The Unspoken Challenges to the Profession of Medicine

More and more, we are practicing in a challenging environment. Job satisfaction for our profession is at an all-time low, burnout at an all-time high and there exists an alarming depression rate. As a profession, we face no shortage of problems. Our medical student graduates await many hurdles and need to be prepared to deal with increasing educational costs, ACGME duty hour changes, declining interest in primary care, health care reform, declining Medicare reimbursement, assaults to fee for service designs, bundled payments, care for the uninsured, medical malpractice, ABIM recertification, and MOC changes, the electronic health record, among many others.

If you are like most physicians, you have found yourself grappling with patients seeking a particular drug especially when that drug is a controlled substance or an antibiotic. You want your patient’s approval of your care and maybe even avoidance of their anger while providing the appropriate care that is based on your best judgment.  The accrediting bodies like American Board of Medical Specialties and ACGME in overall policies require that those seeking board certification have demonstrated “altruism, accountability, excellence, duty, service, honor, integrity and respect for others” (1). A reaction of anger or disapproval challenges our wish to strive toward achieving goals of being altruistic, knowledgeable, skillful, and dutiful. How does a patient review on various internet sites or hospital administrators’ perspectives address essential elements of medical professionalism? Most of us now work for large organizations (2). So we all have an interest in conforming to their wishes. In fact we do not have independent choice in what we do and probably very few docs practice with independent choice. Whether it be medication formularies, patient satisfaction scores or performance measures that seem geared more to justify institutional financial goals than to truly improve patient care. 

Uncertainty has long characterized the practice of medicine despite advances in technology or biomedical knowledge. Medical professionalism is defined by what we do and how we act, by demonstrating that we are worthy of the trust bestowed upon us by our patients and the public. My friend shared with me “I try to use independent judgment but always take into account how much or what to do for a patient, thinking what would seem acceptable to others at work if the patient went home and died, and my care got reviewed”. More and more we are judged by everyone, and not just our peers. The opinions of non-medical professionals who lack insight are taken into account and some of that has to do with the lack of solidarity to our peers in front of the public which diminishes confidence for the whole profession (3). 

Listening to our patients is the first key step in adding critical insight to our decisions. Long term we are expected to be providing fiscally prudent appropriate care to the public. In an era of ever increasing drug abuse we need to focus on making our decisions and behavior based on patient’s best interests and the publics good and not on current organizational financial goals, health trends or other distractions from our profession.  

Medical professionalism requires subordinating your own interest to the interest of the patient’s and public’s health. We have a duty to do right and to avoid doing wrong in principles of beneficence and nonmaleficence. As an example, our profession has been criticized for both under and over prescribing pain medications and antibiotics. Resisting the current trends or an individual’s unsupported drug request in favor of patient and public’s good is what we need to exercise. We need to exercise accountability not just for ourselves but for our colleagues, including intervening and not abrogating our responsibility early in the slippery slope of such behaviors as being chronically late for over commitments for monetary gain, derogatory comments about institution/hospital that degrade trust in our profession to the public, outbursts of anger and inappropriate work place sexual harassment or alternatively false allegations of such type of behavior (4). The Public trust demands that we make appropriate decisions in face of complex environments and often unscientific pressures for the overall care of patient and public if we are to do our part in maintaining a profession (5). We need to continue to strive toward benefiting our patients and subordinating our interests to best meet the needs of our patients and we should stand our ground to pillars of our profession, otherwise maybe we should amend our thinking to accept the fact that we have become corporate or political factotums and not here for a higher calling. Our voices should be united, altruistic and with medical professionalism to maintain public’s trust. Create goals that will prevent burnout and focus lifestyle expectations that realistic and fulfilling in order to avoid the need to rush through the long queues of patients in the waiting room and its associated dissatisfaction (6).  

F. Brian Boudi, MD

Phoenix Veterans Administration Health Care System

University of Arizona College of Medicine

Phoenix, Arizona

Connie S. Chan, MD

Phoenix Veterans Administration Health Care System

Phoenix, Arizona 

References

1. American Board of Internal Medicine. Project Professionalism. 2013. Available at:  https://medicinainternaucv.files.wordpress.com/2013/02/project-professionalism.pdf (accessed 6/29/17).
2. G Hamel, Zanini M.  More of us are working in big bureaucratic organizations than ever before. Harvard Business Review. July 5, 2016. Available at: https://hbr.org/2016/07/more-of-us-are-working-in-big-bureaucratic-organizations-than-ever-before (accessed 6/29/17). 
3. Pardes H. The future of medical schools and teaching hospitals in the era of managed care. Acad Med. 1997 Feb;72(2):97-102. [CrossRef] [PubMed]
4. Scott KM, Berlec Š, Nash L, Hooker C, Dwyer P, Macneill P, River J, Ivory K. Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students. Med Humanit. 2017 Mar;43(1):68-70. [CrossRef] [PubMed]
5. Relman AS. Education to defend professional values in the new corporate age. Acad Med. 1998 Dec;73(12):1229-33. [CrossRef] [PubMed]
6. Barkil-Oteo A. Have physicians finally joined the working class? KevinMD.com. November 3, 2016. Available at: http://www.kevinmd.com/blog/2016/11/physicians-finally-joined-working-class.html (accessed 6/29/16).

Cite as: Boudi FB, Chan CS. The unspoken challenges to the profession of medicine. Southwest J Pulm Crit Care. 2017;14(6):222-4. doi: https://doi.org/10.13175/swjpcc085-17 PDF 

EMR Fines Test Trump Administration’s Opposition to Bureaucracy

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

• Six clinicians couldn't provide a mandatory analysis of security risks;
• Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
• Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
• One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
• One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF

Breaking the Guidelines for Better Care

Two events happened this past week that inspired this editorial. First, on Wednesday morning I read the editorial titled “Breaking the Rules for Better Care” by Don Berwick et al. in JAMA (1). Berwick reports a survey of about 40 hospitals done by The Institute of Healthcare Improvement (IHI). The survey asked the question “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”. The answers were not surprising. Most centered on annoying hospital rules such as visiting hours, not waking patients, correct HIPPA interpretation, and eliminating the 3-day rule. Although these are correct, in the whole they have minimal effect on healthcare. Other suggestions more likely to improve patient care included improving access, reducing wait times and earlier patient mobility. From the suggestions, it seems likely that most were from administrators. In the editorial Berwick decried, “Habits embedded in organizational behaviors, based on misinterpretations and with little to no actual foundation in legal, regulatory, or administrative requirements”. He goes on to say, “Health care leaders may be well advised to ask their clinicians, staffs, and patients which habits and rules appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them.” As a clinician, I thoroughly agree with both of Berwick’s points.

Later that afternoon, I listened to a lecture by Clement Singarajah on sepsis guidelines. He reviewed the severe sepsis bundles promoted by the Surviving Sepsis Campaign and IHI, the latter being Berwick’s organization who wrote the editorial noted above (Table 1) (2,3).

Table 1.  Severe Sepsis Bundles.

The Severe Sepsis 3-Hour Resuscitation Bundle contains the following elements, to be completed within 3 hours of the time of presentation with severe sepsis:

• Measure Lactate Level
• Obtain Blood Cultures Prior to Administration of Antibiotics
• Administer Broad Spectrum Antibiotics
• Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L

The 6-Hour Septic Shock Bundle contains the following elements, to be completed within 6 hours of the time of presentation with severe sepsis:

• Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg)
• In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL):
  • Measure Central Venous Pressure (CVP)
  • Measure Central Venous Oxygen Saturation (ScvO2)
• Remeasure Lactate If Initial Lactate Was Elevated

We carefully reviewed each of the metrics, and concluded most were non-evidence based, outdated, or contradicted by more recent and better trials. The only exception was early antibiotic administration. Most of us reaffirmed our belief in the germ theory and felt that early administration of the correct antibiotics was probably mostly evidence-based and reasonable (4).

Is it possible that most of the metrics in the bundle are merely a waste of time as we concluded or could some be harmful? First, a recent meta-analysis examined a conservative fluid strategy in sepsis compared with a liberal strategy (the goal-directed therapy as advocated by the sepsis bundles) (5). Although there was no change in mortality, a conservative strategy resulted in increased ventilator-free days and reduced length of ICU stay. The meta-analysis concluded that the studies were underpowered to show a mortality benefit. Second, most of us had experienced delays in initiating antibiotics, the only guideline that makes a difference, while waiting for blood cultures to be drawn. None of us knew data that drawing blood cultures makes a difference in patient outcomes.

Berwick recommended asking clinicians which rules may be harming care. Rather than chiding others to do something, a good place to start might be IHI’s sepsis guidelines. The issue of continued support for non-evidence based or outdated guidelines points out the rigid dichotomy between self-delusional beliefs and science. Many (some would say most) guidelines are based on opinions and not science (6). Healthcare would be better if groups such as the Surviving Sepsis Campaign, IHI and the Centers for Medicare and Medicaid Services would follow their own advice and not burden healthcare providers with non-evidence based guidelines. Instead, they should only issue guidelines after carefully conducted, randomized, controlled trials establish a guideline rather than mandating the self-delusional beliefs of a few.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Berwick DM, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017 Jun 6;317(21):2161-2. [CrossRef] [PubMed]
2. Surviving Sepsis Campaign. Updated bundles in response to new evidence. Available at: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf (accessed 6/9/17).
3. Institute for Healthcare Improvement. Severe sepsis bundles. Available at: http://www.ihi.org/resources/Pages/Tools/SevereSepsisBundles.aspx (accessed 6/9/17).
4. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017 Jun 8;376(23):2235-44. [CrossRef] [PubMed]
5. Silversides JA, Major E, Ferguson AJ, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017 Feb;43(2):155-170. [CrossRef] [PubMed]
6. 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. [CrossRef] [PubMed]

Cite as: Robbins RA. Breaking the guidelines for better care. Southwest J Pulm Crit Care. 2017;14(6):285-7. doi: https://doi.org/10.13175/swjpcc072-17 PDF 

Worst Places to Practice Medicine

Medscape periodically publishes a “Best” and “Worst” places to practice medicine (1). We were struck by this year’s list because three of the five worst places to practice medicine are in the Southwest (Table 1).

Table 1. Medscape’s “worst” places to practice medicine.

1. New Orleans, Louisiana
2. Phoenix, Arizona
3. Las Vegas, Nevada
4. Albuquerque, New Mexico
5. Tulsa, Oklahoma

While Minneapolis rated the best place to practice, only 2 cities from the Southwest made the top 25 “Best” list-Salt Lake City at 13^th and Colorado Springs at 24^th. Most of the top 25 are from the Midwest or Northeast. None from California made the best places list and only the only Southern location was Virginia Beach, Virginia. 

Rankings resulted from the combination of twelve 50-state rankings: medical board actions per doctor; malpractice lawsuits per doctor; office-based primary care physicians per population; physician income; employer-based insurance rate per population; insurance coverage per population; reported rates of well-being of the general population; violent crime rates; participation in wildlife-related recreation; divorce rates; use of family-friendly amenities; and cost of living.

Phoenix, Las Vegas and Albuquerque were singled out for high rates of uninsured patients. Phoenix was also singled out for its moderately high malpractice suit rate.

