The Implications of Increasing Physician Hospital Employment

Several years ago, Dr. Jack had a popular, solo internal medicine practice in Phoenix. However, over a period of about 15-20 years, the profitability of Jack’s private practice dwindled and he was working 60+ hours per week to keep his head above water. This is not what he planned in his mid-50’s when he hoped to be settling into a comfortable lifestyle in anticipation of retirement. Jack eventually closed his practice and took a job as a hospital-employed physician. Jack’s story has become all too common. The majority of physicians are now hospital-employed (1).

The increase in hospital-employed physicians raises at least 2 questions: 1. How can a busy private practice not be profitable? and 2. Is it good to have most physicians hospital-employed? Like Jack, it seems most physicians seek hospital employment for financial and lifestyle reasons. But how can a primary care practice like Jack’s not be profitable when the cost of healthcare has risen so markedly?

To understand why a practice can be busy but not necessarily profitable we need to follow the money. First, reimbursement for private practice has decreased in real dollars (Figure 1) (2). 

Figure 1. Inflation and Medicare physician fee schedule (MPFS) growth in percent from 2006-2017 (2).

Private practice physician reimbursement is the only major cost center that the Centers and Medicaid Services (CMS) has singled out for asymmetrical negative annual fee schedule adjustments. The other major cost centers—hospital inpatient and outpatient, ambulatory surgical centers, and clinical laboratories—all had fee schedule adjustments that were nearly equal to and typically greater than inflation (2). Of course, private insurance companies follow CMS’ lead and so reimbursement to private practice physicians dramatically decreased (3).

In addition, increased requirements for documentation and paperwork were imposed by CMS and quickly picked up by private insurers. These required more physician time and/or the hiring of additional personnel. In addition, there were increasing annoyances and burdens placed on physicians to review and sign forms and prescriptions which already been electronically submitted. Often these annoyances were so the durable medical equipment provider, pharmacy, etc. could be reimbursed. These later burdens now take up to one-sixth of a physicians’ time, decrease office efficiency, and not surprisingly, greatly decrease physician job satisfaction (4).

The second question is whether hospital-employed physicians is a good thing for patients. Although hospitals have argued that hospital-based physicians provide better care, patient outcomes appear to be no different (5). Hospitals have engaged in a number of practices resulting in physicians being financially squeezed. The American Hospital Association (AHA) has lobbied CMS and Congress for payments that are much higher than independent physicians’ offices, assuring hospital profitability. However, under the Trump administration, CMS proposed to pay the same rate for services delivered at off-campus hospital outpatient departments and independent doctors' offices (called site neutrality) (6). This would result in about a 60% cut to the hospitals for these services (7). Not surprisingly, hospitals complained and lobbied Congress to rescind the rule (7). Later the AHA sued CMS challenging the "serious reductions to Medicare payment rates" as executive overreach (8). The case is currently pending before the courts.

Hospitals have also engaged in a number of practices to limit competition from physicians’ offices. First, several have employed a non-compete clause as a condition of obtaining staff privileges. These clauses mean that should a physician leave a hospital, the physician is unable to reestablish a practice within a specified distance of the hospital (often within a radius of 50 miles) (9). Of course, in a metropolitan area this means the physician has to leave the city, or in the case of a large hospital chain, the physician may have difficulty finding areas to practice even in the same state. Second, with the “hospitalist movement” many hospitals have seized on the opportunity to essentially self-refer. That is, the hospitals schedule follow-up appointments with primary care or other physicians employed by the hospitals.

A study documents that healthcare costs for four common procedures rose with increasing hospital physician employment (10). A 49% increase in hospital-employed physicians led to CMS paying $2.7 billion more for diagnostic cardiac catheterizations, echocardiograms, arthrocentesis and colonoscopies delivered in hospital outpatient settings than it would for treatment in independent facilities. CMS beneficiaries footed an additional $411 million.

Although many decry a fee-for-service healthcare system as being too expensive, the increase in hospital-employed physicians seems to only have increased healthcare costs. Action by CMS is needed not only for site neutrality but also a number of other areas to ensure health competition in healthcare.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Kane CK. Updated data on physician practice arrangements: For the first time, fewer physicians are owners than employees. Policy Research Perspectives. American Medical Association. 2019. Available at: https://www.ama-assn.org/system/files/2019-05/prp-fewer-owners-benchmark-survey-2018.pdf (accessed 5/11/19).
2. Cherf J. Unsustainable physician reimbursement rates. AAOS Now. October, 2017. Available at: https://www.aaos.org/AAOSNow/2017/Oct/Cover/cover01/ (accessed 5/11/19).
3. Clemens J, Gottlieb JD. In the shadow of a giant: Medicare's influence on private physician payments. J Polit Econ. 2017 Feb;125(1):1-39. [CrossRef] [PubMed]
4. Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians' working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635-42. [CrossRef] [PubMed]
5. Short MN, Ho V. Weighing the effects of vertical integration versus market concentration on hospital quality. Med Care Res Rev. 2019 Feb 9:1077558719828938. [CrossRef] [PubMed]
6. Robbins RA. CMS decreases clinic visit payments to hospital-employed physicians and expands decreases in drug payments 340b cuts. Southwest J Pulm Crit Care. 2018;17(5):136. [CrossRef]
7. Luthi S, Dickson V. Medicare's site-neutral pay plan targeted in hospitals' lobbying. Modern Healthcare. September 25, 2018. Available at: https://www.modernhealthcare.com/article/20180925/TRANSFORMATION04/180929928/medicare-s-site-neutral-pay-plan-targeted-in-hospitals-lobbying (accessed May 11, 2019).
8. Luthi S. Hospitals sue over site-neutral payment policy. Modern Healthcare. December 04, 2018. Available at: https://www.modernhealthcare.com/article/20181204/NEWS/181209973/hospitals-sue-over-site-neutral-payment-policy (accessed May 11, 2019).
9. Darves B. Restrictive covenants: A look at what’s fair, what’s legal and everything in between, Today’s Hospitalist. April 2006. Available at: https://www.todayshospitalist.com/restrictive-covenants-a-look-at-whats-fair-whats-legal-and-everything-in-between/ (accessed May 11, 2019).
10. Kacik A. Hospital-employed physicians drain Medicare. Modern Healthcare. November 14, 2017. Available at: https://www.modernhealthcare.com/article/20171114/NEWS/171119942/hospital-employed-physicians-drain-medicare (accessed May 11, 2019).

Cite as: Robbins RA. The implications of increasing physician hospital employment. Southwest J Pulm Crit Care. 2019;18(5):141-3. doi: https://doi.org/10.13175/swjpcc025-19 PDF 

More Medical Science and Less Advertising

A recent article appeared in JAMA Open Access reporting that wait times to see a provider in the Department of Veterans Affairs (VA) have improved (1). You might remember that in the not so distant past the VA was embroiled in a controversy for reporting falsely short wait times (2). The widely publicized scandal was centered in Phoenix and led to the firing, resignation or retirement of a number of administrators in VA Central Office, the Southwest Veterans Integrated Service Network (VISN) and the Phoenix VA. What was not as well publicized, but perhaps even more disturbing, was that up to 70% of VA facilities also were reporting deceptively shortened wait times (3). Congress appropriated additional money for the VA to fix the wait times but it is unclear how the money was spent (2).

Now the VA reports that the wait times have shortened and compares favorably to the private sector. The VA’s history has to lead to some skepticism about the data. Is it true? Is it accurate? The short answer is that we do not know because the VA data is largely self-reported. The VA used a different method, the secret shopper approach, for the private sector assessment. In this method a caller requests a routine appointment with a randomly selected care physician in a given health care market. The reported VA data may not be representative of the VA as a whole. Only some metropolitan areas were selected and did not include non-metropolitan facilities and no facilities from the Southwest VISN where there was a known problem. Furthermore, the data is only for new patients requesting a primary care, dermatology, cardiology, or orthopedic appointment. Data for wait times to see other specialties is not reported.

An accompanying editorial by two VA investigators does a good job in explaining the nuances of the study (4). Editorials in response to a specific article are often authored by the reviewers. If these editorial authors were also the article’s reviewers, they can hardly be blamed for saying nice things about the manuscript since “biting the hand that feeds you” is usually a dangerous practice. However, why JAMA published the article in the first place is puzzling. Certainly, lack of timely access to healthcare is very important and lack of access has been associated with higher costs and worse outcomes (4,5). However, this article reports nothing about how the VA achieved this improvement in access. Was it by hiring additional physicians to see the patients or by hiring additional scheduling clerks or additional practice extenders such as physician assistants or nurse practitioners?

The VA data could be easily manipulated. If access by a limited number of new patients is all that is being reported, there may be a tendency to underfund other areas. What about other specialty areas such as oncology, nephrology, pulmonary, neurology, general surgery, ENT, audiology, and ophthalmology to name just a few? What about established patients? What about financial incentives? Were the administrators given bonuses for improving access in these highly selected areas but none or less in others? This is the system the VA used during the wait times scandal and likely contributed to the falsification of data (6).

As it now stands the manuscript represents more advertising than medical science. Medical journals owe their readers better. Hopefully, we at the Southwest Journal are doing a better job of publishing articles that allows the practitioners to better care for their patients and not administrators make their bonus.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Penn M, Bhatnagar S, Kuy S, Lieberman S, Elnahal S, Clancy C, Shulkin D. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. 2019 Jan 4;2(1):e187096. [CrossRef] [PubMed]
2. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening? The Arizona Republic. October 23, 2016. Available at: https://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 1/25/19).
3. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/ (accessed 1/25/19).
4. Kaboli PJ, Fihn SD. Waiting for Care in Veterans Affairs Health Care Facilities and Elsewhere. JAMA Netw Open. 2019 Jan 4;2(1):e187079. [CrossRef] [PubMed]
5. Roemer MI, Hopkins CE, Carr L, Gartside F. Copayments for ambulatory care: penny-wise and pound-foolish. Med Care. 1975 Jun;13(6):457-66. [CrossRef] [PubMed]
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9.

Cite as: Robbins RA. More medical science and less advertising. Southwest J Pulm Crit Care. 2019;18(1):29-30. doi: https://doi.org/10.13175/swjpcc005-19 PDF 

Cite as: Robbins RA

The Need for Improved ICU Severity Scoring

How do we know we’re doing a good job taking care of critically ill patients? This question is at the heart of the paper recently published in this journal by Raschke and colleagues (1). Currently, one key method we use to assess the quality of patient care is to calculate the ratio of observed to predicted hospital mortality, or the standardized mortality ratio (SMR). Predicted hospital mortality is estimated with prognostic indices that use patient data to approximate their severity of illness (2). Examples of these indices include the Acute Physiology and Chronic Health Evaluation (APACHE) score, the Simplified Acute Physiology Score (SAPS), the Mortality Prediction Model (MPM), the Multiple Organ Dysfunction Score (MODS), and the Sequential Organ Failure Assessment (SOFA) (3).

Raschke et al. (1) evaluated the performance of the APACHE IVa score in subgroups of ICU patients. APACHE is a severity-of-illness score initially created in the 1980s and subsequently updated in 2006 (4,5). This index was developed using data from 110,558 patients from 45 hospitals located throughout the United States, and encompassed 104 intensive care units (ICUs) including mixed medical-surgical, coronary, surgical, cardiothoracic, medical, neurologic, and trauma units. The final model used 142 variables including information from the patient’s medical history, the admission diagnosis, and physiologic data obtained during the first day of ICU admission (4). Although it subsequently has been validated using other large general ICU patient cohorts, its accuracy in subgroups of ICU patients is less clear (6).

To benchmark whether the APACHE IVa performed sufficiently, Raschke et al. (1) employed an interesting and logical strategy. They created a two-variable severity score (2VSS) to define a lower limit of acceptable performance.  As opposed to the 142 variables used in APACHE IVa, the 2VSS used only two variables: patient age and need for mechanical ventilation. They included 66,821 patients in their analysis, encompassing patients from a variety of ICUs located in the southwest United States. The APACHE IVa and 2VSS was calculated for all patients. Although the APACHE IVa outperformed the 2VSS in the general cohort of ICU patients, when patients were divided into subgroups based on admission diagnosis the APACHE IVa showed surprising deficiencies. In patients admitted for coronary artery bypass grafting (CABG), the APACHE IVa did no better in predicting mortality than the 2VSS. The ability of APACHE IVa to predict mortality was significantly reduced in patients admitted for gastrointestinal bleed, sepsis, and respiratory failure as compared to its ability to predict mortality in the general cohort (1).

