BETTER MEDICINES, BETTER TREATMENT, BETTER HEALTH, BUT LOWER COSTS

Promoting Rational Use of Medicine &

Preventive Measures in the community

Yayasan Orangtua Peduli

Compassion, Courage, Commitment

ROAD MAP

1. Doctors

2. EBM

3. RUM

4. Patient & IT

5. Lesson learnt & Action

1. WHO ARE WE….?

The good physician treats the disease;

the great physician treats the patients

that has the disease.

The great physician UNDERSTANDS the

patient and the context of that patient’s

illness.

To err is human…

Institute of Medicine

PRIMUM NON NO CERE …

Above all, do not HARM ....

Who will define what constitutes HARM? Hippocrates

460-377 B.C.

"…he who aspires to treat correctly

of human regimen must first acquire

knowledge & discernment of the nature of man in

general –

knowledge of its primary constituents, discernment of the

components by which it is controlled. …

though they are made from the same materials, NO TWO ARE ALIKE…”

Hippocrates 460-377 B.C.

PRIMACY OF THE PATIENT

CARE

Human understanding, Empathy

Somehow …… Do we LISTEN? Are we humble & trustable?

Human understanding

Empathy

Today’s health-care context is highly complex.

Care is often delivered in a pressurized and fast-

moving environment, involving a vast array of

technology and, daily, many individual decisions and

judgements by health-care professional staff.

In such circumstances things can and do go wrong.

PATIENT SAFETY – cost-effectiveness

Exhausted, overwhelmed, frustrated, and ….

ability to listen & communicate

3 Oct 2012: Reporter Jeanne Lenzer investigates overtreatment at the heart of healthcare.

Overly aggressive treatment is estimated to cause 30 000

deaths among Medicare recipients alone each year.

Overall, unnecessary interventions are estimated to

account for 10-30% of spending on healthcare in the US, or

$250bn-800bn (£154bn-490bn; €190bn-610bn) annually.

Shannon Brownlee, acting director of the New America

Health Policy Program and author of : Overtreated: How

Too Much Medicine is Making Us Sicker and Poorer,

Harm?

Impact of ADRs

THE COST FACTOR

588 million $/year - Germany (1997),

> $ 177.4 billion – US - year2000,

$847 million/year - UK (2006, BMJ)

$ 1.4 million/year (exceeds DM, CV); 1/5 hospital death

HUMANITARIAN REASONS:

• 4-6th leading cause of death (Lazarou et al, JAMA; ’98)

• S/d 19 % inpatients - experience ADR (Davies et al, J Clin Pharm & Ther; 2006);

• 2 millions – serious ADR, 100000 death/year

• up to 70 % are preventable (Pirmohamed et al, BMJ; 2006)

Harm?

US: 2/3 patients – Rx

10 drugs/person, year 2000

ADR - 4 drugs

Why …. ADR!!

Katanya – Autoimmune hepatitis, harus biopsi hati

“Bu, makan obat apa sebelum sakit?”

“…Cuma vitamin paru2” …. ?????

Harm?

Doctors – not medical technicians, mending a human machine

• Indonesia: increase 10 – 13% per year

• High cost - sophisticated procedures/tests–

65%

• Overtreatment -- 56%

Global trend: • Cost shifting of acute in- to out-patient services

• Higher utilization of prescriptions drugs.

New drugs … are expensive and often over-prescribed.

• Utilization of high cost injectables and new treatment

regimes has increased.

COST – Out of Pocket?

Harm?

COST – 10 TOP CONDITIONS

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

Outpatient

Inpatient 31/1

340/6

109/8

Harm?

Each physician must decide if the circumstances of

practice are threatening his or her adherence to the

values that the medical profession has held dear for

many millennia.

APA SIH YANG DIPEROLEH DI SEKOLAH KEDOKTERAN? From: "uwi" >To: <sehat@yahoogroups.com> Sent: Tuesday, July 12, 2005 10:45 AM

Dear dr…. & SP's,

Pengen sharing .. mudah2an nggak bete ya bacanya E... Demam, batuk pilek. ... tumben, barengan. Ayahnya agak khawatir. Ya udah deh ke dokter ... Oh ya DSA udah 2 kali ganti.

Dokter I yang menangani kelahirannya nggak komunikatif. Dokter II pasiennya bejibun, seneng banget ngasih obat-vitamin. Saya dapat dokter III ... katanya RUD... So, kemaren ke situ.