Before everyone in the Southwest decides to move, these ratings may be meaningless, much like hospital rankings (2). Furthermore, there seems little that physicians can do to improve the situation based on the selected metrics. What can be done is to continue our efforts through our professional organizations to educate the public and their elected representatives that job satisfaction is necessary to recruit and retain physicians, as well as nurses and other health care professionals. A healthcare organization without these well-educated and caring people lacks quality and attempts to substitute substandard care is much like trying to substitute a Yugo for a Mercedes.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Page L. Best places to practice to avoid burnout. Medscape. May 10, 2017. Available at: http://www.medscape.com/viewarticle/879573 (accessed 5/16/17).
2. Robbins RA, Gerkin RD. A comparison between hospital rankings and outcomes data. Southwest J Pulm Crit Care. 2013;7(3):196-203. [CrossRef] 

Cite as: Robbins RA. Worst places to practice medicine. Southwest J Pulm Crit Care. 2017;14(5):236-7. doi: https://doi.org/10.13175/swjpcc060-17 PDF 

Pain Scales and the Opioid Crisis

In the last year, physicians and nurses have increasingly voiced their dissatisfaction with pain as the fifth vital sign. In June 2016, the American Medical Association recommended that pain scales be removed in professional medical standards (1). In September 2016, the American Academy of Family Physicians did the same (2). A recent Medscape survey reported that over half of surveyed doctors and nurses supported removal of pain assessment as a routine vital sign (3).

In the 1990’s there was a widespread impression that pain was undertreated. Whether this was true or an impression created by a few practitioners and undertreated patients with the support of the pharmaceutical industry is unclear. Nevertheless, the prevailing thought became that identifying and quantifying pain would lead to more appropriate pain therapy. The American Society of Anesthesiologists and the American Pain Society issued practice guidelines for pain management (4,5). Subsequently, both the Department of Veterans Affairs and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated a pain scale as the fifth vital sign (6-9). Most commonly these scales ask patients to rate their pain on a scale of 1-10. The JCAHO mandated that "Pain is assessed in all patients” and would give hospitals "requirements for Improvement" if they failed to meet this standard (9). The JCAHO also published a book in 2000 for purchase as part of required continuing education seminars (9). The book cited studies that claimed "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addiction side effects "inaccurate and exaggerated." The book was sponsored by Purdue Pharma makers of oxycodone.

Almost as soon as the standards were initiated, suggestions emerged that pain treatment was becoming overzealous. In 2003 a survey of 250 adults who had undergone surgical procedures reported that almost 90% were satisfied with their pain medications. Nevertheless, the authors concluded that “many patients continue to experience intense pain after surgery … additional efforts are required to improve patients’ postoperative pain experience” (8). Concerns about overaggressive treatment for pain increased after Vila et al. (10) reported in 2005 that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100 000 inpatient hospital days after the hospitals implemented a numerical pain treatment algorithm. As early as 2002 the Institute for Safe Medication Practices linked overaggressive pain management to a substantial increase in oversedation and fatal respiratory depression events (11). Articles appeared questioning the wisdom of asking every patient to rate their pain noting that implementation of the scale did not appear to improve pain management (12). The JCAHO removed its standard to assess pain in all patients but not until 2009.

The US has seen a dramatic increase in the incidence of opioid deaths (13). It is unclear if adoption of the pain scale and its widespread application to all patients contributed to the increase although the time frame and the data from Vila et al. (10) suggest that this is likely.

There have been other factors that may have also contributed to the increase in opioid deaths. The Medscape survey mentioned above asked participants how often they feel pressure to prescribe pain medication in order to keep patient satisfaction levels high (3). Specifically mentioned was the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS. HCAHPS is a patient satisfaction survey required for all hospitals in the US. About two thirds of doctors and nurses felt there was pressure (3). The survey also asked respondents about the influence of patient reviews on opioid prescribing. Forty-six percent of doctors said the reviews were more than slightly influential. The surveys seemed to carry more weight with nurses. Seventy-three percent said the reviews were influential. Others have blamed pharmaceutical company marketing opioids as a way of reducing pain and increasing patient satisfaction (14). Clearly, there has been a dramatic increase in narcotic prescriptions. Not surprisingly, pharmaceutical companies have done little to curb the use of their products.

Earlier this year, former CDC Director Tom Frieden said "The prescription overdose epidemic is doctor-driven…It can be reversed in part by doctors' actions” (15). Some physicians have taken this as blame for the entire opioid crisis, including deaths from heroin and illegal fentanyl. There may be some validity in this belief since abuse of illegal narcotics sometimes evolves out of abuse of prescribed narcotics. However, the actions of the health regulatory agencies that mandated pain scales and created guidelines for pain management were not mentioned by Dr. Frieden. Also, not mentioned are the patient satisfaction surveys. 

About a year ago the CDC issued guidelines for prescribing opioids for chronic pain (15). These guidelines were developed in collaboration with a number of federal agencies including the Department of Veterans Affairs which was one of the first to mandate pain scales and the Centers for Medicare and Medicaid Services (CMS) which mandated HCAHPS. Pain is a subjective symptom and quantification and treatment are imprecise. The goal cannot be to deliver perfect pain management but to reduce the incidence of under- and overtreatment as much as possible. Someone needs to assess patients’ pain complaints and prescribe opioids appropriately. No one is better qualified and prepared than the clinician at the bedside.

No one condones the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, meddling by unqualified bureaucrats, administrators and politicians emphasizes guidelines over appropriate care. As detailed above, the present opioid crisis may be an unattended consequence of the pain scale and opioid prescribing guidelines. Further intrusion by the same groups who created the crisis is unlikely to solve the problem but is likely to create additional problems such as the undertreatment of patients with severe pain. As I write this on the ides of March it may be appropriate to paraphrase a line from Julius Cesar, “The fault lies not in our doctors but in our regulators”.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Anson P. AMA drops pain as vital sign. Pain News Network. June 16, 2016. Available at: https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign (accessed 3/2/17).
2. Lowes R. Drop pain as the fifth vital sign, AAFP says. Medscape Medical News. September 22, 2016. Available at: http://www.medscape.com/viewarticle/869169 (accessed 3/2/17).
3. Ault A. Many physicians, nurses want pain removed as fifth vital sign. Medscape Medical News. Medscape Medical News. February 21, 2017. Available at: http://www.medscape.com/viewarticle/875980?nlid=113119_3464&src=WNL_mdplsfeat_170228_mscpedit_ccmd&uac=9273DT&spon=32&impID=1299168&faf=1 (accessed 3/2/17).
4. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995 Apr;82(4):1071-81. [CrossRef] [PubMed]
5. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005 Jul 25;165(14):1574-80. [CrossRef] [PubMed]
6. National Pain Management Coordinating Committee. Pain as the 5Th vital sign toolkit. Department of Veterans Affairs. October 2000. Available at: https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf (accessed 3/2/17).
7. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117-8. [CrossRef] [PubMed]
8. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540. [CrossRef] [PubMed]
9. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 3/2/17).
10. Vila H Jr, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101(2):474-480. [CrossRef] [PubMed]
11. Institute for Safe Medication Practices. Pain scales don’t weigh every risk. July 24, 2002. Available at: https://www.ismp.org/newsletters/acutecare/articles/20020724.asp (accessed 3/2/17).
12. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006 Jun;21(6):607-12. [CrossRef] [PubMed] 
13. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 16;65. Published on-line. [CrossRef] [PubMed]
14. Cha AE. The drug industry’s answer to opioid addiction: More pills. Washington Post. October 16, 2016. Available at: https://www.washingtonpost.com/national/the-drug-industrys-answer-to-opioid-addiction-more-pills/2016/10/15/181a529c-8ae4-11e6-bff0-d53f592f176e_story.html?utm_term=.36c5992fa62f (accessed 3/2/17).
15. Lowes R. CDC issues opioid guidelines for 'doctor-driven' epidemic. Medscape. March 15, 2016. Available at: http://www.medscape.com/viewarticle/860452 (accessed 3/2/17).

Cite as: Robbins RA. Pain scales and the opioid crisis. Southwest J Pulm Crit Care. 2017;14(3):119-22. doi: https://doi.org/10.13175/swjpcc033-17 PDF 

In Defense of Eminence-Based Medicine

An internal memo to the members of the Society for Truculent Underappreciated Practitioners of Inpatient Doctoring

Brigham C. Willis, MD, MEd

Department of Medical Education and Division of Cardiovascular Intensive Care
Phoenix Children's Hospital
Phoenix, AZ USA

To arms, august compatriots! Our very way of life is threatened by the hordes of barbarians at our gates. Armed not with pitchforks and torches, but with Cochrane reviews, “multicenter randomized controlled trials”, the Interwebs, and “tablet computers”, they besiege our traditions and values, and threaten our place in the hierarchy of medicine. In no uncertain terms, they want to remove us from our place of reverence, from our position of respect, and replace us with guidelines, pathways, and protocols. To do nothing is to perish. We must stand together, and fight this tide, or be swept away in the tidal wave of journals and statistical analyses buffeting our land. Join or Die!

For generations, we have preserved our careers and medicine itself by strictly honoring a system based on “eminence-based medicine” or “EBM”. This is the practice of making the same sound decisions with increasing confidence over an impressive number of years (some of the barbarians have even mocked and disregarded this definition, co-opting “EBM” for their own purposes and replacing “sound decisions” in the true definition with “mistakes”. The nerve.) Upon what else does our hallowed practice rest than this? Imagine the disorder and chaos if students or lowly interns were allowed to question the decisions we, the wise practitioners, make. I have seen enough patents with pyemia or blood rot in my time to know how to treat them, thank you very much. I don’t need some unwashed whelp of a trainee waiving a New England Journal article in my face, saying I am giving too much or too little fluid to the patient. I once took care of a septic patient and gave them absolutely no fluid, and they survived. So much for the so-called “evidence”. There is no amount of evidence that can replace intuition and sound clinical acumen. As many of you likely can affirm, a true clinician can almost feel the right thing to do. A challenge to this as the basis of medicine is akin to advocating a change from the “art of medicine” to the “science of medicine”. Blasphemy!

I am sure each of you have experienced some form of this assault. In fact, the medical literature today is full of direct attacks on eminence (1-3). The threat is becoming more acute by the day, as even the lowliest trainee has access to the entire world’s archive of medical literature in their pocket. To survive, we must arm ourselves and fight back. We must have at the ready an armamentarium of weapons and tools to stem the tide, and turn back the latter-day Visigoths who fling their regression analyses, critical appraisal tools, and “levels of evidence” at our battlements. What follows is an attempt to codify some of those tools, and help all of our eminent practitioners to soldier on in the fight.

