Follow the Money

Many years ago there was a Federal whistleblower, Deep Throat, who leaked confidential Government information about the Nixon White House to reporters from the Washington Post. Fans of the book and movie will remember that his famous line was, “Follow the money.” That line came to mind when an article appeared in Health Affairs summarizing the US health care expenditures for 2010 (1). The main gist of the article is that the rate of growth in health care expenditures had slowed to only 3.9% and approximated the slowed growth from 2009 which was 3.8%. Previously the growth had been much larger averaging 7.2% from 2000-8 (2). The article points out that during recession expenditures usually slow but the expected decline in healthcare expenditures usually occurs far after the beginning of the recession. The authors state that the “lagged slowdown in health spending growth from the recent recession occurred more quickly than was the case in previous recessions. This was the result of a combination of factors, including the highest unemployment rate in twenty-seven years, a substantial loss of private health insurance coverage, employers’ increased caution about hiring and investing during the recovery, and the lowest median inflation adjusted household income since 1996.”

Following Deep Throat’s suggestion to follow the money, healthcare expenditures are listed below in Table 1.  

Table 1. Cost, growth and increase of health care expenditures 2010 compared to 2009 arranged from greatest to least percent growth.

*Calculated as the product of cost X percent growth.

The categories accounting for the largest dollar increase in expenditures appear to be net cost of health insurance, hospital costs and physician and clinical services. Although the article in Health Affairs has a fairly comprehensive discussion of each expenditure, the exact definitions of these categories were unclear. A little searching revealed that net cost of health insurance is calculated as the difference between calendar-year incurred premiums earned and benefits paid for private health insurance (2). This includes expenses such as personnel, executive bonuses, marketing, advertising, etc., but also includes profit. Health insurers average about 20% of their premiums going for expenses and profit (3). It is estimated that about 1-10% of the health insurance premiums go to profit (3). This would translate to about 10-50% of the net cost of health insurance going for profit or about 1.2-6.1 billion in costs during 2010.

A second cost was hospital care costs which accounted for nearly 40% of the increase in expenditures. “Hospital care is a summation of incurred benefits for inpatient hospital care, outpatient hospital care, and hospital-based hospice, hospital-based nursing home care and hospital-based home health care. Also included in hospital care are estimated ’combined billing’ amounts for services of hospital-based physicians…” (2). Examining this definition, administrative costs are glaringly missing. In 1999, administrative costs accounted for 24.3% of hospital expenses and were increasing (4). Conservatively assuming that the same percentage of administrative costs account for the increase in expenditures, this 24.7% would translate to about 9.7 billion in 2010.

Physician and clinical services includes offices of physicians and outpatient care centers, plus the portion of medical and diagnostic laboratories services that are billed independently by laboratories. Physician services account for 81% of these expenditures, but this portion of the physician and clinical services grew only 1.8% in 2010. Recalculating using 81% of the 515.5 billion for physician and clinical services and a 1.8% increase, the increase in expenditures for physician services accounted for 7.5 billion. According to the article in Health Affairs, 2010 was a year when people decided to forgo care, slowing growth in elective hospital procedures, the number of prescriptions dispensed, and physician office visits (1). In other words, less healthcare led to a slowing of expenses.

The above data suggest that physicians account for only about 16% of the healthcare costs and their portion of the healthcare pie seems to be decreasing compared to other healthcare expenditures. To control healthcare costs but not decrease healthcare, policymakers need to focus on those areas of expenditures that account for much of the increase in cost, and especially those that provide no healthcare product. Cuts in the net cost of health insurance and hospital administrative costs would seem two areas where considerable cost savings could be achieved with little to no reduction in patient care.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Martin AB, Lassman D, Washington B, Catlin A; the National Health Expenditure Accounts Team. Growth In US Health Spending Remained Slow In 2010; Health Share Of Gross Domestic Product Was Unchanged From 2009. Health Aff (Millwood) 2012;31:208-219.
2. https://www.cms.gov/NationalHealthExpendData/downloads/dsm-10.pdf (accessed 1-17-12).
3. http://thinkprogress.org/health/2009/08/05/170897/are-health-insurers-making-too-much-money/?mobile=nc (accessed 1-17-12).
4. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-75.

Reference as: Robbins RA. Follow the money. Southwest J Pulm Crit Care 2012;4:19-21. (Click here for a PDF version of the editorial)

Happy First Birthday SWJPCC!

With the end of 2011, the Southwest Journal of Pulmonary and Critical Care (SWJPCC) completed its first full year of operation. Planning for SWJPCC began in August, 2010 and our first manuscript was posted on November 11, 2010. This has been a year of growth. We posted 8 manuscripts our first year and 68 this year (Table 1).

Table 1. Postings by SWJPCC 2010 and 2011.

 

We had manuscripts submitted from each fellowship programs in the Southwest (Phoenix, Tucson, Albuquerque and Denver) but also received submissions from outside the Southwest including from foreign countries such as the UK, India and Boston (which views itself as a separate country). Our readership has also steadily grown from 30 unique IP addresses in November, 2010 to nearly 1000 during December, 2011 (Figure 1, Panel A). Accompanying this increase in uniques has been an increase in the number of page views (the number of files that are requested from a site, also known as “hits”, Figure 1, Panel B).

Figure 1. Panel A. Unique IP addresses accessing the SWJPCC site by month. Panel B. Page views accessing the SWJPCC site by month.

With the increase in manuscripts we have expanded the number of associate editors from the original 5 to 13 with representatives from each pulmonary fellowship in the Southwest. For a list of editors click here.

Overall, this has been a good start and many need to be thanked. First, thanks to our authors. You took a chance on a new journal and we appreciate the opportunity to publish your work. Second, thanks to our reviewers.  SWJPCC, like all journals, relies upon expert reviewers in order to publish the highest quality manuscripts. We thank the reviewers for their time and effort in the prompt submission of their reviews. A list of reviewers for 2011 is below.

• Owen Austrheim
• David Baratz
• Richard Gerkin
• Michael Gotway
• Manoj Mathew
• Vijaychandran Nair
• Jennie O'Hea
• Lilibeth Pineda
• Francisco Ramirez
• Robert Raschke
• Patricia Rocha
• John Roehrs
• Clement Singarajah
• Linda Snyder
• Gerald Swartzberg
• Allen Thomas
• Carolyn Welsh
• Lewis Wesselius

Several are deserving of special thanks. First, our gratitude goes to the Arizona Thoracic Society (AZTS). We are the only local thoracic society who publishes a journal and SWJPCC would have not been possible without the support of AZTS members and officers including Rick Helmers, George Parides and Mary Kurth. Second, thanks to Eric Reece, our webmaster, who set up the journal, registered the domain, etc. and who continues to serve as a consultant. Third, a personal note of appreciation to Stuart Quan whose experience as editor of Sleep has been invaluable in guiding us through the development of SWJPCC. Fourth, SWJPCC acknowledges the Phoenix Pulmonary and Critical Care Research and Education Foundation who has provided the monetary support for SWJPCC. Last, and most importantly, thanks to our readers. Please visit as often as you can and feel free to provide us with your input. The journal is for you and we will strive to do our best to fulfill your needs.

Richard A. Robbins MD, Editor, SWJPCC

Reference as: Robbins RA. Happy first birthday SWJPCC! Southwest J Pulm Crit Care 2012;4:1-3. (Click here for a PDF version) 

The Hefty Price of Obstructive Sleep Apnea

Reference as: Budhiraja R. The hefty price of sleep apnea. Southwest J Pulm Crit Care 2011;3:169-71. (Click here for a PDF version)

Obesity is approaching an epidemic level in the United States. The association between obesity and obstructive sleep apnea (OSA) is quite strong and likely causal. Approximately half of obese individuals have OSA and the risk of OSA increases with increasing BMI. Conversely, majority of individuals with OSA are obese. However, whether this relationship is bidirectional and OSA can, in turn, contribute to obesity is unclear.

The study by Brown and colleagues in the Journal attempts to answer this question ¹. The authors analyzed prospectively obtained data from a large community-based cohort and found that the participants with more severe sleep disordered breathing at baseline demonstrated a modest increase in body mass index (BMI) over a 5 year follow up period.

What can these intriguing results be attributed to? Pathophysiology of obesity is a multifactorial and complex process and may include dietary, lifestyle and genetic components.  As the authors hypothesize, an alteration in leptin-ghrelin levels in OSA may contribute to obesity. However, independent effect of sleep apnea on these metabolic hormones is still not clear. Studies in OSA, in contrast to those with sleep deprivation, actually suggest increased daytime leptin levels, primarily explained by obesity ². Similarly, contradictory data exist regarding ghrelin levels in OSA. While some studies demonstrate an increase in ghrelin levels ^{3, 4}, others do not ^{5, 6}. A decrease in energy expenditure is a plausible mechanism whereby OSA may lead to further weight gain. It is easily fathomable that disturbed sleep in obese people may contribute to daytime fatigue and lethargy and promote a more sedentary lifestyle.  However, convincing data from large studies confirming such an association is again lacking. Finally, an altered feeding behavior with a preference for a weight-gain promoting diet may be seen in sleep disordered breathing and contribute to obesity ⁷.