The work by Raschke et al. (1) convincingly shows that APACHE IVa underperforms when evaluating outcomes in subgroups of patients. In some instances, it did no better than a metric that used only two input variables. But why does this matter? One might argue that the APACHE system was not created to function in this capacity. It was designed and validated using aggregate data. It was not designed to determine prognosis on individual-level patients, or even on subsets of patients. However, in real-world practice it is used to estimate performance in individual ICUs, which have unique cases mixes of patients that may not approximate the populations used to create and validate APACHE IVa. Indeed, other studies have shown that the APACHE IVa yields different performance assessments in different ICUs depending on varying case mixes (2).

So where do we go from here? The work by Raschke et al. (1) is helpful because it offers the 2VSS as an objective method of defining a lower limit of acceptable performance. In the future, more sophisticated and personalized tools will need to be developed to more accurately benchmark ICU quality and performance.  Interesting work is being done using local data to customize outcome prediction (7,8). Other researchers have employed machine learning techniques to iteratively improve predictive capabilities of outcome measures (9,10). As with many aspects of modern medicine, the complexity of severity scoring will likely increase as computational methods allow for increased personalization. Given the importance of accurately assessing quality of care, improving severity scoring will be critical to providing optimal patient care.

Sarah K. Medrek, MD

University of New Mexico

Albuquerque, NM USA

References

1. Raschke RA GR, Ramos KS, Fallon M, Curry SC. The explained variance and discriminant accuracy of APACHE IVa severity scoring in specific subgroups of ICU patients. Southwest J Pulm Crit Care. 2018;17:153-64. [CrossRef]
2. Kramer AA, Higgins TL, Zimmerman JE. Comparing observed and predicted mortality among ICUs using different prognostic systems: why do performance assessments differ? Crit Care Med. 2015;43:261-9. [CrossRef] [PubMed]
3. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;14:207. [CrossRef] [PubMed]
4. Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. 2006;34:1297-1310. [CrossRef] [PubMed]
5. Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL. Intensive care unit length of stay: Benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV. Crit Care Med. 2006;34:2517-29. [CrossRef] [PubMed]
6. Salluh JI, Soares M. ICU severity of illness scores: APACHE, SAPS and MPM. Curr Opin Crit Care. 2014;20:557-65. [CrossRef] [PubMed]
7. Lee J, Maslove DM. Customization of a Severity of Illness Score Using Local Electronic Medical Record Data. J Intensive Care Med. 2017;32:38-47. [CrossRef] [PubMed]
8. Lee J, Maslove DM, Dubin JA. Personalized mortality prediction driven by electronic medical data and a patient similarity metric. PLoS One. 2015;10:e0127428. [CrossRef] [PubMed]
9. Awad A, Bader-El-Den M, McNicholas J, Briggs J. Early hospital mortality prediction of intensive care unit patients using an ensemble learning approach. Int J Med Inform. 2017;108:185-95. [CrossRef] [PubMed]
10. Pirracchio R, Petersen ML, Carone M, Rigon MR, Chevret S, van der Laan MJ. Mortality prediction in intensive care units with the Super ICU Learner Algorithm (SICULA): a population-based study. Lancet Respir Med. 2015;3:42-52. [CrossRef] [PubMed]

Cite as: Medrek SK. The need for improved ICU severity scoring. Southwest J Pulm Crit Care. 2019;18:26-8. doi: https://doi.org/10.13175/swjpcc004-19 PDF

A Labor Day Warning

Today is Labor Day, a public holiday honoring the American labor movement and the contributions that workers have made to the strength, prosperity, laws, and well-being of the country. Though this holiday dates back to the end of the nineteenth century, the concept of organized labor is under increasing attack. While many of the physician and nurse readers may think that “labor” does not apply to them, after all they are professionals, management would likely disagree.

In Arizona v. Maricopa County Medical Society in 1982, the Supreme Court ruled that when physicians negotiate collectively with insurers about fees, and as a consequence do not compete with one another, such negotiations represent a horizontal agreement among competitors to fix prices (1). This was based on the concept of physicians being independent from hospitals or healthcare systems. However, more physicians are now hospital employed which has been in no small part due to cuts in physician compensation by Medicare with the insurers rapidly following. This increase in physician employment has been associated with increased billings leading to increased profits and decreased physician compensation (2,3).

The Nation’s largest healthcare system is the Department of Veterans Affairs (VA). The pace of VA hiring has not kept pace with the growth of patients leading to prolonged wait times first reported in Phoenix (4). Two recent decisions will likely affect physician hiring and retention at the VA. First, President Trump announced cancellation of the the planned salary increase for civilian employees (5). Second, VA Secretary Robert Wilkie, cancelled collective bargaining rights when it comes to professional conduct and patient care by VA providers (6). In the private sector, hospital employed physicians seem to becoming increasingly discontented because of 1. Having to deal with a lot of rules; 2. Having to deal with a large bureaucracy. 3. Not having a staff under their control; and 4. Having little control over compensation models (7).

All in all, this does not bode well for physicians or patients. The data suggest that the Medicare has helped destroy independently employed physicians while over compensating hospital employed physicians whose fees are collected by the hospital (7). This trend will likely continue until Medicare realizes that the existence of the independent practitioner keeps healthcare costs down. By financially squeezing the independent practitioner Medicare’s actions lead to decreased competition and increased healthcare costs.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Halper HR. Arizona v. Maricopa County: a stern antitrust warning to healthcare providers. Healthc Financ Manage. 1982 Oct;36(10):38-42. [PubMed]
2. Lowes R. Hospital-employed physicians cost Medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772#vp_1 (accessed 9/3/18).
3. Kane L. Medscape physician compensation report 2018. Medscape. April 11, 2018. Available at: https://www.medscape.com/slideshow/2018-compensation-overview-6009667#12 (accessed 9/3/18).
4. Davidson J. VA doctor shortage fueled by management issues, poor pay The Washington Post. July 16, 2018. Available at: https://www.washingtonpost.com/news/powerpost/wp/2018/07/16/va-doctor-shortage-fueled-by-management-issues-poor-pay/?utm_term=.070275d06e2a  (accessed 9/3/18).
5. Liptak K. Trump cancels pay raises for federal employees. CNN. August 31, 2018. Available at: https://www.cnn.com/2018/08/30/politics/trump-cancels-federal-employee-pay-raises/index.html (accessed 9/3/18).
6. Department of Veterans Affairs. VA secretary clarifies collective bargaining authority for patient care. August 29, 2018. Available at: https://www.managedhealthcareconnect.com/content/va-secretary-clarifies-collective-bargaining-authority-patient-care?hmpid=cmlja3JvYmJpbnNAY294Lm5ldA== (accessed 9/3/18).
7. Mertz GJ. Physicians employed by hospitals. Medscape. January 01, 2018. Available at: https://www.medscape.com/viewarticle/891120#vp_1 (accessed 9/3/18).
8. Lowes R. Hospital-employed physicians cost medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772 (accessed 9/3/18).

Cite as: Robbins RA. A labor day warning. Southwest J Pulm Crit Care. 2018;17(3):95-6. doi: https://doi.org/10.13175/swjpcc106-18 PDF 

Keep Your Politics Out of My Practice

“Nothing so needs reforming as other people's habits. Fanatics will never learn that, though it be written in letters of gold across the sky.”

-Mark Twain

Politicians have repeatedly inserted themselves into exam rooms and under hospital gowns, telling doctors what they can and cannot discuss with patients; forcing providers to recite scripted medical advice they know to be factually inaccurate; and even instructing physicians to prioritize the financial interests of private companies over the health of their patients (1,2).

In 2011 Florida passed a sweeping law barring doctors from routinely asking patients whether they had guns in their homes, counseling them on common-sense firearm storage measures or recording any information about gun ownership in their medical files. Four states (Pennsylvania, Ohio, Colorado, and Texas) have passed legislation relating to disclosure of information about exposure to chemicals used in the process of hydraulic fracturing (“fracking”). Some new laws require physicians to discuss specific practices that may not be necessary or appropriate at the time of a specific encounter with a patient. For example, New York enacted legislation in 2010 that requires physicians and other health care practitioners to offer terminally ill patients “information and counseling regarding palliative care and end-of-life options appropriate to the patient, including . . . prognosis, risks and benefits of the various options; and the patient's legal rights to comprehensive pain and symptom management.” Still other laws would require physicians to provide — and patients to receive — diagnostic tests or medical interventions whose use is not supported by evidence, including tests or interventions that are invasive and required to be performed even without the patient's consent. In Virginia, a bill requiring women to undergo ultrasonography before having an abortion was passed despite objections from the American College of Physicians. Arizona required physicians to tell women that drug-induced abortions may be “reversible” a claim that is unsupported by scientific evidence. A growing number of states have instituted mandatory waiting periods for abortions when there is no apparent medical need.

Healthcare providers who do not observe with these laws could face fines, license revocation, and even jail time for failure to comply. Fortunately, many have been struck down by the courts. However, a new tact for some has been to allow objection to certain types of medical treatment such as abortions based on the healthcare provider’s religious or moral beliefs. These providers have a new defender in the Trump administration (3). The top civil rights official at the Department of Health and Human Services (HHS) is creating the Division of Conscience and Religious Freedom to “protect” doctors, nurses and other health care workers who refuse to take part in procedures like abortion or treat certain people because of moral or religious objections. "Never forget that religious freedom is a primary freedom, that it is a civil right that deserves enforcement and respect," said Roger Severino, an anti-abortion Catholic lawyer who directs HHS's Office for Civil Rights. Here in Arizona healthcare professionals are not required to provide services that conflict with their religious beliefs, including abortion, abortion-inducing medication, emergency contraception, end of life care, and collection of umbilical cord blood (4).

Two recent incidents in Arizona involving pharmacists have brought this law under scrutiny (5). Hilde Hall, a transgender woman in Arizona, was allegedly denied hormone prescriptions by a CVS pharmacist in Fountain Hills. She was unable to fill the prescription at that location and despite her doctor requesting it, the pharmacist refused to transfer the order. CVS apparently fired the pharmacist. This comes within weeks of the case of Nicole Arteaga, who was denied medication for a nonviable pregnancy by a Walgreens pharmacist in Peoria, Brian Hreniuc PharmD. The Arizona State Board of Pharmacy has agreed to review Ms. Arteaga’s complaint against Dr. Hreniuc.

The Arizona Republic put it well. “The person in the white coat behind the counter should be there to help. To answer questions and ensure that the patient understands what the medicine is, how to take it and is aware of possible side-effects. Not to humiliate, question or refuse to serve the client” (5).  Assuming the accounts in the Arizona Republic are accurate, both pharmacists committed several transgressions of the code of ethics of the American Pharmacists Association including a commitment to the patient’s welfare; protecting the dignity of the patient; serving the patient in a private and confidential manner; respecting the autonomy and dignity of each patient; promoting the right of self-determination; recognizing individual self-worth; and acknowledging that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient (6).

Whether the Arizona State Board of Pharmacy will decide to enforce professional standards or uphold a politically motivated law is unclear. At a time when pharmacists seek to extend their scope of practice, the behavior of these two pharmacists make one question who they would serve if given more responsibility-the patient or themselves? Also disappointing has been the lack of condemnation from other pharmacists and pharmacy professional groups such as the Arizona Pharmacists Association. This lack of action makes expansion of the scope of practice questionable. We as healthcare providers are entitled to our politics just like anyone else but the line is crossed when you impose your politics on me or my patients.  

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med. 2012 Oct 18;367(16):1557-9. [CrossRef] [PubMed]
2. Rampell C. Politicians are invading our medical exam rooms. Washington Post. October 19, 2015. Available at: https://www.washingtonpost.com/opinions/politicians-playing-doctor/2015/10/19/7b1af280-769e-11e5-bc80-9091021aeb69_story.html?utm_term=.ae6df6d65643 (accessed 7/22/18).
3. Kodjak A. Trump admin will protect health workers who refuse services on religious grounds. NPR. January 18, 2018. Available at: https://www.npr.org/sections/health-shots/2018/01/18/578811426/trump-will-protect-health-workers-who-reject-patients-on-religious-grounds (accessed 7/22/18).
4. Center for Arizona Policy. Arizona religious freedom laws. January 2014. Available at: http://www.azpolicypages.com/religious-liberty/arizona-religious-liberty-laws/ (accessed 7/22/18).
5. Price TF. CVS pharmacist who refused transgender patient's prescription abused Arizona law. Arizona Republic. July 20, 2018. Available at: https://www.azcentral.com/story/opinion/op-ed/2018/07/20/hilde-hall-transgender-prescription-denied-cvs-pharmacy/809450002/ (accessed 7/22/18).
6. American Pharmacists Association. Code of Ethics. October 27, 1994. Available at: https://www.pharmacist.com/code-ethics (accessed 7/22/18).

Cite as: Robbins RA. Keep your politics out of my practice. Southwest J Pulm Crit Care. 2018;17(1):42-4. doi: https://doi.org/10.13175/swjpcc096-18 PDF 

*The views expressed are the author's and do not necessarily represent those of the American Thoracic Society or its affiliates.