1. “Harrumph and eye roll”. When confronted with what seems like sound evidence that counters the way you have treated something for many years, simply roll your eyes in a dramatic way, make a “harrumph”-ing sound quite loudly, and say something like “Well, balanced salt solutions may make physiologic sense, but normal saline has worked for me for many years.” The italics imply rhetorically stressing the avenue of attack chosen by the challenger, and throwing it back at them in a mocking, or sarcastic way, and then reminding them of how much more experience you have than they do. While seemingly basic and perhaps puerile, it is astounding how effective this technique can be. But the “harrumph” you throw in must be emphatic, and said with conviction. This technique rests entirely on how invested in it you can be.
2. “My specific patient is different”. These evidence cultists always want to assume that their numbers and ratios always apply to everyone. It is relatively simple to find some minor clinical difference between the particular patient under discussion and the participants in whatever trial your foe is citing. For example, when challenged on your management of a ventilated patient, you can say, “Well, in that trial, they didn’t specifically analyze the subgroup of patients with influenza and CHF, did they?” or “the secretions of influenza in a patient with CHF are clearly unique”. Defenses like this usually put them on their heels, as they will either have to go back to the trial itself to check, or admit that they are not quite sure.
3. “In my experience…” No matter how much evidence is presented, it is always possible to unearth the musty contents of your own shadowy past. Ill-defined and utterly unverifiable, your “experiences” with individual patients, if described colorfully and in detail, can easily counter dry references to impersonal literature reports. It can also refute arguments of physiology. If you have seen something before, your eye-witness account is much more reliable than some “deep understanding of physiologic principles”.
4. Question the quality of the training of the evidence-hound. No matter what they say or how many “facts” they can cite, one can almost always cast aspersions on their training in some way. “When I was at Harvard...” is a near-perfect oratory introduction to asserting your proper place.
5. Point out some minute problem in the design of the study being quoted. Although somewhat unsavory, as it may require stooping to the tactics employed by our attackers, it is always possible to take issue with some aspect of any given study. “I can’t believe they used a Kolmogorov–Smirnov test, when they clearly should have used Pitman’s permutation test. The results of this study are suspect to say the least.” This should require quite a bit of investigation by the whelp, by which time you should be safely ensconced in the doctor’s lounge.
6. Cite a report that supports your viewpoint. Again somewhat unsavory, but even when someone states that 3 randomized control trials (RCTs) have shown that a certain treatment is “clearly” superior to how you have been doing things, you can almost always cite a trial that does support you (“while it is interesting that those investigations show that digitalis is not effective in heart failure in general, Jones et al. showed that it reduced readmission rates in the Congo when given to patients with CHF due to parasitic disease...”). Always remember to end the discussion with “so clearly the jury is still out on this subject.”
7. Lean heavily on the axiom that “lack of evidence of efficacy is not evidence of lack of efficacy”. This is very powerful and can be carried quite far. No matter how many trials show that a treatment doesn’t work, this single sentence irrefutably ends discussion in most cases.
8. Utilize physiologic smoke screens. Delve deeply into your medical school texts, and have at the ready in depth discussions of biochemical and physiologic pathways. Learn to describe how they interact in such detail that no one can really follow what you are getting at, but throw in enough polysyllabic words and pathway intermediates and you are untouchable, no matter how much evidence is tossed around. In today’s world, most trainees’ education in biochemistry, physiology, and anatomy has been short-shrifted to a stunning degree by the addition of silly classes on biostatistics, ethics, diversity, professionalism, and other such drivel, so you can be generally assured they will have no comeback for this defense.
9. “Cookbook medicine”. Throw out derogatory terms such as “cookbook medicine” and wax nostalgic for the times when doctors truly “thought” about their patients and cared about them. This is particularly effective when you can question the humanity of your foe, asserting that “statistics and numbers can never substitute for the human being in the bed in front of you. You would do well to remember that.” Followed up with a moving patient story where your attention to detail and the history of that individual patient made all the difference, and where your diagnosis and treatment plan flew in the face of the naysayers, and you are safe.
10. Parachutes. Go nuclear, and question evidence itself. This is obviously high-risk, but can be very effective. Building on the excellent article utilizing the example of the parachute as a preventative treatment for high-altitude falls that has never been verified in a RCT (despite the fact that there are case reports of parachute-less high-altitude falls resulting in subject survival) (4), make the point that medicine is more than evidence. Rub their nose in the fact that true doctors can see the value in treatments that are of “obvious” value, even without evidence.
11. Question the work ethic or integrity of the evidence bearer. No matter what they say, find some fault with their daily routine, or pre-rounding attention to detail, or accuracy of information they provided about the patient. Proceed to vociferously point out their deficiencies, making sure that everyone in ear shot is aware of what is happening, and intimate that anything they say is suspect.
12. Trump them. If all else fails, utilize the debate technique made so famous by the current president. Previously known as “vehemence-based medicine” (5), simply raising the volume of your opinion and employing an attitude that your opponent is a complete and utter moron will shut down any opposition. With this technique, if employed correctly, any amount of logic or number of facts will wilt in the glare of your intensity and scorn.
13. Eloquence and elegance based argumentation. Much to the chagrin of the attackers, it is still well-accepted that “brilliant oratory,…a year round suntan, [and/or] a silk suit” (5) can overwhelm the senses of most of the sandal-wearing hippies who worship at the altar of evidence. Keep your style impressive and tighten your bowties!

Be strong, my brothers and sisters! While some furtive attempts have been made to fight back and harness the power of our eminence (6), we are clearly in danger. In the face of this growing threat, our ability to wield our eminence may falter. We hope that the techniques described herein will serve you well in our struggle. Let not these heathens question our place or sacred way of life. Stand tall, and continue to be the face of “EBM”.

References

1. Bhandari M, Zlowodzki M, Cole PA. From eminence-based practice to evidence-based practice: a paradigm shift. Minn Med. 2004 Apr;87(4):51-4. [PubMed]
2. Kros JM. Grading of gliomas: the road from eminence to evidence. J Neuropathol Exp Neurol. 2011 Feb;70(2):101-9. [CrossRef] [PubMed]
3. Pincus T, Tugwell P. Shouldn't standard rheumatology clinical care be evidence-based rather than eminence-based, eloquence-based, or elegance-based? J Rheumatol. 2007 Jan;34(1):1-4. [PubMed]
4. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003 Dec 20;327(7429):1459-61. [CrossRef] [PubMed]
5. Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ. 1999 Dec 18-25;319(7225):1618. [CrossRef] [PubMed]
6. Hay MC, Weisner TS, Subramanian S, Duan N, Niedzinski EJ, Kravitz RL.Harnessing experience: exploring the gap between evidence-based medicine and clinical practice. J Eval Clin Pract. 2008 Oct;14(5):707-13. [CrossRef] [PubMed]

Cite as: Willis BC. In defense of eminence-based medicine. Southwest J Pulm Crit Care. 2017;14(2):69-72. doi: https://doi.org/10.13175/swjpcc019-17 PDF 

Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now

Stuart F. Quan, M.D.

Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

and

Division of Sleep Medicine

Harvard Medical School

Boston, MA USA

and

Asthma and Airway Disease Research Center

University of Arizona College of Medicine,

Tucson, AZ USA

On September 29, 2016, a New Jersey Transit train failed to slow down and stop at the station in Hoboken, New Jersey. The resulting crash injured a number of passengers and killed a young mother who happened to be near the crash site. Subsequently, it was learned that the train engineer who apparently had blacked out was diagnosed as having severe obstructive sleep apnea (OSA) (1). Unfortunately, this was not an isolated incident. Over the past few years, there have been several other well-documented incidents of train, truck and bus crashes resulting from their operators falling asleep from OSA. In 2013, a Metro-North commuter train derailed outside of New York City because of excessive speed approaching a curve, the train engineer reported being “dazed” and was subsequently found to have OSA (2). Four passengers were killed and numerous others were injured. In another well-documented accident in 2013, the driver of a Greyhound bus fell asleep. The bus ran off the road, rolled on its side and injured 35 passengers. The driver had been told to get tested for OSA, but did not have the study done. A subsequent court-ordered polysomnogram showed OSA (3). In another incident in 2009, a truck-tractor semitrailer operator failed to notice slowing and stopped cars in front of him and collided with a passenger vehicle. This led to a series of rear end vehicle collisions resulting in 10 fatalities. The cause of the accident was operator fatigue related in part to OSA (4). These well-publicized incidents are only a few of the sleepiness/fatigue related accidents caused by unrecognized OSA in the transportation industry.

One of the most common symptoms attributed to OSA is daytime sleepiness which can be uncontrollable and unpredictable. Numerous studies have demonstrated that persons with OSA have an increased rate of motor vehicle accidents with up to a 4.9 fold higher risk (5). Accidents involving only a single vehicle are particularly frequent suggesting that the crashes are caused by the operators having fallen asleep. Truck drivers are at even greater risk, most likely because they are disproportionately male, middle aged and overweight, all of which are risk factors for OSA. Over a ten year span from 2004 to 2013, it has been estimated that 3,133 to 8,952 deaths and 77,000 and 220,000 serious injuries have resulted from sleepy operators of commercial motor vehicles, many of whom most likely had undiagnosed and untreated OSA (6).

Given the severe consequences of unrecognized OSA on public safety and the high prevalence of unrecognized OSA among operators of trains, buses and commercial trucks, the imperative to screen and treat these persons for OSA is high. The advisory boards to the Federal Motor Carrier Safety Administration (FMCSA) have recommended that commercial truck drivers be screened for OSA if their body mass index is > 40 kg/m², or >33 kg/m² and have 3 or more conditions or findings associated with OSA, but adoption of these recommendations has not occurred (7). More recently, the Department of Transportation, Federal Railroad Administration and the FMCSA have taken the first steps to mandate screening and treatment of rail and commercial motor vehicle operators for OSA by soliciting public comment (8). Airline pilots are already screened. However, there is substantial opposition from the trucking industry and drivers themselves, the latter because of potential job loss. However, such a screening program in one large trucking company has demonstrated a 5 fold reduction in accident rates in drivers who were adherent to CPAP treatment for OSA (5).

With the development of relatively simple to use ambulatory devices that can identify most persons with OSA, screening for OSA can be done easily and cost-effectively. In the vast majority of cases, referral to a sleep lab is not necessary. Persons diagnosed with OSA can be treated with several different modalities and are able to return to work. Employers may actually experience a reduction in their costs related to fewer accidents and improved employee health. Thus, there is no reason to delay requiring OSA screening programs for all persons working in occupations where public safety is at risk. For regulators, policy makers, and the various industries affected, the time is now. Failure to act places the responsibilities for the ensuing economic costs, injuries and deaths on your shoulders.

References

1. Marsh R, Shortell D. NJ. Train Engineer in Crash had Undiagnosed Sleep Apnea. CNN. October 17, 2016. Available at: http://www.cnn.com/2016/11/17/us/njt-engineer-sleep-apnea/ (accessed 12/2/16).
2. National Transportation Safety Board. Metro-North Railroad Derailment. October 24, 2014. Available at: http://www.ntsb.gov/investigations/accidentreports/pages/RAB1412.aspx (accessed 12/2/16).
3. Five Passengers hurt in 2013 Greyhound Bus Crash Win $6 Million Settlement Attorneys Say. WCPO Cincinnati. http://www.wcpo.com/news/local-news/hamilton-county/cincinnati/five-passengers-hurt-in-2013-greyhound-bus-crash-win-6-million-settlement-attorneys-say (accessed 12/2/16).
4. National Transportation Safety Board. Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44. September 28, 2010. http://www.ntsb.gov/investigations/AccidentReports/Pages/HAR1002.aspx (accessed 12/2/16).
5. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009;5 (6):573–81.[PubMed]
6. Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes. Sleep. 2016 May 1;39(5):967-75. [CrossRef] [PubMed]
7. Miller E. FMCSA Medical Review Board Issues Sleep Apnea Guidelines. Transport Topics. August 24, 2016. Available at:  http://www.ttnews.com/articles/basetemplate.aspx?storyid=42963&page=1 (accessed 12/2/16).
8. Federal Motor Carrier Safety Administration. U.S. DOT Seeks Input on Screening and Treating Commercial Motor Vehicle Drivers and Rail Workers with Obstructive Sleep Apnea. March 8, 2016. Available at: https://www.fmcsa.dot.gov/newsroom/us-dot-seeks-input-screening-and-treating-commercial-motor-vehicle-drivers-and-rail-workers (accessed 12/2/16).