The strengths of this study include a large sample size derived from community-based cohorts, prospective collection of data and objective documentation of sleep abnormalities. However, the readers should bear in mind that the adjusted increase in BMI was fairly modest- in order of 0.21 kg/m² in those with mild OSA and 0.51 kg/m² in moderate to severe OSA. Furthermore, the statistical models used in the study accounted for only 7% of the total variance, suggesting that the factors not included in analysis likely played a prominent role in the weight gain.

Nevertheless, this study adds to emerging literature suggesting SDB as a risk factor for weight gain ^{8, 9}. Ideally, these data suggest need for well conducted prospective studies looking at physical activity, diet and change in BMI in patients with SDB. However, in view of the now well recognized adverse effects of severe sleep apnea, it will not be feasible to conduct long-term studies in these patients without offering treatment.  The other line of evidence that would support the hypothesis that sleep apnea predisposes to weight gain, would be weight loss with adequate therapy. Indeed some studies have assessed this, but with variable results ^10-12. Some of the factors underlying such variability in results may include differences in dietary habits, physical exercise, age of the participants, sleep duration, use of medications and presence of additional comorbidities ¹³. Future studies, apart from controlling for these variables, should also consider evaluating changes in central obesity instead of, or in addition to BMI, as the former may be a better marker of adverse cardiovascular outcomes than BMI ¹⁴.

Finally, obesity is a risk factor for an array of cardiovascular and metabolic adverse outcomes. This study provides further rationale to add abnormal sleep to unhealthy diet and lack of exercise as crucial factors that need to be modified to curb the obesity epidemic. Further longitudinal and interventional studies are required to help confirm these observations and assess the impact of better sleep on health outcomes.

Rohit Budhiraja, M.D.^{1, 2, 3}

Associate Editor

Southwest Journal of Pulmonary and Critical Care 

¹ Department of Medicine, Southern Arizona Veterans Affairs Health Care System (SAVAHCS) , Tucson, AZ

² Arizona Respiratory Center, The University of Arizona, Tucson, AZ

³ Department of Medicine, University of Arizona College of Medicine, Tucson, AZ

Corresponding Author:

Rohit Budhiraja, MD

Southern Arizona VA HealthCare System,

3601 S 6^th Ave,

Tucson, Arizona 85723

rohit.budhiraja@va.gov

Phone: 520-331-2007

Fax: 520-629-4641

References

1. Brown MA, Goodwin JL, Silva GE et al. The Impact of Sleep-Disordered Breathing on Body Mass Index (BMI): The Sleep Heart Health Study (SHHS). Southwest J Pulm Crit Care 2011;3:159-68.
2. Sánchez-de-la-Torre M , Mediano O, Barceló A et al. The influence of obesity and obstructive sleep apnea on metabolic hormones. Sleep Breath 2011 Sep 13. [Epub ahead of print]
3. Harsch IA, Konturek PC, Koebnick C et al. Leptin and ghrelin levels in patients with obstructive sleep apnoea: effect of CPAP treatment. Eur Respir J. 2003;22:251–7.
4. Takahashi K, Chin K, Akamizu T et al. Acylated ghrelin level in patients with OSA before and after nasal CPAP treatment. Respirology 2008;13:810–6.
5. Ulukavak Ciftci T, Kokturk O, Bukan N et al. Leptin and ghrelin levels in patients with obstructive sleep apnea syndrome. Respiration 2005;72:395–401.
6. Papaioannou I, Patterson M, Twigg GL et al. Lack of association between impaired glucose tolerance and appetite regulating hormones in patients with obstructive sleep apnea. J Clin Sleep Med 2011; 7:486-92B.
7. Vasquez MM, Goodwin JL, Drescher AA, Smith TW, Quan SF. Associations of dietary intake and physical activity with sleep disordered breathing in the apnea positive pressure long-term efficacy study (APPLES). J Clin Sleep Med 2008; 4:411-8.
8. Traviss KA, Barr SI, Fleming JA, Ryan CF. Lifestyle-related weight gain in obese men with newly diagnosed obstructive sleep apnea. J Am Diet 2002;102:703-6.
9. Phillips BG, Hisel TM, Kato M et al. Recent weight gain in patients with newly diagnosed obstructive sleep apnea. J Hypertens 1999;17:1297-300.
10. Chin K, Shimizu K, Nakamura T et al. Changes in intra-abdominal visceral fat and serum leptin levels in patients with obstructive sleep apnea syndrome following nasal continuous positive airway pressure therapy. Circulation 1999;100:706–71.
11. Loube DI, Loube AA, Erman MK. Continuous positive airway pressure treatment results in weight loss in obese and overweight patients with obstructive sleep apnea. J Am Diet Assoc 1997; 97:896–7.
12. Redenius R, Murphy C, O'Neill EO, al-Hamwi M, Zallek SN. Does CPAP lead to BMI? J Clin Sleep Med 2008;4:205–9.
13. Quan SF, Budhiraja R, Parthasarathy S. Is There a Bidirectional Relationship Between Obesity and Sleep-Disordered Breathing? J Clin Sleep Med 2008;4: 210–211.
14. Lee CM, Huxley RR, Wildman RP, Woodward M. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. Journal of Clinical Epidemiology 2008; 61: 646-653.

Mismanagement at the VA: Where’s the Problem?

Reference as: Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3. (Click here for a PDF version of the editorial)

At the time I retired from my last Veterans Administration (VA) position there was an ongoing investigation into alleged mismanagement of non-VA fee care funds at this hospital. The VA Office of Inspector General (VAOIG) report of this investigation was released on November 8, 2011 (1). The VAOIG report is reflective of a wide-ranging problem of administrators making what are fundamentally clinical decisions and not allowing clinicians to determine the best allocation of resources - issues that are not unique to the VA. 

The VAOIG’s report substantiated that the hospital experienced a budget shortfall of $11.4 million in 2010, 20 percent of the 2010 Non-VA Fee Care Program funds. According to the VAOIG report highlights, “The shortfall occurred because the hospital lacked effective pre-authorization procedures for Long Term Acute Hospital fee care. Additionally, staff did not monitor inpatient fee care patients to determine if the patients could receive services in a VA facility”. As someone who spent about 1 week a month in the intensive care unit and cared for several of the patients who ultimately were transferred to receive long term acute hospital fee care, these recommendations seem inconsistent with the facts.

The purpose of the Non-VA Fee Care Program is to assist Veterans who cannot easily receive care at a VA medical facility. This program pays the medical care costs of patients to non-VA providers when the VA is unable to provide specific treatments or provide treatment economically. To initiate non-VA care, clinicians sent a consult form to a physician designated by the chief of staff for review. Almost all of the fee care claims were approved. The single, approving physician received hundreds of requests per week and lacked both the expertise and time to perform a detailed review of the requests.

Among the problems singled out by the VAOIG’s report was the use of long term acute care for the purposes of ventilator weaning. The report suggests that there was no determination of whether the VA could provide these services. To my knowledge there was no VA facility that provided long term ventilator care within 100 miles of the hospital.

It is known that predicting the ability to wean a patient from long-term mechanical ventilation is imprecise (2). According to the VAOIG’s report “…30 days was a reasonable limit to attempt ventilator weaning. If the veteran had not weaned in that time, then the [hospital] needed to re-evaluate the appropriateness of continued weaning and consider alternative medical options.” Thirty days is considerably shorter than the 3 months recommended by a collective task force from the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine (2).

The VAOIG report estimated that overspending on long term acute care resulted in $4.5 million of the nearly 12 million dollar in over spending. Although it is not clear how this figure was calculated, it is almost certainly an over estimate of the potential cost savings since these patients require care whether in an acute care facility for weaning or a long-term care facility and is based on a 30 day period rather than a 90 day period of weaning

Later in the VAOIG report two additional problems are identified which more likely explain the overspending: inadequate budgeting and inadequate accounting. Not knowing how much is being spent from an inadequate budget is a problem, but there is also another, more fundamental problem not identified in the VAOIG’s report. Why was there no VA acute care or long term facility available to care for these patients? There is certainly sufficient medical expertise within the VA to perform these services. It seems likely that a comparatively small investment in an appropriate facility could have resulted in considerable savings.

There is no convincing evidence presented in the VAOIG’s report that the non-VA services requested were inappropriate. Yet, the VAOIG’s report suggests replacing the lone, over-worked, part-time clinician with inadequate expertise with a full-time person or committee. These approving official(s) will probably also lack the expertise necessary to make these clinical decisions and do little more than harass clinicians for paperwork and documentation while inadequately reviewing the charts and avoiding responsibility for any decisions.

