Featured Post

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 ...

Tuesday, January 28, 2020

How Will "medicare for alll" be like the military industrial complex?

The following quotes are from the blog "on health care technology" written by Margalit Gur-Arie:



"Go ask Northrup Grumman or Lockheed Martin or General Dynamics or even Boeing or Booz Allen or any other “beltway bandit” how getting money from the Feds really works. There are well-greased revolving doors between the Pentagon and its contractors. There are stock options and executive positions for high ranking Federal employees. There are 535 people in Congress responsible for allocating budgets, and all 535 are for sale. Most of this infrastructure is already in place for health care too and building the HHS Heptagon shouldn’t take very long. The American President has little to no power over Federal spending, and even less so when it comes to large procurement contracts, as the current occupant of the White House discovered the hard way, during the Lockheed F-35 kerfuffle....


Clearly large health systems will survive and thrive under a Medicare For All law, but how about private health insurance? Future President Bernie says they will all be banned. Is that so? Currently a full third of Medicare beneficiaries are insured and “managed” by a handful of large private health insurers. Medicare is paying those private contractors fixed amounts of money per head for their services. Medicaid is doing the same for most of its beneficiaries, and all military health insurance (TRICARE) is contracted out to the usual suspects. Basically, the vast majority of people covered by public insurance, are really insured by gigantic insurance corporations. Fact: under the hood, taxpayer funded health care is the bread and butter of private health insurance companies."

So her analysis suggests very little difference at all.

The well known revolving door in regard to government and the defense industry is paralleled by the what goes on in the health care and pharmaceutical industry.See here 

Monday, December 16, 2019

Important changes happening(and happened) in Med School Education what is it about?

Drs. Accad and Koka  discuss  major changes in Medical school education with Dr. Stanley Goldfarb.See here for the podcast.

Are the changes in the medical school curriculum designed to develop social and political advocates rather than well trained physicians?Dr. Goldfarb argues that it is.

The changes are all about population medicine,some thing I have blogged about often before see here.

Courses about climate and medical conditions are already on the curriculum of several medical schools ( see here ).One school mentioned in the linked article actually giving instructions on how to write op-eds about climate change supply a concrete example of Goldfarb's argument.Classes on
environmental justice are also appearing on the schedule.

The degree to which a progressive view point is often part of primary,high school and college education should make it no surprise that med school students are actually requesting courses
in social and environmental justice.



Friday, December 13, 2019

Should journals always report fragility index on a clinical trial.

Interesting article in December 2019 Circulation.(See here.) that discusses the "robustness" of a number of cardiovascular disease trials.

A  purported measure of robustness is the Fragility Index (FI) which is the number needed to move from the non-event group to the event group to turn a statistically significant finding into a non-significant event. A FI of 1 would mean that if one subject was moved from the event to the non event group there would no longer be a significant  difference.

A related concept is  the comparison of the FI to the number of subjects lost to follow up. The trial's results would be considered less robust if the number lost is greater than the FI.

Ridgeon et published a review of 56 RCTs in critical care treatment topics.The median FI was 2 and slightly greater that 40% of trials had a FI of one or less.So does that suggest that clinical guidelines based entirely or in part on those low FI studies are built on shifting sands?


But wait, listen to this criticism of the concept of FI by Dr. F.Perry Wilson before rushing to trash a RCT simply because the FI is too low. Wilson shifts the problem to one of having too much reliance on the p value in the first place.



1)Ridgean EE et al Crit. Care Med 2016,vol 44 ,1278

Thursday, December 05, 2019

What could possibly go wrong when legislators think they know how to practice medicine

Here is another item from the file labelled "I'm so glad I don't practice medicine any longer"

A proposed bill from the Ohio legislature breaks new ground in the land of the  ignorant and absurd.

It would require a physician to transplant an embryo from the fallopian tubes to the uterus of the mother or face a charge of capital "abortion murder".See here

Friday, November 29, 2019

State legislatures act to increase collateral damage in the opioid epidemic war


This Thanksgiving I am particularly thankful that I am not a practicing physician any longer and
no one in my family suffers from chronic pain.

Several state legislatures have passed legislation that mandate chronic pain patients sign adhesion "contracts" and agree to periodic urine tests and a drug test prior to obtaining their first prescription for an opioid .I do not know if there are any penalties for physicians who do not comply with the law.

Here are details of the Pennsylvania law known as Opioid patients Prescription Agreement Act.It requires in order for a patient to get a prescription for an opioid for chronic pain they must sign an agreement  and consent to an initial urine drug test and then periodic tests.Credit is due to
the Pennsylvania Medical Society for their opposition to this ill advised law

Treating patients like criminals or potential criminals will do little to stem the opioid epidemic but is bad news of physicians,patients,dentists and pharmacists.

This recently enacted,effective immediately, Pennsylvania law is a poster child for an act of legislation that will make chronic pain patients lives even more miserable,doctor's practices more difficult and will decrease the number of opioid deaths not at all. To force patients to do periodic urine drug tests is to not even pretend to act for the welfare of the patient sacrificing it to some nebulous, hypothetical goal of decreasing the diversion of unused prescription drugs.(the idea here apparently being that if the patients tests negative for drugs that they may well be selling their medications) .

In an earlier era physicians would likely be pleased when their patient with chronic pain used less pain medicine- now they are expected and perhaps legally obliged to consider their patient might be involved in criminal activity.

 That is so different from the comment,traditionally attributed to
Maimonides

"May I never see in the patients anything but a fellow creature in pain"



What does a physician do if a chronic pain patient tests negative which raises the possibility of the patients diverting the pills.Is the physician obligated to investigate or call the police or the DEA? What if he doesn't?

Probably it is best to not have chest surgery or shoulder surgery or a Pacemaker implantation in Kentucky, Tenn. or Fla. as the legislatures in those states have mandated that a initial opioid prescription be limited to a 3 or 4 days supply.(1) Who would know better how to practice medicine  than the democratically elected officials ?Managing chronic medical conditions must be thought to be too important to be left in the hands of the patients and their physicians.


Dr.Jeffery A. Singer,surgeon and Cato fellow, has been studying and speaking out about  the harm done by the war on drugs for years and is worth quoting:

"Evidence continues to mount that curtailing prescription opioid use serves divert nonprescription use to heroin....most opioid users initiate drug use for non medical reason."

In short, the opioid problem is not because of the way physicians treat pain and limiting the access of patients with pain to pain relief will only make the "epidemic" worse.We have the wrong diagnosis and the wrong treatment.

1)National Conference of State Legislators. Prescribing Policies: States Confront Opioid Overdose Epidemic. NCSL website. http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx. Published October 31, 2018

Saturday, November 16, 2019

is Google being a "business associate" of Ascension Health Care something to worry about

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 is   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. "