Cite as: Quan SF. Screening for obstructive sleep apnea in the transportation industry—the time is now. Southwest J Pulm Crit Care. 2016;13(6):285-7. doi: https://doi.org/10.13175/swjpcc132-16 PDF

Mitigating the “Life-Sucking” Power of the Electronic Health Record

An article in PulmCCM discussed “life-sucking” electronic health care records (EHR) (1). It is in turn based on an article in the Annals of Internal Medicine on the work time spent by physicians (2). The latter, funded by the American Medical Association, observed 57 physicians in internal medicine, family medicine, cardiology, and orthopedics over hundreds of hours. The study revealed that physicians spend almost two hours working on their electronic health record for every one hour of face-to-face patient time. Interestingly, physicians who used a documentation assistant or dictation spent more time with patients (31 and 44%) compared to those with no documentation support (23%).

The PulmCCM goes on to list some of the reasons that the EHR requires so much time:

• The best and brightest minds in software design don't go to work for Epic, Cerner, Allscripts, and whoever the other ones are.
• There's a high barrier to entry for competition now that most major health systems have implemented the big-name systems.
• The vendors can't easily improve the front-end design's user-friendliness (like web pages and consumer software have) because it rests on clunky, proprietary frameworks built in the 1990s and which can't be substantially changed for stability reasons. Think Microsoft Office, but way worse.
• Software designers are congenitally incapable of accepting the reality that a user would be better off the less they use the product, and designing it that way. They think their EHR is super cool, and can't fathom that it actually sucks to use.

Let me add another possibility. Those who demand implementation of the EHR see documentation as being most important because of the bottom line. It if comes at the price of physician efficiency so be it-as long as it does not hurt payment. Physicians are not paid for the required increased documentation much of which is unnecessary, redundant and, in some cases, downright silly (3). Furthermore, the concept that this improves patient outcomes largely seems to be a myth (4). Those manuscripts that report improved “quality” of care usually have examined meaningless surrogate metrics that often have little or even inverse relationships with patient outcomes (3). For example, high patient satisfaction seems to come at the price of increased mortality (5).

What is the solution-charge for the time. As it now stands, there is no downside to demanding pointless documentation. Third party payers can deny payment when something like the rarely beneficial family history is omitted. There should be a charge for seeing and caring for the patient and another “documentation fee” that is based on time. That would mean that a 20 minute office call would not be billed at 20 minutes but at the 1 hour of physician time the visit really consumes. Those physicians who use a documentation assistant or dictation can pay for these services by seeing more patients. Only in this way can the trend of wasting physicians’ most precious resource, their time, be mitigated.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. PulmCCM. Life-sucking power of electronic health records measured, reported, lamented. November 25, 2016. Available at: http://pulmccm.org/main/2016/outpatient-pulmonology-review/life-sucking-power-electronic-health-records-measured-reported-lamented/ (accessed 11/28/16).
2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016 Sep 6. [Epub ahead of print] [CrossRef] [PubMed]
3. Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. [CrossRef]
4. Yanamadala S, Morrison D, Curtin C, McDonald K, Hernandez-Boussard T. Electronic health records and quality of care: an observational study modeling impact on mortality, readmissions, and complications. Medicine (Baltimore). 2016 May;95(19):e3332. [CrossRef] [PubMed]
5. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-11. [CrossRef] [PubMed]

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as: Robbins RA. Mitigating the “life-sucking” power of the electronic health record. Southwest J Pulm Crit Care. 2016;13(5):255-6. doi: https://doi.org/10.13175/swjpcc125-16 PDF

Has the VA Become a White Elephant?

As I write this Dennis Wagner is publishing a series of articles in the Arizona Republic describing his quest to find out if care at VA hospitals has improved over the last 2 years (1). To begin the article Wagner describes the fable of the King of Siam who presented albino pachyderms to his enemies knowing they would be bankrupted because the cost of food and care outweighed all usefulness. A modern expression derives from this parable: the white elephant.

The Department of Veterans Affairs (VA) has prided itself on being a leader in healthcare. It is the largest healthcare system in the US, implemented the first electronic medical record, and more than 70 percent of all US doctors have received training in the VA healthcare system (2). This year the VA is celebrating the 70th anniversary of its partnership with US medical schools. Beginning in 1946, the VA partnered with academic institutions to provide health care and to train physicians, nurses and other healthcare professionals. “We are extremely proud of the long-standing, close relationships built over the past 70 years among VA and academic institutions across the country” said VA Secretary Robert A. McDonald. “These partnerships strengthen VA’s healthcare system, and provide high quality training for the nation’s healthcare workforce. We cannot do what we do without them.” On this Veterans Day these appear to be empty words.

To understand the VA wait list scandal and why it will be difficult to fix, it is important to understand the history of the VA academic affiliations. The VA initially affiliated with medical schools in 1946 because it had trouble attracting enough quality physicians to staff its hospitals. These affiliations led to the formation of "dean's hospitals" (3). These were VA hospitals closely affiliated with medical schools and made the VA hospitals teaching hospitals. The medical school faculty was in charge of patient care and teaching and the dean's committee oversaw it all. Not surprisingly, these dean's committees were largely despised by the non-physician directors of the VA business offices. In the mid-1990's they persuaded Veterans Health Administration undersecretary, Kenneth W. Kizer, to place them in charge of the VA hospitals as hospital directors. The dean's committees were dissolved, freeing the directors from any real local oversight. This set the foundation for the VA to return to 1945 and a culture that makes it difficult to attract sufficient numbers of quality physicians.

The inability to attract physicians is largely responsible for the widely publicized VA wait time crisis. Although the VA blames their inability to recruit on pay below what the private sector pays, this is only part of the story. VA administrators have repeatedly attempted to direct patient care leading to physician job dissatisfaction and poor morale. Rather than quality healthcare, the VA developed a list of largely meaningless metrics that substituted for quality. These so called "performance-measurements" were favored by VA administration in no small part because of the bonuses they generated for the administrators. This created a cycle of increasing numbers of measurements to generate increasing bonuses. Physicians were often pressured to remind patients to wear seat belts, not keep guns in the home, etc. leaving insufficient time to deal with real and immediate healthcare problems. In retrospect, even Kizer himself called the expanding number of performance measurements "bloated and unfocused" (4).

At first VA administrators tried to deny the problem of delayed care due to insufficient staffing. Next VA Central Office tried to make all VA clinics walk-in clinics, essentially shifting the problem to the physicians. When caught in lies about short wait times, VA Secretary McDonald fired a few administrators in Phoenix and then tried to minimize the problem (5). When announcing their progress on the problem, the VA touts the number of people it has hired but usually does not specify the number of physicians or other healthcare providers. Now the VA has decided to let nurses and pharmacists pick up the slack. The VA has proposed removing physician supervision of nurse practitioners and has begun using pharmacists for primary care (6,7).

A number of medical groups have opposed the increased authority for nurses (8). Neither nurses nor pharmacists have the length of training of physicians (9).  However, objections by the AMA and other groups are likely to fall on deaf ears. Unless the VA can recruit physician which seems unlikely without reform, what other choice do they have? It is unclear if the VA and courts will hold these less experienced and lower skilled practitioners to the same high standards they have held physicians. However, given that the VA administrators are knowingly replacing physicians with less skilled practitioners, this would seem reasonable.

Wagner's series in the Arizona Republic seems to suggest that the VA's lack of transparency makes it difficult to determine if care at VA hospitals have improved over the last 2 years (9). The conclusion from the series appears to be that the VA has not. This is not surprising given that no real reform has taken place and McDonald appears not to be in control of the VA. For example, two short years ago McDonald was proposing to downsize the VA administration (10). Like so many reforms, this seems to have fallen by the wayside under opposition from VA administration. In fact, Wagner implies that VA administration may actually have grown beyond what was already a bloated bureaucracy (9).

President-elect Trump has been critical of the VA and McDonald. It seems likely he will be gone this January but the VA administrators will remain. Hopefully, McDonald's replacement will do better in reforming the VA. If not, it might be time to view the VA as what it has become, a white elephant whose cost outweighs all usefulness. Consideration should be given to replacing the VA with care in the private sector. Although care will be more expensive, it is better than no or poor care which is what the VA patients are receiving now.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening?. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 10/27/16).
2. Department of Veterans Affairs. VA celebrates 70 years of partnering with medical schools. Available at: http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2747 (accessed 10/27/16).
3. Department of Veterans Affairs. Still going strong - the history of VA academic affiliations. Available at: http://www.va.gov/OAA/videos/transcript_affiliation_history.asp (accessed 10/27/16).
4. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jul 24;371(4):295-7. [CrossRef] [PubMed]
5. Rein L. VA chief compares waits for veteran care to Disneyland: They don’t measure and we shouldn’t either. Washington Post. May 23, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/23/va-chief-compares-waits-for-veteran-care-to-disneyland-they-dont-measure-and-we-shouldnt-either/ (accessed 10/27/16).
6. Department of Veterans Affairs. VA Proposes to grant full practice authority to advanced practice registered nurses. May 29, 2016. Available at: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793 (accessed 10/27/16).
7. Galewitz P. VA shifts to clinical pharmacists to help ease patients’ long waits. Kaiser Health News. October 25, 2016. Available at: http://khn.org/news/va-treats-patients-impatience-with-clinical-pharmacists/ (accessed 10/27/16).
8. Rein L. To cut wait times, VA wants nurses to act like doctors. Doctors say veterans will be harmed. Washington Post. May 27, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/ (accessed 10/27/16).
9. Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. [CrossRef]
10. Krause J. MyVA re-org likely set to downsize VA workforce, a lot. DisabledVeterans.org. Jan 28, 2015. Available at: http://www.disabledveterans.org/2015/01/29/myva-reorganization-likely-set-downsize-va-workforce-lot/ (accessed 10/27/16).

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as Robbins RA. Has the VA Become a White Elephant? Southwest J Pulm Crit Care. 2016;13(5):235-7. doi: https://doi.org/10.13175/swjpcc108-16 PDF 

The Most Influential People in Healthcare

Recently Modern Healthcare released their annual 2016 listing of the most influential people in Healthcare (1). Leading the list is President Barack Obama for his Affordable Care Act. The list consists of a monotonous list of bureaucrats, politicians, large healthcare chain CEOs, insurance company CEOs, health interest organizations (American Hospital Association, America's Health Insurance Plans Healthcare, etc.), professional organizations (American Medical Association, American Nurses Association, etc.), nongovernmental healthcare interest organizations (Joint Commission,  National Quality Forum, etc.) and vendors (Epic, McKesson, etc.). From the Southwest the list includes at least 11 hospital chain CEOs including 1 from Arizona, 3 from Colorado and 7 from California.

Striking is the lack of influential healthcare professionals who made the list. Only two are leading academicians-Atul Gawande, a surgeon and author at Harvard, and Robert Wachter, an internist and pioneer in the hosptialist movement at University of California San Francisco. John Noseworthy (Mayo Clinic) and Ronald DePinho (MD Anderson) were noteworthy academicians prior to becoming hospital CEOs. Underrepresented are deans at major medical colleges (e.g., Talmadge King, Skip Garcia), influential researchers and clinicians (e.g., Marvin Schwarz, Stuart Quan), influential training organizations (e.g., American College of Graduate Medical Education, American Board of Internal Medicine), and even editors of prominent medical journals (e.g., Jeff Drazen at the New England Journal, Howard Bauchner at JAMA).

Every year I am offended by the domination of this list by bureaucrats, politicians and businessmen and the lack of true healthcare professionals. However, the list reflects the reality that political and business interests direct medicine. Everything from my interaction with a patient, documentation through in an electronic healthcare record, and diagnostic testing and prescribing based on the which tests and drugs are least expensive for a particular insurance plan are influenced by these non-medical interests. Unfortunately, what is lost is the interests of the patient and the role of doctors and nurses as patient advocates.