Diagnosa: radang tenggorokan.

Tanpa penjelasan ABCD, sang dokter menulis resep.

Kemudian : "bu, ini racikan ya, yang ini antibiotik"

"untuk apa ya dok antibiotiknya?” ... "untuk radangnya" "emang radang perlu antibiotik dok?” "iya, tenggorokannya sudah merah begitu" Ampun! Ya namanya radang kan pasti memerah!

Racikan: Theofilin, Salbuven, Celestamin, Mucopect, Sirup: -Lapicef Syrup & -Encephabol Syrup

Saya tanya temen yang jaga UGD: "emang perlu AB?" Jawab: "ya perlu dong untuk mengobati radangnya".

Trus curhat ke teman (sedang ambil spesialisasi syaraf). Responnya membuat saya shock ... "Makanya lo jangan sok tau deh! AB tuh emang perlu untuk ngobatin radang. Kita dokter2 suka sebel ama pasien yang ngotot dan sok tau"

Harm?

Selain angka rujukan yang tinggi, biaya tertinggi - obat - 1x kunjungan - flu sampai Rp 150 rb asma Rp 300 rb.

2005 - program baru, kerjasama dg klinik dan RS terpilih Membuat STANDARISASI JENIS OBAT. Masalah: ketidak setujuan (ketidak sukaan) dan penolakan dari klinik-RS (terutama); paling banyak - konsultan ahli (merasa diintervensi). Belum lagi karyawan yang merasa tidak mendapat obat seperti sebelumnya.

waktu baru lulus - saya sangat HEBOH dg kemampuan saya mengobati pasien. Kemudian ditempatkan di klinik dg dokter advisor A’lia dan Afrika Selatan. Waduh, saya jadi bahan olok-olok & merasa sangat bodoh.

Pengobatan yang saya berikan ternyata tidak mempunyai dasar ilmiah yang bisa dipertanggung jawabkan. Sebagian besar hanya berdasarkan pengalaman dan nyontek dari senior atau konsultan semasa kuliah

From: ju…@as…...id To: sehat@yahoogroups.com Sent: Thursday, January 18, 2007 9:30 AM Subject: [sehat] Tentang resep (was Re: Haruskah Kita Mengekspor Pasien?)

Docs, Just curious......

Apa memang ada standar/aturan/kode etik agar tulisan dokter pada lembar resep 'sulit dibaca' awam?? kan baiknya 'mudah dibaca'......

Sedikit usul, mungkin bisa dijadikan standar prosedur dokter, agar menerangkan setiap obat yang diberikan ke pasien: dosis, kegunaan, kapan diberikan, kapan distop, efek samping, dll. Klo ini dijadikan standar prosedur, kan lebih baik.... walaupun inisiatif bisa juga datang dari pasien sendiri.

Just my 200rups, Ju…. Z…..

-still learn to be a father for a son- Harm?

1. Best clinical

evidence

3. Patient’s

value

2. Clinical

experience

TO IMPROVE

Outcomes,

Patients’ safety,

Cost

effectiveness

2. EVIDENCE BASED MEDICINE (EBM)

Grade of

recommend-

ation

Level of

evidence

Interventions

A 1a Systematic review of RCTs

1b Individual RCT

B

2a Systematic review of cohort

studies

2b Individual cohort study

3a Systematic review of case-

control studies

3b Individual case-control study

C 4 Case series

D 5 Expert opinion

“Koleksi Resep?”

EBM → guidelines

Clinical practice guidelines are systematically

developed statements that aim to help

physicians and patients reach the best health

care decisions. Good guidelines have many

attributes (validity, reliability, reproducibility, clinical

applicability and flexibility, clarity), development

through a multidisciplinary process, scheduled

reviews, and documentation.

More than 2000 guidelines are currently

represented in the National Guideline

Clearinghouse (www.guideline.gov).

GUIDELINES AND RULES: FRIEND OR FOE? Dr Jonathan Adler, Massachusetts General

Hospital.

Physicians should take the time to be

familiar with the most important guidelines

in their specialty.

They should adopt the best guidelines

because they represent the best practice

and are best for the patient.

