence of gasping.

In addition, they said, gasping is not diagnostic of ventricular fibrillation arrest.  

New Doctors Still Too Tired for Safety

Report recommends extended rest breaks after 30-hour shifts

WASHINGTON - Doctors-in-training are still too exhausted, says a new U.S. report that calls on hospitals to let them have a nap.

Regulations that capped the working hours of bleary-eyed young doctors came just five years ago, limiting them to about 80 hours a week.

Tuesday, a panel of the prestigious Institute of Medicine recommended easing the workload a bit more: Anyone working the maximum 30-hour shift should get an uninterrupted five-hour break for sleep after 16 hours.

"Our committee's charge was not to focus necessarily on longer scheduling or shorter scheduling, but smarter scheduling to try to really identify the areas where we could have an impact in preventing excessive fatigue, both acute and chronic, that might contribute to medical errors," Dr. Daniel Munoz of Johns Hopkins University School of Medicine in Baltimore, a member of the panel, said in a telephone interview.

At issue is how to balance patient safety with the education of roughly 100,000 medical residents, doctors fresh out of medical school who spend the next three to seven years in on-the-job training for their specialty.

These junior doctors frequently are the front-line medical staff on duty around the clock in teaching hospitals. The long hours are in some ways a badge of the profession; doctors cannot simply clock out if a patient is in danger.

But sleep deprivation fogs the brain, a problem that can lead to serious medical mistakes. So in 2003, the Accreditation Council for Graduate Medical Education issued the first caps. Before then, residents in some specialties could average 110 hours a week.

As an illustration of the fatigue residents may experience, the panel noted that research has shown they have an increased risk of being involved in traffic accidents or falling asleep at the wheel after an extended-duty shift.

The panel urged the ACGME to adopt the recommendations within two years. The independent Institute of Medicine provides advice to U.S. policymakers.

The accreditation council didn't immediately say if it would follow the recommendations.

Common violation
The government asked the institute to study the current caps. Violations of current limits are common and residents seldom complain, the committee found. While quality of life has improved, there's still a lot of burnout.

And despite one study that found residents made more errors while working longer shifts, patient safety depends on so many factors that it is impossible to tell yet if the caps helped that problem, the report said.

It also recommends:

• Experienced physicians should more closely supervise residents.
  
• Better overlap of schedules during shift changes to reduce chances for error as one doctor hands patients' care over to the next.
  
• Increase mandatory days off each month, and extend hours off between shifts depending on how long the resident worked, during day or night.
  

"Cutting hours alone won't do it," added Dr. Ann Rogers of the University of Pennsylvania School of Nursing in Philadelphia, who also served on the committee. 

"We need to pay attention to work load. We need to pay attention to supervision. The whole package will make a difference. Without it, you could end up with a more severely stressed resident trying to do more work with less hours."

Rebecca Sadun of the American Medical Student Association said the recommendations are "unambiguously a step in the right direction." She said the 2003 limits have proven to be insufficient because the current 30-hour shifts do not enable residents to remain at a high level of functioning throughout. 

Sadun, a medical student at University of Southern California's Keck School of Medicine, added that her association hears many accounts from residents about how the current 80-hour work weeks in reality are 100-hour work weeks, with school administrators insisting that residents fill out time logs dishonestly.

CT Scans to Determine Heart Disease in the Emergency Room

Courtesy of Physorg.com, Nov 27, 2007. Source: University of Pennsylvania.

In the future, patients who arrive at a hospital Emergency Department complaining of chest pain may be diagnosed with a sophisticated CT scan. If the diagnosis is negative, the patient can go home—and the total time at the hospital will be much shorter than it is today.

That is the theory behind a study being presented at the RSNA (Abstract ID: 5009389) by Rajan Agarwal, M.D., a resident in Radiology at the University of Pennsylvania School of Medicine.

“The cost of chest pain triage (where patients in the Emergency Department are prioritized based on their symptoms) and management has been estimated to be as high as $8 billion annually, with most patients ultimately not having to remain in the hospital. Therefore,” Dr. Agarwal states, “there is a tremendous opportunity to reduce health care costs if we can demonstrate the cost-effectiveness of this procedure with low-risk patients who go to the Emergency Department.”

Further, this reduced length of stay improves resource utilization by decreasing costs, improving inpatient bed shortages and reducing crowding in the Emergency Department.

