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A private practice oncologist told me years ago about a patient of his. The oncologist takes his vacation at the end of August. The patient was supposed to come in for chemotherapy on Wednesday, the day before the oncologist left. The patient couldn't make it. The oncologist, therefore, did what he always did in that situation, wrote a prescription to be "filled" at a nearby, large, comprehensive, NCI-designated cancer center. Had the patient received treatment in the office, the oncologist would have received $6,000, which the oncologist said was very generous. The NCI-designated cancer center, however, billed $28,000, and was paid 75% of this amount. (The oncologist knows about the large disparity between what the NCI cancer centers get and what he gets). I thought this was very revealing. In 2007, NCI launched the Community Cancer Centers Program, a three-year pilot phase of a new program that is supposed to help bring state-of-the-art cancer care to patients in community hospitals across the United States. The program is designed to encourage the collaboration of private-practice medical, surgical and radiation oncologists, with close links to NCI research and to the network of 63 NCI-designated cancer centers principally based at large research universities. Wed the NCI-designated cancer centers with the community cancer centers. NCI-designated cancer centers are a very large business which act as a base of power for academic clinical oncologists who made a mess of clinical cancer research, since the time Nixon first declared war on cancer. http://blog.aperio.com/articles/Fortune_Cancer.pdf

A Medical Director at California Cancer Care, an oncology practice in Northern California wrote a candid letter to the Health Beat blog by Maggie Mahar. He is a member of The Century Foundation's Working Group on Medicare Reform. A very experienced and successful oncologist who has served on the board of the American Society of Clinical Oncology and the Association of Northern California Oncologists. http://www.healthbeatblog.org/2009/01/a-very-open-letter-from-an-oncologist.html

Now that Healthcare IT is part of the stimulus package, what are the fundamentals of Healthcare IT? Here's a primer with the top 10 questions and answers: http://www.thehealthcareblog.com/the_health_care_blog/2009/03/a-healthcare-it-primer.html

Nursing Homes, like deteriorating public schools, crumbling bridges and other pieces of our society's essential infrastructure have been neglected for a long time. http://www.healthbeatblog.com/2009/03/the-111th-congress-at-work-.html

Sen. Chuck Grassley and Sen. Herb Kohl will reintroduce the Nursing Home Transparency and Improvement Act on March 19th. The bill, which would require disclosure of nursing home ownership and operations and give consumers better information about nursing home quality, deficiencies, nurse staffing, expenditures, and enforcement, will contain most of the provisions that were in the legislation when it was first introduced in February 2008. However, it will not require increases in civil monetary penalties that were in the original bill and the focus on independent audits of facilities that are part of chains has shifted to internal quality assurance and compliance and ethics programs that include procedures to detect criminal, civil, and administrative violations. Congress should increase those penalties to as much as $100,000 if a resident is harmed or dies due to negligent care. If simply composing a typical generic Plan of Correction is the only remedy required for verified violations, where is the motivation for the facility to change their practices? The most critical aspect of nursing homes is the lack of staffing which can be explained in simplified terms, right down to the basic facts that, without it, residents don't receive even basic humane care; i.e., fed, hydrated, changed, bathed, turned, given their meds on time and/or given correctly. Lack of staffing, in turn, creates a constant high turnover among even the most highly-trained, dedicated workers. Mandatory staffing levels were taken out of last year's bill, hoping it had a better chance of passing. Mandatory staffing levels should be put back into this legislation. House sponsors of the legislation, Rep. Pete Stark and Rep. Jan Schakowsky, are expected to reintroduce their version of the bill in April.