Medicine has too often become a series of meaningless metrics leading to expensive but poorer care because of these political and business interests. Furthermore, the practice of medicine is becoming increasingly unpleasant and unrewarding for the doctors and nurses. The domination of these non-medical interests has led to an explosion in non-professional administrators who consume 40% of the healthcare dollar and to a large extent annoy providers leading to their dissatisfaction with their professions (2). For example, Deputy Secretary of Veterans Affairs, Sloan Gibson, recently touted improvements made by the Phoenix VA (3). According to Gibson the Phoenix VA had a net increase of 758 employees in the past 2 years with an additional 23 doctors and 48 nurses. That calculates out to 91% of their hires being something other than physicians and nurses. It is unclear what these people do but hopefully something more than demand that providers fill out forms which they shuffle leading to ever larger administrative bonuses. Otherwise, those new hires will quickly leave and the shortage of providers that created the VA scandal in the first place will not improve. Incidentally, Gibson's boss, Robert McDonald was number 36 on the list.

What can we do? Unfortunately, there would appear to be no quick fixes. Most of us are just trying to get by caring for our patients and doing the best we can. It will take education of the public to what is going on and how their healthcare dollar is spent. Ultimately, it will be patients that can demand the changes that are needed. Although the solutions may be difficult, one way we might be able to detect improvement is when fewer bureaucrats, politicians and businessmen make Modern Healthcare's most influential list.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Modern Healthcare. 100 Most Influential People in Healthcare 2016. Available at: http://www.modernhealthcare.com/community/100-most-influential/2016/ (accessed 9/3/16).
2. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. [CrossRef]
3. Wagner D. Top VA brass says Phoenix hospital is off critical list, cites improvements. Arizona Republic. September 1, 2016. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/09/01/va-deputy-secretary-touts-phoenix-hospital-improvements/89666526/ (accessed 9/3/16).

*The opinions expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as: Robbins RA. The most influential people in healthcare. Southwest J Pulm Crit Care. 2016;13(3):123-4. doi: http://dx.doi.org/10.13175/swjpcc089-16 PDF

Remembering the 100,000 Lives Campaign

Earlier this week the Institute for Healthcare Improvement (IHI) emailed its weekly bulletin celebrating that it has been ten years since the end of the 100,000 Lives Campaign (Appendix 1). This was the campaign, according to the bulletin, that put IHI on the map. The Campaign started at the IHI National Forum in December 2004, when IHI's president, Don Berwick, announced that IHI would work together with nearly three-quarters of the US hospitals to reduce needless deaths by 100,000 over 18 months. A phrase borrowed from political campaigns became IHI's cri de coeur: “Some is not a number. Soon is not a time.”

The Campaign relied on six key interventions:

• Rapid Response Teams
• Improved Care for Acute Myocardial Infarction
• Medication Reconciliation
• Preventing Central Line Infections
• Preventing Surgical Site Infections
• Preventing Ventilator-Associated Pnemonia [sic]

According to the bulletin, the Campaign’s impact rippled across the organization and the world. IHI listed some of the lasting impacts:

• IHI followed with the 5 Million Lives Campaign – a campaign to avoid 5 million instances of harm.
• Don Berwick and Joe McCannon brought lessons from leading the Campaigns to Centers for Medicare and Medicaid Services (CMS) and the Partnership for Patients.
• Related campaigns were launched in Canada, Australia, Sweden, Denmark, UK, Japan, and elsewhere.

IHI's profile definitely grew. One indicator tracked by IHI was media impressions, which rose to 250 million in the final year of the Campaign. IHI even put a recreational vehicle on the streets to promote their Campaign (Appendix 1). Campaign Manager Joe McCannon was on CNN to discuss the results of the Campaign.

How did IHI achieve such remarkable results in saving patients' lives? The answer is they did not. Review of the evidence basis for at least 3 of these interventions revealed fundamental flaws (1). The largest trial of rapid response teams failed to result in any improvements and the interventions to prevent central line infections and ventilator-associated pneumonia were non- or weakly-evidenced based and unlikely to improve patient outcomes (2-4). The poor methodology and sloppy estimation of the number of lives saved were pointed out in the Joint Commission’s Journal of Quality and Safety by Wachter and Pronovost (5). IHI failed to adjust their estimates of lives saved for case-mix which accounted for nearly three out of four "lives saved." The actual mortality data were supplied to the IHI by hospitals without audit, and 14% of the hospitals submitted no data at all. Moreover, the reports from even those hospitals that did submit data were usually incomplete. The most striking example is that the IHI was so anxious to announce their success that the data was based on only 15 months of data. The final three months were extrapolated from hospitals’ previous submissions. Important confounders such as the background of declining inpatient mortality rates were ignored. Even if the Campaign "saved" lives, it would be unclear if the Campaign had anything to do with the reduction (5). Buoyed by their success, the IHI proceeded with the 5,000,000 Lives Campaign (6). However, this campaign ended in 2008 and was apparently not successful (7). Although IHI promised to publish results in major medical journals, to date no publication is evident.

A fundamental flaw in the logic behind the 100,000 Lives Campaign was that preventing a complication, for example an infection, results in a life saved. Many of our patients in the ICU have an infection as their life-ending event. However, the patients are often in the ICU because their underlying disease(s). In many instances their underlying disease(s) such as cancer, heart disease, or chronic obstructive pulmonary disease are so severe that survival is unlikely. It is akin to poisoning, stabbing, shooting and decapitating a hapless victim and saying that had the decapitation been prevented, survival was assured. IHI also assumed that the data was collected completely and honestly. However, the data was incomplete as pointed out above and the honesty of self-reported hospital data has also been called into question (8).

The bulletin correctly pointed out that Berwick did carry this political campaign with its sloppy science to Washington as CMS' administrator. Under Berwick's leadership, CMS would announce a campaign, have the hospitals collect the data, extrapolate the mortality or other benefit, and prepare a press release. This scheme continues until this day (9). CMS further confounded the data by providing financial incentives to hospitals, often resulting in bonuses to hospital executives, making the data further suspect. Certainly, CMS would not examine the hospital data with skepticism because the success of their campaign was in their own political best interest.

The 100,000 Lives Campaign also had one other outcome. It made many of us who believe in the power of evidence-based medicine to enrich patients' lives to be suspicious of these political maneuvers. To rephrase a well-known quote, "The first victim of politics is the truth". These campaigns certainly financially benefit hospitals and their administrators and politically benefit bureaucrats, but whether they benefit patients is questionable. The bulletin from IHI should be viewed for what it is, a political self-promotion to rewrite the failed history of the 100,000 Lives Campaign.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
2. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris A; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091-7. [CrossRef] [PubMed]
3. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
4. 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.
5. Wachter RM, Pronovost PJ. The 100,000 Lives Campaign: A scientific and policy review. Jt Comm J Qual Patient Saf. 2006;32(11):621-7. [PubMed]
6. Institute for Healthcare Improvement. 5 million lives campaign. Available at: http://www.ihi.org/about/Documents/5MillionLivesCampaignCaseStatement.pdf (accessed 6/24/16).
7. DerGurahian J. IHI unsure about impact of 5 Million campaign. Available at: http://www.modernhealthcare.com/article/20081210/NEWS/312109976 (accessed 6/24/16).
8. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med. 2012;157:305-12. [CrossRef] [PubMed]
9. AHRQ Report: Hospital-Acquired Conditions Continue To Decline, Saving Lives and Costs. Dec 1, 2015. Available at: http://www.ahrq.gov/news/newsletters/e-newsletter/496.html#1 (accessed 6/24/16).

Cite as: Robbins RA. Remembering the 100,000 lives campaign. Southwest J Pulm Crit Care. 2016;12(6):255-7. doi: http://dx.doi.org/10.13175/swjpcc058-16 PDF 

The Evil That Men Do-An Open Letter to President Obama

"The evil that men do lives after them; the good is oft interred with their bones". William Shakespeare, Julius Caesar, Act 3, Scene 2

Dear President Obama:

Late in a second term, a President's attention often turns to framing their legacy. I suspect you are no exception and have given this considerable thought. You might wish to be remembered for the Affordable Care Act, even called Obamacare, which brought the US closer to universal healthcare coverage. However, I recall the end of President Clinton's second term a short 16 years ago. During that administration the Federal coffers were full; an unprecedented business boom occurred; and foreign entanglements that might have led to war were avoided. However, most of us do not remember those positives, but recall a White House intern and a certain blue dress. As pointed out by Shakespeare over 400 years ago powerful men are remembered not so much for the good they do but the bad.

Robert McDonald, your Secretary of Veterans Affairs (VA), was brought on board two years ago to deal with concerns about long waiting times for Veterans Administration medical services-concerns and the subsequent lies that were told to cover it up that led you to fire his predecessor, Eric Shinseki. McDonald was talking to reporters in the week leading up to Memorial Day, when attention always turns not just to honoring America's war dead but to whether the government is delivering services it promised living Veterans. The reporters asked McDonald why the VA doesn't publicly report the date when veterans first ask for medical care so as to better measure waiting times (1). His reply:

"The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran's satisfaction. What really counts is: How does the veteran feel about their encounter with the VA? When you go to Disney, do they measure the hours you wait in line?"

Although McDonald later apologized for his remarks, they were offensive to me as a physician who worked in the VA, and I might point out wrong on several fronts. First, Disney does track its wait times. Second, the remark shows a fundamental disconnect between upper echelon management and healthcare. As we pointed out several years ago, satisfaction with healthcare does not mean better healthcare, in fact, it may mean worse care, perhaps because the focus is more on satisfaction than good care (2). Third, McDonald's remark was truly disingenuous. McDonald is concerned about wait times which led you to fire his predecessor. Otherwise, why would the VA lift the supervision requirement for nurse practioners which they did later in the week (3)?

The prolonged wait times occurred because an insufferable VA administration created a hostile work environment for physicians. Many left and the VA was unable to replace them. Although salary is part of this, it is less of a problem than those inside the Beltway believe. The VA abandoned its academic affiliations and created a work environment where physicians seeing patients is largely put in the same category as janitors waxing a floor. Middle level administrators who know nothing about healthcare are now directing physicians on what they should do. The goal has become less about healthcare than the administrators being in charge. The replacement of physicians by nurse practioners is in line with this concept. The goal will not be as much to deliver quality healthcare, a concept that is often nebulous and hard to define, but rather to redefine quality. For example, replacing timely and good care with a measure such as making sure that on each visit the Veteran is reminded to fasten their safety belt (a current requirement), is certainly measurable, cheap and does not require a physician. In most businessmen's minds it matters little whether it does any good or not. It is a measure of someone's concept of quality and the VA will deliver quality as long as it does not cost too much and an administrator can receive a bonus for it. Based on the VA, many physicians are suspicious that this is the long term goal of Obamacare.

So on this Memorial Day, let us remember our Veterans, Mr. President, and consider your legacy. My view is that unless changes are made, your misdirection of healthcare both at the VA and nationally through Obamacare, could be your White House intern in a blue dress.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Capital Gazette editorial board. Our say: McDonald gaffe points to a deeper problem. Capital Gazette. May 30, 2016. Available at: HTUhttp://www.capitalgazette.com/opinion/our_say/ph-ac-ce-our-say-0529-20160529-story.htmlUTH (accessed 5/30/16).
2. Robbins RA, Rashke RA. A new paradigm to improve patient outcomes: a tongue-in-cheek look at the cost of patient satisfaction. Southwest J Pulm Crit Care 2012;5:33-5. Available at: HTU/editorial/2012/7/17/a-new-paradigm-to-improve-patient-outcomes.htmlUTH (accessed 5/30/16).
3. Japsen B. VA would join 21 states already lifting nurse practitioner hurdles. Forbes. May 26,2016. Available at: HTUhttp://www.forbes.com/sites/brucejapsen/2016/05/26/va-would-join-21-states-lifting-nurse-practitioner-hurdles/#2d4e391e9f2cUTH (accessed 5/30/16).