The Highest Paid Clerk

Physicians are the highest paid clerks in healthcare, but we only have ourselves to blame. At one time charts were often unavailable or illegible and x-rays or outside medical records were often missing. How we longed to have searchable records available. Now we have them but digital medicine has come at a cost. For every hour physicians spend with patients nearly two hours are spent with the electronic healthcare record (EHR) (1). Nurses in the hospital spend nearly as much time with the EHR (2). If a picture is worth a thousand words, the drawing by a 7-year-old depicting her visit to the doctor may say it best with the doctor staring at a computer with his back to the patient (Figure 1).

Figure 1. Drawing by a 7-year-old of her visit to the doctor (3).

The EHR has done some very positive things. It has reduced medication errors; it assembles laboratory and imaging information; it allows visualization of X-rays; the notes are always legible; and although introduction of an EHR results in an initial increase in mortality, there appears to be an eventual reduction (3,4). However, EHRs were not built to enhance patient care but to augment billing. Despite the effort that goes into collecting and recording data, much of the data is unseen or ignored (3). Our daily progress notes have become cut-and-paste spam monsters that are mostly irrelevant and nearly impossible to interpret. The diagnoses can be difficult to locate, the documentation for the diagnosis is often incomprehensible, and the plan is unintelligible. Of course, billings have increased but not due to improved care, but because of the electronic gobbledygook that serves as a record. 

Several other recent examples illustrate that doctors are viewed and being used mainly as clerks. I recently, applied to renew my hospital privileges. This involved completing about a 25-page on-line form to including uploaded documentation of all licenses, board certifications, CME hours, a TB skin test and a DTaP vaccination. For this privilege, not only are medical staff dues paid but a $100 fee needs to accompany the application. Pity the poor physician who goes to several hospitals. In our office every piece of paperwork is scanned into the computer and signed by the physician. This includes the insurance forms, notes from co-managing physicians, the prescriptions that I have written and signed, the pulmonary function tests that I have interpreted and signed, the scored Epworth sleepiness scales that the patient has completed and are included in my note, etc.

A recent court decision may further increase the physician clerical load. The Pennsylvania Supreme Court in a 4-to-3 decision ruled that a physician may not "fulfill through an intermediary the duty to provide sufficient information to obtain a patient's informed consent” (5). What this essentially means is that a physician, presumably the operating surgeon, must obtain an informed consent which usually involves signing a piece of paper. However, signing an informed consent form does not assure informed consent and the form’s main purpose is to protect the hospital or surgical center against litigation by shifting culpability to the surgeon. Now a surgeon must not only inform the patient about the operation but must have a form signed to protect the hospital and discuss every adverse outcome and all alternatives, a clearly impossible task. Will it be long before an unintelligible informed consent is required before prescribing an aspirin?

Many physicians, including myself, have resorted to voice recognition software using a template to generate notes due to increasing documentation requirements. Although this seems to decrease documentation time and increase face-to-face time with the patient, a recent article points out that voice recognition makes mistakes (6). Although there is little doubt that this is true, other documentation methods have their problems such as typographical errors, spelling errors, and omissions in documentation. Hopefully, a hullabaloo will not be made over voice recognition mistakes like was made over copying-and-pasting (7,8). Copy-and-paste errors seem to be mostly trivial and the information they contain is mostly for billing and probably does not need repeating in the medical record in the first place.

Physicians have cowered too long to insurer or hospital interests to avoid being labeled as “disruptive”. Many physicians would be happy to carefully proof every note or spend an hour getting the hospital’s informed consent form signed, but only if adequately compensated. Whining about physician lack of autonomy and increased clerical load either in the doctor’s lounge or in the pages of a medical journal will have no effect. The trend of shifting clerical workload to the healthcare providers will likely continue until either physicians refuse to do these clerical tasks or receive fair compensation for their services.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Verghese A. How tech can turn doctors into clerical workers. NY Times. May 16, 2018. Available at: https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-what-we-lose-with-data-driven-medicine.html (accessed 7/13/18).
2. Stokowski LA. Electronic nursing documentation: Charting new territory. Medscape. September 12, 2013. Available at: https://www.medscape.com/viewarticle/810573_1 (accessed 7/13/18).
3. Toll E. A piece of my mind. The cost of technology. JAMA. 2012 Jun 20;307(23):2497-8.
4. Lin SC, Jha AK, Adler-Milstein J. Electronic health records associated with lower hospital mortality after systems have time to mature. Health Aff (Millwood). 2018 Jul;37(7):1128-35. [CrossRef] [PubMed]
5. Fernandez Lynch H, Joffe S, Feldman EA. Informed consent and the role of the treating physician. N Engl J Med. 2018 Jun 21;378(25):2433-8. [CrossRef] [PubMed]
6. Zhou L, Blackley SV, Kowalski L, et al. Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.  JAMA Network Open. 2018;1(3):e180530. [CrossRef]
7. Centers for Medicare and Medicaid Services. Electronic Healthcare Provider. December 2015. Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf (accessed 7/13/18).
8. The Joint Commission. Preventing copy-and-paste errors in EHRs. QuickSafety. February 2015. Available at: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_10.pdf (accessed 7/13/18).

Cite as: Robbins RA. The highest paid clerk. Southwest J Pulm Crit Care. 2018;17(1):32-4. doi: https://doi.org/10.13175/swjpcc089-18 PDF 

The VA Mission Act: Funding to Fail?

Yesterday on D-Day, the 74^th anniversary of the invasion of Normandy, President Trump signed the VA Mission Act. The law directs the VA to combine a number of existing private-care programs, including the so-called Choice program, which was created in 2014 after veterans died waiting for appointments at the Phoenix VA (1). During the signing Trump touted the new law saying “there has never been anything like this in the history of the VA” and saying that veterans “can go right outside [the VA] to a private doctor”-but can they? Although the bill authorizes private care, it appropriates no money to pay for it. Although a bipartisan plan to fund the expansion is proposed in the House, the White House has been lobbying Republicans to vote the plan down (2). Instead Trump has been asking Congress to pay for veteran’s programs by cutting spending elsewhere (2).

We in Arizona are very familiar with what is likely ahead if the VA Mission Act goes unfunded. One example is Arizona Child Protective Services (CPS). After enduring years of funding cuts after the 2007 recession, many CPS employees left and the caseloads of those remaining became unmanageable. In 2013 a scandal erupted when it was uncovered that over 6000 cases of child abuse or neglect were not investigated (3). Many legislators who were responsible for the funding cuts blamed poor management and eventually CPS was reformed as a separate agency.

Arizona schools may be going to the same direction as CPS. After reducing funding to the point that Arizona schools spend less per pupil that any state in the nation, Governor Doug Ducey and many of the Arizona legislators favor charter/private schools (4). However, tax dollars are funneled away from public schools by the expansion of the charter/private school voucher system (4).

The VA may also be getting this “funding to fail” treatment with the VA Mission Act. If confirmed, Veterans Affairs Secretary nominee, Robert Wilkie, would lead the effort to implement the VA Mission Care Act (2). With no funding Wilkie will undoubtedly need to take money from other VA programs leading to their failure. Down the road, he can expect criticism for the failed programs and be fired by a tweet as did the previous Secretary for Veterans Affairs (5).

Un- or under-funded mandates have become a favorite of politicians who take credit for voting for something good but avoid the blame of voting to pay for it. However, at the moment the economy seems sufficiently strong that Congress enacted a $1.5 trillion tax cut and can fund an expensive border wall. The VA Mission Act can provide the healthcare the VA has been unable to perform but only if accompanied by the $50 billion funding it requires to be successful.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Slack D. Trump signs VA law to provide veterans more private health care choices. USA TODAY. June 6, 2018. Available at: https://www.usatoday.com/story/news/politics/2018/06/06/trump-signs-law-expanding-vets-healthcare-choices/673906002/ (accessed 6/7/18)
2. Werner E, Rein L. Trump signs veterans health bill as White House works against bipartisan plan to fund it. Washington Post. June 6, 2018. Available at: http://www.chicagotribune.com/news/nationworld/politics/ct-trump-veterans-health-bill-20180606-story.html (accessed 6/7/18)
3. Santos F. Thousands of ignored child abuse allegations plague Arizona welfare agency. NY Times. December 10, 2013. Available at: https://www.nytimes.com/2013/12/11/us/thousands-of-ignored-abuse-allegations-plague-arizona-welfare-agency.html (accessed 6/7/18)
4. Alan Singer. How charter schools buy political support. Huffington Post. August 10, 2017. Available at: https://www.huffingtonpost.com/entry/how-charter-schools-buy-political-support_us_598c3149e4b08a4c247f287d (accessed 6/7/18).
5. Robbins RA. What does Shulkin's firing mean for the VA? Southwest J Pulm Crit Care. 2018;16(3):172-3. [CrossRef]

Cite as: Robbins RA. The VA mission act: Funding to fail? Southwest J Pulm Crit Care. 2018;16(6):334-5. doi: https://doi.org/10.13175/swjpcc074-18 PDF 

What the Supreme Court Ruling on Binding Arbitration May Mean to Healthcare

The Supreme Court ruled Monday (5/21/18) that companies can prohibit workers from using class-action litigation to resolve workplace disputes. In a 5-4 decision on three consolidated cases, the justices said companies can include clauses in employment contracts that require employees to use individual arbitration to resolve disputes.

In one of the cases, Jacob Lewis sued Epic, the electronic health record vendor, for denying him and others overtime pay. Epic contended that its contracts prohibited employees from such group litigation and required them to individually undergo arbitration. The Supreme Court ultimately agreed with Epic, saying that companies can require employees to resolve disputes individually outside of court, even if the situation affects many people.

"The virtues Congress originally saw in arbitration, its speed and simplicity and inexpensiveness, would be shorn away and arbitration would wind up looking like the litigation it was meant to displace" if workers gathered their complaints under class action lawsuits, Justice Neil Gorsuch wrote for the court (1). "This is a major victory for employers," said Richard Glovsky, co-chair of Locke Lord's labor and employment practice group (1). "The court's ruling clears the path, and a judicial logjam, to employers restricting the rights of employees to participate in class actions and who insist that they have their day in court."

Justice Ruth Bader Ginsburg read her dissent from the bench, a sign of profound disagreement. In her written dissent, she called the majority opinion “egregiously wrong.” In her oral statement, she said the upshot of the decision “will be huge under-enforcement of federal and state statutes designed to advance the well being of vulnerable workers.” Binding arbitration seems to favor the defendant with lower win rates and lower awards for the plaintiff compared to litigation (3). Arbitration clauses in employment contracts are a recent innovation, but they have become quite common. In 1992, Justice Ginsburg wrote, only 2 percent of non-unionized employers used mandatory arbitration agreements, while 54 percent do so today (2). Under those contracts, Justice Ginsburg wrote, it is often not worth it and potentially dangerous to pursue small claims individually. “By joining hands in litigation, workers can spread the costs of litigation and reduce the risk of employer retaliation,” she wrote.

The contracts may also encourage misconduct, Justice Ginsburg wrote (2). “Employers, aware that employees will be disinclined to pursue small-value claims when confined to proceeding one-by-one, will no doubt perceive that the cost-benefit balance of underpaying workers tips heavily in favor of skirting legal obligations,” she wrote, adding that billions of dollars in underpaid wages are at issue.

Although one of the Supreme Court cases involved Epic, the decision doesn't single out healthcare companies and won't have a unique impact on the industry. Arbitration clauses with class waivers are now commonplace in contracts for things like cellphones, credit cards, and rental cars. Generally, binding arbitration has been seldom used in healthcare, and when used, it has been between patients and nursing homes, and to a much lesser extent, between patients and hospitals or physicians. Arbitration has rarely been used in healthcare disagreements between employers and employees. However, it seems likely as healthcare organizations become larger and increasingly consolidate healthcare providers as employees this will likely change. Currently, many physicians, including myself, must sign an agreement prohibiting litigation against the hospital as conditions for hospital privileging. This Supreme Court ruling continues the trend of favoring corporations at the expense of individuals (4).

Justice Ginsburg called on Congress to fix the problem of forced binding arbitration. It seems unlikely that this will be immediately forthcoming. However, when Congressional makeup changes as it always does, the members of Congress may wish to also include healthcare providers, not as professionals, but as the employees they are increasingly becoming. 

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Arndt RZ. Supreme court rules in favor of Epic in arbitration case. Modern Healthcare. May 21, 2018. Available at: http://www.modernhealthcare.com/article/20180521/NEWS/180529998 (accessed 5/21/18).
2. Liptak A. Supreme court upholds workplace arbitration contracts barring class actions. NY Times. May 21, 2018. Available at: https://www.nytimes.com/2018/05/21/business/supreme-court-upholds-workplace-arbitration-contracts.html (accessed 5/21/18).
3. Alexander J.S. Colvin AJS. An empirical study of employment arbitration: Case outcomes and processes. Journal of Empirical Legal Studies 2011;8(1):1-23. Available at: https://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?referer=http://scholar.google.com/&httpsredir=1&article=1586&context=articles (accessed 5/22/18).
4. Liptak A. Corporations find a friend in the Supreme Court. NY Times. May 4, 2013. Available at: https://www.nytimes.com/2013/05/05/business/pro-business-decisions-are-defining-this-supreme-court.html (accessed 5/22/18).

