Urologists Threaten the Autonomy of the U.S. Preventive Services Task Force

Over at HealthNewsReview.org  Gary Schwitzer has published a disturbing piece that looks at American Urological Association support for a bll that would make “significant changes to the U.S. Preventive Services Task Force.”

The guest post is written by Dr.Richard Hoffman, who is both one of HealthNewsReivew’s reviewers, and an editor at the Informed Medical Decisions Foundation a group that promotes “shared decision making.”   The Foundation, which was co-founded by Dr.Jack Wennber, the father of the Dartmouth Reserach,uses medical evidence to produce outstanding videos, pamphlets and web-based programs that help patients understand the potential risks and benefits of  elective surgeries and tests..  (I have written about “shared decision making” in past posts ). 

Below, an excerpt from Hoffman’s piece:

“Last week, the Supreme Court largely upheld the Affordable Care Act. Two weeks ago, legislation (H.R. 5998) was introduced that threatens the autonomy of the U.S. Preventive Services Task Force.

“The legislation proposes to mandate a more transparent process for guideline development, a greater role for specialists and advocacy groups, and eliminating the Department of Health and Human Services’ secretarial discretion to withhold Medicare funding for interventions that lack convincing evidence for benefit The legislation, which comes on the heels of the Task Force’s controversial D rating against prostate cancer screening, is strongly supported by several prominent urological associations. 

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A New Team at the FDA — Sharfstein’s Critics

Over the week-end, when I heard that President Obama had selected Margaret  Hamburg as FDA commissioner and Joshua Sharfstein as deputy commissioner, I began Googling “Sharfstein.”  I already had read about Hamburg and I knew the former New York City health commissioner has earned very high marks. 

But I didn’t know much about Sharfstein. So my heart sank when I read this in the “Comment” section of yesterday’s Guardian: “Although Dr Margaret Hamburg, the nominee for commissioner, boasts significant experience in government and is highly thought of in the public health community, her new deputy, Dr. Joshua Sharfstein, is an inconceivably poor choice.”

Reportedly, Sharfstein is going to be the point man regulating drugs and devices. Meanwhile Hamburg  will ovesee food safety and tobacco—if the agency wins some control over the substance. (According to the Wall Street Journal, a bill that puts tobacco under FDA regulation seems poised for passage next session).  Given how the FDA’s work will be divided, Sharfstein’s appointment becomes extremely important. Indeed,  the “Comment” in the Guardian notes: “from the vantage point of industry and patients, this would make Sharfstein a far more influential figure than his nominal boss – but without requiring confirmation by the Senate.” Here they seem to be implying that the Obama administration is trying to slip a weak candidate past the Senate.

But then the article’s authors, Jeff Stier and Henry Miller set out to explain why they object to Sharfstein. And at this point, I begin to smile.They portray Pharma as an industry that has been bullied, by the government and the press: “The new FDA leadership must  confront a trend that has become popular – especially among members of Congress and the media – of vilifying drug companies, and even alleging that regulators have become too cosy with industry.”  Imagine that.

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Open Question: Should Physicians Be Involved in Lethal Injection?

In the newest issue of JAMA, two authors affiliated with the AMA offer their opinions on physicians’ role in implementing the death penalty via lethal injection. Hint: they don’t approve of it.

The article says that unlike other methods of execution, lethal injection “has elements of medical practice: insertion of intravenous lines, intravenous injection of medicinal drugs, and monitoring vital signs.” Small wonder then, that 35 of the 38 states that allow the death penalty either require or permit physician participation in executions.

Typically the identity of physicians who participate in executions is held confidential by state authorities. Even if they are made known, licensing boards in death penalty states have trouble taking any action against physicians who participate in executions. Since the boards deal with illegal activities, they can’t crack down on physicians who participate in executions that are legal.

But medical societies have more wiggle room. AMA prohibits involvement of physicians in executions, saying that it goes against the physician’s role as a healer. As the authors put it, “any form of participation in causing death by lethal injection is unethical because it violates the physician’s role, thereby undermining trust….the penal system, not the medical profession, is responsible for finding a way to perform executions.”