In the study, a total of 202 patients, older than age 30, who came to the Emergency Department at the Hospital of the University of Pennsylvania between October 2005 and February 2007, and whose primary complaint was chest pain, were given an electrocardiogram and a specialized CT scan.

Patients were excluded from the study who were allergic to an iodine contrast, had an abnormal heart rate or could not take beta blockers. Patients who were admitted to the hospital were also excluded.

“We looked to determine the length of stay and times between critical points in the treatment of low-risk patients,” Dr. Agarwal explained.

“Patients were divided into three areas: all patients who received CT scans; patients who received the scans during 7 a.m. to 6 p.m. (ON hours) when the scans were available and 6 p.m. to 6 a.m. (OFF hours) when the scans were not available.

Results showed that patients who came into the Emergency Department during ON hours spent a total of 9 hours and 39 minutes in the department before being discharged; patients who came to the Emergency Department during OFF hours spent a total of 12 hours and 15 minutes in the unit. Patients who were referred to the CDU (Clinical Decision Unit, which provided the CT scan, as well as additional evaluation and observation) spent 21 hours and 50 minutes in the hospital if they came during ON hours and 18 hours and 38 minutes if they came during OFF hours.

Future studies, Dr. Agarwal suggests, will look at all the costs, including lab tests and diagnostic tests, associated with a low-risk patient’s visit to the Emergency Department.

Google Uses Searches to Track Flu’s Spread

New York Times - Technology

By MIGUEL HELFT

Published: November 11, 2008

SAN FRANCISCO — There is a new common symptom of the flu, in addition to the usual aches, coughs, fevers and sore throats. Turns out a lot of ailing Americans enter phrases like “flu symptoms” into Google and other search engines before they call.

That simple act, multiplied across millions of keyboards in homes around the country, has given rise to a new early warning system for fast-spreading flu outbreaks, called Google Flu Trends.

Tests of the new Web tool from Google.org, the company’s philanthropic unit, suggest that it may be able to detect regional outbreaks of the flu a week to 10 days before they are reported by the Centers for Disease Control and Prevention.

In early February, for example, the C.D.C. reported that the flu cases had recently spiked in the mid-Atlantic states. But Google says its search data show a spike in queries about flu symptoms two weeks before that report was released. Its new service at google.org/flutrends analyzes those searches as they come in, creating graphs and maps of the country that, ideally, will show where the flu is spreading.

The C.D.C. reports are slower because they rely on data collected and compiled from thousands of health care providers, labs and other sources. Some public health experts say the Google data could help accelerate the response of doctors, hospitals and public health officials to a nasty flu season, reducing the spread of the disease and, potentially, saving lives.

“The earlier the warning, the earlier prevention and control measures can be put in place, and this could prevent cases of influenza,” said Dr. Lyn Finelli, lead for surveillance at the influenza division of the C.D.C. From 5 to 20 percent of the nation’s population contracts the flu each year, she said, leading to roughly 36,000 deaths on average.

The service covers only the United States, but Google is hoping to eventually use the same technique to help track influenza and other diseases worldwide.

“From a technological perspective, it is the beginning,” said Eric E. Schmidt, Google’s chief executive.

The premise behind Google Flu Trends — what appears to be a fruitful marriage of mob behavior and medicine — has been validated by an unrelated study indicating that the data collected by Yahoo, Google’s main rival in Internet search, can also help with early detection of the flu.

“In theory, we could use this stream of information to learn about other disease trends as well,” said Dr. Philip M. Polgreen, assistant professor of medicine and epidemiology at the University of Iowa and an author of the study based on Yahoo’s data.

Still, some public health officials note that many health departments already use other approaches, like gathering data from visits to emergency rooms, to keeping daily tabs on disease trends in their communities.

“We don’t have any evidence that this is more timely than our emergency room data,” said Dr. Farzad Mostashari, assistant commissioner of the Department of Health and Mental Hygiene in New York City.

If Google provided health officials with details of the system’s workings so that it could be validated scientifically, the data could serve as an additional, free way to detect influenza, said Dr. Mostashari, who is also chairman of the International Society for Disease Surveillance.

A paper on the methodology of Google Flu Trends is expected to be published in the journal Nature.

Researchers have long said that the material published on the Web amounts to a form of “collective intelligence” that can be used to spot trends and make predictions.