Cite as: Robbins RA. What the Supreme Court ruling on binding arbitration may mean to healthcare. Southwest J Pulm Crit Care. 2018;16(5):283-4. doi: https://doi.org/10.13175/swjpcc068-18 PDF 

Kiss Up, Kick Down in Medicine

This past week the phrase “kiss up, kick down” was used to describe Ronny Jackson, then a nominee for the Secretary of Veterans Affairs (1). Wikipedia defines the phrase as “a neologism used to describe the situation where middle level employees in an organization are polite and flattering to superiors but abusive to subordinates” (2). Like most, I do not know Jackson and have no knowledge of the truth. However, the behavior attributed to Dr. Jackson is pervasive and harmful in medicine.

Kiss up, kick down is part of a blame culture. McLendon and Weinberg, see the flow of blame in an organization as one of the most important indicators of organization robustness and integrity (3). They argue that blame flowing upwards in a hierarchy proves that management can take responsibility for their orders and supply the resources required to do a job. However, blame flowing downwards, from management to staff, or laterally between professionals, indicate organizational failure. In a blame culture, problem-solving is replaced by blame-avoidance. Weinberg emphasizes that blame coming from the top generates "fear, malaise, errors, accidents, and passive-aggressive responses from the bottom", with those at the bottom feeling powerless and lacking emotional safety (4).

Calum Paton, Professor of Health Policy at Keele University, describes kiss up kick down as a prevalent feature of the UK National Health Service culture. He raised this point when giving evidence at the public inquiry into concerns of poor care and high mortality at Stafford Hospital in England (5). According to Paton, credit was centralized and blame devolved or transferred to a lower level. "Kiss up kick down means that your middle level people will kiss-up, they will please their masters, political or otherwise, and they will kick down to blame somebody else when things go wrong."

The VA scheduling scandal is a similar American example where management failed to provide the number of providers necessary to care for the patients. When caught, management attempted to blame the physicians (6). This is hardly surprising given that the physicians are often leaderless without anyone to speak for them. Too often physician leaders are not chosen from the best and brightest to protect the best interests of the patient and staff. Rather they are selected because they are the most compliant with management (kiss up).

Physicians near the top of a hierarchy are usually administrators peripherally involved in patient care. They may not always act with the best interests of the patient and staff but with what is best for their bosses and themselves as both the Stafford and VA examples illustrate. As such, they can be expected to “roll over on anyone” (kick down), a phrase used to describe Dr. Jackson (1). Furthermore, their practice skills may be weak or outdated making them particularly dangerous to the organization.

Physicians who put patient needs first often find themselves at odds with what is best for management. It may be time to reconsider how physician leaders are chosen. The medical staff is probably in the best position to judge which physicians are the best physician leaders rather than the obsequious leaders often chosen by management (7). If the medical staff chosen physician leader can work with management, the organization will have a dyad leadership. If not, then the physician leaders with the support of the staff can oppose those policies deemed harmful to patients or the organization.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Blake A. The lengthy list of allegations against Ronny Jackson, annotated. The Washington Post. April 25, 2018. Available at: https://www.washingtonpost.com/news/the-fix/wp/2018/04/25/the-list-of-allegations-against-ronny-jackson-annotated/?utm_term=.9ee75ad66c9b (accessed 4/28/18).
2. Kiss up kick down. Wikipedia. Available at: https://en.wikipedia.org/wiki/Kiss_up_kick_down (accessed 4/28/18).
3. McLendon J, Weinberg GM. Beyond blaming. Aye Conference Article Library. 1996. Available at: http://www.humansystemsinaction.com/beyondblaming/ (accessed 4/28/18).
4. Gerald M. Weinberg: Beyond Blaming, March 5, 2006, AYE Conference. Available at: http://www.ayeconference.com/beyondblaming/ (accessed 4/28/18).
5. Mid Staffordshire Public Inquiry Transcript - day 103. June 21, 2011. Available at: http://webarchive.nationalarchives.gov.uk/20150407092403/http://www.midstaffspublicinquiry.com/sites/default/files/transcripts/Tuesday_21_June_2011_-_transcript.pdf (accessed 4/28/18).
6. Robbins RA. Don't fire Sharon Helman-at least not yet. Southwest J Pulm Crit Care. 2014;8(5):275-7. [CrossRef]
7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]

Cite as: Robbins RA. Kiss up, kick down in medicine. Southwest J Pulm Crit Care. 2018;16(4):230-1. doi: https://doi.org/10.13175/swjpcc060-18 PDF 

What Does Shulkin’s Firing Mean for the VA?

David Shulkin MD, Secretary for Veterans Affairs (VA), was finally fired by President Donald Trump ending long speculation (1). Trump nominated his personal physician, Ronny Jackson MD, to fill Shulkin’s post. The day after his firing, Shulkin criticized his firing in a NY Times op-ed claiming pro-privatization factions within the Trump administration led to his ouster (2). “They saw me as an obstacle to privatization who had to be removed,” Dr. Shulkin wrote. “That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”

Former Secretary Shulkin’s tenure at the VA has had several controversies. First, as undersecretary of Veterans Healthcare and later as secretary money appropriated to the VA to obtain private care under the Veterans Access, Choice, and Accountability Acts of 2014 and the VA Choice and Quality Employment Act of 2017 appears to have been largely squandered on administrative salaries and expenses rather than hiring healthcare providers to shorten VA wait times (3). Second, Shulkin took a trip with his wife to Europe eventually ending up at Wimbledon to watch tennis (4). The purpose of his trip was ostensibly to attend a London Summit with senior officials from the United States, the United Kingdom, Canada, Australia, and New Zealand to discuss topical issues related to veterans. Although the summit occurred over 2 1/2 days, Shulkin and his wife traveled for 11 days at the taxpayer expense including a side trip to Denmark.

“The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war,” Dr. Shulkin wrote (2). “Working with community providers to adequately ensure that veterans’ needs are met is a good practice. But privatization leading to the dismantling of the department’s extensive health care system is a terrible idea.” Going on Shulkin states that, “Unfortunately, the department [VA] has become entangled in a brutal power struggle, with some political appointees choosing to promote their agendas instead of what’s best for veterans … These individuals, who seek to privatize veteran health care as an alternative to government-run VA care, unfortunately fail to engage in realistic plans regarding who will care for the more than 9 million veterans who rely on the department for life-sustaining care.”

However, the VA for many years has engaged in a relentless expansion of administration at the expense of healthcare. In the absence of sufficient oversight, Shulkin and VA Central Office did little to curb this trend (3).

Assuming he is confirmed, what will Ronny Jackson, Shulkin’s replacement, do? It seems likely that he will do exactly what Shulkin alleges and Trump apparently wants, i.e., privatize VA healthcare. Whether Jackson will be able to bend the large VA bureaucracy towards privatization is another matter given his lack of healthcare administrative experience. Shulkin may also be right that privatization may only reward select people and companies with profits rather than improving veterans’ care. Regardless, healthcare is more expensive than not delivering healthcare, so the price will probably rise. Time will tell, but something needs to be done. To paraphrase former VA undersecretary Ken Kizer, it is time for another “Prescription for Change” at the VA. 

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Rein L, Rucker P, Wax-Thibodeaux E, Dawsey J.  Trump taps his doctor to replace Shulkin at VA, choosing personal chemistry over traditional qualifications. Washington Post. March 29, 2018. Available at: https://www.washingtonpost.com/world/national-security/trump-ousts-veterans-affairs-chief-david-shulkin-in-administrations-latest-shake-up/2018/03/28/3c1da57e-2794-11e8-b79d-f3d931db7f68_story.html?utm_term=.7bcfe44b4ff6 (accessed 3-30-18).
2. Shulkin DA. Privatizing the V.A. will hurt veterans. NY Times. March 28, 2018. https://www.nytimes.com/2018/03/28/opinion/shulkin-veterans-affairs-privatization.html (accessed 3-30-18).
3. US Government Accountability Office. Better data and evaluation could help improve physician staffing, recruitment, and retention strategies. GAO-18-124. October 19, 2017. https://www.gao.gov/products/GAO-18-124 (accessed 3-30-18).
4. VA Office of Inspector General. Administrative investigation: VA secretary and delegation travel to Europe. Report No. 17-05909-106. February 14, 2018. Available at: https://www.va.gov/oig/pubs/VAOIG-17-05909-106.pdf (accessed 3-30-18).

*Dr. Robbins has received compensation for providing healthcare to veterans under the VA Choice Act.

Cite as: Robbins RA. What does Shulkin's firing mean for the VA? Southwest J Pulm Crit Care. 2018;16(3):172-3. doi: https://doi.org/10.13175/swjpcc052-18 PDF 

Guns, Suicide, COPD and Sleep

Within the past year two tragic events, the shootings in Las Vegas and Florida have renewed the debate about guns. The politics and the money that fuels the political debate have sharply divided politicians. As tragic as these mass shootings are, deaths by suicide far outnumber the loss of live in these shootings. In 2014 suicide was the tenth most common cause of death with 42,826 lives lost (1). Half of the suicides were by firearm (21,386).

The medical profession has traditionally been reluctant to speak about politically sensitive issues such as abortion, sexuality, and guns. However, beginning early in this millennium some medical societies such as the American Academy of Pediatrics, the US Preventative Services Task Force and even the Department of Veterans Affairs were suggesting physicians ask patients about gun behavior, but a few patients complained (2-5). There were some anecdotal reports of patients feeling “pressured” to answer questions about guns (5). One grumbled that it was invasion of privacy. The National Rifle Association also viewed the medical community’s gun-related questions as discriminatory and a form of harassment. In 2011, the Republican-controlled Florida legislature, with the support of the then and still state’s Republican governor, Rick Scott, passed restrictions aimed at limiting physician inquiries about gun ownership and gun habits. Under the law, doctors could lose their licenses or risk large fines for asking patients or their families about gun ownership and gun habits. Fortunately, this law was struck down by the 11th U.S. Circuit Court of Appeals (5). The Court ruled in 10-1 decision that the law violated the First Amendment rights of doctors and did nothing to infringe on the Second Amendment right to bear arms.

Eight health professional organizations and the American Bar Association have released a call for action to reduce firearm-related injury and death in the United States (6). Specific recommendations include the following:

• Criminal background checks should be a universal requirement for all gun purchases or transfers of ownership.
• Opposition to state and federal mandates interfering with physician free speech and the patient–physician relationship, such as laws preventing physicians from discussing a patient's gun ownership.
• All persons who have a mental or substance use disorder should have access to mental health care, as these conditions can play a significant role in firearm-related suicide.
• Recognition that blanket reporting laws requiring healthcare providers to report patients who show signs of potentially causing serious harm to themselves or others may stigmatize persons with mental or substance use disorders and create barriers to treatment. The statement urges that such laws protect confidentiality, do not deter patients from seeking treatment, and allow restoration of firearm purchase or possession in a way that balances the patient's rights with public safety.
• There should be restrictions for civilian use on the manufacture and sale of large-capacity magazines and military-style assault weapons, as private ownership of these represents a grave danger to the public.

Our national professional societies including the American Thoracic Society, the American College of Chest Physicians and the Society of Critical Care Medicine have all endorsed this call for action to gun violence (7).

Editors of the Annals of Internal Medicine have recently urged physicians to sign a formal pledge committing to having conversations with their patients about firearms (8). The Annals campaign began in the wake of the Las Vegas shooting and gained momentum after the February 14 school shooting in Parkland, Florida. So far nearly 1000 physicians have signed the pledge (9).

People who commit firearm violence against themselves or others often have notable risk factors that bring them into contact with physicians. We in the pulmonary, critical care and sleep communities are positioned to prevent some of these deaths. Patients with chronic diseases including COPD and sleep deprivation are known to be at higher risks for suicide (10,11). By inquiring about guns during these patients’ clinic visits, we may be able to identify potential problems and prevent some deaths.

