s Rationing Healthcare | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

Comments: 1

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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Rationing Healthcare

Steve Jenkin

articles by this author...

Steve Jenkin has spent 40 years in ICT in a wide variety of roles and systems.
He developed an interest in Quality and Turnarounds, "Working Smarter" and reducing wasted effort.
From working in Telecommunications, he was imbued with the notion of "Client First" and owing a "Fiduciary Duty" towards clients, as underlies Medicine. His current interests include the intersection of Quality, Safety and I.T. in Medicine and Healthcare.

What level of Individual Responsibility do we each have in managing our Health and Well-Being, given that 40% of "total health" is due to lifestyle choices and behaviour and only 10% Healthcare Delivery? [1]
How much "free" healthcare, taxpayer funded, are we prepared to give individuals?
Should we limit it?
How?
Unlimited Free Goods guarantee unlimited demand for them.

The typical rationing systems are "cost-shifting", like co-payments or insurance "gaps", or under-servicing through crowding, delays and queues. The George Institute recently cited 11% of Australian Bankruptcies are due to ill-health or lack of health insurance. One 52-yo breast cancer survivor was left with $31,000 in medical bills not covered under Medicare [7]

The Oregon Health Plan explicitly addresses rationing through a multi-pronged approach. [2][3]
One avenue is the Priority list: only the most important 90% of conditions are treated and fully funded.
Another are their policies limiting spending when it will yield negligible benefit:

410-120-1200 (l) That are requested by or for a Client whom OMAP has determined to be non-compliant with treatment and who is unlikely to benefit from additional related, identical, or similar services; [4]

Guideline note 12, treatment of cancer with little or no benefit provided near the end of life.
This guideline only applies to patients with advanced cancer who have less than 24 months median survival with treatment. [5]

Their current "Action Plan" [6] has 8 Foundational Strategies to achieve their Triple Aim:

* Improve the lifelong health of all Oregonians 
* Increase the quality, reliability and availability of care for all Oregonians 
* Lower or contain the cost of care so it is affordable for everyone

Prevention is now their top Medical priority:

* Weight Loss programs and counselling, especially for Diabetics, are paid-for, but bariatric surgery isn't available, nor are supplements.
* Drug and Tobacco addiction-breaking programmes are supported.
* Many specific programs for identified High Risk groups with well known conditions.

So in Oregon, the ever-growing and popular "Pharmacy weight loss programs" won't be State subsidised.
After 6 months of counseling, if you're not losing weight, funding stops.

This strategy of focusing on the biggest determinants of health, on every-day actions and lifestyle choices that people make, seems worthy of investigation. Like "Weight Loss" and "Quit" (smoking) programmes, a whole range of useful ancillary Health Products and Services could be delivered through Pharmacies: they are accessible in the community, have high social trust/standing, have trained specialist staff and already deliver similar Goods and Services.

We know the mind is powerful over itself: Hypnosis demonstrates this with 10-15% of people "highly suggestible" and candidates for anesthetic-free procedures.
An ABC program recently reported an interesting line of research at Macquarie University using hypnosis to produce temporary and reversible "delusions" and obsessions in subjects, so they could be studied at will. The differences in brain function within an individual with/without a condition could be studied. [12]

An emerging field of Immunology, Psychoneuroimmunology [8], describes the links and their mechanisms between our brains, psychological state and immune system. It seems the Mind is also powerfully connected to our Body and Immune system.

The adverse effects of stressors on Health has long been known and proven, forming the basis of successful non-traditional medical approaches, e.g.:

* Dr Jon Kabat-Zin, "Mindfulness Based Stress Reduction" (MBSR) [9]
* (Dr) Patch Adams, 40 years of clowning: happy people heal quicker and better [10]
* laughter clubs: faking smiling and laughing induce the real emotions, reducing stress and improving Health and Healing [11]

All these medical approaches have been researched, published and shown to work. They aren't new, untried or untested. (I've not researched the impact of Hypnosis or Self-Hypnosis on reducing stress, increasing well-being and Health, though you might think there'd be a link, especially for the "highly suggestible".)

This medical evidence is distinct from the wholistic mind-body meditation and nutrition programs for cancer sufferers, such as Ian Gawler's programs. It's medicine as if people matter.

These approaches support the statistics that people in loving relationships and those with a "faith" live longer, are healthier and have a higher quality of life. Is the converse necessarily true: those who are constantly angry, judge others and are "grumpy old people" have more disease and lower lifespans? I don't have the data nor statistical competency to answer that question.

I'd stop a very long way short of saying that people that don't actively manage their stress, don't have a strong belief system and loving relationships are harming themselves, are the agents of their own disease, even though this message may be inferred from the evidence.

Should rational Healthcare Authorities be insisting on individuals taking responsibility for the 40% of their health outcomes within their control with lifestyle & behaviour choices? Why medically treat conditions once they've formed, and with 400% less efficacy, when they can be prevented for little or no cost to the system?

Should those rational Authorities should be requiring of individuals, especially those predisposed to serious conditions, undertaking Evidence-based approaches to Stress Reduction and promoting Health and Well Being?