But the data collected by search engines is particularly powerful, because the keywords and phrases that people type into them represent their most immediate intentions. People may search for “Kauai hotel” when they are planning a vacation and for “foreclosure” when they have trouble with their mortgage. Those queries express the world’s collective desires and needs, its wants and likes.

Internal research at Yahoo suggests that increases in searches for certain terms can help forecast what technology products will be hits, for instance. Yahoo has begun using search traffic to help it decide what material to feature on its site.

Two years ago, Google began opening its search data trove through Google Trends, a tool that allows anyone to track the relative popularity of search terms. Google also offers more sophisticated search traffic tools that marketers can use to fine-tune ad campaigns. And internally, the company has tested the use of search data to reach conclusions about economic, marketing and entertainment trends.

“Most forecasting is basically trend extrapolation,” said Hal Varian, Google’s chief economist. “This works remarkably well, but tends to miss turning points, times when the data changes direction. Our hope is that Google data might help with this problem.”

Prabhakar Raghavan, who is in charge of Yahoo Labs and the company’s search strategy, also said search data could be valuable for forecasters and scientists, but privacy concerns had generally stopped it from sharing it with outside academics.

Google Flu Trends avoids privacy pitfalls by relying only on aggregated data that cannot be traced to individual searchers. To develop the service, Google’s engineers devised a basket of keywords and phrases related to the flu, including thermometer, flu symptoms, muscle aches, chest congestion and many others.

Google then dug into its database, extracted five years of data on those queries and mapped it onto the C.D.C.’s reports of influenzalike illness. Google found a strong correlation between its data and the reports from the agency, which advised it on the development of the new service.

“We know it matches very, very well in the way flu developed in the last year,” said Dr. Larry Brilliant, executive director of Google.org. Dr. Finelli of the C.D.C. and Dr. Brilliant both cautioned that the data needed to be monitored to ensure that the correlation with flu activity remained valid.

Google also says it believes the tool may help people take precautions if a disease is in their area.

Others have tried to use information collected from Internet users for public health purposes. A Web site called whoissick.org, for instance, invites people to report what ails them and superimposes the results on a map. But the site has received relatively little traffic.

HealthMap, a project affiliated with the Children’s Hospital Boston, scours the Web for articles, blog posts and newsletters to create a map that tracks emerging infectious diseases around the world. It is backed by Google.org, which counts the detection and prevention of diseases as one of its main philanthropic objectives.

But Google Flu Trends appears to be the first public project that uses the powerful database of a search engine to track a disease.

“This seems like a really clever way of using data that is created unintentionally by the users of Google to see patterns in the world that would otherwise be invisible,” said Thomas W. Malone, a professor at the Sloan School of Management at M.I.T. “I think we are just scratching the surface of what’s possible with collective intelligence.

Conventional Wisdom on Uninsured Use of the ED Is Only Half True

By Emily P Walker, Washington Correspondant, MedPage Today

Published Oct 21, 2008

ANN ARBOR, Mich. Oct. 21 -- Three of the six most common assumptions about emergency department use by uninsured patients are false, and three are supported by fact but are true for all ED users, insured and uninsured, according to researchers here.

The single most common assumption -- that uninsured patients present to the ED for non-urgent, inappropriate care -- is one of the three not clearly supported by current data, Manya F. Newton, M.P.H., M.S., of the University of Michigan, and colleagues reported in the October 22/29 issue of the Journal of the American Medical Association.

From 1997 through 2005, non-urgent ED visits by uninsured patients increased from 11% to 16.7%, but that was just slightly greater than the four-percentage-point jump in overall visits, according to the National Hospital Ambulatory Medical Care Survey cited by the study authors.

Policy decisions are often borne from supposed "conventional wisdom" regarding the emergency department use by the uninsured expressed in medical literature, by policy makers, and in the media, the researchers said, but many of those claims have yet to be vetted.

So, to see if facts support oft-repeated statements, they examined 127 peer-reviewed studies or editorials published from 1950 through September 2008 that dealt with ED use by uninsured adults ages 18 to 65, excluding visits for psychiatric or dental care.

The researchers pinpointed the six most frequent assumptions from the literature and culled current peer reviewed studies and national data to back them up -- or refute them.

The other five most common assumptions about uninsured patients, in order, were that they:

lack access to primary care

were using ED facilities more frequently

cause overcrowding

present more often than insured patients

were more expensive to treat in the ED than elsewhere

Adding perspective to the issue that the uninsured present with non-urgent problems, the researchers noted that the uninsured are less likely to be admitted than their insured counterparts. But the truth may be that physicians have a higher threshold to admit uninsured patients than they do for insured patients, the researchers said.