$21 billion to provide a 60% subsidy of health care insurance premiums for the unemployed under the COBRA program; $87 billion to help states with Medicaid; $19 billion to modernize health information technology systems; $10 billion for health research and construction of National Institutes of Health facilities. One aspect of the monies was to fund a comparative-effectiveness program to assess whether or not treatments (mostly the newer targeted regimens) are really better than older treatments. Decisions are being made about what cancer treatments patients can actually afford. Comparative research is not rationing health care. The research funding doled out in the recent Stimulus Package would go to the National Institute of Health, the Agency for Healthcare Quality and Research and the Centers for Medicare and Medicaid Services to focus on producing the best unbiased science possible. Comparative research has the potential to tell us which drugs and treatments are safe, and which ones work. This is not information that the private sector will generate on its own, or that the "industry" wants to share. Companies want to control the data, how it is reviewed, evaluated, and whether the public and government find out about it and use it. Just about the way they are controlling data now. Comparative-effectiveness research is not something for patients to be afraid of. It can help doctors and patients, through research, studies and comparisons, undertand which drugs, therapies and treatments work and which don't. Nothing in the legislation will have the government monitoring treatments in order to guide your doctor's decisions. Doctors will still have the ultimate decision, along with the patient. Yet as anyone with even a passing familiarity with the medical science and medical economics literature understands, comparisons are rarely black and white. Most medical technologies only help a fraction of patients. Most medical technologies have some risks associated with their use. Comparative cost-effectiveness analysis is an important tool for accurately evaluating those benefits and risks. Another aspect of the monies is the funding for health information technology in the recovery package is projected to create over 200,000 jobs and a down-payment on broader health care reform. Converting an antiquated paper system to a computer system by making the health care system more efficient. The Congressional Budget Office has estimated that one-third of $2 trillion spent annually on health care in America may be unnecessary due to inefficiencies in the old system such as exessive paperwork. Investing in infrastructure like Health IT would help improve the quality of America's health care. Currently, fewer than 25% of hospitals and fewer than 20% of doctor's offices employ health information technology systems. Researchers have found that implementing Health IT would result in a mean annual savings of $40 billion over a 15-year period by improving health outcomes through care management, increasing efficiency and reducing medical errors. Investing in Health IT would also help primary care physicians who often bear the brunt of tech implementation without seeing immediate benefits, affording the infrastructure for expanison. Some PCPs are ahead of the IT curve but cannot afford the richness of its expansion. They need this important infrastructure.

The $1.1 billion earmarked for comparative effectiveness research remained in the bill that President Obama will sign. The House conferees also insisted on keeping the phrase "comparative effectiveness" throughout the authorizing language, removing the Senate's insertion of the word "clinical." The report language did note its removal was "without prejudice." However, the conferees do not intend for the comparative effectiveness research funding included in the conference agreement to be used to mandate coverage, reimbursement, or other policies for any public or private payer. The funding in the conference agreement shall be used to conduct or support research to evaluate and compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition. We saw a perfect example last week of how comparative cost-effectiveness analysis can be coupled with comparative clinical-effectiveness analysis to provide useful guidance to health practitioners, patients and payers faced with a confusing array of alternatives in one particularly crowded area of health care: colon cancer screening. CMS made a preliminary decision not to pay for virtual colonoscopy. http://www.nytimes.com/2009/02/13/health/policy/13colon.html?scp=1&sq=colonoscopy&st=cse CMS concluded, based on a comparative cost- and clinical-effectiveness analysis conducted by AHRQ, that taking its costs into account, virtually colonoscopy made no sense either medically or economically. Not all comparisons merit a cost-effectiveness analysis. When one drug, device, surgery or other medical technology is clearly superior to another, then the U.S. health care system, which operates without cost controls, pays for it. This legislation reinforces that approach. Yet as anyone with even a passing familiarity with the medical science and medical economics literature understands, comparisons are rarely black and white. Most medical technologies only help a fraction of patients. Most medical technologies have some risks associated with their use. Comparative cost-effectiveness analysis is an important tool for accurately evaluating those benefits and risks. Source: GoozNews

Conservatives have been misinforming the public about the health IT provisions of the stimulus package by falsely claiming that it would lead to the government telling the doctors what they can and cannot treat, and on whom they can and cannot treat. The Hudson Institute fellow, Betsy McCaughey, claimed that the legislation will have the government monitor treatments in order to guide your doctor's decisions. The new language in the bill tasks the (already existing) National Coordinator of Health Information Technology (NCHIT) with providing appropriate information so that doctors can make better informed decisions. The NCHIT provides counsel to the Secretary of HHS and Departmental leadership for the development and nationwide implementation of health information technology. Contrary to Ms. McCaughey's statements, the language in the House bill does not establish authority to monitor treatments or restrict what your doctor is doing with regard to patient care. It addresses establishing an electronic records system so that doctors can have complete, accurate information about their patients. The funding for health information technology in the recovery package is projected to create over 200,000 jobs and a down-payment on broader health care reform. Converting an antiquated paper system to a computer system by making the health care system more efficient. The Congressional Budget Office has estimated that one-third of $2 trillion spent annually on health care in America may be unnecessary due to inefficiencies in the old system such as exessive paperwork. Investing in infrastructure like health IT would help improve the quality of America's health care. Currently, fewer than 25% of hospitals and fewer than 20% of doctor's offices employ health information technology systems. Researchers have found that implementing health IT would result in a mean annual savings of $40 billion over a 15-year period by improving health outcomes through care management, increasing efficiency and reducing medical errors. Investing in health IT would also help primary care physicians who often bear the brunt of tech implementation without seeing immediate benefits, affording the infrastructure for expanison. Some PCPs are ahead of the IT curve but cannot afford the richness of its expansion. They need this important infrastructure.