Obviously this issue has a certain degree of timeliness, given the Supreme Court’s recent agreement to hear challenges to lethal injection on the grounds that the process often gets so mucked up that it constitutes cruel and unusual punishment. But I think the JAMA piece is right in addressing it as a big-picture best practices question. This is primarily a moral question.

And it’s a tough one, even for physicians who might support capital punishment in the criminal justice system. Just because they believe that murderers should die, it doesn’t follow that they feel criminals do or do not deserve a demise that is as painless as possible. Supporting capital punishment and consenting to having a hand in it are two very different things.

So imagine you’re a doctor and the state has asked you to preside over
an execution that will go on with or without a physician present.
What’s your medical duty—to try to ensure that things go smoothly and
spare the inmate unnecessary pain, or abstain from attending because
your presence would mean you were participating in taking a life? Which
choice is truer to the physician’s duty to be a healer?

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Donating an Organ: Should It Be A Gift?

A story in yesterday’s New York Times Magazine raised some very thorny questions about organ transplants. I spent the afternoon reading more about transplants; by evening I had stumbled onto what seems to me at least a partial solution.

The NYT piece tells the story of Sally Satel, a 49-year-old psychiatrist in need of a kidney transplant. In 2004, her kidneys suddenly, quite inexplicably, began to fail. (The cause may have been a medication she had taken in her twenties.)  She had no living relatives except a couple of cousins whom she rarely saw. A close friend came forward, was tested, found that her blood was a match, volunteered to donate a kidney–and then reneged. (It turns out that when she went to chorus practice one evening, “a fellow alto” talked her out of it. The fellow-alto was, of all things, an organ transplant specialist. Satel was enraged: “a transplant surgeon should know how hard it is to get a donor.”)

A second friend volunteered, and again proved a match. But then she, too, got cold feet– though she didn’t tell Satel right away.

Finally, a 62-year-old stranger in Canada saw Satel’s message on an organ match website, called and offered to help her.  He was the right blood type, he seemed “steady” and “honest,” and after a few weeks of phone calls and e-mails, they set a date to do the operations in early January. Then, just before Thanksgiving, he went dark. “Everything turned to radio silence as my e-mail and phone messages went unanswered,” Satel recalls. When her transplant coordinator contacted him, he waffled. He wasn’t sure he would be able to make it in January; he was too heavily involved in a political campaign…

“I was astonished at the Canadian’s . . . what? Negligence, cowardice, rudeness?” Satel writes. “It was a sickening roller-coaster ride: hope yielding to helpless frustration, gratitude giving way to fury. How dare he reduce me to groveling and dependence? Yet I assume he intended no such thing. I think the Canadian was actually quite devoted to the idea of giving a kidney — just not necessarily now or to me.”

By now Satel is desperate. She realizes that her only alternative is dialysis “three days a week, for four debilitating hours at a time, I would be tethered to a blood-cleansing machine… I had an especially morbid dread of dialysis,” Satel admits.  She was haunted by what she had read about “the playwright Neil Simon [who] received a kidney from his longtime publicist in 2004 . . .but before that he endured 18 wretched months on dialysis, suffering cramps and vomiting spells that kept him largely confined to his house. His memory deteriorated, and he hated the time away from his writing. Shortly before his donor came forward (unsolicited, it should be noted), Simon’s doctors said he might have to start spending more time on dialysis. If that were necessary, he said, he had decided, ‘I didn’t want to live my life anymore.’ Neither, I thought, would I.”

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Pilots Use Checklists. Doctors Don’t. Why Not?

This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist” is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long” but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).

Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. “She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.” By then “she has a body temperature of 68 degrees—and no pulse.” A helicopter takes her to a near-by hospital. 
There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “

Slowly, over two weeks, she comes back to life. “Her right leg and left arm [are] partially paralyzed.  Her speech [is] thick and slurry.  But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.” 

“What makes her recovery astounding,” Gawande writes, is “the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of step correctly; placing the heart-pump tubing into her without letting in air bubbles, maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running” all the while “orchestrating each of these steps in the right sequence, with nothing dropped . . .”