In response to the discovery of the shortfall, the hospital initiated several interim approaches to save money including a hiring freeze. This seems reasonable, but in the middle of the hiring freeze, administration did hire an assistant director into a newly created position. However, clinical personnel who had left or retired were not replaced. Second, the chief of staff who oversaw this shortfall placed a measure on the clinicians’ performance plan that non-VA fee basis spending be reduced compared to the previous year. Yet, according to the VAOIG’s report, the problem appeared to be inadequate budgeting and accounting rather than overspending. Not surprisingly, morale suffered and was reflected in an employee survey which ranked in the bottom 10% of the VA in 5 of the 6 categories surveyed. In order to improve these scores, the chief of staff charged the chiefs of each service with improving morale when the problem appeared to lie a little closer to home. Lastly, the hospital determined that chronic ventilator patients be held in the ICU in order to save non-VA fee expenses. The cost of this decision is that when the ICU is full, that VA patients needing ICU care are transferred to another hospital, a cost paid by the VA. Whether this administrative decision will save money is unknown.

This VAOIG’s report fails to emphasize the major problems, i.e., failure of the administration to work with the clinicians, inadequate budgeting and inadequate accounting. Rather than suggesting reasonable solutions, the VAOIG’s report rewards these administrative blunders by offering increasing administrative control over clinicians and apparently increasing administrative personnel as solutions. These recommendations do nothing other than waste resources which could be used for care of Veteran patients.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 11/17/11).
2. MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ; American College of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120:375S-95S.

Editor’s note: Since this budget shortfall came to light, the hospital director retired for medical reasons; the chief of staff was transferred to another VISN as VISN chief medical officer; and the associate director has left the hospital.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Why Is It So Difficult to Get Rid of Bad Guidelines?

Reference as: Robbins RA. Why is it so difficult to get rid of bad guidelines? Southwest J Pulm Crit Care 2011;3:141-3. (Click here for a PDF version of the editorial)

My colleagues and I recently published a manuscript in the Southwest Journal of Pulmonary and Critical Care examining compliance with the Joint Commission of Healthcare Organization (Joint Commission, JCAHO) guidelines (1). Compliance with the Joint Commission’s acute myocardial infarction, congestive heart failure, pneumonia and surgical process of care measures had no correlation with traditional outcome measures including mortality rates, morbidity rates, length of stay and readmission rates. In other words, increased compliance with the guidelines was ineffectual at improving patient centered outcomes. Most would agree that ineffectual outcomes are bad. The data was obtained from the Veterans Healthcare Administration Quality and Safety Report and included 485,774 acute medical/surgical discharges in 2009 (2). This data is similar to the Joint Commission’s own data published in 2005 which showed no correlation between guideline compliance and hospital mortality and a number of other publications which have failed to show a correlation with the Joint Commission’s guidelines and patient centered outcomes (3-8). As we pointed out in 2005, the lack of correlation is not surprising since several of the guidelines are not evidence based and improvement in performance has usually been because of increased compliance with these non-evidence based guidelines (1,9).

The above raises the question that if some of the guidelines are not evidence based, and do not seem to have any benefit for patients, why do they persist? We believe that many of the guidelines were formulated with the concept of being easy and cheap to measure and implement, and perhaps more importantly, easy to demonstrate an improvement in compliance. In other words, the guidelines are initiated more to create the perception of an improvement in healthcare, rather than an actual improvement. For example in the pneumonia guidelines, one of the performance measures which have markedly improved is administration of pneumococcal vaccine. Pneumococcal vaccine is easy and cheap to administer once every 5 years to adult patients, despite the evidence that it is ineffective (10). In contrast, it is probably not cheap and certainly not easy to improve pneumonia mortality rates, morbidity rates, length of stay and readmission rates.

To understand why these ineffectual guidelines persist, one needs to understand who benefits from guideline implementation and compliance. First, organizations which formulate the guidelines, such as the Joint Commission, benefit. Implementing a program that the Joint Commission can claim shows an improvement in healthcare is self-serving, but implementing a program which provides no benefit would be politically devastating. At a time when some hospitals are opting out of Joint Commission certification, and when the Joint Commission is under pressure from competing regulatory organizations, the Joint Commission needs to show their programs produce positive results.

Second, programs to ensure compliance with the guidelines directly employ an increasingly large number of personnel within a hospital. At the last VA hospital where I was employed, 26 full time personnel were employed in quality assurance. Since compliance with guidelines to a large extent accounts for their employment, the quality assurance nurses would seem to have little incentive to question whether these guidelines really result in improved healthcare. Rather, their job is to ensure guideline compliance from both hospital employees and nonemployees who practice within the hospital.

Lastly, the administrators within a hospital have several incentives to preserve the guideline status quo. Administrators are often paid bonuses for ensuring guideline compliance. In addition to this direct financial incentive, administrators can often lobby for increases in pay since with the increase number of personnel employed to ensure guideline compliance, the administrators now supervise more employees, an important factor in determining their salary. Furthermore, success in improving compliance, allows administrators to advertise both themselves and their hospital as “outstanding”.

In addition, guidelines allow administrative personnel to direct patient care and indirectly control clinical personnel. Many clinical personnel feel uneasy when confronted with "evidence-based" protocols and guidelines when they are clearly not “evidence-based”. Such discomfort is likely to be more intense when the goals are not simply to recommend a particular approach but to judge failure to comply as evidence of substandard or unsafe care. Reporting a physician or a nurse for substandard care to a licensing board or on a performance evaluation may have devastating consequences.

There appears to be a discrepancy between an “outstanding” hospital as determined by the Joint Commission guidelines and other organizations. Many hospitals which were recognized as top hospitals by US News & World Report, HealthGrades Top 50 Hospitals, or Thomson Reuters Top Cardiovascular Hospitals were not included in the Joint Commission list. Absent are the Mayo Clinic, the Cleveland Clinic, Johns Hopkins University, Stanford University Medical Center, and Massachusetts General.  Academic medical centers, for the most part, were noticeably absent. There were no hospitals listed in New York City, none in Baltimore and only one in Chicago. Small community hospitals were overrepresented and large academic medical centers were underrepresented in the report. However, consistent with previous reports, we found that larger predominately urban, academic hospitals had better all cause mortality, surgical mortality and surgical morbidity compared to small, rural hospitals (1).

Despite the above, I support both guidelines and performance measures, but only if they clearly result in improved patient centered outcomes. Formulating guidelines where the only measure of success is compliance with the guideline should be discouraged. We find it particularly disturbing that we can easily find a hospital’s compliance with a Joint Commission guideline but have difficulty finding the hospital’s standardized mortality rates, morbidity rates, length of stay and readmission rates, measures which are meaningful to most patients. The Joint Commission needs to develop better measures to determine hospital performance. Until that time occurs, the “quality” measures need to be viewed as what they are-meaningless measures which do not serve patients but serve those who benefit from their implementation and compliance.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Robbins RA, Gerkin R, Singarajah CU. Relationship between the veterans healthcare administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
2. Available at: http://www.va.gov/health/docs/HospitalReportCard2010.pdf (accessed 9-28-11).
3. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med. 2005;353:255-64.
4. Werner RM, Bradlow ET. Relationship between Medicare's hospital compare performance measures and mortality rates. JAMA 2006;296:2694-702.
5. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC Jr, Pollack CV Jr, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006;295:1912-20.
6. Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Int Med 2005;165:1469-77.
7. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008;149:29-32.
8. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM.  Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353:1860-1.
10. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: Job Security

Reference as: Robbins RA. Changes in medicine: job security. Southwest J Pulm Crit Care 2011;3:72-4.  (Click here for a PDF version).

A Medscape article entitled the “Six Biggest Gripes of Employed Doctors” listed job security as a major concern of hospital employed physicians (1). When I left fellowship, most junior physicians joined an established, group practice either as a salaried associate or with a guaranteed income. Few ventured into solo practice, especially in pulmonary and critical care where night calls are frequent and days off are rare. Usually after a few years, the associate became a partner. Partners were entitled to share in profits that they generated, and usually profits of the group. Now that many physicians are employees of hospitals or corporations rather than physician-controlled practices, marked changes in physicians’ business hiring and business practices are occurring.

Some observers don't think job security is a problem for physicians. I would agree. Doctors are in demand and nearly every physician can find a job. Matt Robbins, Senior Director of Marketing for Delta Physician Placement in Dallas, points out that hospitals will hire more physicians as healthcare reform expands coverage and increases the emphasis on care coordination (1). However, the physicians of the future may question the cost of medical school, residency, and fellowship to enter into a “master-servant” relationship with an employer.

For example, a radiologist with a long term private practice relationship with a hospital for many years was told that the hospital was severing this relationship in order to form an all employee model. However, he and his private practice colleagues were given the opportunity of joining the new hospital radiology group. Now his income is dependent on his productivity. It is difficult for him to find time to teach, discuss cases with consultants, or participate in conferences without a financial penalty.