The for-profits are taking over hospices the same way they have taken over nursing homes. The Kaiser Network noted that hospice care was designed to be delivered mainly by not-for-profit groups with affiliations to religious and community groups, but the June 2008 MedPAC report found that since 2000 mostly for-profit companies and hospices have been providing such care. Manor Care operates hospice under their for-profit nursing homes as Heartland Hospice Care. On top of receiving an additional $130 a day for hospice service, above the daily payment they receive providing nursing home care, they take donations to their Heartland Hospice Fund. For-profit hospices, like for-profit nursing homes are run by corporations the are coldly efficient, according to a leading palliative care specialist. If there is a way to play the system to make a higher profit, they will. Nursing home residents are already receiving 24/7 care. The hospice service is an additional $130 a day the home receives. In their quest for Medicare dollars, for-profit hospices don't provide all the care that they should in order to fulfill the hospice mission of maximizing patients' quality of life. In fact, a 2004 Medical Care study of 2,080 patients enrolled in 422 hospices across the country found that terminally ill patients who receive end-of-life care from for-profit hospice providers receive a full range of services only half the time compared with patients treated by nonprofit hospice organizations. That's because for-profit hospices like to keep costs low by skimping on services, particularly so-called "non-core" services like medications and personal care. For example, families of patients receiving care from a for-profit hospice received counseling services, including bereavement counseling, only (45% as often) as those in a nonprofit hospice. When researchers controlled for differences across patients, sicknesses, and conditions, those at for-profit hospices were only half as likely to get the same support provided at nonprofit hospices. A 2005 follow-up study confirmed that for-profit patients receive a narrower range of services than nonprofit patients. But it's not just "non-core" services that for-profit hospices are skimping on. For-profit hospices are only half as likely as nonprofits to provide palliative radiotherapy (RPT), a radiation therapy that has been shown to effectively reduce pain and other symptoms related to tumor growth. The dearth of for-profit RPT probably has a lot to do with the fact that for-profit hospices take on a smaller share of patients with cancer than do nonprofits--in part because it costs a lot to care for cancer. In addition, it's much easier to predict how soon cancer patients will die. They rarely stay in a hospice for more than six months. Indeed, for-profit hospices tend to "cream-skim" patients, both by taking on fewer cancer patients and having a greater share of patients who require a relatively long stay (In this regard, MedPAC's fears are warranted). Worse still, according to research from the University of California, Irvine, patients who stay longer at for-profit hospices receive less high-skilled nursing care--such as tracheotomy care, wound care, and suctioning or feeding tubes--because skimping on these services keeps costs down. In sum, research shows that patients stay longer at for-profit hospices, yet receive less personal care, symptoms management and spiritual support during their stay. This is a pretty good way to make money, and indeed, the largest for-profit hospices are doing very well: a 2005 study in the Journal of Palliative Medicine found that large hospices owned by publicly traded companies generate profit margins nine times higher than those of large nonprofits and three times higher than privately owned for-profit hospices of similar size. In other words the "corporatization" of nursing homes seems to be a major part of the problem. Among them are VITAS, the country's largest for-profit, publicly-owned hospice, which cares for more than 11,000 patients in 16 states; the publicly-owned Odyssey Healthcare and Vista care and the private Heartland Hospice, which is a division of HCR Manor Care. Back in 2007, the major private equity firm The Carlyle Group bought up Manor Care for $6.3 billion. A New York Times story covering the privatization of elderly care noted that large nursing home chains owned by an investment company in 2005 earned $1,700 a resident and were, on average 41% more profitable than the average facility. Like for-profit hospices, these nursing homes cut services in order to reduce costs, but the health care industry isn't like other industries. What may count as "efficiencies" in other fields - reduced labor costs, more streamlined services, etc - compromise the quality of health care to such an extent that patients die. There's just no way around it, health care is labor intensive. What's so frightening about the case of for-profit hospices in particular is that cutting corners undermines the whole mission of hospice care. For-profit hospices risk losing sight of the fundamental principles of hospice because they are not doing all they can to support and comfort patients and families during the final stages of life. There's really no way to do a half-way job with hospice care. You're either doing everything you can to make dying people and their families feel better, or you're not. This is not a calculus that comes down to dollars. More and more, it looks like the business plan of for-profit hospices is to provide relatively minimal care to people who will take a long time to die. If ever there were a strategy antithetical to the principles of hospice, this is it. Source: Health Beat