It is ironic, but hardly surprising, that Florida, a state known for a series of gun-rights laws and its “Stand Your Ground” self-defense law (5), is the site of the latest mass shooting. The shooter, Nikolas Cruz, by all descriptions could have readily been recognized as a potential threat. Perhaps if he had been identified and an intervention performed before the Florida law banning physicians from discussing guns when the he was 12, a tragedy could have been avoided. As Florida Sen. Marco Rubio recently found out, the times may be changing (12). Politicians should keep their politics out of the clinic, hospital and physician-patient relationship. Those who do not, and especially those who by their actions put our patients in peril, do so at their own political risk.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Centers for Disease Control and Prevention. Suicide and self-inflicted injury. March 17, 2017. Available at: https://www.cdc.gov/nchs/fastats/suicide.htm (accessed 3/2/18).
2. American Academy of Pediatrics. Gun violence prevention. Available at: https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/pages/aapfederalgunviolencepreventionrecommendationstowhitehouse.aspx (accessed 3/2/18).
3. United States Preventive Services Task Force. Guide to clinical preventive services. Available at: https://www.ataamerica.com/arc1/users/pdfforms/Guide%20to%20Clinical%20Preventive%20Services.pdf (accessed 3/2/18).
4. Department of Veterans Affairs. Firearms and dementia. August 2017. Available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2731 (accessed 3/2/18).
5. Alvarez L. Florida doctors may discuss guns with patients, court rules. NY Times. February 16, 2017. Available at: https://www.nytimes.com/2017/02/16/us/florida-doctors-discuss-guns-with-patients-court.html (accessed 3/2/18).
6. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015 Apr 7;162(7):513-6. [CrossRef] [PubMed]
7. American College of Physicians. More than two dozen organizations join call by internists and others for policies to reduce firearm injuries and deaths in U.S. ACP Newsroom. May 1, 2015. Available at: https://www.acponline.org/acp-newsroom/more-than-two-dozen-organizations-join-call-by-internists-and-others-for-policies-to-reduce-firearm (accessed 3/2/18).
8. Wintemute GJ. What you can do to stop firearm violence. Ann Intern Med. 2017 Dec 19;167(12):886-7. [CrossRef] [PubMed]
9. Frellick M. More than 1000 doctors pledge to talk to patients about guns. Medscape. March 1, 2018. Available at: https://www.medscape.com/viewarticle/893307?nlid=121033_4502&src=wnl_dne_180302_mscpedit&uac=9273DT&impID=1572032&faf=1 (accessed 3/2/18).
10. Goodwin RD. Is COPD associated with suicide behavior? J Psychiatr Res. 2011 Sep;45(9):1269-71. [CrossRef] [PubMed]
11. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. [CrossRef] [PubMed]
12. Associated Press. Sen. Marco Rubio changes stance on high-capacity magazines after Florida school shooting. Time. February 22, 2018. Available at: http://time.com/5171653/marco-rubio-large-capacity-magazine-parkland-shooting/ (accessed 3/2/18).

Cite as: Robbins RA. Guns, suicide, COPD and sleep. Southwest J Pulm Crit Care. 2018;16(3):138-40. doi: https://doi.org/10.13175/swjpcc039-18 PDF

The Dangerous Airway: Reframing Airway Management in the Critically Ill

Intubation is one of, and perhaps the, highest risk procedures a critically ill patient can require, and the practice has largely been extrapolated from knowledge gained from airway management in the operating room (OR). Trouble arises when one encounters challenges with placing the tube or performing mask ventilation, termed the ‘difficult airway’. The difficult airway in the OR is relatively rare yet can be catastrophic when it is encountered unexpectedly. As a result, significant resources are devoted to developing task forces, guidelines, new devices and airway adjuncts to help manage the difficult airway and prevent avoidable complications. Outside of the OR, the difficult airway is encountered more frequently and with potentially devastating consequences. Reflexively, it is easy to blame the increased incidence on the skill of those managing airways as airway management has historically been viewed as a laryngoscopy problem--difficulty for us is the source of risk for the patient. Many facilities relegate airway management to an on-call anesthesiologist, leading to a significant variability in training and skill in airway management; and physicians skilled in life support but cannot safely put their patients on life support. Newer devices have led to a significant reduction in the difficulty with laryngoscopy, and it is becoming increasing clear to us that the terminology related to airway management outside of the OR should be reconsidered. Airway management outside of the OR commonly starts with the difficult airway because of the severely altered physiology, thus the importance of first-attempt success. Our current definition of the difficult airway lacks complete appreciation of the risks in these patients by focusing on the difficulty with laryngoscopy for the operator. For airway management of critically ill patients outside of the OR to positively impact patient outcomes, we must broaden our understanding of the risks associated with intubation.

There is no doubt that the difficulty one experiences in performing mask ventilation, laryngoscopy or tracheal intubation puts the patient at risk of untoward complications. However, limiting the focus to this traditional definition neglects the danger to the patient, which can occur in the absence of any technical difficulties. There is a strong association in the published literature between the number of intubation attempts and procedural complications (1-3), however there is also a significant risk of complications despite successful first-attempt tracheal intubation (i.e., no difficulty) (3). Thus, skillfully performing laryngoscopy and tracheal intubation that succeeds easily on the first attempt in a patient with physiologic derangements presents significant danger with airway management. This derangement may relate to a host of physiologic or pathologic issues and the resulting danger to the patient often relates to the consequences of hypoxemia or hypotension. To reduce the danger to the patient, careful attention is required to prepare the patient for induction, laryngoscopy and transition to positive pressure ventilation with emphasis on preoxygenation, maintenance of oxygenation and hemodynamic optimization.

Patients may face danger in any of the three phases of airway management: preparation and planning, implementation of the plan, or post-intubation management. Each phase presents both patient and contextual factors that accumulates and potentially compounds danger. Incomplete preparation, prolonged attempts at tracheal tube placement, disturbed physiology, an unskilled operator in a familiar environment or a skilled operator in an unfamiliar environment all contribute to different phenotypes of complications.  All can lead to different phenotypes of complications. Contextual factors include issues such as provider skill, access to equipment and help, various biases and conditions that in part are defined as human factors and are well-known to influence patient outcomes. To help mitigate technical difficulty experienced by the clinician and danger to the patient, special attention must be paid to each phase of airway management.

There are three phenotypes of complications that can arise from tracheal intubation. While the incidence of complications increases with successive attempts, the etiology and opportunity to attenuate those complications differs (Figure 1).

Figure 1. Studies outside of the OR show increased complications with successive attempts, with 10-20% for first attempt, 40-60% for second attempt, etc. However, different phenotypes of complications likely contribute differently at each point during airway management and thus provide various clinical and research targets. Incomplete or inadequate preparation or planning results in avoidable intubation-related complications because of early depletion of oxygen reserve, leading to aborted attempts or adverse events earlier than expected (Green bars). Complications that occur due to difficulty with laryngoscopy, tube placement, or mask ventilation despite pre-intubation optimization and preparation increase with successive attempts (Red bars). This is the traditional “difficult airway.” Complications that occur because of altered physiology likely contribute to the majority of complications with 1 or 2 attempts. These patients are so physiologically disturbed (e.g., hypoxemic respiratory failure, RV failure, tamponade), that they are intolerant of any attempt, any apnea, or the transition to positive pressure ventilation. These are the patients that when they degenerate into cardiac arrest despite first attempt success, we tell ourselves that they were just really sick and there’s nothing we could have done.

Complications can arise from inadequate preparation such as preoxygenation, improper positioning or an incomplete plan. Other complications arise from true difficulty with laryngoscopy, tube placement, or mask ventilation despite adequate preparation. With both of these types of complications, repeated attempts can lead to airway injury and edema that can precipitate a can’t-intubate can’t oxygenate scenario, but also the risk is from an association with the depletion of oxygen reserve, hemodynamic consequences of hypoventilation, or aspiration of gastric contents leading to critical hypoxemia. It is this latter association that should be eliminated with an increased focus on danger. Some patients have physiologic challenges that increase the risk of complications with any attempt (i.e. the “physiologically” difficult airway). These disturbances can be so severe that despite optimal preparation, risk cannot be completely obviated. By better understanding the danger presented by these three phenotypes, there is potential to clinically and scientifically approach airway management in critically ill patients that we have not considered historically. To date, we have typically focused efforts on preventing complications related to difficult laryngoscopy, yet the most significant danger likely comes from incomplete preparation and unfriendly physiology.   

Continuing to use the ‘difficult airway’ nomenclature in the critically ill patient risks confusion and undue variability without addressing the overall danger. For example, does anticipating difficulty and altering the plan, which then results in no difficulty being encountered during the intubation qualify as a difficult airway? Should one write a note in the chart, register the patient with a database, and send the patient a letter notifying them of the difficult airway they were predicted to have, but yet did not have? This presents a Schrödinger’s cat paradox in that the airway is both difficult and not difficult at the same time. From a research perspective, the term ‘difficult airway’ can be fraught with ambiguity or error. Studies comparing devices, techniques, or methods often focus either on the anticipated difficult airway, which is poorly predicted, deliberately exclude difficult airway patients, or isolate one aspect while ignoring the others (e.g. apneic oxygenation while ignoring preoxygenation) (4-11). Conversely, focusing on laryngoscopy-related complications ignores significant danger in airway management from incomplete preparation and difficult physiology-related complications, especially considering most patients are intubated in the first two attempts. We should refocus our energies on mitigating the danger by optimizing the pre- and peri-intubation process. Research should focus on how to best reduce complications associated with multiple attempts and disturbed physiology, and eliminate complications related to poor preparation altogether. These efforts will elevate our expertise in placing patients on life support to the level our patients deserve.

Jarrod M Mosier, MD^1,2,; George Kovacs, MD³; J. Adam Law, MD⁴; John C Sakles, MD¹

¹Department of Emergency Medicine, University of Arizona. 1609 N. Warren Ave, Tucson, AZ 85724

²Division of Pulmonary, Allergy, Critical Care, and Sleep. Department of Medicine, University of Arizona. 1501 N Campbell Ave, Tucson, AZ 85721

³ Departments of Emergency Medicine, Anaesthesia, Medical Neuroscience, Dalhousie University, Halifax, NS B3H 3A7

⁴ Departments of Anesthesiology and Emergency Medicine, Dalhousie University, Halifax, NS B3H 3A7

References

1. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71-8. [CrossRef] [PubMed]
2. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607-11. [CrossRef] [PubMed]
3. Hypes C, Sakles J, Joshi R, Greenberg J, Natt B, Malo J, Bloom J, Chopra H, Mosier J. Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications. Intern Emerg Med. 2017 Dec;12(8):1235-43. [CrossRef] [PubMed]
4. Griesdale DE, Chau A, Isac G, Ayas N, Foster D, Irwin C, Choi P, Canadian Critical Care Trials G: Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial. Can J Anaesth. 2012;59(11):1032-1039. [CrossRef] [PubMed]
5. Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Crit Care Med. 2015 Mar;43(3):636-41. [CrossRef] [PubMed]
6. Driver BE, Prekker ME, Moore JC, Schick AL, Reardon RF, Miner JR. Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Acad Emerg Med. 2016, 23(4):433-9. [CrossRef] [PubMed]
7. Janz DR, Semler MW, Lentz RJ, et al. Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. Crit Care Med. 2016;44(11):1980-7. [CrossRef] [PubMed]
8. Janz DR, Semler MW, Joffe AM, et al. A multicenter randomized trial of a checklist for endotracheal intubation of critically ill adults. Chest. 2017 Sep 14. pii: S0012-3692(17)32685-5. [CrossRef] [PubMed]
9. Semler MW, Janz DR, Russell DW, Casey JD, Lentz RJ, Zouk AN, deBoisblanc BP, Santanilla JI, Khan YA, Joffe AM et al. A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults. Chest. 2017;152(4):712-2. [CrossRef] [PubMed]
10. Semler MW, Janz DR, Lentz RJ, et al. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med. 2016 Feb 1;193(3):273-80. [CrossRef] [PubMed]
11. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video Laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial. JAMA. 2017;317(5):483-93. [CrossRef] [PubMed]

Cite as: Mosier JM, Kovacs G, Law JA, Sakles JC. The dangerous airway: reframing airway management in the critically ill. Southwest J Pulm Crit Care. 2018;16(2):99-102. doi: https://doi.org/10.13175/swjpcc004-18 PDF 

Linking Performance Incentives to Ethical Practice

Health spending is a huge part of the United States economy as it is a large business. We all have seen increasing inclusion of corporate practices in health care. One such inclusion is the incentive programs which have at their core the goal of production of the desired behavioral outcomes directly related either to performance output or extraordinary achievement. However, management influence on the organization’s ethical environment and culture can inadvertently encourage or endorse unethical behavior despite the best intentions. One way would be failing to link performance incentives to ethical practice. When leaders create strong incentives to accomplish a goal without creating equally strong incentives to adhere to ethical practice in achieving the desired goal, they effectively set the stage for ethical malpractice. Incentivizing ethical practice is equally important as incentivizing other behaviors (1). In the health care industry, unlike in the sales industry, professionalism and patient care are not like sale numbers and the costs of not providing excellent care can be serious. When emphasis is more about good performance numbers than accurate performance numbers, hospital accreditation reviews may result in, issuance of orders that are impossible to fulfill, or finding scapegoats to blame in a crisis. This can have powerful effects in shaping the organization’s environment and how staff members perceive the organization, their place in it, and the behaviors that are valued. Ironically, it isn’t unusual for leaders to assume all is fine from an ethical perspective when in fact it may not be. Research has shown that the higher in the organizational level the healthier the perceptions of organizational ethics is perceived (2).

