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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Saturday, November 16, 2019

Google as a "business associate" of Ascension Health Care

In you are or  have been a patent of Ascension health care system your names,diagnosis, date of birth may be accessible to employees of Google according to recent news reports on various sites.The information is reported as including names and date of birth and you do not have to give permission.

For those of you who still think HIPAA i   all about your medical privacy , think again This is said to be perfectly legal under HIPAA as Google is a "business associate" of Ascension Health Care and the data is available to Google without permission of the patients or their physicians and apparently without the need to even notify patients about it.

A detailed explanation is found in a recent article in WIRED. See here.Actually after the story was published on multiple sources both Google and Ascension made  press releases assuring all concerned that there is absolutely nothing wrong and this arrangement is nothing to worry about and that everything is perfectly compliant with HIPAA

We are told that the arrangement and Google's help is " to optimize health and wellness of the individual and the community"

The story goes that what happens in Vegas stays in Vegas but what you tell your physician in the Ascension Health system goes to the Google  cloud.

With all the errors and fabrications I have personally noted on the EHR medical records of two patients and the very big risk of the  GIGO phenomenon  Google will likely devise some interesting optimizations.

Examples of those errors:

1.One erroneous diagnosis of atrial fibrillation
2.One erroneous diagnosis of hyperthyroidism
3.a diagnosis of osteoporosis which had no basis
4.two complete physical exams "documented in the chart" that never happened
5.one designation of an orthopedic abnormality in the wrong extremity
6.one designation of a  "my"primary care physician who I had never heard of

If the number of errors noted in just two patients is extrapolated to even a small percentage of medical records , you have to  be skeptical about how accurate or  useful would Google mega data magic be?.With a significant amount of garbage in won't we expect a bit of garbage out?

So with the privacy issue and the questionable reliability of HCRs ,the business associate relationship between Google and Ascension has a number of people concerned.

Sunday, November 10, 2019

Could government mandated "quality" programs be bad for your health.

Dr. Paul Hsieh explains how exactly that has happened in his recent commentary in Forbes.
He explains how the Hospital Readmission Reduction Program (HRRP) has backfired and likely caused harm. Another example is the "Never"programs in hospitals.

Certain mishaps including patient fall are deemed "never events" and hospitals are penalized for Medicare patient's falls. This apparently has lead to some hospitals and nurses taking various measures to keep patients in bed to prevent falls.Bed rest in the elderly can quickly lead to weakness and a greater tendency to fall.

This reminds one of the famous 4-hour pneumonia rule,which is a great real life example of  Goodhart's law , i.e. when a measure become a target it looses its value as a measure. The folks at CMS appeared to learn nothing from that debacle.

What may even be worse is that physicians may be intimidated by some thing called the disruptive physician concept into not saying the obvious and calling the emperor naked. I quote from an earlier blog entry:


"The mandatory and quasi mandatory nature of guidelines or quality indicators as wielded by the CMS mandarins and other institutional elites become even more dangerous with the spreading use of the "disruptive physician" doctrine. Not only must you go by the rules you can't complain about them without incurring the wrath of the hospital's disruptive physician committee.This doctrine is a brilliant control mechanism.If you challenge the disruptive physician concept you are by definition disruptive. "






Thursday, November 07, 2019

The developing Vison of Primary Care in the Big Rock candy Mountain

Probably the primary care physicians in training who authored a  commentary in the NEJM describing their view of what primary care should be may will have to google the candy mountain reference in the title or just look here.

KA Barnes,J. Kroening-Roche and BW Comfort wrote a perspective piece in the Sept 6 201212 issue of the NEJM.

In it they describe their vision of primary medical care in the U.S. I will not quote their description of what they hope primary care will be but I will quote a sentence that is the essence of what I believe to be a bogus concept.

"Primary care cannot be primary without the recognition that it is communities that experience health and sickness."

Their description of a typical day a primary care practice can be dismissed as idealistic and naive or wishful thinking as in lemon aid springs of the Big Rock Candy Mountain ( at least to an increasingly curmudgeonly old retired doc) but the quoted sentence expresses a conceptual error.