This, Gawande says, is what happens in intensive care units, every day of the year, all across the country. “Intensive care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

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The Drug War versus Health Care

Yesterday President Bush gave a speech on the success of his drug policies in celebration of a new report showing that teen drug use has continued a decline that began in 1997. But it is not entirely clear that there is much cause for celebration: use of some of the most hardcore stuff—such as cocaine, crack, LSD, and heroin—has held steady over the past five years or so. True, recently the use of marijuana, amphetamines, and methamphetamines has dropped, but that’s hardly reason to declare victory in the war on drugs.

Like any good president, Bush wants to take credit for good news. But as the lack of progress in the battle against heroin and crack suggests, the U.S. is on the wrong track when it comes to drugs. Our institutional bias is still to see drug use and drug control as criminal justice issues when we should really be thinking about them as public health concerns.

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program. 

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Doctors Who Know Better—But Do the Wrong Thing

On Health Care Renewal , Dr. Roy Poses reports on a disturbing new study just published in The Annals of Internal Medicine contrasting physicians’ attitudes toward professional norms with their self reports of whether they acted in conformity with these norms.

Poses does an excellent job of summarizing, so I’m re-posting his piece in full below:

“In brief, the authors developed a survey which asked physicians whether they agreed with various professional norms organized according to the 2002 ABIM/ ACP/ ESIM Physician Charter. They also asked them about whether they acted in conformity with these principles in terms of their recent actions, or in responses to scenarios. Physicians surveyed were primary care practitioners (family medicine, general internal medicine, and pediatrics), cardiologists, anesthesiologists, and general surgeons. The overall response rate was 52%.

“In general, large majorities of physicians agreed with the ethical norms. How often they reported acting in agreement with these norms varied. In particular, nearly all physicians reported treating patients honestly (less than 1% reported telling a patient’s family member something untrue in the last 3 years, 3% reported withholding information from a patient or a family member.) However, although 96% agreed that "physicians should put the patient’s welfare above the physician’s financial interests," 24% would refer a patient to an imaging facility in which the physician was an investor, without revealing this conflict of interest.

“Some commentators suggested that external pressures may prevent
physicians living up to the standards they themselves have endorsed.
For example, physicians interviewed in a Washington Post article
suggested that the current emphasis on patient satisfaction may
conflict with the physician’s ethical obligation to avoid wasting
resources when a patient demands an unnecessary but not clearly harmful
test. The Congressional Quarterly reported
quoted the CEO of the Federation of State Medical Boards saying that
physicians "were penned in by the American the health care system,
fighting giant bureaucracies while fearing legal action if they make a
mistake."

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Healthcare IT Is Not a Done Deal—Even in Theory

In a previous post, I briefly mentioned how the U.S. Department of Health and Human Services has started developing regional networks of electronic health information. Eventually, these networks will merge into a “network of networks,” thus working toward a nationwide, compatible system of electronic health records by 2014.

Unfortunately this “network of networks” approach of regional heath information organizations (RHIOs) has some serious faults. And the alternative system currently favored by many, health record data banks, still poses a lot of unanswered questions.

According to an October report from the Information Technology and Innovation Foundation (ITIF), the major problem with RHIOs is coordination: “multiple, heterogeneous databases” require “the extensive use of middleware—that is, software used to interface between incompatible databases and data formats.” Otherwise it’s like trying to run Mac software on a PC. Other coordination challenges include accurate patient identification (is John Smith in the Bronx the same as John Q. Smith in Cleveland?) and ensuring comparable service quality—each network needs to be as fast and secure as its peers.

With all of these inefficiencies, the ITIF study notes that RHIOs don’t make a very compelling business case to the health care providers who are expected to implement and operate the networks. Most of the system’s savings go to patients (because they can expect better care) and insurers (because mistakes can be avoided) rather than hospitals and doctors, who incur all the costs of transitioning to a new IT platform—a fact of which they’re well aware. A 2006 JAMA study showed that health care providers are worried about IT transitions primarily because of start-up costs (installation, consultation, training, etc), ongoing costs (such as compliance with privacy laws—no small matter, given the ambiguity of HIPPA) and the potential loss of productivity as employees learn the new system.