DECONGESTANTS: short-term relief of nasal obstruction for adults, but may not work in children. Are often used, but evidence that they work is scanty. Trials show that single doses are moderately effective. Insufficient evidence to show whether:

■repeated doses are effective, or whether

■single or repeated doses work in children age < 12. link: http://www.cochrane.org/reviews/english/ab001953.html

ANTIHISTAMINES: no convincing evidence can relieve the cold. In combination with decongestives, antihistamines might lead to some general improvement and relief from a blocked and/or runny nose although there is not enough evidence to be certain. link: http://www.cochrane.org/reviews/english/ab001267.html

OTC cold medicines dangerous for kids under 2 (U.S. government research)

2005: 3 babies of < 6 months old died

2004 – 05: more than 1500 children < 2 ys – ER

Can any medications help treat the common cold?

Pain reliever — such as acetaminophen — can reduce a fever and

ease the pain of a sore throat or headache. Remember, however,

low-grade fevers don't need treatment.

Don't give ibuprofen to a child younger than age 6 months, and

don't give aspirin to anyone age 18 or younger. Aspirin has been

associated with Reye's syndrome, a rare but potentially fatal

illness.

Ibuprofen & AKI!

Somehow …

URI; 10 months

A doctor will be able to

cure some of the time,

relieve most of the time

but should

comfort all the time.

REALITY …. Efficacy, safety, cost

Most prescribers choose drugs on the

grounds of efficacy, while side effects

are only taken into consideration after

they have been encountered.

Sometimes kinetic characteristics which

are of little importance are stressed to

promote an expensive drug while many

cheaper alternatives are available.

Public/private diarrhoea treatment all years WHO database, ICIUM 2004

0

10

20

30

40

50

60

70

ORS Antibiotics Antidiarrhoeals STG

compliance

% d

iarrh

oea c

ases t

reate

d

Public (n=24-50) Private for profit (n=5-23)

URI (55) Fever (43) Diarrhea (27) Cough (41)

Total meds 260 186 83 186

Median 5 4 3 4

Max 8 9 7 11

% Puyer 77.4 72.6 55.4 87

% Antibiotic

(% generic)

54.5

7

86.4

0

74.1

5

46.3

10.5

% Generics 16.9 9.7 3.6 19.4

% prescribed med

-Steroid

-Anti histamine

-Anti Convulsion

-Anti Pyretics

-Supplement

61.8

50.9

16.4

36.4

21.8

41.9

53.5

55.8

79.1

34.9

44.4

18.5

11.1

29.6

51.9

\

60.9

36.6

14.6

17.1

2.4

1. General results

0

10

20

30

40

50

60

70

80

90

100

URI COUGHS FEVER Acute GE

% Antibiotics

URI

COUGHS

FEVER

Acute GE

STUDY on ANTIBIOTIC USE in

COMMON CONDITION among children (2006)

n = 166; total meds = 715

URI Prescribing Pattern

(2006)

Prescribing pattern (2008) (n=583)

Jakarta Other cities

Respondent (n) 55 346 237

Median 5 6 6

Max active substances 8 26 14

Types of drugs

Antipyretic 21.8% 40,7% 40,5%

Anticonvulsant 36.4% 24,2% 12,2%

Bronchodilator 50% 57,5% 51,4%

Decongestant 52.7% 48,8% 47,2%

Antihistamine 50.9% 81,5% 75,9%

Mucolitic/expectorant 63% 61,5% 69,1%

Steroid 61.8% 58,3% 56,9%

Antibiotic 54.5% 67,3% 78,4%

Antitussive 10.9% 21,6% 27,4%

Supplement 21.8% 39% 35%

Compounding medicine 77.4% 91,9% 88,6%

Generics 16.9% 28.3% 16.2%

0 100 200 300 400 500 600 700 800

URI

FEVER

Acute GE

Thousands

IMCI

Median

Max

Min

15.000

20.800

56.000

349.000

326.000

747.000

167.000

137.000

117,500

STUDY on COST (rupiah)…. 406 Rx/

IMCI 3.000 – 8.500

PENELITIAN 2010: Puskesmas – Depok Means of drugs 3.8 (1 – 7)

7 drugs: Acute Nasopharyngitis

Non generics

Obat batuk-pilek

Obat diare (kaolin)

Obat mata

Suplemen

Antibiotics: Amoxycillin, Cotrimoxazole, Cephadroxil

Obat non DOEN 36.2%

To: Sehat@yahoogroups.com From: He….@pm…...com Sent: Thursday, August 24, 2006 10:53 AM Subject: Mau curhat nih (sharing & asking)

dear all, my daughter fell off and had stitches on her forehead. What should I do to prevent keloid in the future?