As for the assumption that uninsured patients seek out primary care in the ED because they have nowhere else to go: It is true, the researchers said.

"The problems leading to this national decrease in access to primary care are complex, but substantial evidence exists that uninsured patients' access to sources of care other than the ED has decreased and that ED visits for conditions that could have been prevented with adequate primary care have increased," the researchers wrote.

The percentage of uninsured patients who are evaluated in physicians' offices decreased by 37% between 1996 and 2001, researchers said.

They found that the assumption that the number of uninsured patients presenting to the ED is on the rise is partially supported by current data. But more patients -- both insured and uninsured -- are coming to EDs, so the increase is across the board rather than localized to just uninsured patients.

However, the assumption that uninsured patients are to blame for ED overcrowding is not clearly supported by data.

Of the approximately 115 million annual ED visits, just 17% are made by uninsured patients, which is similar to the proportion of insured and uninsured patients, which suggests that "neither group uses the ED disproportionately," the researchers said.

And ED overcrowding is still an issue in countries with universal insurance, such as Canada and Australia, indicating that the tie between the uninsured and clogged emergency departments isn't necessarily as strong as current rhetoric would indicate.

"The etiology of crowded EDs is multifactorial and includes a lack of staffed inpatient beds, hospital and ED closings, increased ED use by all patients, and an aging population with increasing prevalence of chronic illnesses," the authors wrote.

Although nationally, the uninsured don't account for a large portion of the patients seen at an ED, the researchers noted that in underserved areas, the problem may be more acute.

Another assumption that is true: It is much more expensive to treat uninsured patients in the ED than in other settings such as a physician's office or an urgent care center.

The authors cited a 2005 RAND study that determined that the average cost of treating a patient in the emergency department is between $300 and $400, supporting the "common perception that the ED is an expensive and inefficient place to receive most non-urgent care."

Lastly, the assumption that uninsured patients present more often to the ED than insured patients is not supported, the researchers said.

Half of the studies reviewed found that to be true, but half found no difference in usage patterns between insured and uninsured patients.

Publicly-insured patients, however, do present to the ED much more often than uninsured patients, the researchers said.

Three less common assumptions -- that the uninsured delay seeking care, that they are sicker when they do, and that the uninsured receive less care are "well supported by current data," the researchers said.

They noted that a fourth less common assumption, that uninsured patients go to the ED because it's more convenient to do so, is difficult to prove or disprove because there is no consistent definition of convenience.

The authors noted several limitations to the study, including the fact that it relied entirely on assumptions about ED use that were expressed in the medical literature. A more complete study would include statements by media, policy makers, and private citizens that are expressed as conventional wisdom.

What do you think of this article? Do you believe the research is correct? Submit opinions here on this blog, by clicking the link below.

Health Care Industry Not Immune to Recession

From the St. Louis Today Website (www.stltoday.com)

When people make sacrifices in a tough economy, they usually don't start with their health.

That's one reason the health care industry, if not exactly recession-proof, seems one of the best able to endure the economic downturn.

St. Louis' growing medical sector includes the area's largest employer, BJC HealthCare, with 23,500 workers. Not only are local hospitals not experiencing layoffs, many will continue to hire skilled workers, said Dave Dillon, spokesman for the Missouri Hospital Association.

"There's always going to be a demand for health care," Dillon said .

During economic downturns, sales of prescription drugs and medical devices tend to hold up better than nonessential goods, noted David Wyss, chief economist of Standard and Poor's.

"Generally, you're looking for things that are necessities, not luxuries," Wyss said. "People get sick and need medical care regardless of the state of the economy."

But recent earnings show that drug makers aren't immune from slumping sales that have plagued their peers in the retail and auto industries. Pfizer, which employs 1,200 people in its labs in the St. Louis area, said last month that U.S. sales of its best-selling product, the cholesterol drug Lipitor, fell 13 percent in the last quarter as some financially struggling patients stopped filling their prescriptions.

"The typical safe harbors (for investors) have been pharmaceuticals," said analyst Steve Brozak of WBB Securities. "They're no longer safe; they're now the least bad choice."