In lieu of RHIOs, ITIF recommends health record data banks (HRDBs), a model that has gotten a lot of buzz over recent months—including its own bill in Congress last year.

The simplest way to explain HRDBs is via analogy: think of how you engage with a commercial bank account, and you’re on the right track. Just as you choose a bank from a competitive marketplace of financial institutions, so would you pick an HRDB provider from many vying for your business; just as you open a bank account, so would you start a medical record account; and just as you log in to access financial information, make transactions, and monitor your activity with a bank, so would the HRDB service let you sign in online to access to your medical history, test results, and so on.

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How the Media Covers Health Care

Sometimes health care reporters remind me of the financial journalists who helped hype the bull market of the 1980s and 1990s. I began my career as a journalist at Money magazine, and I remember sitting in an editorial meeting where we talked about an upcoming cover story: “The Ten Best Mutual Funds NOW.”  One intrepid reporter asked: “What if there aren’t ten great mutual funds that you really should invest in right now?”

“Let the fact-checker worry about that,” someone else quipped, referring to the person who would be double-checking the details of the story just before it went to press. Almost everyone sitting around the table laughed.

And Money was generally a pretty responsible magazine that tried to warn investors against the risks of the market. Still, “good news” cover stories sold magazines—just as “breakthrough” medical stories on the local evening news keep viewers from changing the channel.

Gary Schwitzer, an associate professor in the School of Journalism and Mass Communication at the University of Minnesota, recently published a provocative piece about how the media covers health care in the American Editor. Schwitzer begins his piece by asking his reader to “Imagine a reporter filing a story from the Detroit Auto Show. She writes about one car maker’s hot new model as if it is the best thing since the ’57 Corvette. But in the excitement over the chrome and style, she doesn’t mention the cost of the new model, doesn’t compare it with other manufacturers’ offerings in the same class, and doesn’t mention anything about performance (fuel efficiency, handling, braking, safety issues, etc.)

“An editor would certainly raise questions about this kind of puffery.

“But over on the health care beat,” Schwitzer observes, “the majority of stories on new products, procedures, treatments and tests are published without including comparable information. Claims that would never be accepted unchallenged from a politician are accepted unquestioningly from physicians and researchers and company spokespersons.”

Schwitzer, who publishes HealthNewsReview.org, a website that grades health care news stories for accuracy, balance, and completeness, has evidence to back up his claim.  Below I’ve re-posted some of his data on some 400 stories from almost 60 major news organizations (available at his website) to demonstrate how many health care stories “provide a kid-in-the-candy-store portrayal of the health care system that leaves readers with the impression that most products or procedures in health care are amazing, harmless and without a price tag”:

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The Best Health Care Posts

Check out this week’s Health Wonk Review, highlighting the best stories that have appeared on health care blogs in the past two weeks–including a post about “the sorts of people some pharmaceutical companies hire to perform clinical research . . . including one physician-researcher who managed to personally give two of his patients genital herpes . . .”

Health Wonk Review also throws a spotlight on Managed Care Matters, where Joe Paduda recently examined how US universal coverage plans could deal with illegal immigrants, but noted that meanwhile, Mexico may come up with a universal coverage system before the US does.

And on the Agonist Ian Welsh commented on John Edwards’ pledge that if Congress doesn’t pass universal health care by July 2009, “I’m going to use my power as president to take your [legislator’s]  health care away from you.” Time magazine’s Joe Klein was appalled, calling Edwards’ statement “demagogic nonsense.” Welsh disagrees. ( I would be interested in what Health Beat’s readers think.)

This week, Dr. Roy Poses picked the posts for Health Wonk Review.  The editor of Health Care Renewal, Poses specializes in “addressing threats to health care’s core values, especially those stemming from concentration and abuse of power.” 
I began talking to Poses before I started this blog, and I have the greatest respect for his work. He pulls no punches, and backs up his pieces on conflict of interest and fraud with excellent research.  Honest physicians know, better than anyone, what is going on in our health care system, and Poses is one of the guys carrying a torch.

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