That sounds reasonable and medically and financially sound to me, not to mention a whole new line of products and services for Pharmacies. The clincher would be to get more regional Healthcare Authorities to follow the OHA and embrace active Prevention as their primary medical strategy. It's backed by incontrovertible evidence that it is the cheapest, most effective and least intrusive/injurious medical treatment possible.

Along these lines, I've always wondered at the lack of research, the seeming disinterest by the medical and research community, into two of the most well documented, effective and least understood healing mechanisms of the human body:

* Placebo Effect, and
* Spontaneous Remission

Perhaps psychoneuroimmunology has some of the answers...

For some people, is disease All in the Mind? Or is it everyone? How could we even tell?

The Mind healing the Body when it can, would be the ultimate non-invasive, non-injurious and effective medical treatment.
But because you can't bottle it, patent it or limit access to it, economics suggests it won't be investigated or solved anytime soon.

Medical Science likes to be able to replicate results to prove causality: how do capture this lightning in a bottle?
How does Science investigate and discover the mechanisms of cures, not just treatments, that are unpredictable and, by definition, one-off?

It isn't impossible, but the current methodologies don't take us there.


REferences and Links:

"It's all in the Mind, you know" was a catchphrase of the BBC's Goon Show.

1. Figures cited by Dr Brent James in "Managing Clinical Processes: Doing Well by Doing Good".

Contributors to Good Health. Slide 9 "Total Health: How long, how well we live":

40% - Behaviour under control of the Individual (loosely, 'lifestyle choices'). Tobacco, Alcohol, Movement Deficit Disorder [humour!]
30% - Genetics
20% - Environment and Public Health
10% - Health care Delivery (Hospitals and Clinics)

sources:

McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10).
McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).

2. A Brief History of Health Services Prioritization in Oregon
http://sboh.wa.gov/goals/access/documents/OregonHealthSvsPrior.pdf

3. Medical Necessity and Defined Coverage Benefits in the Oregon Health Plan
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380952/pdf/amjph00505-0167.pdf

4. http://www.dhs.state.or.us/policy/healthplan/history/genrules/120rb0106.pdf

5. http://www.oregon.gov/oha/OHPR/HERC/docs/L/Oct2012/Oct12List.pdf

6. Oregon Health Authority 2010 Action Plan

http://www.oregon.gov/OHA/Pages/action-plan/index.aspx
http://www.oregon.gov/oha/action-plan/rpt-2010.pdf

Strategy #1 – Use purchasing power to change how we deliver and pay for health care
Strategy #2 – Shift focus to prevention
Strategy #3 – Improve health equity
Strategy #4 – Establish a health insurance exchange to make it easier for Oregonians to get affordable health insurance
Strategy #5 – Reduce barriers to health care
Strategy #6 – Set standards for safe and effective care
Strategy #7 – Involve everyone in health system improvements
Strategy #8 – Measure progress

7. Medicare rebates don't keep up with inflation and families struggle with medical bills
http://www.dailytelegraph.com.au/news/sydney-news/medicare-rebates-dont-keep-up-with-inflation-and-families-struggle-with-medical-bills/story-e6freuzi-1226518805473

8. Wikipedia on Psycho-neuro-immunology, including links between stress and disease
http://en.wikipedia.org/wiki/Psychoneuroimmunology

9. Wikipedia on MBSR:
http://en.wikipedia.org/wiki/Mindfulness-based_stress_reduction

2003 meta-review conclusion:

Our findings suggest the usefulness of MBSR as an intervention for a broad range of chronic disorders and problems.

Mindfulness-based stress reduction and health benefits. A meta-analysis.
Grossman P, Niemann L, Schmidt S, Walach H.
http://www.ncbi.nlm.nih.gov/pubmed/15256293

10. Patch Adams Mission:
http://www.patchadams.org/mission

... holistic medical care based on the belief that one cannot separate the health of the individual from the health of the family, the community, the world, and the health care system itself.

Gesundheit’s model is designed to protect care as the core of the medical interaction.

Our model is organized around these principles:
* Care is free.
* Patients are treated as friends.
* Ample time is given to the care interaction (e.g. initial interviews with patients are 3 hours long).
* All complementary medicine is welcomed.
* The health of the staff is as important as the health of the patients.
* Care is infused with fun and play.

11. Laughter Yoga, Indian physician Madan Kataria
http://en.wikipedia.org/wiki/Laughter_Yoga
http://laughteryoga.org/index.php?option=com_content&view=section&layout=blog&id=16&Itemid=266

News, including research articles:
http://laughteryoga.org/index.php?option=com_content&view=category&layout=blog&id=125&Itemid=275

From: http://laughteryoga.org/index.php?option=com_content&view=article&id=7439:new-laughter-yoga-research-from-australia-for-workplace-wellbeing&catid=125:latest-&Itemid=275

A new study, recently conducted by Deakin University's School of Psychology, on the effects of Laughter Yoga found that it has a real and positive effect on workplace wellbeing weeks after laughter sessions are finished.

12. ABC Radio National:  Delusions for Research http://www.abc.net.au/radionational/programs/allinthemind/hypnotic-delusion/4373812

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