*The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. The evil that men do-an open letter to President Obama. Southwest J Pulm Crit Care. 2016 May;12(5):201-2. doi: http://dx.doi.org/10.13175/swjpcc048-16 PDF

Using the EMR for Better Patient Care

The medical record was developed in the US in major teaching hospitals in the 19th century and widely adopted when it was realized the records benefited patients, nurses and doctors (1). These paper records continued (although with many alterations) until the early 21st century when electronic medical or healthcare records (EMR) were mandated by the Federal government. EMRs offer great promise by handling the enormous amounts of data generated in healthcare. Furthermore, in those instances where early identification of disease process seems to make a difference, EMRs would seem an ideal tool to alert nurses and doctors. Sepsis is a disease process which would seem appropriate for early identification by EMR since early recognition can be difficult but early intervention improves outcomes (2). However, previous attempts to use the EMR to identify septic patients have been disappointing (3,4). In this issue of the SWJPCC Fountain and her colleagues (5) used clinical decision support systems (CDSSs) incorporated into EMRs to successfully identified septic patients with reasonable sensitivity and positive predictive value.

Why did Fountain et al. succeed while others failed? The 20 year old definition of sepsis that required two or more systemic inflammatory response syndrome criteria to define sepsis did not identify the sickest patients at the greatest risk for death (6). Realizing this weakness, Fountain and colleagues shifted their diagnostic focus from systemic inflammation to infection-triggered organ failure consistent with the new definition of sepsis proposed by the international Sepsis Definitions Task Force (7). This insight would seem most likely to account for their success.

Fountain's success also raises the question of why so many EMR interventions for sepsis and other disease processes have failed to improve patient care. In order to be successful, CDSSs need to pick diseases with well grounded criteria and interventions. This requires extensive expertise in reading and evaluating the medical literature. It seems too often a quick internet search by a non-expert committee chooses poorly. For example, ventilator-associated pneumonia is a disease with no well established criteria or accepted prevention other than extubation. Too often EMRs have increased workload and inefficiency without apparent patient benefit, even potential patient harm as suggested by some.

If Fountain's criteria is replicated in randomized trials and early identification improves outcomes, it may represent a major step forward in sepsis care. However, perhaps more importantly it could represent a major step forward in how CDSSs are conceived and developed.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Gillum RF. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. Am J Med. 2013 Oct;126(10):853-7. [CrossRef] [PubMed]
2. Miller RR 3rd, Dong L, Nelson NC, Brown SM, Kuttler KG, Probst DR, Allen TL, Clemmer TP; Intermountain Healthcare Intensive Medicine Clinical Program. Multicenter implementation of a severe sepsis and septic shock treatment bundle. Am J Respir Crit Care Med. 2013 Jul 1;188(1):77-82. [CrossRef] [PubMed]
3. Tafelski S, Nachtigall I, Deja M, Tamarkin A, Trefzer T, Halle E, Wernecke KD, Spies C. Computer-assisted decision support for changing practice in severe sepsis and septic shock. J Int Med Res. 2010 Sep-Oct;38(5):1605-16. [CrossRef] [PubMed]
4. Umscheid CA, Betesh J, VanZandbergen C, Hanish A, Tait G, Mikkelsen ME, French B, Fuchs BD. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10(1):26-31. [CrossRef] [PubMed]
5. Fountain S, Perry J III, Stoffer B, Raschke RA. Design of an electronic medical record (EMR)-based clinical decision support system to alert clinicians to the onset of severe sepsis. Southwest J Pulm Crit Care. 2016 Apr;12(4):153-60. [CrossRef]
6. Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015 Apr 23;372(17):1629-38. [CrossRef] [PubMed]
7. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. [CrossRef] [PubMed] 

Cite as Robbins RA. Using the EMR for better patient care. Southwest J Pulm Crit Care. 2016 Apr;12(4):161-2. doi: http://dx.doi.org/10.13175/swjpcc034-16 PDF 

State of the VA

Earlier this week, President Obama gave his last State of the Union Address. Although this usually is a speech giving the President the opportunity of flaunt his accomplishments, no mention was made of the VA (1). Given the troubles at the VA, there seems little to tout.

Over 70% of the VA medical centers were discovered to have falsified wait times (2). Because of the wait scandal, VA Secretary Eric Shinseki resigned and VA undersecretary, Robert Petzel MD, retired under pressure. Ironically, Shinseki, a retired Army general and member of the Joint Chiefs of Staff, was viewed in a favorable light by the current administration because of a spat with the Bush administration's Secretary of Defense, Donald Rumsfeld, over the number of troops needed to secure Iran and Afghanistan (3). However, during Shinseki's tenure the number of VA "medical troops", doctors and nurses, was insufficient to care for the number of veterans. It is unclear if the new secretary, Bob McDonald, has done much to correct the problem.

Locally, the director of the Phoenix VA regional office, Susan Bowers, retired under pressure and former Phoenix VA Director Sharon Helman was fired (4). However, Helman was allowed to keep her bonus for the falsely reported shorter wait times and is appealing her firing. Her deputies, Lance Robinson and Brad Curry, were placed on administrative leave, but after over a year and a half have recently returned to work in the Phoenix VA regional office. Darren Deering DO, the Phoenix chief of staff, underwent a VA internal investigation because of retaliating against one of the Phoenix VA whistleblowers, Katherine Mitchell MD. Disciplinary action was recommended but no action was taken. In October 2015, the IG released a new report citing critical staffing shortages at the Phoenix VA.

Earlier this week the Senate Veterans Affairs Committee approved the nomination of Washington lawyer Michael Missal as the new permanent Department of Veterans Affairs inspector general (VAIG) (5). Lawmakers from both parties have sought a permanent VAIG for over 2 years. The chairman of the Senate veterans panel, Republican Sen. Johnny Isakson of Georgia, says the top priority of the inspector general must be to "hold bad actors at the VA accountable" for chronic delays for veterans seeking medical care and other problems at the agency.

If confirmed by the full Senate which is expected, Missal might be busy. Whether Isakson is serious or this is more political posturing is unclear. Rather than a few “bad actors” the wait scandal suggests that fraud, waste and abuse are common, perhaps even rampant, within the VA. Rather than being held “accountable”, the bad actors are more often protected and even rewarded by VA Central Office. Although Veterans and the public might be optimistic, it is likely that they will be disappointed by Missal, as they have by VAIGs and others charged with VA oversight in the past.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Graf N. Veterans' affairs left out of State of the Union; Phoenix VA whistleblower disappointed in speech. ABC15 Arizona. January 13, 2016. Available at: http://www.abc15.com/news/region-phoenix-metro/central-phoenix/veterans-affairs-left-out-of-state-of-the-union-phoenix-va-whistleblower-disappointed-in-speech (accessed 1/15/16).
2. Klimas J. Huge backlog: 70 percent of VA facilities used alternative waitlists. Washington Times. June 9, 2014. Available at: http://www.washingtontimes.com/news/2014/jun/9/audit-more-57000-await-initial-va-visits/?page=all (accessed 1/15/16).
3. DeFrank T. How Donald Rumsfeld complicated Eric Shinseki’s last administration exit. National Journal. May 31, 2014. Available at: http://www.nationaljournal.com/white-house/2014/05/31/how-donald-rumsfeld-complicated-eric-shinsekis-last-administration-exit (accessed 1/15/16).
4. Arizona Republic. VA in crisis: the Republic investigation. Available at: http://www.azcentral.com/investigations/vahealthsystem/ (accessed 1/15/16).
5. Daly M. Senate panel backs lawyer Missal as VA watchdog. Washington Post. January 12, 2016. Available at: https://www.washingtonpost.com/politics/whitehouse/senate-panel-backs-lawyer-missal-as-va-watchdog/2016/01/12/d13db550-b96d-11e5-85cd-5ad59bc19432_story.html (accessed 1/15/16).

*The opinions expressed are those of the author and not necessarily the opinions of the Arizona, New Mexico, Colorado or California Thoracic Socities or the Mayo Clinic.

Cite as: Robbins RA. State of the VA. Southwest J Pulm Crit Care. 2016;12(1):28-9. doi: http://dx.doi.org/10.13175/swjpcc008-16 PDF

Kaiser Plans to Open "New" Medical School

The not-for-profit health maintenance organization (HMO) giant, Kaiser Permanente, announced plans to open a medical school in Southern California with the first class expected to enroll in the fall of 2019 (1). Kaiser is taking the unusual step of creating its own medical school instead of partnering with a university like recent deals made by North Shore-Long Island Jewish in New York and Beaumont Health in suburban Detroit. “We're not just launching another medical school,” Kaiser CEO Bernard Tyson said. “This is really a medical school in which we're bringing forward all the knowledge and wherewithal we've accumulated over the years as our physicians continue to innovate and drive population health and individual health.” Kaiser still has to work through the details of how the school will be funded and the amount of their investment. Kaiser's annual revenue was $56.4 billion last year, with an operating income of $2.2 billion (2).

Kaiser also announced that Dr. Christine Cassel would leave her role as CEO of the National Quality Forum to lead a team tasked with designing the school's teaching approach (1). Until 2013 Cassel was President and CEO of the American Board of Internal Medicine.

The Association of American Medical Colleges (AAMC) estimates a shortage of between 45,000 and 90,000 U.S. physicians by 2025 (3). “The opening of a new medical school will help address this shortage,” Dr. John Prescott, AAMC chief academic officer. However, Kaiser’s announcement is just the first step in building and operating a medical school, which must be accredited by the Liaison Committee on Medical Education, recognized by the U.S. Department of Education as the reliable authority for accrediting medical schools. “It’s a multistage process of moving from an idea to a fully accredited medical school,” Prescott said. “What Kaiser has done is announce its intentions. It’s years away from being a fully accredited school.”

Health care experts say opening its own medical school will provide a steady stream of physicians trained in the "Kaiser way" – a team approach of doctors, nurses, therapists and social workers working on behalf of patients (1). Prescott noted that the establishment of a school was a logical step forward for Kaiser (2).

Commercial interests are becoming increasingly involved in medical education. The University of Arizona's College of Medicine-Phoenix medical school was cited in June by the AAMC in four areas that needed to be addressed to avoid probation or loss of accreditation (4). Two of the four areas stemmed from uncertainties about Banner Health's alliance with the medical school after completing a $1 billion-plus acquisition of the two-hospital University of Arizona Health Network in Tucson.

The question is whether medical education will be independent from commercial interests. The physician should be first and foremost the patient’s advocate. However, the perception of many physicians is they are increasingly impaired in this role by the healthcare delivery systems in which they practice. A major concern is whether financial concerns of healthcare delivery systems might be the real motivation behind corporate interest in medical education. This conflict of interest should be a major concern to the AAMC and raises the important question of who will determine the medical education program in Kaiser's medical school-Kaiser or an independent medical school faculty?