No, communities do not experience anything;nor do they choose anything nor do they suffer or rejoice. Only sentient beings can do any of those things and communities are an abstraction . Similar terms ( society,the country, etc) can sometimes be useful summary ways of thinking and talking- a useful short hand. To say that a community is ill or well is a figure of speech;to say that Mr. Brown is sick is an empirical fact. Mr.Brown can regret his earlier excessive use of alcohol, but to say the community regrets anything is a category error.

This is not to deny that there are economic factors and social factors that might impact someone's health but to the degree that such things happen they impact the health of individual, real life people not society and not a community.Government programs can improve the health of individuals, with such things as immunization campaigns and providing health care to the indigent.But it is not the community whose health improves it is the individuals who can benefit.

Society or communities are not some super being or entity apart from the individuals who comprise it. To consider that they are or to reify this abstraction lays the foundation for consideration of weighing the value of the individual against this mythical creature and presto we have the new medical ethics.

Reification refers to the treating of an abstraction as if it were a concrete real thing or an actual physical entity.In short turning an idea into a thing and treating it as if the idea posses the attributes of an actual being.

It is the public health paradigm taking over clinical medicine. I hope that when I get older and ill that the physician I consult will realize that I am her patient and not the community in which I reside or the HMO to which I belong.

Sunday, November 03, 2019

More long time followup on his bundle pacing

Dr. Francesco Zanon of Italy and Dr. Pugashendhi  Vijayaramen of the Geisinger Clinic in Pennsylvania report on the long term performance and safety of 884 patients implanted between 2004 and 2016.

The first 368 were implanted using a deflectable delivery system while for  the next 476 patients a fixed curve delivery system was used.There was a significant difference in both the capture threshold and in the complication rate between  the two groups,with the data strongly favoring the fixed curve system.

Complications  were fewer in the fixed curve group (11.9 % and 4.2%) and the capture threshold was lower (2.4 volts versus 1.7 volts)The complication rate difference could at least in part been due to  the learning curve as the fixed curve system was used later.

1) Zanon, F, Long term performance and safety of His Bundle pacing:A multicenter experience.
J.of Cardiovascular Electrophysiology, 2019, July 16







Friday, October 25, 2019

Does your doctor really work for a venture capital firm

Some of the docs who see you in the ER,or read your imaging study, or give you Propofol for an endoscopy may well be the employees of a company that is owned by venture capital companies such as KKR.And if you have been hit by a big surprise medical bill because the ER doc for example is not part of the network your insurance covers it is even more likely .Apparently at least some  medical staffing companies owned by venture capital companies are accused of being heavily into balance billing.The names  Envision and EmCare come to mind.

Dr.Roy Poses had published an excellent report entitled "Who advocates for surprise medical billing?" on this topic on his blog, Health Care Renewal.See here for some eye-opening information.

Emergency room physicians are often supplied by physician staffing firms, such as Envision and EMcare.

 According to the HCR blog commentary these two are said to be  owned by  the global investment firm KKR.However the entry on Wikepedia on EmCare gives a different description of the various buyout and mergers surrounding EMcare not mentioning KKR.In any event we are talking about the corporate practice of medicine which is still not legal (although various states have exemptions of the rule) in some states. EmCare operates in 42 states.Envision, however, was acquired by KKR in 2018 for 9.9 billion.It is more complicated than that as Em Care through a series of buyouts  may have actually become Envison.Whatever may be the history of these company's buyout name changes, the point is that  venture capital companies own corporate entities that in turn supply physicians in various roles- i.e.ER docs,anesthesia services and even ICU doctors.So in the interest of transparency those doctors could have white coats with the logo of KKR.

The wide spread operations of companies such as these does not mean that laws restricting the corporate practice of medicine are no longer enforced  even  though their control of medical practice have greatly decreased..For recent examples of medical practices and non physicians owners getting caught by corporate practice law see here.

The basis of the corporate practice doctrine is usually said to be the conflict between the fiduciary obligation of the corporation to its shareholders to maximize profit  and the fiduciary role of the physician to the patients.