The CMS (Centers for Medicare & Medicaid Services) has issued quality ratings for 15,800 nursing homes throughout the USA that participate in Medicare or Medicaid. Each nursing home is assigned a star rating, from one to five - with five being the best. The ratings are based on health inspection surveys, staffing information, and quality of care measures. http://www.medicalnewstoday.com/articles/133903.php State Surveys are independent evaluations of nursing facility performance. Annual surveys are conducted by state survey agencies, usually the state's department of health, using protocols, procedures, and forms developed by the Centers for Medicare & Medicaid Services (CMS). A consumer concern about surveys is the repeated finding by the Government Accountability Office (GAO), in a series of reports issued since 1998, that surveys understate deficiencies and cite deficiencies as less serious than they actually are. The survey component of CMS's proposed ranking system provides a more positive statement about quality than justified. States are increasingly using their state enforcement systems, instead of the federal system, to sanction facilities for noncompliance with standards of care. State enforcement actions do not appear on Nursing Home Compare. The National Senior Citizens Law Center recommends that consumers use the new rating system with caution, and only as an aid while also pursuing other information and strategies. Consumers need to understand that the five-star system is a beginning, not an end. A nursing home's quality can shift from month to month, so you have to be savvy in asking the right questions. Existing residents and their family members should be asked for their opinions. Inspection data is mostly based on a once-a-year survey and may not accurately reflect the nursing home's performance today. Staffing information and quality measures are "self-reported" data by the nursing homes themselves. Self-reported data makes nursing home quality "appear" to be better than it actually is. It cannot easily be reduced to a star rating. A recent GAO study found that nursing homes over-report staffing levels compared with staffing reported on audited Medicaid cost reports. Over-reporting of nursing coverage is associated with for-profit ownership of nursing homes. Researchers recommend more careful scrutiny of staffing levels in for-profit facilties during the survey process and that improvements be made to the process of public reporting of staffing levels. CMS should provide more and better information on Nursing Home Compare, including links to the actual survey forms and information about staff turnover. Also, CMS should use payroll data to report staffing information. Anything to do with "quality indicators" is bogus. When de-regulation failed under the present administration, they wanted, among other things, the "quality indicator" process to eventually replace traditional annual surverys because it relies upon self-reported, unaudited data supplied by the facilities themselves and is without consequences for failures. But it still relies upon self-reported, unaudited data supplied by the facilities themselves. It leaves you with that warm-n-fuzzy "we'll-help-them-fix-their-problems," even though 99% of their failures are failures of practices they should already be experienced in before they are granted a license. It is part of the "kid-gloves," don't be-so-hard-on-the-poor-poor-nursing-homes" from the Bush administration.