Being a physician is a profession. Doctors should be trained to be doctors, not to be employees of healthcare delivery systems. The tone of the announcement is that Kaiser plans on training the latter.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Rubenfire A. Kaiser plans to take care model to the source: physician training. Modern Healthcare. December 17, 2015. Available at: http://www.modernhealthcare.com/article/20151217/NEWS/151219881?utm_source=modernhealthcare&utm_medium=email&utm_content=20151217-NEWS-151219881&utm_campaign=am (accessed 12/18/15).
2. Terhune C. HMO giant Kaiser Permanente plans to open a medical school in Southern California. Los Angeles Times. December 17, 2015. Available at: http://www.latimes.com/business/la-fi-kaiser-school-of-medicine-20151217-story.html (accessed 12/18/15).
3. Gordon LK. Managed care giant Kaiser to open medical school. Yahoo! Health. December 18, 2015. Available at: https://www.yahoo.com/health/managed-care-giant-kaiser-to-1323494699909174.html (accessed 12/18/15).
4. Alltucker K. UA pursues medical-school fixes for accreditors. Arizona Republic. December 10, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/12/10/ua-pursues-medical-school-fixes-accreditors/77106640/ (accessed 12/18/15).

Cite as: Robbins RA. Kaiser plans to open "new" medical school. Southwest J Pulm Crit Care. 2015;11(6):275-6. doi: http://dx.doi.org/10.13175/swjpcc156-15 PDF 

CMS Penalizes 758 Hospitals for Safety Incidents

The Centers for Medicare and Medicaid Services (CMS) is penalizing 758 hospitals with higher rates of patient safety incidents, and more than half of those were also fined last year, as reported by Kaiser Health News (1).

Among the hospitals being financially punished are some well-known institutions, including Yale New Haven Hospital, Medstar Washington Hospital Center in DC, Grady Memorial Hospital, Northwestern Memorial Hospital in Chicago, Indiana University Health,  Brigham and Womens Hospital, Tufts Medical Center, University of North Carolina Hospital, the Cleveland Clinic, Hospital of the University of Pennsylvania, Parkland Health and Hospital, and the University of Virginia Medical Center (Complete List of Hospitals Penalized 2016). In the Southwest the list includes Banner University Medical Center in Tucson, Ronald Reagan UCLA Medical Center, Stanford Health Care, Denver Health Medical Center and the University of New Mexico Medical Center (for list of Southwest hospitals see Appendix 1). In total, CMS estimates the penalties will cost hospitals $364 million. Look now if you must, but you might want to read the below before on how to interpret the data.

The penalties, created by the 2010 health law, are the toughest sanctions CMS has taken on hospital safety. Patient safety advocates worry the fines are not large enough to alter hospital behavior and that they only examine a small portion of the types of mistakes that take place. On the other hand, hospitals say the penalties are counterproductive and unfairly levied against places that have made progress in safety but have not caught up to most facilities. They are also bothered that the health law requires CMS to punish a quarter of hospitals each year. CMS plans to add more types of conditions in future years.

I would like to raise two additional concerns. First, is the data accurate? The data is self-reported by the hospitals and previously the accuracy of these self reports has been questioned (2). Are some hospitals being punished for accurately reporting data while others rewarded for lying? I doubt that CMS will be looking too closely since bad data would invalidate their claims that they are improving hospital safety. It seems unlikely that punishing half the Nation's hospitals will do much except encouraging more suspect data.

Second, does the data mean anything? Please do not misconstrue or twist the truth that I am advocating against patient safety. What I am advocating for is meaningful measures. Previous research has suggested that the measures chosen by CMS have no correlation or even a negative correlation with patient outcomes (3,4). In other words, doing well on a safety measure was associated with either no improvement or a negative outcome, in some cases even death. How can this be? Let me draw an analogy of hospital admissions. About 1% of the 35 million or so patients admitted to hospitals in the US die. The death rate is much lower in the population not admitted to the hospital. According to CMS' logic, if we were to reduce admissions by 5% or 1.75 million, 17,500 lives (1% of 1.75 million) would be saved. This is, of course, absurd.

Looking at hospital acquired infections which make up much of CMS' data, CMS' logic appears similar. For example, insertion of urinary catheters, large bore central lines or endotracheal intubation in sick patients is common. The downside is some will develop urinary, line or lung infections as a complication of these insertions. Many of these sick patients will die and many will have line infections. The data is usually reported by saying hospital-acquired infections have decreased saving 50,000 lives and saved $12 billion in care costs (5). However, the truth is that hospital-acquired infections are often either not the cause of death or the final event in a disease process that caused the patient to be admitted to the hospital in the first place. If 50,000 lives are saved that should be reflected in the hospital death rates or a savings on insurance premiums. Neither has been shown to my knowledge.

So look at the data if you must but look with a skeptical eye. Until CMS convincingly demonstrates that the data is accurate and that their incentives decrease in-hospital complications, mortality and costs-the data is suspect. It could be as simple that the hospitals receiving the penalties are those taking care of sicker patients. What this means is that some hospitals, perhaps the ones that need the money the most, will have 1% less CMS reimbursement, which might make care worse rather than better.

Richard A. Robbins, MD

Editor

SWJPCC

References

1. Rau J. Medicare penalizes 758 hospitals for safety incidents, Kaiser Health News. December 10, 2015. Available at: http://khn.org/news/medicare-penalizes-758-hospitals-for-safety-incidents/ (accessed 12/11/15).
2. Robbins RA. The Emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5.
3. Robbins RA, Gerkin RD. Comparisons between Medicare mortality, morbidity, readmission and complications. Southwest J Pulm Crit Care. 2013;6(6):278-86
4. Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367(15):1428-37. [CrossRef] [PubMed]
5. Department of Health and Human Services. Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided. December 2, 2014. Available at: http://www.hhs.gov/about/news/2014/12/02/efforts-improve-patient-safety-result-1-3-million-fewer-patient-harms-50000-lives-saved-and-12-billion-in-health-spending-avoided.html (accessed 12/11/15).

Cite as: Robbins RA. CMS penalizes 758 hospitals for safety incidents. Southwest J Pulm Crit Care. 2015;11(6):269-70. doi: http://dx.doi.org/10.13175/swjpcc153-15 PDF

Honoring Our Nation's Veterans

Today is Armistice Day, renamed Veterans Day in 1954, to honor our Nation's Veterans. In Washington the rhetoric from both the political right and left supports our Veterans. My cynical side reminds me that this might have something to do with Veterans voting in a higher percentage than the population as a whole, but let me give the politicians this one. Serving our Country in the military is something that deserves to be honored. I was proud to serve our Veterans over 30 years at four Department of Veterans Affairs (VA) hospitals.

However, the VA has had a very bad year. First, in Washington there were the resignations of the Secretary of Veterans Affairs, Eric Shinseki; the undersecretary for the Veterans Health Administration, Robert Petzel; and the undersecretary for the Veterans Benefits Administration, Allison Hickey. Locally, in the light of the VA wait scandal there were the firing of the Phoenix VA Medical Centers director, Sharon Helman, and her deputies along with the retirement of her boss, Susan Bowers. Furthermore, there seem to be a never-ending string of scandals ranging from the mundane of greed-driven fraud to the more exotic of accusing a VA whistleblower of engaging in sexual threesomes. Despite a healthy increase in funding, there was the threat by VA administrators of closing VA hospitals to meet a VA budget shortfall. This resulted in Congress knuckling under to allow the use of emergency funds. Veterans groups are using billboards to accuse the VA of lying (Figure 1).

Figure 1. Billboard across from the VA October 12, 2015.

I could go on and on. However, the real question is not so much of what dirty deeds are being done, but how the VA administrators get away with it.

There has been both a lack of oversight and lack of accountability. Robert McDonald, who replaced Shinseki, has promised to punish the evil doers but has replaced action with the mantra "all is well" and has done nothing. In several instances wrong-doing has apparently been rewarded, such as Bowers replacement having lied to Congress (1). If the VA cannot police itself-and it apparently cannot-there are a multitude of regulatory agencies that have shirked their oversight responsibilities. I thought it was time to mention a few.

First, there are both the Veterans Integrated Service Networks, the regional VA offices, and VA Central Office itself in Washington. Both these organizations have been caught in the scandals and have done nothing. Second, there is Congress. The House Veterans Affairs Committee has seemed to make a sincere effort to identify some of the problems but Secretary McDonald and his cadre of 11,000 in Central Office has repeatedly stone-walled any investigation and Congress has done nothing. Third, there is the White House. The Obama Administration has seemed more interested in declaring the problem fixed than actually fixing the problem and has done nothing.

Those are the obvious but there are some less obvious regulatory failures. First, there are the multiple hospital inspectors. Within the VA is the Office of Inspector General (IG) who is charged with investigating wrong-doing within the VA. Locally they had been called to Phoenix multiple times including for the wait time scandal but have done nothing. The poor performance resulted in the resignation of the acting VA IG, Richard Griffin, under pressure. Second, there is the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). The Phoenix VA Medical Center managed to go from a "top performer" in 2011 to noncompliant "with U.S. standards for safety, patient care and management" in 2014. Only the naive would believe that a hospital can transition that much in 3 years. There is also the Arizona Board of Medical Examiners and Nursing. Both doctors and nurses were involved in the cover-up of the wait scandal but these boards have done nothing. The VA is the largest system for training future physicians and nurses, and it seems that the future doctors and nurses might not be learning the highest professional and ethical standards. Nonetheless, the Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing have done nothing.

However, my personal disgust is highest for the Department of Justice (DOJ). It is known that seventy percent of the hospitals were fudging their wait data. The administrators, not the doctors or nurses, received bonuses for short wait times. None of the administrators have gone to jail or even been charged with fraud. None have even had to repay their bonuses. The DOJ has done nothing. If 70% of the doctors were caught faking data to received bonuses, I have every confidence that the legal eagles at DOJ would gleefully put each and every one on trial.

So what can be done? There appears to be no oversight. This was clearly illustrated in the report from the recent Human Resources (HR) team from Central Office sent to Phoenix to help with what can be kindly described as a dysfunctional department. They were essentially shown the door by the acting director, Glen Grippen, saying that he "calls the shots" (2).

The solution is that Mr. Grippen and others of his ilk should no longer call the shots. They have shown a consistent arrogance and disregard for our Nation's Veterans and those that serve them. He and others need oversight, not by a far-off committee in Washington as President Obama has proposed which will likely fare no better than Congress. Oversight could be best provided by local physicians and nurses who have interest in Veteran care but are not employed by the VA. This used to occur in many VA hospitals and was called the Dean's Committee. The dean of the local medical school along with the chairman of the departments of medicine, surgery, pathology, radiology, and others formed a committee that oversaw care at the VA. The committee had interests in the patient care of Veterans but also in the physicians who were faculty at the local medical school and the medical students, residents and fellows who were under their supervision. This committee was a victim of Ken Kizer's "prescription for change" in the 1990s. Now, this old system might be an antidote for Kizer's prescription which has seemed to turn poison.

The VA is pushing to hire more personnel to deal with wait times and lack of patient care. However, it is unclear how many of the new hires are doctors and nurses contributing to patient care and how many are administrators and bureaucrats.  My experiences and conversations with my colleagues convinces me that not all hospitals are as badly managed as those in the Southwest. Those considering a career at the VA need to carefully investigate each hospital to see if it is the type of place that the leadership will provide the resources to care for the Veterans, which is after all, the definition of leadership.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Wagner D. Department of Veterans Affairs names new regional health director. Arizona Republic. October 15, 2015. Available at: http://www.azcentral.com/story/news/arizona/politics/2015/10/15/department-veterans-affairs-names-new-regional-health-director/73900478/
2. Wagner D. VA team blasts Phoenix personnel office. Arizona Republic. November 2, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/11/02/va-team-blasts-phoenix-personnel-office/74763366/

Cite as: Robbins RA. Honoring our Nation's Veterans. Southwest J Pulm Crit Care. 2015;11(5):228-30. doi: http://dx.doi.org/10.13175/swjpcc141-15 PDF

Capture Market Share, Raise Prices

Two principles in medical economics central to the Affordable Care Act (ACA) were dealt blows by recently published studies. The first principle is the belief that economies of scale will result in lower prices. The theory is that larger insurers will have lower prices because they are more administratively efficient. The second principle is that provider-owned health plans, usually hospitals, will reduce premiums. The theory is that  by controlling doctors over charging health plans in a fee-for-service model will lower prices.