Several of the Phoenix pulmonary and critical care fellows were previously employed as hospitalists. One was jobless after the group that had provided hospital services for services for several years did not have their contract renewed. The hospital hired their own hospitalists, mostly young physicians just out of training. However, within a few months most had left because of dissatisfaction, especially with the workload.

Although lack of physician productivity, hospital financial losses or hospital mergers have been cited as reasons for terminating or modifying physician contracts, it would appear that maximizing profits is more likely. In the “master-servant” relationship inherent with a hospital-employed physician, the downside may be increasing workload, decreasing income and declining autonomy. Although some would argue that this increasing competition is good for the patient consumer, the rising healthcare costs with declining physician income argue against this.

However, if a physician is unhappy, he or she can always leave. After all the relationship is “master-servant” not “master-slave” and most contracts can be cancelled with a few months notice. However, more and more contracts have noncompete clauses, requiring a physician not to practice within a certain distance after leaving (1). With many hospitals or hospital corporations expanding, many physicians may have to move from their previous practice area, even from a large metropolitan area. There is also the possibility that if the separation is acrimonious, the quality assurance process can be used make a physician’s relocation even more difficult. While the hospital administrator has the option of complaining about a physician, the reverse is often not true. Hospital employed physicians are frequently required to sign contracts stating that they cannot discuss their employment.

The negative side of hospital employment should cause physicians to pause and carefully examine a contract. The negatives may outweigh the positives. Furthermore, with hospital mergers and administrators frequently changing, even the best situation could quickly deteriorate.

What is needed is increased oversight of the physician-hospital relationship. First and foremost, an administrator directing or pressuring physician employees to order certain tests, prescribe certain medications, etc. is an unlicensed practice of medicine by the administrator. It increases the cost of healthcare by the ordering of unnecessary testing, procedures, or therapy where profit margin is more a consideration than patient benefit. This should be reported to state licensing agencies. Second, it is questionable that hospitals should be allowed to hire physicians. California has a law prohibiting hospital or corporation ownership of physician’s practices (2) but the law is complicated and appears to be largely unenforced (3). As hospitals hire more physicians, laws to protect both patients and physicians from unscrupulous hospital administrators need to be both enacted and enforced. Third, physicians should be wary of noncompete and no discussion clauses in contracts. These are red flags that could signal potential dire professional and financial consequences to a physician who is in a difficult employment which they wish to leave.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
2. http://www.mbc.ca.gov/licensee/corporate_practice.html (accessed 9-23-11).
3. Fichter AJ. Owning a piece of the doc: state law restraints on lay ownership of healthcare enterprises. Journal of Health Law 2006:39:1-76.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: the Decline of Physician Autonomy

Reference as: Robbins RA. Changes in medicine: the decline of physician autonomy. Southwest J Pulm Crit Care 2011;3:49-51. (Click here for a PDF version)

Thirty years ago when I left fellowship, there were predominantly two career paths, private practice or academics. I had chosen academics by virtue of doing a fellowship at a heavily research-based program, the National Institutes of Health (NIH). However, even at the NIH many of my colleagues eventually ended up in private practice, which was more lucrative and much more common than the academic practice I chose. Now a third path has become more common, practice as a hospital employee. I became a hospital employee over 30 years ago when I became a part-time, and later, full-time physician at a Department of Veterans Affairs (VA) medical center affiliated with a university. Apparently I was ahead of my time. In an article entitled “Majority of New Physician Jobs Feature Hospital Employment” 56% of physician search assignments by the national physician search firm Merritt Hawkins in 2011 were for hospitals (1). This had increased from 51% in 2010 and 23% in 2006. In contrast, only 2% of the firm's 2011 search assignments featured openings for independent, solo practitioners, down from 17% in 2006. "The era of the independent physician who owns and runs his or her practice is fading," according to Travis Singleton, a senior vice-president at Merritt Hawkins.

The reason that hospitals want to employee physicians is obvious-money. By increasing market share and collecting professional fees, hospitals profit from physician employment. Physicians may be fearful of the cost of setting up a private practice with the increasing uncertainties of reimbursement, making a salaried hospital position attractive. This is especially true for a new physician not wishing to add to the debt incurred during training or seeking less than full-time employment for family or personal reasons (2).

Although quality or efficiency is often touted as a major reason for hospitals to employee physicians, recent research suggests that neither result. Kuo and Goodwin (3) reviewed over 50,000 Medicare admissions and found that hospital length of stay was 0.64 day less and costs $282 lower among patients receiving hospitalist care compared to primary care physician care. However, this reduction in inpatient costs under the care of hospitalists was more than offset by a $332 increase in charges after discharge.  Furthermore, patients cared for by hospitalists were less likely to be discharged to home; more likely to have emergency department visits; more likely to be readmitted to the hospital; less likely to have a follow up visit with their primary care physician; and more likely to be admitted to a nursing facility. As the authors point out this is nothing more than cost shifting, and hospitalists, who are typically hospital employees, may be more susceptible to behaviors that promote cost shifting. Consistent with this concept, O’Malley et al. (4) state that hospital employed physicians increase costs by higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care.

Although the disadvantages of hospital employment are several, “Ultimately, the loss of control over their own professional lives is what irks employed doctors the most…” (5). As someone who worked as a hospital employee for the VA for over 30 years, I found an increasing “master-servant relationship” particularly annoying. Decisions were often based on financial or political considerations by nonphysicians or under-qualified clinicians. For example, some have recommended propofol as a standard in conscious sedation (6). It offers a number of advantages including ease of titration and short duration of action. Propofol has been used by our group for years in the ICU. Our group applied for “privileges” to use propofol for bronchoscopy which was endorsed by the pharmacy and therapeutics committee. Yet, the clinical executive board denied the application which our group found puzzling.  I was later told by a quality assurance nurse that the basis of this decision was that propofol is what killed Michael Jackson.  Hopefully medical decision making meets a higher standard than the singular example of what may have happened to a pop star.

Another example is the guidelines from groups like the Institute for Healthcare Improvement (IHI) that quickly becomes hospital mandates. Many of these guidelines are, at best, weakly evidence based (7). Furthermore, the guidelines are bundled, i.e., several guidelines are grouped together. Bundling makes it difficult, if not impossible, to determine which guidelines are effective. Most have probably had little impact on patient outcomes, but at least one proved to be catastrophic. Tight control of blood sugar in the intensive care unit was mandated and monitored by the VA based on IHI recommendations. However, as demonstrated in the NICE-SUGAR study, tight control actually resulted in a 14% increase in patient mortality (8). This increase in mortality would translate to 9503 excess deaths at all VA hospitals between 2002 and 2009 or about 1 death for every 84 patients treated with tight control of glucose. After publication of the NICE-SUGAR study the IHI dropped the issue from its web site and the VA switched to also monitoring hypoglycemia. One might think that a guideline which resulted in a 14% increase in ICU mortality would cause an outcry to punish those responsible, but instead resulted only in a deafening silence.

I am hopeful that we have trained our young physicians to practice for their patients’ benefit, rather than the financial or political well-being of the hospital. Yet, I fear that the financial pressures of beginning practice and protecting one’s reputation and livelihood may be too great a pressure to resist. Until physicians are not supervised by non- or under-trained administrators in a “master-servant” relationship, incidents such as the increase in ICU mortality secondary to tight control of glucose are bound to reoccur.

Richard A. Robbins MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Crane M. Majority of New Physician Jobs Feature Hospital Employment. Medscape 2011. http://www.medscape.com/viewarticle/744504?sssdmh=dm1.695421&src=nldne (accessed 8-22-11).
2. Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7.
3. Kuo Y-F, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011;155:152-9
4. O'Malley AS, Bond AM, Berenson RA. Rising hospital employment of physicians: better quality, higher costs? Center for Studying Health System Change (HSC) 2011. http://www.hschange.com/CONTENT/1230/#ib5 (accessed 8-23-11).
5. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
6. Eichhorn V, Henzler D, Murphy MF. Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room. Curr Opin Anaesthesiol 2010;23:494-9.
7. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
8. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283-97.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: Fellowship

Reference as: Robbins RA. Changes in medicine: fellowship. Southwest J Pulm Crit Care 2011:3:34-36. (Click here for a PDF version)

Pulmonary fellowship in the late 70’s and early 80’s was largely unstructured.  I had the advantage of doing two fellowships. One was at the University of Nebraska Medical Center and was predominantly clinical. There was one other fellow and we spent our time going to clinic, reading pulmonary function tests, supervising exercise testing,  doing consults, and providing inpatient care both on the floors and the intensive care unit (ICU). We became involved with most of the patients in the ICU who were there for more than a day or two. The work was long and hard. We were mostly autonomous and only loosely supervised.

