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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, 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

"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. "

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 2012 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 could 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