It takes a great deal more than high ideals and good intentions to have ethical authority. It requires commitment and a proactive effort to achieve high standards. If executives are to meet the challenge of fostering an ethical environment and culture, it’s essential that they cultivate the required specific knowledge, skills, and habits. More and more, the public expects its leaders to hold themselves and their employees accountable and high on that expectation is ethical practice.

A focused example is the current opioid crises. In 2004 Centers for Medicare & Medicaid Services added pain scale as the 5^th vital sign. Subsequently, both the Department of Veterans Affairs and The Joint Commission mandated a pain scale as the 5^th vital sign (3-8). These pain scales ask patients to rate their pain on a scale of 1-10. The Joint Commission mandated that "Pain is to be assessed in all patients” and would give hospitals "Requirements for Improvement" if they failed to meet this standard (8). The Joint Commission also published a book in 2000 for purchase as part of required continuing education seminar (8). The book, sponsored by the opiate manufacturer Purdue Pharma (maker of oxycodone), 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 addictive side effects "inaccurate and exaggerated." The health organizations used patient satisfaction scores for Performance Incentives and some patients who were addicted or on their way to becoming addicted would complain to administrators when they did not get drugs they were seeking.

No one excuses the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, intrusion by unqualified bureaucrats, administrators and politician’s incentivizing more pain medications and punishing appropriate care likely contributed to the current crisis. In November 2017 four cities in West Virginia teamed up to file suit against The Joint Commission over the organization’s handling of pain management standards (9). In healthcare, physicians must advocate for their patients, build trust, insist on high standards of care, and participate creatively in improving the health care system in a fiscally responsible way (10). We should hold firm to pressures from manufacturers, administrators, and medical boards s to do what is in the best interests of our patients. Preserving the standards of professionalism in medicine while maintaining the highest levels of ethical standards has the best chance of healing this opiate epidemic. Let's maintain the trust and professionalism of our discipline during this crisis. 

F. Brian Boudi, MD

Associate Editor, SWJPCC

References

1. Wynia MK. Performance measures for ethics quality. Eff Clin Pract. 1999;2(6):294-9. [PubMed]
2. Treviño LK. Ethical culture: What do we know? Fellows Meeting, July 2003, Ethical Research Center. Available at: www.ethics.org/download.asp?fl=/downloads/Ethical_Culture_Summary.pdf; last accessed December 18, 2006.
3. 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]
4. 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]
5. 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 2/22/17).
6. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117 [CrossRef] [PubMed]
7. 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]
8. 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 2/22/18).
9. Sullivan W, Plaster L. Four West Virginia cities sue The Joint Commission. Emergency Physician Monthly. December 5, 2017. Available at: http://epmonthly.com/article/four-west-virginia-cities-sue-joint-commission/ (accessed 2/22/18).   
10. The unspoken challenges to the profession of medicine. Boudi FB, Chan CS. Southwest J Pulm Crit Care. 2017;14(6):222-4. [CrossRef]

Cite as: Boudi FB. Linking performance incentives to ethical practice. Southwest J Pulm Crit Care. 2018;16(2):96-8. doi: https://doi.org/10.13175/swjpcc036-18 PDF 

Brenda Fitzgerald, Conflict of Interest and Physician Leadership

Barely noticed in the news last week was Brenda Fitzgerald’s resignation as director of the Centers for Disease Control (CDC) after only 6 months on the job (1). Her resignation came one day after Politico reported that she bought shares in a tobacco company one month after assuming the CDC directorship (2). The stock was one of about a dozen new investments that also included Merck and Bayer (3). Fitzgerald had come under criticism by Senator Patty Murray for slow walking divestment from older holdings that government officials said posed potential conflicts of interest (1). While serving as director of the Georgia Department of Health, Fitzgerald owned stock in five other tobacco companies: Reynolds American, British American Tobacco, Imperial Brands, Philip Morris International, and Altria Group (4).

“It gives you a window, I think, into her value system,” said Kathleen Clark, a professor of law focusing on government ethics at Washington University in St. Louis (2). “It doesn’t make her a criminal, but it does raise the question of what are her commitments? What are her values, and are they consistent with this government agency that is dedicated to the public health? Frankly, she loses some credibility.” Purchasing tobacco stocks by any physician is disturbing, even more so when done by the director of the agency that spearheads the US government’s efforts to reduce smoking.

The influence of money on healthcare legislation has become increasingly concerning. Merck, whose stock Fitzgerald purchased on August 9, has been working on developing an Ebola vaccine and also makes HIV medications (2,3). Bayer, whose stock she purchased on August 10, has in the past partnered with the CDC Foundation to prevent the spread of the Zika virus (2,3). Fitzgerald’s purchases of tobacco stocks represent just one more instance of a potentially inappropriate relationship between politicians and business. Previous research published in the Southwest Journal of Pulmonary and Critical Care (SWJPCC) demonstrated a correlation between tobacco company political action committee contributions and support of pro-tobacco legislation (5).

Fitzgerald’s ethics issues are apart from a broader assessment of her leadership at the CDC. She had no research experience while leading an organization where research is one of its primary functions. She had previously promoted anti-aging medications to her patients despite no evidence of their efficacy (6).  She made few public statements during her time at the CDC and waited 133 days before holding her first staff meeting. She was scheduled several times to testify before Congress but sent deputies instead.

Fitzgerald seems to represent a high-profile version of the obsequious physician executive (OPIE), i.e., a physician obedient or attentive to an excessive or servile degree (7). Like the OPIE at the local hospital, Fitzgerald may have been appointed not for skill as a leader but her compliance as a subordinate to her supervisors. It raises the question of who would want to be director of the CDC when the current administration has been openly hostile, targeting the agency for deep budget cuts.

Hopefully, the next director of the CDC will be less conflicted. Previously, the SWJPCC has published tobacco company PAC contributions to candidates for political office (5). At the request of the Arizona Thoracic Society we intend to do the same prior to the November 2018 elections (8). In the interim, you can check tobacco company PAC contributions to federal candidates on the Campaign for Tobacco Free Kids website or for contributions at the state level at followthemoney.org (9,10).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Sun LJ. CDC director resigns because of conflicts over financial interests. Washington Post. January 31, 2018. Available at: https://www.washingtonpost.com/news/to-your-health/wp/2018/01/31/cdc-director-resigns-because-of-conflicts-over-financial-interests/?utm_term=.05ee75769108 (accessed 2/3/18).
2. Karlin-Smith S, Ehley B. Trump's top health official traded tobacco stock while leading anti-smoking efforts. Politico. January 30, 2018. Available at: https://www.politico.com/story/2018/01/30/cdc-director-tobacco-stocks-after-appointment-316245 (accessed 2/3/18).
3. Fitzgerald B. Periodic Transaction Report | U.S. Office of Government Ethics; 5 C.F.R. part 2634 Executive Branch Personnel Public Financial Disclosure Report: Periodic Transaction Report (OGE Form 278-T). Revised 12/21/17. Available at: https://www.politico.com/f/?id=00000161-4804-d9fe-a9fd-5af5834d0000 (accessed 2/3/18).
4. Fitzgerald B. Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e). Revised 10/12/17. Available at:  https://www.politico.com/f/?id=00000161-4867-da2c-a963-cf770b6b0000 (accessed 2/3/18).
5. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
6. Levitz E. Trump’s CDC pick peddled ‘anti-aging’ medicine to her gynecologic patients. New York Magazine. July 10, 2017. Available at: http://nymag.com/daily/intelligencer/2017/07/trumps-cdc-pick-peddled-anti-aging-medicine-to-patients.html (accessed 2/3/18).
7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]
8. Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. [CrossRef]
9. Campaign for Tobacco Free Kids. Tobacco PAC contributions to federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions (accessed 2/3/18).
10. The National Institute on Money in State Politics. Money in state politics. Available at: https://www.followthemoney.org/tools/election-overview/?s=AZ&y=2016 (accessed 2/3/18).

Cite as: Robbins RA. Brenda Fitzgerald, conflict of interest and physician leadership. Southwest J Pulm Crit Care. 2018;16(2):83-5. doi: https://doi.org/10.13175/swjpcc029-18 PDF 

Seven Words You Can Never Say at HHS

The recent announcement of the seven words you can never say at Health & Human Services (HHS) reminded me of the late George Carlin’s routine, “Seven Words You Can Never Say on Television” (1). Policy analysts at the Centers for Disease Control (CDC) in Atlanta were told of the list of forbidden words at a meeting last Thursday, December 14, with senior CDC officials who oversee the budget, according to an analyst who took part in the 90-minute briefing (2). The forbidden words are "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said. In other cases, no replacement words were immediately offered.

This is the latest attempt by government departments to distort fact. As an example, The New York Department of Education tried a similar tactic in 2012 (3). Among the words were dinosaur, birthday, and Halloween. Some of the reasons given were that dinosaurs suggest evolution which creationists might not like; Halloween was targeted because it suggests paganism; and birthday because it isn’t celebrated by Jehovah’s Witnesses; The Bush administration waged a similar war on climate change (4). That war has been extended by the Trump Administration as part of their war on any science that the Trump administration does not like (5). Science that does not fit Trump’s agenda or ideology is insulted or called “fake news”. Climate change is fact and not a hoax dreamed up the Chinese as Trump has claimed (6).

Mr. Carlin is not alive to make fun of the latest war on free speech but perhaps others will take up Carlin’s calling. Seven words they might suggest be banned include stupid, moron, fool, clown, weird, dumb and incompetent-all frequently used by President Trump on Twitter (7). The CDC is a scientific organization. Appointing unqualified politicians to head scientific organizations to carry out a political agenda is like mixing oil and water. No matter how times you say it, the water will not float on top of the oil. Science relies on a precise vocabulary and is not Republican or Democrat, conservative or liberal, or right or left. In my view, those that banned these words made an indirect attack on fact and should be “ashamed” (7).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Carlin G. 7 words you can never say on television. Available at: https://www.youtube.com/watch?v=kyBH5oNQOS0 (accessed 12/18/17).
2. Sun LH, Eilperin J. Words banned at multiple HHS agencies include ‘diversity’ and ‘vulnerable’. Washington Post. December 16, 2017. Available at: https://www.washingtonpost.com/national/health-science/words-banned-at-multiple-hhs-agencies-include-diversity-and-vulnerable/2017/12/16/9fa09250-e29d-11e7-8679-a9728984779c_story.html?utm_term=.c983e2f2af81 (accessed 12/18/17).
3. CBS News New York. War on words: NYC dept. of education wants 50 ‘forbidden’ words banned from standardized tests. March 26, 2012. Available at: http://newyork.cbslocal.com/2012/03/26/war-on-words-nyc-dept-of-education-wants-50-forbidden-words-removed-from-standardized-tests/ (accessed 12/18/17).
4. Union of Concerned Scientists. Scientific integrity in policy making. September, 2005. Available at: https://www.ucsusa.org/our-work/center-science-and-democracy/promoting-scientific-integrity/reports-scientific-integrity.html#.Wjf0TFWnGUk (accessed 12/18/17).
5. Editorial Board. President Trump’s war on science. New York Times. September 9, 2017. Available at: https://www.nytimes.com/2017/09/09/opinion/sunday/trump-epa-pruitt-science.html (12/18/17).
6. Marcin T. What has Trump said about global warming? Eight quotes on climate change as he announces Paris agreement decision. Newsweek. June 1, 2017. Available at: http://www.newsweek.com/what-has-trump-said-about-global-warming-quotes-climate-change-paris-agreement-618898 (accessed 12/18/17).
7. Lee JC, Quealy K. The 394 people, places and things Donald Trump has insulted on twitter: a complete list. New York Times. November 17, 2017. Available at: https://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html (accessed 12/18/17).

Cite as: Robbins RA. Seven words you can never say at HHS. Southwest J Pulm Crit Care. 2017;15(6):294-5. doi: https://doi.org/10.13175/swjpcc154-17 PDF 

Equitable Peer Review and the National Practitioner Data Bank

The General Accounting Office (GAO) recently reported that Department of Veterans Affairs (VA) did not report most physicians whose clinical care was found to be, or suspected of being, substandard to the National Practitioner Data Bank (NPDB) or to state licensing boards (1). The GAO examined 5 VAMCs and found required reviews of 148 providers’ clinical care after concerns were raised from October 2013 through March 2017. Of the 148, 5 were subjected to adverse privileging actions and 4 resigned or retired while under review but before adverse actions were taken. Only 1 of these 9 was reported to the NPDB and none was reported to his or her state medical board.