The attending physicians relied on us to call when we needed help or there was something we thought they should know. Call was at home but it was unusual to leave before 8 PM. The fellows alternated call every other weekend making it tolerable. There were plenty of procedures.  I did over 150 bronchoscopies my first year and performed sufficient numbers of intubations, thoracentesis, chest tubes, pulmonary artery cathers, etc. to be comfortable. There was little time or emphasis on research or other scholarly activity.

The other fellowship at the National Institutes of Health was the opposite. Research was clearly emphasized and most of our time was spent in the laboratory. Patient care was confined to patients on research protocols or consults to other services who had patients with incidental pulmonary problems. Procedures other than our research based protocols were rare.

At the time there were few critical care fellowships.  A fellow interested in the ICU usually entered a pulmonary fellowship or more rarely a cardiology fellowship. Anesthesia also practiced in the ICU at some institutions. Pediatric ICUs were left to the pediatricians. The American Board of Internal Medicine did require 36 months of fellowship but only 12 months needed to be clinical which was largely undefined.

A number of regulatory agencies entered fellowship regulation during the past 30 years. Most importantly has been the Accreditation Council on Graduated Medical Education (ACGME). As with residencies, the ACGME accredits the fellowship, and therefore, makes the rules. ACGME now recommends 24 months of clinical activity with a host of training requirements pertaining to patient care and medical knowledge (1). In addition, requirements now exist for competencies in practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.  Procedural training such as bronchoscopy (minimum now at 100) and the newer procedures such as sleep studies and ultrasound are also recommended or required. Fellowship directors are familiar with the ACGME’s program information form (PIF) which now extends to at least 75 pages describing the program. In addition, much of the PIF is devoted to answering questions such as “Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles” or “Describe the learning activity(ies) through which residents achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; and, advocate for quality patient care and optimal patient care systems and work in interprofessional teams to enhance patient safety and care quality”. So the educational requirements to meet patient care and medical knowledge requirements as well as the newer requirements have been greatly extended leaving little time for scholarly activity or research. Many, if not most, fellows now leave their fellowship having never conducted a research study nor authoring a peer-reviewed manuscript.

Other organizations such as the Joint Commission of Healthcare Organizations, American College of Chest Physicians (2) and a variety of insurance carriers have waded in on credentialing requiring certain numbers of procedures for fellows to be certified as competent. Although these requirements are not unreasonable, they are arbitrary and the evidence basis on which they were formed is unclear.

The amount of paperwork regarding fellowships has undoubtedly increased for both the fellowship programs as well as the fellows themselves tracking procedures, etc. The number of personnel necessary to administer these regulatory activities has also undoubtedly increased. Supervision of fellows has also increased with attending physicians having more input into patient care. However, whether these lead to better trained physicians or better patient care is unknown. My suspicion is that it has not, at least there appears to be no evidence that anyone benefits. On the other hand, the amount of resources spent on supervision and documentation may actually lead to a decrease in the resources available for important educational and patient care activities actually result in harm to the fellows and possibly the patients. Regulatory agencies should investigate before mandating or even recommending educational requirements. More commonly the agency convenes a group of “experts” for advice. Often there is no reliable data, and therefore, the “expert’ panel makes recommendations based on their opinions. Not only the regulatory agencies but the panels of experts need to show restraint in making recommendations when there is no data. We often tell our fellows that it is alright to say “I don’t know”. Regulatory agencies and expert panels should also be willing to admit their limitations.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. http://www.acgme.org/ (accessed 8-8-11).
2. Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: guidelines from the American college of chest physicians. Chest 2003;123;1693-1717.

Changes in Medicine: Residency

Reference as: Robbins RA. Changes in medicine: residency. Southwest J Pulm Crit Care 2011:3:8-10. (Click here for a PDF version)

The most important time in a physician’s educational development is residency, especially the first year. However, residency work and responsibility have come under the scrutiny of a host of agencies and bureaucracies, and therefore, is rapidly changing. Most important in the alphabet soup of regulatory agencies is the Accreditation Council for Graduate Medical Education (ACGME) which accredits residencies and ultimately makes the governing rules.

Resident work hours have received much attention and are clearly decreasing. However, the decline in work hours began in the 1970’s before the present political push to decrease work hours. The residency I entered in 1976 had every third night call during the first year resident’s 6-9 months on general medicine or wards. It had changed from every other night the year before. On wards, we normally were in the hospital for our 24 hours of call and followed this with a 10-12 hour day before going home and getting some well needed sleep. The third day was again a 10-12 hour day before repeating the cycle. This averages over 100 hours per week. There was one week of paid vacation and days off were rare. Both days off and vacations were expected to be done on electives.

First year residents were often poorly supervised despite a senior resident being on call with every 2 interns. Attending physicians were never in the hospital at night. I remember being told by a senior resident, that he was going to bed but I could call him if there was an emergency I could not handle-but he expected me to handle any emergency. I got the message not to call him.

The reduction in work hours was driven by residency directors trying to recruit sufficient residents to fill their slots. Residencies that required every other night call or had indigent level salaries were quickly becoming noncompetitive. By the time I left residency after 3 years, call had decreased to every fourth or fifth night and salaries had risen from about $10,000/year to $14,000/year for first year residents.

The reduction in work hours was brought to public attention and accelerated by the Libby Zion case of 1984 (1). The 18 year old Zion died from a complication of the monoamine oxidase inhibitor she had taken prior to hospitalization exacerbated by administration of meperidine and possibly by cocaine. When her father, Sidney Zion, a journalist/lawyer, learned that her doctors had been medical residents covering dozens of patients and receiving supervision only by phone, he became convinced his daughter's death was due to inadequate staffing at the New York teaching hospital where she died. Determined to ensure that others not fall victim to the same gaps that he blamed for his daughter's death, he crusaded to change resident work hours and supervision with frequent editorials and public appearances.

Over several years a sequence of events occurred to keep Zion’s death in the public eye: a grand jury was called to investigate Zion’s death; the New York State health commissioner appointed the Bell Committee to make recommendations regarding work hours; and a civil lawsuit against the doctors and hospitals was filed by Sidney Zion. All deemed the hospital negligent for leaving a first year resident alone in charge of 40 patients that night. The Bell Commission recommended that residents could work no more than 80 hours a week or more than 24 consecutive hours and senior physicians needed to be physically present in the hospital at all times and these recommendations were adopted by New York State.

The ACGME under political pressure to deal with resident work hours, appointed the Work Group on Resident Duty Hours and the Learning Environment in September 2001. The work group recommended new ACGME standards that were remarkably similar to those of the Bell Commission and these were adopted by the ACGME in 2003 (2).

The rationale behind the work hour reduction is that by working fewer hours and under greater supervision the care delivered by more rested and supervised residents will be better. A tragedy, in addition to Ms. Zion’s death, is that 27 years later we still do not know if this basic premise is true. Although the reduction in resident work hours and the in house presence of attending physicians has undoubtedly increased costs, the impact on length of stay and mortality remain largely unknown (3). The observational, retrospective research that has been done on the impact of resident hour reduction has been sufficiently flawed to make conclusions difficult (4-6). This is unfortunately part of a common trend in administrative medicine, i.e., to initiate changes based on political pressure and later attempt studies to justify the changes.

Concern has been voiced that reduction in work hours and autonomy due to increased supervision may compromise resident education (7). Although there would appear to be little evidence to date supporting this one way or another, I add my voice to those who raise this concern. Making independent decisions is vital to the maturation of residents to independent physicians. The present trend of reducing work hours and increasing supervision, may delay that learning experience to the first year or two of independent practice where correction and constructive criticism are unlikely to occur.

As work hours of residents decline, as medical knowledge expands, and as medical care becomes more complex our residencies will be hard pressed to train competent physicians. One approach is to lengthen the residencies to compensate for the reduced work hours (8). Adding another year or two of residency and/or fellowship is nothing more than extending the indentured servitude of residents to teaching hospitals. 3-6 years of post-graduate training is enough and extending the resident’s time may be more to provide adequate in house coverage than to improve the residents’ education.

I would recommend some carefully designed studies to investigate the impact of shorter work hours. The impact on mortality and length of stay should be examined along with the resident’s fund of knowledge. Perhaps armed with some sound data policy makers can make sound decisions regarding resident education, something we might call evidence-based medicine.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Lerner BH. A Case That Shook Medicine. The Washington Post, November 28, 2006. Available at http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html

2. Friedmann P, Williams WT Jr, Altschuler SM, et al. Report of the ACGME Work Group on Resident Duty Hours. 2002. Available at: http://www.acgme.org/DutyHours/wkgroupreport611.pdf

3. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009;360:2202-15.

4. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.

5. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH.. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975-83.

6. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:984-92.

7. McCoy CP, Halvorsen AJ, Loftus CG, McDonald FS, Oxentenko AS. Effect of 16-hour duty periods on patient care and resident education. Mayo Clin Proc. 2011;86:192-6.

8. Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Reynolds E, Sandy L, Schroeder S, Wenger N, Williams M; Task Force on the Domain of General Internal Medicine. Society of General Internal Medicine (SGIM). The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004;19:69-77.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: Medical School

Reference as: Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7. (Click here for a PDF version)

I recently retired and have been encouraged to write about what has changed in medicine. However, the changes have been sufficiently extensive that one editorial would be too long. Therefore, this will be the first of several editorials examining medical school, residency, fellowship and practice.

The beginning of my own medical career was 1972 when I entered medical school, graduating in 1976. My reasons for choosing the specific school I entered were several: 1. A scholarship was provided that paid tuition; 2. It was a state school and otherwise relatively cheap; 3. The school would accept me after 3 years of college and without a college degree; 4. It was the medical school of my undergraduate school and I knew many of the entering students; and 5. I was told that it mattered less where you did your medical school training than where you did your residency. I saw no reason to delay admission to obtain a college degree and wanted to proceed with my medical education.

Most medical students in 1972 were like me, white and male. The most obvious change in the past 40 years has been the increasing number of women. My class of about 150 had only a few, maybe 5, women. The percentage of women graduates has gradually risen until in 2009-2010, women received 8,133 (48.3%) of the 16,838 MD’s awarded (1). However, the numbers of underrepresented minorities has not kept pace with the increasing percentage of women. The number of blacks graduating from medical school has modestly risen from about 700 in 1980 to a little over 1109 in 2008 with a rise in Hispanics from a few hundred in 1980 to 1183 in 2008. Yet those numbers still only represent 6.9% and 7.3% of medical school graduates, respectively, far below the 12% for blacks and over 15% for Hispanics of the general population (2,3).

Over 30 years of academic medicine I have not observed much change in the medical students’ abilities by the time I see them on a pulmonary or critical care rotation their senior year. The high numbers of applicants suggest that medical school acceptance is still difficult and the mean grade point average from college of an entering student is still well above 3.5. There has been little significant change in medical school education since the Flexner report in 1910 (4). Most medical schools still consist of 2 years of pre-clinical and 2 years of clinical education just like it did when I matriculated way back in 1972-6.  There have been the occasional novel educational programs in medical schools such as 3 year programs, a combined 6 year undergraduate and MD, or earlier clinical introduction, but most of these have fallen by the wayside. I’ve witnessed graduates from several of these programs and these medical education experiments do not seem to have adversely affected the medical students’ performance by the time I see them their senior year. I still find them bright, enthusiastic and articulate and ready to continue their journey to becoming doctors as house officers.

However, a major change which may be influencing medical training and career choice is the debt incurred by medical students. Although poverty was common in my class of 1976, large debt was rare. Now approximately 86 percent of U.S. medical students graduate with some debt, and of those, the average debt is almost $160,000 (6). Students at Doctor of Osteopathy (DO) schools appear to be particularly hard hit. In the US there are only 26 osteopathic schools compared to 133 allopathic medical schools that offer the MD degree. Yet, 6 of the top 10 medical schools that lead to the most medical student debt are osteopathic schools. Medical students graduating from those 6 schools averaged over $198,000 of indebtedness in 2009 (7). It has been claimed that this debt is a major influence on residency choice with fewer students going into residencies as primary care physicians because of their debt (7). However, medical student debt seems less likely to influence residency choice since most residencies pay about the same. Rather it seems that income potential after completing training may be having some influence. Primary care physicians often receive incomes half of some specialists (6).  Medical students realize this income differential and for some may be a major influence on choosing a specialty.

The concern that medical student indebtedness can influence the rest of their careers has been voiced by many and I echo this concern. This is especially true given that medical students face at least 3 years as a house officer, where salaries of about $50-60,000/year is insufficient to allow quickly paying off student loans. Although it seems unlikely that the high cost of some medical schools can be justified, I would not suggest Government cost regulation of medical school fees. My own experience with over 30 years of Government bureaucracy is that inevitably they will dictate medical curriculum based on politics, rather than science. Instead, I would propose a system of relieving medical student debt by allowing some students to obtain debt forgiveness by Government service. More on this in the later editorials in this series.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. https://www.aamc.org/download/153708/data/charts1982to2011.pdf (accessed 7-10-11).
2. http://www.scribd.com/doc/53281274/Minorities-and-Medical-Education-AAMC-Facts-and-Figures (accessed 7-10-11).
3. Cammarata J. Minorities in Medicine: Still an Unmet Need. Medscape 2010 http://www.medscape.com/viewarticle/720541 (accessed 7-10-11).
4. Flexner A. Medical Education in the United States and Canada, 1910. Available online at http://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf (accessed 7-10-11).
5. http://www.washington.edu/uaa/advising/downloads/gpamcat.pdf (accessed 7-10-11).
6. Prep V. Weigh Medical Student Debt, Specialty Choice. US News and World Report.  2011. Available on line at http://www.usnews.com/education/blogs/medical-school-admissions-doctor/2011/06/20/weigh-medical-student-debt-speciality-choice (accessed 7-10-11).
7. Hopkins K. 10 Medical Schools That Lead to Most Debt: Some students are graduating with more than $200,000 in debt. US News and World Report. 2011. Available online at http://www.usnews.com/education/best-graduate-schools/articles/2011/04/14/10-medical-schools-that-lead-to-most-debt (accessed 7-10-11).
8. Back PB, Kocher R. Why Medical School Should Be Free. New York Times. 2011. Available online at http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=2&ref=contributorshttp://www.nytimes.com/2011/05/29/opinion/29bach.html (accessed 7-10-11).

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

The Pain of the Timeout

Reference as : Robbins RA. The pain of the timeout. Southwest J Pulm Crit Care 2011:2:102-5. (Click here for a PDF version)

An article in the Washington Post entitled “The Pain of Wrong Site Surgery” (1) caught my eye earlier this month. In 2004 the Joint Commission of Healthcare Organizations (Joint Commission or JCAHO), prompted by media reports of wrong site surgery, mandated the “universal protocol” or surgical timeout. These rules require preoperative verification of correct patient, correct site, marking of the surgical site and a timeout to confirm everything just before the procedure starts. In announcing the rules, Dr. Dennis O’Leary, then president of the Joint Commission, stated “This is not quite ‘Dick and Jane,’ but it’s pretty close,” and that the rules were “very simple stuff” to prevent events such as wrong site or patient surgery which are so egregious and avoidable that they should be “never events” because they should never happen. During the following years different components have been added to the timeout and the timeout has been extended to cover most procedures in the hospital.

However, the article goes on to state that “some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse, although spotty reporting makes conclusions difficult”. Last year 93 cases were reported to the Joint Commission in 2009 compared to 49 in 2004. Furthermore the article states that reporting data from Minnesota and Pennsylvania, two states that require reporting have not shown a decrease over the past few years.

The reason for the increasing incidence of wrong site or wrong patient operations is not totally clear. Dr. Mark Chassin, who replaced O’Leary as president of the Joint Commission in 2008, said he thinks such errors are growing in part because of increased time pressures. Preventing wrong-site surgery also “turns out to be more complicated to eradicate than anybody thought,” he said, because it involves changing the culture of hospitals and getting doctors — who typically prize their autonomy, resist checklists and underestimate their propensity for error — to follow standardized procedures and work in teams. Dr. Peter Pronovost, medical director of the Johns Hopkins Center for Innovation in Quality Patient Care, echoed those sentiments by suggesting that doctors only pay lip service to the rules. Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. Dr. Ken Kizer, former Undersecretary at the Department of Veterans Affairs and President of the National Quality Forum, advocates reporting doctors to a federal agency so wrong site surgery or patient cases can be investigated and the results publicly reported.

Several points made in the article need to be clarified

1. The reason that it is unclear whether the present Joint Commission mandates actually prevents wrong site or patient surgery is that no data was systematically collected prior to implementation of the timeout to ensure that it works and no data has been collected since implementation. As with most bureaucracies, the Joint Commission emphasis has been more on ensuring compliance rather than studying the effectiveness of an intervention.
2. Although no one condones wrong site or patient surgery, it is fortunately relatively rare. Stahel et al. (2) reported 132 wrong-site and wrong-patient cases during a 6 and a half year period by over 5000 physicians. They found only one death which was attributed to a wrong-sided chest tube placement for respiratory failure (2). This is questionable because a wrong sided chest tube does  not necessarily result in a patient’s death (3). Another 43 patients had significant harm from their wrong site or patient procedure and are listed below (Table 1). 
3. Based on the above, occurrence of these wrong site or patient operations would appear to be mostly in the operating room. The surgeon often enters the operating room after the patient is under general anesthesia, prepped and draped. Unless the surgeon saw the patient in the operating room prior to anesthesia and marked the operative site, it would not be possible for the surgeon to know that the correct site and patient are present.  It is not stated in the article how many of the operations reported had a timeout or the surgeon labeled the operative site but it is implied in the article that it was few. The first author of the manuscript, Philip Stahel, an orthopedic surgeon from the University of Colorado, explained the results stating that “many doctors resent the rules, even though orthopedists have a 25 percent chance of making a wrong-site error during their career….” Dr. John R. Clarke, a professor of surgery at Drexel University College of Medicine and clinical director of the Pennsylvania Patient Safety Authority, agreed stating, “There’s a big difference between hospitals that take care of patients and those that take care of doctors…The staff needs to believe the hospital will back them against even the biggest surgeon.”
4. Dr. Peter Pronost extends this sentiment by stating “Health care has far too little accountability for results. . . . All the pressures are on the side of production; that’s how you get paid.” He adds that increased pressure to turn over operating rooms quickly has trumped patient safety, increasing the chance of error.