I haven’t bought the prescription (I did browse; it contains vitamins and 2 antibiotics). Am I doing the right thing?

1. - amoxsan 500 mg (amoxicilin)

- Riboflavin

- Omeprazole

- …amid 100 mg

2. - biothicol 60 ml... (Chloramphenicol)

Please advice, thx

EBM – Guidelines

Essential Drug List

Formulary

3. RUM (Rational Use of Medicine)

THERAPY :

1. advice & information

2. non-drug therapy

3. DRUGS

4. referral, 2nd opinion

5. combination

RUM: Patients receive medications APPROPRIATE to their

clinical needs,

• in DOSES meet their individual requirements for an

• ADEQUATE PERIOD of time,

• accurate INFORMATION, and

• at the LOWEST COST to them and their community. WHO conference of experts Nairobi 1985

PROBLEM/S DIAGNOSIS

GOAL – THERAPY

DRUG SELECTION

START THERAPY

MONITOR -

EVALUATE

The process of rational treatment

Efficacy

Safety

Suitability

Cost

Availability

Choosing

a P drug

INFORMATION,

instruction, warnings

1

2

3

4

5

6

P drugs - COMMON COLDS

Goal of treatment: Comforting the child, Not curing the infection

Inventory – effective treatment:

■ Advice & Information: • Offer plenty of fluids.

• Encourage rest.

• Moisten the air.

■ Drug treatment: • Try saline drops. Saline nose drops can loosen thick nasal mucus and make it easier for your child to breathe.

• Soothe a sore throat. For older children, gargling salt water or sucking on hard candy may soothe a sore throat.

■ Referral for treatment: Not necessary

P drug & P treatment Acute GE – mild to moderate dehydration

Goal of treatment :

(1) to prevent dehydration or to prevent it from worsening

(2) rehydration;

the goal is not to cure the infection!

Inventory - effective therapy:

Advice & information: continue breastfeeding & other food; observation

Non-drug treatment: additional fluid

Drug treatment: ORS, oral or NGT

Referral for treatment: Not necessary.

P drug & P treatment Acute GE – mild to moderate dehydration

Metronidazole & antibiotics (cotrimoxazole or ampicillin), are not listed in the inventory (not effective in treating watery diarrhoea).

■ Antibiotics are only indicated for persistent bloody and/or slimy diarrhoea (less common than watery diarrhoea);

■ metronidazole is mainly used for proven amoebiasis.

Antidiarrhoeal drugs are not indicated, especially for children, (mask the continuing loss of body fluids into the intestines and may give the false impression that ‘something is being done’).

Your P-treatment: advice to continue feeding and to give extra fluids and to observe the child carefully.

Review of the comments on the Report of the Informal Expert Meeting on Dosage Forms of Medicines for Children http://www.who.int/medicines/publications/TRS958June2010.pdf

The Committee also considered extemporaneous preparations

involving polypharmacy. The Committee noted that in 1985 WHO

defined rational use of medicines as requiring that “patients receive

medications appropriate to their needs”. The custom in some

places is to treat sick children with a mixture of several medi-

cines (“puyer”) not necessarily all appropriate to their needs.

Commonly, adult solid dosage forms are mixed together ground to a

powder and the powder divided into assumed paediatric doses and

then dispensed for administration to the child. Often, some medicines

in the mixture are not indicated for the condition being treated. These

medicines add to the risk of adverse events without any possi-

bility of conferring additional benefit. The Committee recom-

mended that as this practice is irrational it should not be used.

Prof Rianto Setiabudi … Permasalahan seputar puyer

1. Kemungkinan kesalahan manusia

2. Stabilitas obat tertentu dapat menurun

3. Toksisitas obat dapat meningkat

4. Waktu penyediaan obat lebih lama

5. Efektivitas obat dapat berkurang

6. pencemaran lingkungan

7. tingkat higienis

8. biaya lebih mahal

9. Dokter tidak tahu obat mana …

10.Potensial IRUD

GMP

GPP

EBM

RUD

“Resep senior??; Resep template??”