Pfizer and Schering-Plough Corp. were able to offset weak revenue in the U.S. with higher sales abroad. But other companies, such as Merck & Co. Inc., have been less successful. Merck said recently it will cut 7,200 jobs after reporting sales declines.

Experts say pharmaceuticals are more vulnerable to economic cycles because employers have shifted more of the financial burden for care to patients, with higher copays and deductibles.

"With consumers having more cost-sharing in their benefits, you're going to see a greater effect on their health care spending right away," said Paul Ginsburg, President of the nonprofit Center for Studying Health System Change.

That means more uninsured or under-insured patients seeking care through hospital emergency rooms and other safety-net providers. Between 2000 and 2005, 125,000 people in Missouri went off employment-based health insurance, said James Kimmey, president and CEO of the Missouri Foundation for Health.

"If the recession leads even more employers to back down a bit from their current coverage levels, it could increase the uninsured pretty fast," Kimmey said.

The lagging economy and rising unemployment have made it harder for health insurers such as UnitedHealth Group Inc. and Humana Inc. to raise prices to offset higher costs and investment losses.

Health care companies least affected are those that sell inexpensive medical products directly to hospitals, bypassing cash-strapped consumers.

Becton, Dickinson & Co. and Baxter International Inc., for example, reported sharp profit gains for the most-recent quarter and boosted their full-year earnings estimates. Becton Dickinson specializes in syringes and surgical tools; Baxter sells drugs to treat blood and immune disorders.

"The products they offer aren't high-tech things," said Aaron Vaughn, an analyst with Edward Jones. "They are health care staples that people need."

A focus on lifesaving medicine also is expected to reward makers of high-priced biotech drugs.

Genzyme Corp. and Celgene Corp., for example, have built businesses around niche drugs for life-threatening diseases. Health care investment firm Leerink Swann gives both companies an "outperform" rating, along with peers Amgen Inc., Biogen Idec Inc. and Gilead Sciences Inc.

Texas Medical Board Issues Record Number of Physician Licenses

From the Texas Medical Board Fall 2008 Newsletter, found at www.tmb.state.tx.us

With the help of additional resources appropriated by the Texas Legislature, along with some streamlining of its processes, the Texas Medical Board set a record in Fiscal Year 2008 by licensing more than 3,600 doctors. This surpassed the previous record, set in FY 2007, by almost 300 licenses. TMB also eliminated an application backlog that had grown to more than 500 applications by February. The Board also took steps to improve efficiency in the application processing system by conducting a statewide series of licensing seminars to provide training for credentialing, recruiting and other health care entity staff responsible for assisting physicians with their licensure applications. Fewer mistakes on completed applications will usually result in faster processing time.

 “Texas is a popular place to practice medicine, as evidenced by the dramatic increase over the past few years in the number of doctors who apply to be licensed here,” said Dr. Roberta Kalafut, TMB’s board president. “We have applicants coming to Texas from all over the country and all over the world.

 “Our staff has responded to this greatly increased and varied demand,” Dr. Kalafut said. “We are issuing more licenses than ever, more quickly than ever, and we have eliminated the backlog of applications awaiting processing, all without compromising the quality of physicians licensed in Texas.”

 TMB licensed 3,621 doctors in FY 2008, an increase of almost nine percent over the former record of 3,324 licenses that were issued in FY 2007. The 2007 record eclipsed by almost 500 licenses the previous record, 2,828 licenses, which were issued in FY 2002.

 Processing times for licenses also have been greatly reduced, and exceed legislative requirements. The Board licensed 1,549 doctors in the fourth quarter of 2008 in an average of 42 days. The Texas Legislature in 2007 appropriated six additional employees for the licensing division, while mandating that licenses be issued in an average of 51 days or less.

 To build on this success, during the spring and summer of 2008 TMB conducted 13 licensing seminars in all regions of the state. About 200 individuals attended the three-hour seminars, which offered in-depth instruction on proper preparation of a physician licensure application, with an emphasis on the most common mistakes found on applications. If applications are complete and correct when TMB receives them, processing can be completed much more quickly.

 The training is helpful because of the complexity of license applications. Before TMB can license a physician, it first must determine that the physician’s education and training are substantially equivalent to the medical education and training provided in Texas. This can prove challenging, as TMB last year licensed physicians who were trained in 45 states and 83 other countries.

 Almost 30 percent of the physicians licensed in Texas last year, 1,032, received their medical educations at international schools.