I would offer some suggestions:

1. Focus should be on the operating room since this is where most of the wrong site or wrong patient procedures occur. I’m frustrated by the unnecessary timeouts that occur during bronchoscopy. For example, where the patient is known to me, enters the bronchoscopy suite awake and alert, and the biopsies are done under direct vision, fluoroscopic or CT guidance there is no real chance of wrong site or patient surgery. Similar procedures do not need a timeout. The Joint Commission needs to recognize this and stop its “one size fits all” approach.
2. What is needed is data. Right now it is unclear whether a timeout makes any difference. A scientific valid study of the timeout procedure is needed but not observational studies, designed only to create political statistics that a timeout works. The Joint Commission and other regulatory health care organizations need to break the habit of mandating interventions based on no or little evidence.
3. The Joint Commission mandates have apparently had little impact on reducing wrong site or patient operations. Making further mandates would seem to offer little hope. If, as Dr. Chassin believes, that time is the issue, adding more items to a checklist will not likely improve the problem and probably make it worse.
4. If time is the culprit in the operating room then simplifying the process as much as possible might be useful. I have been told of one operating room in Phoenix where a timeout is so extensive that it can take up to 30 minutes. Marking the site by the surgeon should be mandatory and a simplified, standardized checklist read and confirmed by the nurse, anesthesiologist and/or surgeon will hopefully simplify the timeout and enhance data collection.
5. I would agree with both Provost and Kizer that accountability needs to be present. However, Kizer’s idea of a Federal repository may be ineffectual at improving outcomes. Witness the National Practioner Databank which has done nothing to improve health care and blames only physicians for lapses in healthccare. It would seem that many of the physicians quoted above do the same, i.e., blame only the doctors. Dr. Chassin suggests a team approach to medicine, i.e., an operating room team. I agree but it seems inconsistent to refer to a team approach and only hold the physicians accountable. Instead, I would suggest a mandatory reporting system with a free, transparent and searchable data base available to everyone. This data bank should report not only the surgeon(s) but everyone else in the operating room. Hospitals also need to be identified so that they cannot deflect their accountability by blaming surgeons while emphasizing operating room turn around over patient safety. This means not only the hospital but the CEO or administrator needs to accept some responsibility. The CEO or administrator controls the finances and often touts their “accountability”. It is time to put some teeth to that claim. Such a transparent data base will not only allow patients to check on surgeons but also hospitals, nurses, and anesthesiologists. Furthermore, it will allow the healthcare providers to check on each other as well as substandard hospitals and their administrators.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Boodman SG. The pain of wrong site surgery. Washington Post. Published June 20, 2011. Available at URL http://www.washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html (accessed 6-21-11).
2. Stahel PF, Sabel AL, Victoroff MS, Varnell J, Lembitz A, Boyle DJ, Clarke TJ, Smith WR, Mehler PS. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg.2010;145:978-84
3. Singarajah C, Park K. A case of mislabeled identity. Southwest J Pulm Crit Care 2010;1:22-27.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Guidelines, Recommendations and Improvement in Healthcare

“You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.”-Thomas Sowell

Reference as: Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37. (Click here for PDF version)

In the February, 2011 Critical Care Journal Club two articles were reviewed that dealt with Infectious Disease Society of America (IDSA) guidelines (click here for Critical Care Journal Club). The first by Lee and Vielemeyer (1) reviewed the evidence basis for the 4218 IDSA recommendations and found that only 14% were based on Level 1 evidence (data from >1 properly randomized controlled trial). The graph summarizing the data in Figure 1 of the manuscript is exemplary in its capacity to communicate the weak evidence basis for many of the IDSA recommendations.

A second study by Kett et al. (2) examined the outcomes when the American Thoracic Society (ATS)/IDSA therapeutic guidelines for management of possible multidrug-resistant pneumonia were followed. The authors found a 14% difference in survival when the guidelines were followed, but surprisingly, the survival was better if the guidelines were not followed. Dr. Kett and colleagues are to be congratulated for their candor in reporting their retrospective analysis of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. The ATS/IDSA guidelines (3) state that “combination therapy should be used if patients are likely to be infected with MDR pathogens (Level II or moderate evidence that comes from well designed, controlled trials without randomization…”. However, the ATS/IDSA guidelines go on to state, “No data have documented the superiority of this approach compared with monotherapy, except to enhance the likelihood of initially appropriate empiric therapy (Level I evidence…from well conducted, randomized controlled trials)” (4).

The problem comes with the interpretation and implementation of these and other guidelines. Some, usually inexperienced clinicians or nonclinicians, seem to believe that following any set of guidelines will enhance the “quality” of patient care. Not all guidelines or studies are created equally. Some are evidence-based, important, correct and likely to make a real difference. These usually come from professional societies and are authored by well-respected, experts in the field whose goal is improve patient outcomes. As suggested by Kett’s article even these guidelines may not be infallible. Other guidelines are not evidence-based, unimportant, incorrect and can border on the trivial. These are often authored by nonprofessional, nonexperts to create a “political statistic” (5) rather than improve patient care.

If some guidelines are bad, how can those be separated from the good? We suggest 5 traits of quality guidelines: 

1. The guideline’s authors are identified and are well-respected, experts in the field appropriate to the guideline.
2. The authors identify potential conflicts of interest.
3. The evidence is graded and supported by references to relevant scientific literature.
4. The guidelines state how they selected and reviewed the references on which the guidelines are based.
5. After completion, the guidelines are reviewed by a group of reasonably knowledgeable individuals (for example the IDSA Board of Directors) that can be identified and are willing to risk the reputation of themselves and their organization on the guidelines.

Even with the above safeguards guidelines may be non-evidence-based, unimportant, incorrect or trivial, and if so, implementation may be at best a waste of resources, or at worst harmful to patient care. We ask that guideline writing committees show restraint in authoring documents which are little more than their opinions. Not every medical question, especially the trivial and the unimportant, needs a guideline. Furthermore, we would ask an endorsement from professional organizations that only guidelines based on randomized clinical trials be given a strong recommendation. As pointed out by Lee and Vielemeyer (1) only 23% of the IDSA guidelines were supported by randomized trials while 37% of strong recommendations were supported only by opinion or descriptive studies.

IDSA states on their guidelines website, “It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to the guidelines listed below to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances” (6). Despite this and other disclaimers, guidelines often take on a life onto themselves, frequently carrying the weight of law, regardless of the supporting evidence. We call for professional societies to end the practice of strongly recommending those guidelines based on opinion. Such practices have led and will continue to lead to systematic patient harm. Only those guidelines based on strong evidence should be given a strong recommendation. If the professional societies believe an opinion on a particular issue is appropriate despite a lack of evidence, a different designation such as recommendation or suggestion should be used to clearly separate it from a guideline.  The term guideline should be reserved for those statements that are evidence-based, important, and almost certainly correct and can make a real difference to patients.

Richard A Robbins MD, Allen R Thomas MD, and Robert A Raschke MD

References

1. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind infectious diseases society of America practice guidelines. Arch Intern Med. 2011;171:18-22.
2. Kett DH, Cano E, Quartin AA, Mangino JE, Zervos MJ, Peyrani P, Cely CM, For KD, Scerpella EG, Ramirez JA. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study.  Lancet Infect Dis 2011 Jan 19. [Epub ahead of print].
3. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.
4. Paul M, Benuri-Silbiger I, Soares-Weiser K, Liebovici L. Beta-Lactam monotherapy versus beta-lactam–aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and metaanalysis of randomised trials. BMJ, doi:10.1136/bmj.38028.520995.63 (published March 2, 2004). Available at URL http://bmj.bmjjournals.com/cgi/reprint/bmj.38028.520995.63v1.pdf?ck_nck (accessed February 11, 2011).
5. Churchill, Winston. London, UK. 1945. as cited in The Life of Politics, 1968,  Henry Fairlie, Methuen, pp. 203-204.
6. Infectious Disease Society of American. Standards, Practice Guidelines, and Statements Developed and/or Endorsed by IDSA. Available at URL http://www.idsociety.org/content.aspx?id=9088 (accessed February 12, 2011).