Prescribing is a complex

and challenging task which

must be based on accurate

and objective information

and not an automated

action, without critical

thinking

or a response to

commercial pressure.

Guidelines, Essential drug list-Formulary

Somehow ……

PRIMUM NON NO CERE ….

RUM, EBM

WHO:

Avoid mixing drugs

As few drugs as possible

Drug = substance + INFORMATION

WHO, Dept. Essential Drugs and Medicines Policy

Irrational use …. Health hazards & wastage

At least, 50% prescription – unnecessary,

inappropriate.

Drugs – prescribed when actually not needed …

Patients are provided with wrong medicines,

ineffective or unsafe ….

Effective medicines, the essential drugs -

underused

Age 15 months Fever, coughs, runny nose

Effective treatment:

• Close monitoring

• Wait & see approach

• Lots of fluid

• +/- Paracetamol

15 active

substances!

Age 3 ys: Acute GE

R/ Biothicol 200 mg (chloramphenicol)

luminal 12.5 mg (phenobarbitone)

CTM 1.25 mg (antihistamine)

mfpulv dtd No XX … 4 dd 1

R/ Nifural syr… 3dd cth (antibiotic) R/ Pedialite (ORS)

R/ Pankreon (pancreatic enzymes)

R/ B complex ½ tab (vit B)

Curcuma ½ tab (appetite stimulant)

Cobazim 1000 mg (CoenzymeB12)

Lysagor ¼ tab (appetite stimulant)

Isoniazid 50 mg ..

mfpulv dtd No XV … 2 x 1 pulv

Effective treatment?

• Close monitoring

• ORS

• +/- Paracetamol

10 active

substances!

URI

A 2 year old boy

IMCI (MTBS) – URI …???

Reasons/Causes for Irrational Drug Use

• What will happen if an antibiotic is given for a diarrhoea due to

“food poisoning” of short duration?

• What will happen to a patient with a cold (=coryza) if he is given an

antibiotic?

• What will happen to a 5 year old boy given antibiotics for a Upper

Respiratory tract due to a viral infection?

In all 3 situations the patient will eventually get better

What would have been the natural course of the illness?

What is the contribution of the antibiotic?

Can the effects of the 2 (natural course & antibiotics) be

differentiated?

Other examples – NSAIDS and antacids/H2 receptor blockers

WHO, Dept. Essential Drugs and Medicines Policy

WHO, Dept. Essential Drugs and Medicines Policy

Reasons/Causes for Irrational Drug Use

Income of the Dispensing Doctor

Separation of Prescribing and Dispensing

National Health Service (UK) – very few

dispensing doctors

Study showed this small group had higher

prescription rates

Attitude of Doctor

Active, interventionist – do something for the

patient, encourages prescribing

IRRATIONAL POLYPHARMACY for daily health problems; why?

It takes 2 years to train a doctor about a drug,

3 years to teach him when to use it and

a lifetime to teach him when not to use that drug.

Despite 4 year period of investigation and

continuous discussion …. Doctors … extremely

reluctant to change their prescribing habits.

WHO, Dept. Essential Drugs and Medicines Policy

WHO, Dept. Essential Drugs and Medicines Policy

Reasons/Causes for Irrational Drug Use

Strong Commercial factor

If the one who decides does not pay

And the one who pays does not decide …

And if the one who decides is “paid” …..

(A very good example of an Imperfect Market)

Doctors = Patients?

4. Patient & IT

A well informed patient is easier to care for

More than 70 000 websites disseminate health information; in excess of 50 million people seek health

information online. The Internet offers widespread access to health information, and the advantages of interactivity,

information tailoring and anonymity.

According to the Pew Research Center’s Internet & American Life Project, 61 percent of U.S. adults go online for health information. What’s more, nearly all (60 percent) say their findings have influenced a decision about how to treat an illness and that the advice they found was helpful—a pretty strong indicator that, when used with requisite caution, the Internet can (and does) play a positive and vital role in health care.

The Internet is changing not just the way patients get medical

information, but the way they interact with doctors.

Despite the wealth of public information and the good quality

of many Internet resources, Doctors are necessary, Berland

states. "But we are still not doing a great job at talking

with our patients."

