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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 ...

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.