State Surveys are independent evaluations of nursing facility performance. Annual surveys are conducted by state survey agencies, usually the state's department of health, using protocols, procedures, and forms developed by the Centers for Medicare & Medicaid Services (CMS). A consumer concern about surveys is the repeated finding by the Governement Accountability Office (GAO), in a series of reports issued since 1998, that surveys understate deficiencies and cite deficiencies as less serious than they actually are. The survey component of CMS's proposed ranking system provides a more positive statement about quality than justified. States are increasingly using their state enforcement systems, instead of the federal system, to sanction facilities for noncompliance with standards of care. State enforcement actions do not appear on Nursing Home Compare. The National Senior Citizens Law Center recommends that consumers use the new rating system with caution, and only as an aid while also pursuing other information and strategies. Consumers need to understand that the five-star system is a beginning, not an end. A nursing home's quality can shift from month to month, so you have to be savvy in asking the right questions. Existing residents and their family members should be asked for their opinions. Inspection data is mostly based on a once-a-year survey and may not accurately reflect the nursing home's performance today. Staffing information and quality measures are "self-reported" data by the nursing homes themselves. Self-reported data makes nursing home quality "appear" to be better than it actually is. It cannot easily be reduced to a star rating. A recent GAO study found that nursing homes over-report staffing levels compared with staffing reported on audited Medicaid cost reports. Over-reporting of nursing coverage is associated with for-profit ownership of nursing homes. Researchers recommend more careful scrutiny of staffing levels in for-profit facilties during the survey process and that improvements be made to the process of public reporting of staffing levels. CMS should provide more and better information on Nursing Home Compare, including links to the actual survey forms and information about staff turnover. Also, CMS should use payroll data to report staffing information. Anything to do with "quality indicators" is bogus. When de-regulation failed under the present adminitration, they wanted, among other things, the "quality indicator" process to eventually replace traditional annual surverys because it relies upon self-reported, unaudited data supplied by the facilities themselves and is without consequences for failures. It leaves you with that warm-n-fuzzy "we'll-help-them-fix-their-problems," even though 99% of their failures are failures of practices they should already be experienced in before they are granted a license. It is part of the "kid-gloves," don't be-so-hard-on-the-poor-poor-nursing-homes" from the Bush administration.

Nursing home residents (including any cancer patients) are already supposed to be receiving 24/7 care. The hospice service is an additional $130 a day the home receives. Because Medicare does not collect detailed data about the medical treatments a hospice patient receives, there is very little information about what services are actually being provided. Neglect is the silent killer in nursing homes. By some estimates, malnutrition, dehydration, bedsores and infection - caused by neglect - account for half of nursing home deaths and injuries. A recent indication of negligent care for cancer patients at nursing homes involved a woman in Pennsylvania who was put on the chemotherapy drug Nexavar. Its side effects include decreased blood flow to the heart, heart attack and high blood pressure. The woman was supposed to get emergency care immediately if she started to exhibit any signs of the side effects. The woman reported a dull heavy chest pain and a severe band-like pressure around her head. Her blood pressure (200/123) was far higher than normal. There was no evidence that a physician was contacted about the situation. Later, a physician said she would have sent the woman to a hospital emergency room immediately. Instead of calling the physician or getting the woman to the emergency room, the nursing home nurse gave the woman her scheduled dose of painkiller. Two hours later, the woman was found face-down in a small puddle of blood. The home was cited for violating regulations relating to quality of care, management, patient rights, records and more. The home had previously been cited for similar violations. There would be a much higher level of care given to residents if adequate staffing were provided. But, "for-profit" nursing homes, the desire for profit margins translates into less staffing at nursing homes, less training for the staff that they do have, less food (or a lower quality of food) for the residents, and less management and oversight. A conflict arises between saving dollars and providing good care. Administrators benefit from the amount of profit generated by the nursing home they manage, usually paid annual bonuses based on bed-count. They must choose between increasing the profit margins of their individual facilities or supplying more support staff for the care of residents. Even nursing home abuse may occur because of the desire for profit. Caregivers who work in nursing homes are often stretched beyond their ability. They try to do the best job that they can, but the lack of additional support restricts what they can do to help residents. The House Energy and Commerce subcommittee on oversight and investigations had not held an oversight hearing about nursing home care since 1977. The last significant change in nursing home regulations was the Nursing Home Reform Act of 1987. Now is the time for caregivers of loved-ones in a nursing home, to call/write their federal legislative representatives to pass the "Nursing Home Transparency and Quality of Care Improvement Act of 2008," with "mandatory staffing levels" put back into the bill.