In response to GAO's report and in testimony to the Subcommittee on Oversight and Investigations, VA officials said the agency was taking three steps to improve reporting of providers who don't meet required standards:

1. Reporting more clinical occupations to the NPDB;
2. Improving the timeliness of reporting;
3. Enhancing oversight to ensure that no settlement agreements waive the VA's ability to report to NPDB and state licensing boards (2).

What is lacking in the report is determination if substandard actually occurred and how it was determined. The VA has 3 ways of identifying substandard care (1).

1. Tort claims (the VA equivalent of a medical malpractice lawsuit);
2. Complaints or incident reports;
3. Peer review.

Each has major problems of accuracy and fairness at the VA.

The majority of US physicians have been sued (3). The minority of suits are associated with malpractice and malpractice has no apparent association with the outcome of the litigation (4). Over 90% of medical malpractice cases are settled out of court (5). A common misconception is that settling a case before trial means a large financial settlement. However, 90% of the 90% or 82% of all claims, close with no payment (5). However, the VA uses US District Attorney to defend malpractice claims (6). In many instances, the US District Attorney’s office settles the case without determining if there is malpractice. The VA then submits the offending physician(s) name to the NPDB or state boards whether malpractice has been shown or not.

Complaints or incident reports are common in many hospitals, and many, if not most, have little merit (7). However, the weight given to a complaint should be viewed differently depending on the source. When colleagues raise concern about a physician’s care this is more credible than a patient complaining about not receiving their narcotics to a patient advocate. In the GAO report it is unclear if this was a source the of possible substandard care.

Lastly, there is peer review. There are several problems with this process in the VA. The VA selects the “peers”. In many instances the reviewers are un- or under-qualified to review the case (6). Furthermore, the selected reviewers may be conflicted clouding a balanced and fair determination if the physician’s care met the standard of care. There are multiple instances of this at the VA, of which a couple have been cited in the SWJPCC (6).

No surprisingly, a bureaucracy in the federal government has suggested a bureaucratic solution to a nonexistent problem. The goal should not be for more bureaucratic reporting, but a system for determining if a physician’s care has met the standard of care. The VA has shown it is incapable of making this determination fairly and accurately. What is needed is an outside review separated from VA influence and politics. If malpractice is still questioned after an initial VA review, the medical schools or private practioners could provide a source of physician peer review. The case could be presented to a panel of non-VA physician peers chosen in an equitable ratio by the VA and the accused practitioner. In the absence of a more equitable review process, the VA will only succeed in driving away the quality practitioners the veterans need.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. General Accounting Office. VA health care: improved policies and oversight needed for reviewing and reporting providers for quality and safety concerns. Report to the chairman, committee on veterans’ affairs, House of Representatives. GAO-18-63 (Washington, D.C.: November, 2017). Available at: http://www.gao.gov/assets/690/688378.pdf (accessed 12/6/17).
2. Terry K. VA medical centers fail to report substandard doctors, GAO says. Medscape. December 5, 2017. Available at: https://www.medscape.com/viewarticle/889600?nlid=119420_4502&src=wnl_dne_171206_mscpedit&uac=9273DT&impID=1501593&faf=1 (accessed 12/6/17).
3. Matray M. Medscape malpractice report 2017 finds the majority of physicians sued. Medical Liability Monitor. November 15, 2017. Available at: http://medicalliabilitymonitor.com/news/2017/11/medscape-malpractice-report-2017-finds-the-majority-of-physicians-sued/ (accessed 12/6/17).
4. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec 26;335(26):1963-7. [CrossRef] [PubMed]
5. Chesanow N. Malpractice: when to settle a suit and when to fight. Medscape. September 25, 2013. Available at: https://www.medscape.com/viewarticle/811323_3 (accessed 12/6/17).
6. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013 Dec 1;2(3):e27. [CrossRef] [PubMed]
7. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight bureaucracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.

Cite as: Robbins RA. Equitable peer review and the national practitioner data bank. Southwest J Pulm Crit Care. 2017;15(6):271-3. doi: https://doi.org/10.13175/swjpcc152-17 PDF

Fake News in Healthcare

An article in the National Review by Pascal-Emmanuel Gobry points out that there is considerable waste in healthcare spending (1). He blames much of this on two entitlements-Medicare and employer-sponsored health insurance. He also lays much of the blame on doctors. “Doctors are the biggest villains in American health care. ... As with public-school teachers, we should be able to recognize that a profession as a whole can be pathological even as many individual members are perfectly good actors, and even if many of them are heroes. And just like public-school teachers, the medical profession as a whole puts its own interests ahead of those of the citizens it claims to be dedicated to serve.”

Who is Pascal-Emmanuel Gobry and how could he say something so nasty about teachers and my profession? A quick internet search revealed that Mr. Gobry is a fellow at the Ethics & Public Policy Center, a conservative Washington, D.C.-based think tank and advocacy group (2). According to his biography, Gobry writes about religion, culture, politics, economics, business, and technology, but not health care. He is a columnist at The Week, a contributor at Forbes, a blogger at the Patheos Catholic and his writing has appeared in the Wall Street Journal, The Atlantic, and The Daily Beast amongst others. He holds a Master of Science in management from HEC Paris (Hautes études commerciales de Paris, a quite prestigious business school) and lives in Paris.

To make his point on waste, Mr. Gobry comments on Atul Gawande’s 2007 New Yorker “exposé on the Herculean efforts by a handful of scientists to get intensive-care physicians to implement a basic hygiene measures checklist so as to stop hospital-borne diseases” (3). He goes on to quote the Centers for Disease Control that hospital-borne diseases kill about 100,000 people per year, that the checklist was of no cost to the doctors, and its scientific rationale was unquestionable. “Doctors still resisted it with all their might because they found it mildly inconvenient; perhaps they found it even less acceptable that anybody might tell them how to do their jobs”. I showed this article to one of my former pulmonary/critical care fellows who has been in practice about 10 years. He commented, “Another guy who doesn’t practice medicine or know what he’s talking about.”

Gobry is referring to the Institute of Healthcare Improvement (IHI) central line associated blood stream infection (CLABSI) guidelines. These include hand washing, sterile gloves, sterile gown, wearing of a cap, full body drape, chlorhexidine, and not using femoral sites for insertion. In our intensive care units only chlorhexidine usage was associated with a decline in CLABSI (4). Every ICU I have practiced in has emphasized handwashing and demanded use of sterile gloves, gowns and drapes. The remaining guidelines are not supported by good evidence.

Gobry also claims that a computer is better at diagnosis than most physicians. He claims that the evidence is “pretty robust at this point, and the profession resists it tooth and nail. In a few years, we’ll be able to know how many unnecessary deaths this led to, but the number will have lots of zeroes”. However, in the only direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms (84.3% vs. 51.2%) (5).

Journalists like Gobry are writing melodramatic articles about medicine and often getting it wrong. In this case he sensationalized Gawande’s article and misquoted the evidence for both the IHI guidelines and computer diagnosis.

There’s a TV commercial about an actor playing a doctor. Gobry is a business journalist attempting to play a doctor at the National Review. My former fellow is right. Gobry is a guy who does not know what he is talking about. Unfortunately, his writings can affect public policy and influence politicians who know even less. As President Trump said, “Nobody knew that health care could be so complicated” (6).

I am a doctor playing a journalist at the Southwest Journal of Pulmonary and Critical Care. Our articles may not be as sensational as Gobry’s, but we stick to what we know-pulmonary, critical care and sleep medicine. I think we usually get it right. President Trump has railed against “fake news”, most recently on Lou Dobbs Tonight (7). Journalists like Gobry contribute to fake news by being deliberately obtuse, appealing to emotions, name-calling, and omitting or distorting facts. As physicians, we have been denigrated by journalists like Gobry and others who make outrageous claims for their own purposes. It is the responsibility of physicians to challenge those like Gobry who get it wrong.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Gobry P-E. The most wasteful health spending is also the most popular. National Review. October 25, 2017. Available at: http://www.nationalreview.com/article/453088/health-care-spending-wasteful-popular (accessed 10/25/17).
2. Ethics & Public Policy Center. Pascal-Emmanuel Gobry. https://eppc.org/author/pascal-emmanuel-gobry/ (accessed 10/25/17).
3. Gawande A. The Checklist. The New Yorker. December 10, 2007. Available at: https://www.newyorker.com/magazine/2007/12/10/the-checklist (accessed 10/25/17).
4. Hurley J, Garciaorr R, Luedy H, et al. 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. Available at: /critical-care/2012/5/10/correlation-of-compliance-with-central-line-associated-blood.html. 
5. Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016 Dec 1;176(12):1860-1861. [CrossRef] [PubMed]
6. Howell T Jr. Trump: 'Nobody Knew That Health Care Could Be So Complicated'. Fox News. February 27, 2017. Available at: http://nation.foxnews.com/2017/02/27/trump-nobody-knew-health-care-could-be-so-complicated (accessed 10/25/17).
7. Trump DJ. Lou Dobbs Tonight. October 25, 2017. Available at: http://video.foxbusiness.com/v/5624925494001/?#sp=show-clips (accessed 10/26/17).

Cite as: Robbins RA. Fake news in healthcare. Southwest J Pulm Crit Care. 2017;15(4):171-3. doi: https://doi.org/10.13175/swjpcc132-17 PDF 

Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad Leadership

Obsequious is defined as “obedient or attentive to an excessive or servile degree”. Obsequious comes from the Latin root sequi, meaning "to follow”. An Obsequious PhysIcian Executive (OPIE) is more likely to be servile to the hospital administration than a leader of the medical staff. This is not surprising since they are chosen for a “leadership” position not by the physicians they purportedly lead, but by the hospital administration they serve. OPIEs become the administration’s representative to the physicians and not the physicians’ or patients’ representative to the administration. Their job often becomes keeping the medical staff “in-line” rather that putting the success of the medical center first.

My own views have developed over 40 years of observing OPIE behavior in a multitude of medical centers. Although there are many exceptions, OPIEs often share certain characteristics:

1. Academic failure. OPIEs are usually academic failures. They are the antithesis of the triple threat who excels as a physician, teacher and researcher. In contrast, they excel at nothing and often are obstructionistic of others’ attempts to accomplishment anything meaningful.
2. Advanced degrees not pertaining to medicine. Frustrated by their lack of success, they seek advancement by alternative routes such as nontraditional career paths or obtaining degrees outside of medicine, e.g., a master’s degree in business administration (MBA). Though they will argue that they are just serving a need or advancing their education, more likely they are seeking the easiest path for advancement, especially if their past accomplishments are best described as “modest”. Beware the unaccomplished physician with a MBA.
3. Blame others for failure. Not all ideas, even from good people, are successful. Some are bad ideas destined to failure. When an OPIE’s idea fails, they blame others. Worse yet, they lie about a staff in order to place themselves in a good light. This appears to be one of the root causes of the waiting time scandal at the VA. In contrast, a leader accepts responsibility for failure and proposes a new and hopefully better plan.
4. Bullying. OPIEs often fail to see two sides to any argument and are usually impatient and short-tempered with any who disagree. Rather that attempting to build a consensus, they attempt to bully those who show any resistance.
5. Retaliation. If bullying fails, OPIEs seek retaliation. This can be through various means-often denial of resources. For example, one chief of staff sat for over a year on a request for a Glidescope (a fiberoptic instrument used for intubation) in the intensive care unit and then was faultfinding when a critical care fellow did not use a Glidescope during an unsuccessful intubation intubation. OPIEs might limit clinic space or personnel but then disparage the physicians when patients are not seen quickly enough to meet an administrative guideline. Lastly, if all else fails they may retaliate by invoking quality assurance. Quality is often ill-defined and it is all too easy in this day of “patient protection” to slander a good physician.

One of the latest buzzwords in healthcare is dyad leadership, a term that refers to physician/administrator teams that jointly lead healthcare organizations (1). A recent editorial touted the success of the partnership between Will Mayo MD and Harry Harwick at the Mayo Clinic in Rochester (2). My own positive example comes from Mike Sorrell MD, Charlie Andrews MD, and Bob Baker at the University of Nebraska Medical Center in Omaha. However, simply putting a physician and administrator together in leadership positions does not guarantee organizational success. In fact, if not done correctly, it leads to confusion, resentment, lack of consistent direction and divided organizational factions.