COPD, COOP and BREATH at the VA

Reference as: Robbins RA. COPD, COOP and BREATH at the VA. Southwest J Pulm Crit Care 2011;2:27-28. (Click here for PDF version)

The February 2011 Pulmonary Journal Club reviews a study by Rice and colleagues (1) of high-risk COPD patients (click here for Pulmonary Journal Club). This review was authored by Kevin Park who also authored an ACP Journal Club review (2). In Rice’s study a single educational session, an individualized care plan, and monthly case-manager telephone calls, resulted in a 41% decrease in hospitalizations and emergency room visits and a nonsignficant trend toward decreased mortality.

Rice’s study was supported and conducted in the Veterans Integrated Service Network (VISN) 23 (Minnesota, Iowa, Nebraska and the Dakotas). The COPD patients in this study were recruited and followed primarily using the VA computer system. The study represents a potential model of data-based management leading to improved patient outcomes. The authors; Robert Petzel MD, then VISN 23 Director (now Veterans Healthcare Administration Undersecretary); and Janet Murphy, then VISN Primary Care Service Line CEO (now VISN 23 Director) are to be congratulated for their insight into conducting and supporting this study. Unfortunately, many VA administrators are not as far-sighted and restrict or place unreasonable obstacles to investigators’ access to VA data. VA administrators at the National, VISN and local levels should be encouraged to follow Dr. Petzel’s and Ms. Murphy’s lead in utilizing the VA computer system to conduct studies such as Rice’s.

At the time this study was ongoing, a similar study was also being conducted through the VA Cooperative studies program known as Bronchitis and Emphysema Advice and Training to Reduce Hospitalization (BREATH) trial (3). Like Rice’s study, the BREATH study incorporated self-management education, an action plan, and case-management to decrease the risk of hospitalizations due to COPD. However, in contrast to Rice’s study, the patients in BREATH had all been hospitalized within the past year and likely had more severe underlying COPD. Although this multi-center, randomized study which was planned for 5 years was on target for recruitment (425 subjects), it was cancelled after about 2 years. The reasons for the cancellation were never shared with the site investigators (of which this editor was one). It seems unlikely that a behavior study such as BREATH would result in a significant medically adverse outcome to mandate study cancellation. However, if such an outcome occurred in BREATH, it would throw the largely positive results of Rice’s study into question.

Richard A. Robbins MD, Editor, SWJPCC

References

1. Rice KL, Dewan N, Bloomfield HE, Grill J, Schult TM, Nelson DB, Kumari S, Thomas M, Geist LJ, Beaner C, Caldwell M, Niewoehner DE. Disease Management Program for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial. Am J Respir Crit Care Med 2010;182:890-6.

2. Park K, Robbins RA. ACP Journal Club: A COPD disease management program reduced a composite of hospitalizations or emergency department visits.  ACP Journal Club 2011;154:JC3-5.

3. http://clinicaltrials.gov/ct/show/NCT00395083?order=1. Accessed 2/9/2011.

SWJPCC: The first three months

Reference as: Robbins RA. SWJPCC: The first three months. Southwest J Pulm Crit Care 2011;2:1-2. (click here for PDF)

During the Arizona Thoracic Society meeting on 1-18-11 a report was given to our sponsoring organization regarding the progress of the SWJPCC. Below is a synopsis of the report along with a link to a PowerPoint slide presentation at the end.

Planning for the journal began in August, 2010 with discussions at the Arizona Thoracic Society.  Several decisions were made at that meeting: 1. To proceed with the creation of an on-line journal; 2. To adopt the name Southwest Journal of Pulmonary and Critical Care; 3. To emphasize clinical medicine; 4. To peer review all manuscripts; and 5. To accept no sponsorship from organizations with a potential conflicts of interest such as hospitals, pharmaceuticals companies, etc. unless it was clear that such sponsorship was unrestricted.  During September and October, 2010 a web site manager was hired, Eric Reece from Bethesda, MD; the domain registered; a website created; and editorial board established. The first posting was an editorial on October 16^th, 2010 and our first manuscript was submitted on November 7^th, 2010.  This manuscript was peer reviewed, revised, and posted on November 11^th 2010. During 2010 we posted 8 articles: 2 in Imaging; one in Proceedings of the Arizona Thoracic Society; one Pulmonary Journal Club; two Critical Care Journal Clubs; one Sleep Journal Club; and one Editorial.  At the suggestion of Stuart Quan, a member of the editorial board, volumes and page numbers were assigned to each publication for ease of reference and the reference is given under the title of each posting.

As of 1-24-11 we have had 1043 page views for an average of 35/day.  One hundred and forty-three unique visitors have visited the site for an average of 4 unique visitors/day.  Hopefully, this will continue to grow.

A special thanks to our authors and reviewers, the latter are listed below. Without their help SWJPCC could not function:  Mike Gotway, Manny Mathew, Vijay Nair, Allen Thomas, and Lew Wesselius.

For the future, we are planning a short synopsis of each Arizona Thoracic Society meeting which can be found in a new section titled "Arizona Thoracic Society Notes" under "Proceedings of the Arizona Thoracic Society" on the left hand portion of the home page. We hope to soon post material authored outside the Phoenix area and to proceed with full-length manuscript publications under the Pulmonary, Critical Care and Sleep headings at the top of the home page.

Richard A. Robbins, M.D. , Editor, SWJPCC

Powerpoint Slide Set

Why Start A New Pulmonary/Critical Care Journal?

Reference as: Robbins RA. Why start a new pulmonary/critical care journal? Southwest J Pulm Crit Care 2010:1:1-2. (Click here for PDF Version)

With apologies to Paul McCartney, “You'd think that people would have had enough of [pulmonary and critical care journals]. But I look around me and I see it isn't so” (1). With the inception of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) we have several goals, not adequately filled by the present pulmonary and critical care publications.

First, the primary goal of the SWJPCC is pulmonary and critical care medicine fellow education. The American College of Graduate Medical Education has placed increasing requirements for clinical education in post-graduate medical education while simultaneously increasing the requirements for scholarly activity for fellows and faculty, yet restricting fellow work hours (2). It seems that these conflicting goals are unrealistic, unless clinical scholarly activity can be incorporated into a training program. In starting the SWJPCC, we hope to fulfill the scholarly needs of both fellows and faculty while emphasizing clinical medicine through the publication of such time honored activities as case presentations and reviews of the literature.

Second, peer-reviewed journals send articles out for review. While we will do the same, we have certain expectations of our reviewers. Unfortunately, reviewers are not always carefully chosen.  Sometimes inexperienced reviewers, feeling the need to establish themselves, indulge their own sense of self-importance by becoming “nagging nabobs of negativism” (3) demanding the answer to “the ultimate question of life, the universe and everything” (4) before a manuscript will see the light of publication. While emphasizing the highest medical journal standards, we realize that fellow and faculty time is limited and we hope to be reasonable regarding expectations of our authors.

Third, there has been a trend in some journals towards publishing articles emphasizing the “short-comings” of physicians while emphasizing the virtues of identifying these “faults”. For example, the New England Journal of Medicine published an article from a health regulatory organization (the Joint Commission), touting improved healthcare through administration of the pneumococcal vaccine to adults (5). This article implied that physicians who did not provide this vaccination to their adult patients were delinquent, and the Joint Commission’s efforts “corrected” this deficiency. However, previous publications have shown that pneumococcal vaccination in older adults results in a slight increase in the risk for hospitalization, but does not decrease mortality nor the risk for pneumonia (6), findings largely confirmed by a recent meta-analysis (7). Publication of articles substituting politics or opinions (especially when they are self-serving) for evidence-based care is not part of the mission of the SWJPCC.

Last, the SWPCC aspires to be a resource for practicing physician education, emphasizing case presentations, clinical articles, review articles, imaging, and journal clubs. We hope this journal will be useful for busy clinicians, assisting them in better serving the needs of their patients while also providing insight regarding practice matters of interest to the pulmonary and critical care medicine community.

With that, we begin.

Richard A. Robbins, M.D. on behalf of the Editors

References

1. McCartney, Paul. “Silly Love Songs”. Wings at the Speed of Sound. Palorphone/EMI, 1976.
2. http://www.acgme.org/acWebsite/nav/Pages/navPDcoord.asp
3. Agnew, Spiro. San Diego, CA. 1970.
4. Adams, Douglas. Life, the Universe and Everything. ISBN 0-330-26738-8.
5. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.
6. Jackson LA, Neuzil KM, Yu O, Benson P, Barlow WE, Adams AL, Hanson CA, Mahoney LD, Shay DK, Thompson WW; Vaccine Safety Datalink. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med. 2003;348:1747-55.
7. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ. 2009;180:48-58.