It does not take much imagination to think of situations in which what is good for the corporate bottom line does not correspond to what is good for the patients.






Thursday, October 10, 2019

Aristotle trial,bad data from China,but apixaban probably still better than warfarin

In 2011, the Aristotle trial was published in the NEJM.It demonstrated aprixaban's superiority over warfarin in the treatment of non-valvular atrial fibrillation (AF)- fewer strokes, less bleeding and apparently a decreased over all death rate. But wait. The  FDA did not quickly approve apixaban.

One major problem was questionable  data from a China trial site which included mixed up medication distribution and some possibility of fraudulent data. Critics also noted that  there was no mortality benefit noted in the European cohort and that 35% of the warfarin group did not achieve a therapeutic INR.

After considerable back and forth between the drug companies and the FDA apixaban ( Eliquis) was approved for  treatment of non-valvular AF but not the claim that the overall mortality was reduced.

That should have been the end of it but recently an analysis of a number of meta analyses revealed that the original  Aristotle data ( including  the tainted China  cohort) was included.A number of these MAs claimed a benefit for Apixaban that is said to have  vanished when the questionable data were excluded.

Even with the flawed trial apixaban is preferable to warfarin for non-valvular AF.In the treatment arm, there were fewer strokes driven mainly by fewer hemorrhagic strokes there being only a slight advantage to apixaban in regard to ischemic strokes.Apixaban is safer and dietary and medications interactions much less of a problem than with warfarin and no needed for frequent follow up blood tests.

After Homer quit his job at the Kwik E mart,Abu said:

"He slept,he stole,he was rude to customers.Still there goes the best damned employee a convenience store ever had."




Wednesday, October 02, 2019

RPU-responsible physician unit-possible replacement by "systems"


The following is a re-do of an essay I wrote 14 years ago.


In the March 1, 2005 Annals of Internal Medicine the "Improving Patient Care"section deals with a case in the discussion about which the author emphases the problems associated with lack of follow up by and "hand offs" to physicians.

 A 70 year old man with a history of alcoholism presents with cough and weight loss.His chest xray showed "RUL pneumonia with a dense infiltrate with extensive fibronodular disease and upper lobe volume loss. No tb studies were done and the patient was discharged on antibiotic therapy.Through a series of lapses it is some 2 months later and after the patient was sent to and then sent back from a nursing home before the diagnosis of tb was finally made and treatment started, but apparently too late. He died of respiratory failure shortly thereafter.

The author discusses various methods to ensure followup . He does not mention, however, a well established method of obtaining follow up of lab tests. It is the RPU. This stands for responsible physician unit. The physician caring for the patient is responsible for finding out what were the results of the tests 

The clinical picture and chest film shouted r/o tb ( rule out TB). The narrative of sequential foul-ups is disturbing and the author's comments about the important of systems to ensure that reports are seen by doctors are appropriate. However, the original "fumble" occurred because of the apparent ignorance of the medicine resident ( I assume they were medical residents). While the subsequent events are alarming-and may be mitigated or eliminated by appropriate systems and safeguards- the lack of basic clinical knowledge demonstrated in this case is astonishing.

I cannot believe even a first year resident would not think "rule out tb" when he encounters an alcoholic with cough, weight loss and a upper lobe infiltrate. (the initial radiologist's report displays a equally high level of cluelessness also by not mentioning tb as a diagnostic possibility) Even if the resident was ignorant about tb,where was the attending?Not doing tb tests in this type case is comparable to not doing biomarkers for heart damage in er patients with chest pain.

At the county hospital where I trained that patient's arrival would have lead to the intern, resident and medical student spending the next few hours getting sputum samples and doing AFB stains. Even if the smears were negative the patient would have likely been hospitalized in a contagion unit to rule out tb given the very high "pre-test" probability of tb.

The author speaks of algorithms for this and algorithms for that. What is the nature of the algorithm to prevent house officers from harming patients based on their ignorance? In a earlier - less politically correct era- in regard to the first house office who saw the patient- we would have asked where did he go to med school.