Based on their Mayo Clinic experience, Smoldt and Cortese list five key success factors they believe bring success to a dyad leadership (2):

1. Common core values. Perhaps the most important factor in a successful dyad is that members of the physician/administrator team have the same core values and goals. Furthermore, these need to be consistent with the staffs' values and goals. Smoldt and Cortese (2) point out that at Mayo Clinic the core value of “the needs of the patient come first” is deeply imbedded. The staff of an organization will primarily deduce leadership core values from their daily actions. Administrative bonuses or increased reimbursement are not necessarily common core values, and if emphasized over patient care, the dyad is doomed to failure.
2. Willingness to work together toward a common mission and vision. In a medical center, if the administrative leadership and staff can work together toward a vision, it is more likely to be achieved. If leadership becomes too territorial or engages in OPIE behavior, the ideal of leveraging each other’s strengths will be lost. If the staff perceives that the dyad is emphasizing their personal goals and finances over institutional success, the staff will be unwilling to work with or support the dyad.
3. Clear and transparent communication with each other and the organization. To gain the most from dyad leadership, each member of the team should leverage and build on the strengths of the other. The more time the individuals spend together as a leadership team and with staff at a medical center, the more frequent and open the communication will be. If over time, communication declines, it is probably a sign that the dyad is not working and is often followed by the OPIE behaviors of bullying, lying and retaliation.
4. Mutual respect. A team works best if its members operate in an atmosphere of mutual respect. If the dyad team does not share or show mutual respect for each other, mutual respect will likely also be lost among the healthcare delivery team. It is especially important for the dyad to remember that respect must be earned, and a big part of earning respect is to show respect for the views and positions of the staff.
5. Complementary competencies. No one organizational leader is good at everything that needs to be done in a medical center. Employing a dyad leadership approach can expand the level of competence in the top leadership. For example, in a physician/administer leadership team, it is not unusual for the administrator to have better financial skills than the physician. It goes without saying that physicians and nurses have better medical skills in their own scope of practice than an administrative/physician dyad.

Integrated delivery of care is an absolute for a successful medical center. OPIE behavior dooms the medical center. Establishing a physician/administrator dyad leadership team with the right administrator and physician can be a good step towards success.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Zismer DK, Brueggemann J. Examining the "dyad" as a management model in integrated health systems. Physician Exec. 2010 Jan-Feb;36(1):14-9. [PubMed]
2. Smoldt RK, Cortese DA. 5 success factors for physician-administrator partnerships. MGMA Connection Plus. September 24, 2015. Available at: http://www.mgma.com/practice-resources/mgma-connection-plus/online-only/2015/september/5-success-factors-for-physician-administrator-partnerships (accessed 10/4/17).

Cite as: Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. doi: https://doi.org/10.13175/swjpcc121-17 PDF

Disclosures for All

The August 15 edition of the Annals of Internal Medicine published an article “Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination - Randomized Controlled Trial" (1). The study examined open book vs. closed book testing for the American Board of Internal Medicine (ABIM) examination and found no or minimal changes in the outcomes between the two testing conditions.

All in all, this is not very exciting. However, what is interesting is a blog on the article written by Westby G. Fisher, MD in his Dr. Wes blog (2). He examined the disclosures from the Annals editors of the article who claimed no financial relationships or interests to disclose. However, Fisher points out that on its last available Form 990, the publishers of the Annals of Internal Medicine, the American College of Physicians (ACP), earned over $24.6 million in a single year selling their Medical Knowledge Self-Assessment Program to US physicians to study for their board certification and recertification examinations (3). Furthermore, Fisher notes that an accompanying editorial written by ACP's former senior executive vice president, Steven E. Weinberger, MD, a pulmonologist and an employee of the ACP, also did not disclose any meaningful conflicts. However, with compensation of nearly $800,000 in 2014, Weinberger’s compensation was over 3 times the average compensation of pulmonolgists in the Middle Atlantic states of $226,000 (3,4). It seems unlikely that unless their financial status was healthy that the ACP could have afforded a luxury such as Dr. Weinberger.

Fisher notes that the study was conceived exclusively by the American Board of Internal Medicine and executed by their corporate partners at PearsonVue and Wolters Kluwer. However, PearsonVue had more than a minor role in the research and had access to the study registrants' names, addresses, and probably more (2). Each of the 825 physicians enrolled in the study received $250 from the ABIM Foundation. None of the participants were told about the financial benefits to the ABIM, PearsonVue, Wolters Kluwer, or their content creators for participation in this study.

The financial future of many of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) and the 18 approved medical specialty boards of the American Osteopathic Association (AOA) was in doubt until maintenance of certification (MOC) was conceived back in the 1980’s (2). Since then there have been multiple attempts to show MOC leads to better patient outcomes, but to my knowledge, no meaningful improvements have been shown (5-7). Furthermore, advertising for MOC programs with slogans such as “Is your doctor board-certified?” likely led to an erosion of faith in the medical profession. These MOC programs can largely be lumped with other money-making schemes such as continuing medical education and hospital recertification which are funded on the backs of physicians, are time-consuming and have not been shown to improve care.

According to Fisher (2), “conflicted research” as published in the Annals of Internal Medicine misleads the public and represents little more than a free advertising for the financial agendas of MOC organizations who benefit from the research. Furthermore, “…it sets and incredibly low (and untrustworthy) bar for all of academic publishing.”

Although this is strong language, Fisher is right. Disclosures need to be full and honest from all. Here are ours. The cost of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) is funded by the non-profit Phoenix Pulmonary and Critical Care Research and Education Foundation. None of the foundation board of directors, the editors, associate editors, staff, reviewers or authors receive any compensation. Our operating expenses are less than $5000/year and our income is dependent on donations to our foundation. We hope this reassures our readers that we have no hidden agenda and that what they read in the SWJPCC is honestly reviewed.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Lipner RS, Brossman BG, Samonte KM, Durning SJ. Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial. Ann Intern Med. 2017 Aug 15 [Epub ahead of print]. [CrossRef] [PubMed]
2. Fisher WG. Fake news: Annals of Internal Medicine's disclosures. Dr. Wes. August 16, 2017. Available at: http://drwes.blogspot.com/2017/08/fake-news-annals-of-internal-medicines.html (accessed 8/17/17).
3. CitizenAudit.org. American College of Physicians Form 990. 2014. Available at: http://pdfs.citizenaudit.org/2015_05_EO/23-1520302_990_201406.pdf (accessed 8/17/17).
4. Peckham C. Medscape pulmonologist compensation report 2014. Medscape. April 15, 2014. Available at: http://www.medscape.com/features/slideshow/compensation/2014/pulmonarymedicine (accessed 8/17/17).
5. Buscemi D, Wang H, Phy M, Nugent K. Maintenance of certification in Internal Medicine: participation rates and patient outcomes. J Community Hosp Intern Med Perspect. 2013 Jan 7;2(4). [CrossRef] [PubMed]
6. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA.Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. 2014 Dec 10;312(22):2358-63. [CrossRef] [PubMed] 
7. Gray BM, Vandergrift JL, Johnston MM, Reschovsky JD, Lynn LA, Holmboe ES, McCullough JS, Lipner RS. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. [CrossRef] [PubMed] 

Cite as: Robbins RA. Disclosures for all. Southwest J Pulm Crit Care. 2017;15(2):87-9. doi: https://doi.org/10.13175/swjpcc105-17 PDF 

Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to Require Sleep Apnea Testing in Commercial Transportation Operators

In another move favoring business interests and against the common good, the Trump administration’s Department of Transportation announced recently that they are rescinding plans to require testing for obstructive sleep apnea (OSA) in train and commercial motor vehicle operators (1). As exemplified by its withdrawal from the Paris climate accords, this decision is another example of how the current administration disregards scientific findings and present-day events in establishing policy that will be detrimental to Americans.

Let us step back for a moment and briefly review the evidence that the Trump administration has ignored.

• It is well established that obstructive sleep apnea (OSA) can result in daytime sleepiness (2) and that sleepiness is detrimental to safe operation of a train or motor vehicle.
• Many studies have established that persons with OSA have an increased risk of motor vehicle crashes (3).
• Studies in commercial truck drivers have observed that this population has a high prevalence of OSA (4).
• It is estimated that OSA costs the American economy $150 billion annually (5).
• There now are relatively easy and inexpensive protocols to screen high risk individuals for OSA (4).
• Obstructive sleep apnea is a treatable condition, and treatment mitigates OSA impairment in sleepiness and reduces crash risk (6,7). In contrast, non-compliance with treatment is associated with a five-fold increase in crash risk (6).
• The costs of diagnosis and treatment are much lower than the costs that ensue when OSA persists untreated (5). For example, significant healthcare savings result from successful treatment of truck drivers (8).
• Failure to recognize and treat OSA has resulted in several high-profile transportation accidents. The following are some recent incidents:
  • September 2016: A commuter rail train slammed into the station at Hoboken, NJ killing a female bystander and leaving a child without a mother. The engineer had undiagnosed severe OSA (9).
  • December 2013: A Metro North commuter rail engineer fell asleep and his train sped around a curve resulting in a crash that killed 4 and injured 70 (10). The National Transportation Safety Board determined that undiagnosed severe OSA was the probable cause of the accident. The lack of a policy which required sleep disorder screening was further determined to be a contributing factor (11).
  • September 2013: A Greyhound bus overturned on Interstate 70 because the driver fell asleep resulting in multiple injuries. The driver was later found to have untreated OSA (12).
  • June 2009: A tractor-trailer traveling at a high speed did not see stopped cars ahead on Interstate 44 resulting in a crash that killed 10 and injured 6. It was later determined that the truck driver had mild OSA contributing to fatigue (13).

Despite the weight of the aforementioned evidence, the current administration has chosen to ignore it in favor of letting private industry regulate itself implying the current regulations are sufficient. As illustrated by the incidents cited above, recent events have proven them wrong. As Sir Winston Churchill once said “Those who fail to learn from history are doomed to repeat it”. Continuing with the current policy will inevitably result in further preventable disasters and more loss of life.

What can be done? At the federal level, one should consider advocating to your own congressional representatives for reconsideration of this poorly considered policy. On a personal level, federal policy is ultimately guided by the “ballot box”, which is something to consider for the next election. Finally, be aware that the next time you are driving down the interstate, the truck or bus driver approaching you from behind may have untreated OSA!

Stuart F. Quan, M.D.^1,2, Laura K. Barger, Ph.D.¹, Matthew D. Weaver, Ph.D.¹, and Charles A. Czeisler, Ph.D., M.D.¹

¹Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

Harvard Medical School, Boston, MA USA

²Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Federal Register. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. Last updated: 2017. Available at: https://federalregister.gov/d/2017-16451 (Accessed: August 10, 2017)
2. Committee on Sleep Medicine and Research Board on Health Sciences Policy. Sleep disorders and Sleep Deprivation--An Unmet Public Health Problem. Washington, D.C.: National Academies Press, 2006; 404.
3. 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 Dec 15;5(6):573-81. [PubMed]
4. Kales SN, Straubel MG.Obstructive sleep apnea in North American commercial drivers. Ind Health. 2014;52(1):13-24. [CrossRef] [PubMed]
5. Anonymous. Hidden health crisis costing America billions. Underdiagnosing and undertreating obstructive sleep apnea draining healthcare system. Last updated: 2016. Available at: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx (Accessed: August 15, 2017)
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. Tregear S, Reston J, Schoelles K, Phillips B.Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1373-80. [CrossRef] [PubMed]
8. Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med. 2010 May;52(5):473-7. [CrossRef] [PubMed]
9. Anonymous Hoboken train crash investigation hampered by heavy damage. CBS News. 2016; Available at: http://www.cbsnews.com/news/hoboken-train-crash-investigation-hampered-heavy-damage/ (Accessed: August 15, 2017)
10. Anonymous. December 2013 Spuyten Duyvil derailment. Last updated: 2017. Available at: https://en.wikipedia.org/wiki/December_2013_Spuyten_Duyvil_derailment (Accessed: August 10 , 2017)
11. National Transportation Safety Board. ​Metro-North Railroad Derailment. Last updated: 2014. Available at: https://www.ntsb.gov/investigations/AccidentReports/Pages/RAB1412.aspx (Accessed: August 15, 2017)
12. Lee D.  Sleep Test Leads to $6M Greyhound Settlement. Last updated: 2016. Available at: http://oldarchives.courthousenews.com/2016/03/09/sleep-test-leads-to-6m-greyhound-settlement.htm (Accessed: March 9, 2017)
13. National Transportation Safety Board. Highway Accident Report: Truck‐Tractor Semitrailer Rear‐End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma June 26, 2009. Last updated: 2010. Available at: https://www.ntsb.gov/investigations/AccidentReports/Reports/HAR1002.pdf (Accessed: August 10, 2017)

Cite as: Quan SF, Barger LK, Weaver MD, Czeisler CA. Saving lives or saving dollars: The Trump administration rescinds plans to require sleep apnea testing in commercial transportation operators. Southwest J Pulm Crit Care. 2017;15:84-6. doi: https://doi.org/10.13175/swjpcc102-17 PDF 

Disclosures 

Editor's note: In 2016 Dr. Quan authored an editorial titled "Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now" in SWJPCC. The editorial encouraged screeening of transportation workers for sleep apnea.