HEALTH CARE is a two way process

• www.who.int

• www.cdc.gov

• www.aafp.org

• www.drugs.com

• www.aap.org

• www.rch.org

• www.mayoclinic.com

www.drug-interactions.com

www.arizonacert.com

www.epocrates.com

www.penncert.com

www.sph.unc.eduhealthoutcomes/certs/index.htm

www.bmj.co.or.id

• www.milissehat.web.id

• www.kidshealth.org

www. breastfeeding.com www.kellymom.com

Ask Doctor 3Qs:

What should

I do?

What is my

problem? When should

I worry?

Diagnosis

Treatment Plan Complications

Smart patients & Rx/, Lab

Please ask:

■ Active ingredient

■ Indications

■ Administration, dose

■ Risk of side effects

■ Contraindications

Please ask for

generics!

• Purpose? • Why? Is it really important? • Consequences if not done? • Other alternative(s)? • Cost? • Accuracy? • Positive, confirmed that I

am sick? • If negative, I am not sick? • Etc etc

5. LESSON LEARNT & ACTION

“To be treated you have to

be a very healthy person,

because apart from

disease you have also to

tolerate the medication”

Moliere

Related to HARM: So where is that point, and might we have reached it already?

Most doctors believe medicine to be a force for good. Why

else would they have become doctors?

Yet while all know medicine's power to harm individual

patients and whole populations, presumably few would

agree with Ivan Illich that “The medical establishment has

become a major threat to health.”

Many might, however, accept the concept of the health

economist Alain Enthoven that increasing medical inputs will

at some point become counterproductive and produce

more harm than good.

Unsafe Safe

A long long long long way to go

Phase 1: Awareness

- Denial

- Anger

- Acceptance

Phase 2:

How, what?

Phase 3:

Implementing safe

practices

Paradox

New

drugs

Antibiotic

resistance

SAVE THE PILL

FOR THE VERY ILL

TOO MUCH MEDICINE - CAMPAIGN BMJ – Helping doctors make better decision

Dr Godlee : "Like the evidence based medicine and quality

and safety movements of previous decades, combatting

excess is a contemporary manifestation of a much older

desire to avoid doing harm when we try to help or heal.

"Making such efforts even more necessary are the

growing concerns about escalating healthcare spending

and the threats to health from climate change. Winding

back unnecessary tests and treatments, unhelpful

labels and diagnoses won’t only benefit those who

directly avoid harm, it can also help us create a more

sustainable future."

http://www.preventingoverdiagnosis.net/?page_id=12

Evidence

Factors influencing

the use of research

evidence

”TRANSLATING”

LOST IN TRANSLATION !!

Practice

Severe

problem

Healthy,

mild

diseases

What can/should we DO?

OVERUSE, UNDERUSE, MISUSE of

medicine – difficult to eliminate

In Relation to Rational Use of Medicine

Power – balancing?

Ethical aspect

Respect for autonomy

Benefiscense, non malifiscense

Justice

Competency

Transparency

Just as patients depend on their physician,

physicians also depend on their patients

What do we need today?

Ethical Value & Action

Value

Conviction

Commitment

Decision

ACTION

WHO, Dept. Essential Drugs and Medicines Policy

WHY DO WE NEED EBM?

• Save LIVES!

• We want to do the right thing – what is best for our patients

WHY USE EBM?

• Daily need for information

• Inadequacy of traditional sources of in formation

• Disparity between our diagnostic skills & clin judgement vs

up to date knowledge and clinical performance

• Develop skills for life long learning

Medicine is a rapidly changing field, dissemination - slow

WHO, Dept. Essential Drugs and Medicines Policy

translate the evidence

• Stay up to date

• Medical information changes constantly

• Unlike bread, our knowledge does not become

visibly moldy or stale – we just keep using it

• Patient care is driven by the continual generation of

new evidence

• We usually fail to get new information in a timely

manner

• Up to date knowledge and clinical performance –

deteriorate over time THE SLIPPERY SLOPE

• Better therapeutics

• Less side effects

• Saves money:

– Patient,

– Hospital,

– Country

• Ethics and Equity

WHY RUM … ?

Protecting patients from :

- Over-treatment

- Under-treatment

- Miss-treatment

RUM ---- 1985 to 2013 …..????

• Making changes

“awkward”

• Changes take practice

• Feel uncomfortable doing

it?

It is OK, DO IT ANYWAY

Each patient represent a story ….

Be a great physician. Understand the full story.

Make correct diagnosis.

Consult the patient in designing the treatment plans

that best fit the patient.