The first study published in Technology Science found that the largest insurer in each of the states served by HealthCare.gov raised their prices in 2015 by an average of over 10 per cent compared to smaller competitors in the same market (1). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

The second study published by HealthPocket compared the lowest monthly premiums for provider-owned to nonprovider-owned plans within twelve counties across the US (2). The counties analyzed were spread across the eastern, central, and western regions of the U.S. Premiums were based on a 40-year-old, non-smoker profile. Insurance offered by health-care providers such as hospitals, was on average 12% more expensive compared to  traditional insurers. The data were also analyzed by the type of plan under the ACA: bronze, silver and gold. There were too few platinum plans to perform an analysis. Table 1 shows the local results in the three western states analyzed.

Table 1. Monthly premiums for Provider and Non-Provider Health Plans Under the ACA (2).

Silver plans account for two-thirds of plan selections on the ACA marketplaces during the 2015 annual enrollment period (3). Only the premiums for the bronze and silver provider-owned health plans in Arizona cheaper. Both in New Mexico and Utah all the provider-owned health plans and the more frequently selected silver plan in Arizona were all more expensive.

The premises of economies of scale and elimination of the fee-for-service reimbursement are both central to the ACA. Both appear to be myths. The results of these studies illustrate the sobering reality that the best intentions in reforming American healthcare do not necessarily produce the intent imagined. Despite the theoretical promise of reducing expenses by eliminating waste, both studies show an increase in healthcare costs, opposite the direction that traditional economics predict. Both larger companies and provider-owned health plans have a profit motive with numerous conflicts which likely accounts for these increases in premiums. Rather than allowing mergers and focusing on controlling physician behavior as strategies in reducing costs, it is time to focus on the insurers. Their strategy appears to be "capture market share, raise prices" and therefore their profits. This later premise agrees more with the data. Most of us who work in healthcare know this, it is time for those in Washington to pay attention to what is going on rather than their prejudices and political beliefs. 

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References 

1. Wang E, Gee G. Larger Issuers, Larger Premium Increases: Health insurance issuer competition post-ACA. Technology Science. 2015081104. August 11, 2015. Available at: http://techscience.org/a/2015081104 (accessed 8/31/15).
2. Colemen K, Gleeson J. Cheapest healthcare provider-owned insurance plans still 12% more expensive than cheapest insurance plans not owned by providers. HealthPocket. August 20, 2015. Available at: https://www.healthpocket.com/healthcare-research/infostat/fee-for-service-and-provider-health-plans#.VeRqLPlVhBd (accessed 8/31/15).
3. Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report. ASPE Issue Brief. (March 10, 2015).

*The views expressed are those of the author and do not necessarily represent those of the Southwest Journal of Pulmonary and Critical Care, the American Thoracic Society or the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. Capture market share, raise prices. Southwest J Pulm Crit Care. 2015;11(2):88-9. doi: http://dx.doi.org/10.13175/swjpcc115-15 PDF

Guns and Sleep

Gun deaths are a problem in America. Irrespective of one’s position on gun control, the statistics do not lie. According to the Centers for Disease Control and Prevention (CDC), there were 11,208 deaths caused by firearms in 2013 (1). The recent high profile cases in Cincinnati, OH, Lafayette, LA and Memphis, TN further highlight the issue. Obviously, each case of death by a firearm had its own set of underlying factors that contributed to the final fatal outcome, but one wonders whether sleep deprivation can be implicated in some of them.

Sleep duration in adults over the past approximately 30 years has been declining in the United States (2). A variety of reasons can be cited as underlying causes such as greater use of artificial lighting, an expanding 24 hour non-stop society, promotion of a work ethic that values “burning the midnight oil”, and use of electronic devices before bedtime (especially those that emit blue wavelength light). In addition, both legal and illegal drugs have important impacts on sleep quality and quantity. For example, amphetamines can cause insomnia and by extension a reduction in sleep time (3), and perhaps more importantly, caffeine will have the same effect if used to excess (4). The most recent recommendation from the American Academy of Sleep Medicine is for adults to sleep at least 7 hours per night (5). However, recent CDC data indicate that 29.2% of adults sleep less than 6 hours per night and are thus chronically sleep deprived (2).

Symptoms of sleep deprivation include longer reaction times, lapses in attention or concentration, poor short term memory, errors of omission and sleepiness. However, sleep deprivation also leads to confusion, stress, irritability and impulsivity. Importantly, decision making and the ability to formulate reasonable moral judgments are impaired. All of these negative impacts of sleep deprivation can lead to high-risk behavior. Thus, can it be posited that in some cases, sleep deprivation, perhaps fueled by the legal or illegal use of stimulant compounds, leads to impaired judgment and increased impulsivity, poor decisions and fatal shootings?

Several years ago, I was asked to be a defense expert in a case where a jilted wife fatally shot her husband’s lover. After learning about her husband’s affair, the wife had become distraught and unable to sleep for ~2 days. She then sought out the victim and shot her. Her sleep deprivation was used as a mitigating factor to reduce the charge from 1^st to 2^nd degree homicide. Although not a shooting, more recently, a Florida man was acquitted of the murder by suffocation of his father because he was sleep deprived after consuming a large amount of Red Bull (80 mg caffeine per 8.46 fluid ounces). Cases such as these have led to speculation that sleep deprivation may be an effective defense where the fatal act could plausibly be explained by a change in mood or cognitive impairment.

The potential impact of sleep deprivation is likely not limited to citizens accused of fatal shooting, but law enforcement officers as well. Police officers frequently work overnight or rotating shifts, and many accept overtime duty as well. A recent survey of 4957 police officers found that >40% screened positive for at least one sleep disorder with 28.5% being excessively sleepy, suggesting an element of sleep deprivation (5). Most troubling was that those who were identified as having a sleep disorder had a 51% greater likelihood of making an error or safety violation and a 63% greater chance of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects. Could some of the recently publicized adverse interactions between police officers and citizens be partially explained by lack of sleep?

Although a possible causal link between gun violence and sleep deprivation is speculative, there is no doubt that insufficient sleep is becoming endemic in our society and has significant personal and public health consequences. There should be a concerted effort on the part of public health officials, public and private institutions and individuals to reverse this trend by publicizing the adverse impact of insufficient sleep, undertaking policy measures to promote adequate sleep and set themselves as examples of healthy sleepers.

Stuart F. Quan, MD

Gerald E. McGinnis Professor of Sleep Medicine

Harvard Medical School

Brigham and Women's Hospital

Boston, MA

References

1. Centers for Disease Control. Fast stats. Available at: http://www.cdc.gov/nchs/fastats/homicide.htm (accessed 8/6/15). 
2. Ford ES, Cunningham TJ, Croft JB. Trends in self-reported sleep duration among US adults from 1985 to 2012. Sleep. 2015;38(5):829-32. [CrossRef] [PubMed]
3. Coghill DR, Caballero B, Sorooshian S, Civil R. A systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014;28(6):497-511. [CrossRef] [PubMed]
4. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013 Nov 15;9(11):1195-200. [CrossRef] [PubMed]
5. Watson NF, Badr MS, Belenky G, et al. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(6):591-2. [CrossRef] [PubMed]
6. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA. Harvard work hours, health and safety group. JAMA. 2011;306(23):2567-78. [CrossRef] [PubMed]

Reference as: Quan SF. Guns and sleep. Southwest J Pulm Crit Care. 2015;11(2):68-9. doi: http://dx.doi.org/10.13175/swjpcc107-15 PDF

Is It Time for a National Tort Reform?

With the Supreme Court upholding the nationwide implementation of the ACA, the topic of tort reform adoption on a national scale has been in the limelight again.

Since the 1970s, the issue of national tort reform has had several reincarnations in the country’s different legislative bodies (1). The duration of the debates and discussions are largely dependent on the interest and influence of the two major stakeholders - the insurance companies and the physicians.

Currently, 38 states have implemented various versions of tort reform, mostly centered on the caps on noneconomic damages (2).

Groups advocating for national tort reform argue that having no limits on medical malpractice financial awards, has fueled the practice of ‘defensive medicine’. This leads to costly but ineffective medical interventions and higher insurance premiums. Both consequences are cited as major contributors to the country’s spiraling healthcare expenditure (1,2). Proponents also contend that the absence of tort reform negatively affects the size and composition of the physician workforce (3). Statistics show that states with damage caps have 12% more physicians per capita than those without (4).

On the other hand, those against national tort reform claim that caps on medical malpractice lawsuits would lead to more medical errors and negligent physician practices. They also cited the lack of supporting evidence of tort reform’s favorable effect on the reduction of healthcare spending (1).

Most studies on tort reform are related to healthcare spending and based on state-level enforcement. The data show that healthcare costs are only modestly affected by increases in malpractice premiums and litigation costs (3,5). The CBO estimated that if a national tort reform package was enacted, healthcare spending would be reduced by 0.5% (5). Baiker and Chandra (3), showed that state implementation of tort reform did not lead to physician shortages except for a minor reduction in some rural areas. The CBO (2009) reported that state tort reforms did not result in adverse patient health outcomes (2,5).

It is evident from these findings that there needs to be a comprehensive tort reform that does not solely focus on the cost and risk of malpractice litigation. Tort reform should be approached from a different perspective where the emphasis is on interventions that improve physicians’ efficiency, promote patient safety and reduce costs. Once studies consistently show the benefits of a multidimensional tort reform package adhering to nationally-accepted standards, then its nationwide implementation may be closer to becoming a reality.

Cielo Marie Maca, MD

Pulmonary, Critical Care and Sleep Medicine

Covering VA Medical Centers in VHA 23, VHA 16, VHA 18

References

1. Scott B. Who benefits from tort reform?. Medical Economics. Aug. 9, 2013. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/alice-g-gosfield/who-benefits-tort-reform?page=full (Accessed July 9, 2015).
2. Congressional Budget Office. A CBO Paper: The effects of Tort reform: Evidence from the States. June 2004. Available at: http://www.cbo.gov/sites/default/files/report_2.pdf (Accessed July 9, 2015).
3. Baicker K, Chandra A. The effect of malpractice liability on the delivery of health care. Forum for Health Economics & Policy (Abstract) 2005;8(1). http://www.degruyter.com/view/j/fhep.2005.8.1/fhep.2005.8.1.1010/fhep.2005.8.1.1010.xml?format=INT DOI: 10.2202/1558-9544.1010 (Accessed July 10, 2015).
4. New Physician. Which States Have Tort Reform? http://www.newphysician.com/articles/tort_reform_list.html (accessed July 10, 2015).
5. Congressional Budget Office. Letter of the CBO to US Senator Orrin G. Hatch. Oct. 9, 2009. https://www.cbo.gov/sites/default/files/10-09-tort_reform.pdf (Accessed July 10, 2015).

Reference as: Maca CM. Is it time for a national tort reform? Southwest J Pulm Crit Care. 2015;11(1):45-6. doi: http://dx.doi.org/10.13175/swjpcc092-15 PDF