Improve transparency and accountability in the ownership and operations of nursing homes Corporations would be required to disclose their owners, operators, financers, and other related parties. Facilities that were part of chains would be required to submit annual audits. Purchasers would have to demonstrate that they were financially able to run facilities. Require disclosure of how Medicare and Medicaid funds are spent Providers would have to report wage and benefit expenditures for nursing staff on cost reports. Cost reports would be revised to categorize spending for direct care, such as nursing and therapies; indirect care, such as housekeeping and dietary services; capital costs, including buildings and land; and administrative costs, which often include the company's profits. Establish independent monitoring of chains The federal government would develop a protocol for an independent monitor of chains to analyze their financial performance, management, expenditures, and nurse staffing levels. It would provide for corrective action and collection of civil monetary penalties. Collect accurate information about nurse staffing The government would collect data electronically from nursing homes on the number of RNs, LPNs, and nursing assistants, using payroll records and contracts with temporary agencies as the source. Data would include turnover and retention rates and hours of care per resident provided by each category of worker. Provide better public information about nursing homes Nursing Home Compare would be updated with more timely reporting of surveys; ownership information; accurate nurse staffing data, including turnover and retention rates; links to survey reports (Form 2567) when states put them online; enforcement actions; and all Special Focus Facilities identified for three years. The government would undertake a study on how to improve the website to make it more useful and understandable. Implement new consumer complaint processes The government would develop a standardized form consumers could use in filing complaints with the state regulatory agency or ombudsman. States would be required to establish a complaint resolution process for residents' representatives who were retaliated against, including denied access to residents, if they complained about quality of care or other issues. Provide for higher civil monetary penalties and other CMP reforms Federal civil monetary penalties would be increased for the first time since the 1987 Nursing Home Reform Act - up to $100,000 in the case of a resident's death. Fines would be held in escrow during appeals of deficiencies, no longer delayed until appeals were resolved. Federal CMP funds, which are now returned to the U.S. Treasury, are encouraged to be used for the benefit of residents. Provide for reporting of closures and continuation of federal payments Nursing homes would be required to give 60 days notice of closure, including a relocation plan and assurances that residents would be transferred to the most appropriate facility or other setting. No new residents could be admitted after the notice was given, and the federal government could continue Medicare and Medicaid funding for residents until relocation was completed. Authorize studies of temporary management; special focus facilities; culture change; and nurse aide training The bill provides for studies of temporary management; the characteristics of Special Focus Facilities, including ownership; best practices in culture change; and training of nurse aides and supervisors. Dementia management would be added to the initial 75-hour nurse aide. The one provision that is utmost important is "Mandatory Staffing Levels." That provision was taken out of the bill, probably thinking that it had a better chance of being approved without it. It needs to be put back in! Many states fought twenty world-wars to get mandatory staffing levels, even then, it was constantly being attacked. In one state, when there was a possibility of cutting Medicaid funding, the industry jumped at the chance to use that funding cut as an excuse to abandon the staffing level requirements. Federal law only requires nursing homes to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident, and we know this is insufficient. There have been numerous federal bills requiring various mandatory staffing levels, only to be defeated or die on the vine. Now is the time for those mandatory staffing levels!

Elderly nursing home residents receive relatively few cancer care services, according to a study published in the Journal of the National Cancer Institute. Few studies have examined cancer treatment and care among elderly patients residing in nursing homes. Yet, as the population ages, more people will move into nursing homes, many of whom will later be diagnosed with cancer. Cancer risk increases as people age. http://www.sciencedaily.com:80/releases/2007/12/071226004314.htm Congress has introduced the "Nursing Home Transparency and Quality of Care Improvement Act of 2008." The bill increases the transparency of nursing home ownership, ensures that residents and their families have information about the quality of care at these facilities, and strengthens enforcement of nursing home compliance with quality of care standards. The Nursing Home Act enables nursing home residents and government regulators to better know who actually owns the nursing home and who controls the decision-making that impacts the quality of care provided. In addition, the bill improves the reporting of information on staffing levels and direct patient care expenditures. http://www.bestsyndication.com:80/?q=20081017_nursing_homes_legislation.htm

Benign Neglect and the Nursing Shortage http://www.thehealthcareblog.com/the_health_care_blog/2007/08/why-do-we-have-.html The nursing shortage, with UPDATE from The Industry Veteran http://www.thehealthcareblog.com/the_health_care_blog/2004/07/quality_the_nur.html Why We Don't Have Enough Nurses http://www.thehealthcareblog.com/the_health_care_blog/2007/10/why-we-dont-hav.html Advice to future nurses http://www.thehealthcareblog.com/the_health_care_blog/2008/05/advice-to-futur.html