Schwitzer offers a guide to reading health care news stories

Gary Schwitzer, writing in JAMA Internal Medicine -- in an article that has been moved out in front of the paywall --- freely accessible for 6 months -- summarizes the work of a team of reviewers from HealthNewsReview.org who evaluated the reporting by US news organizations on new medical treatments, tests, products, and procedures between 2006 and 2013.  The results:

After reviewing 1889 stories (approximately 43% newspaper articles, 30% wire or news services stories, 15% online pieces [including those by broadcast and magazine companies], and 12% network television stories), the reviewers graded most stories unsatisfactory on 5 of 10 review criteria: costs, benefits, harms, quality of the evidence, and comparison of the new approach with alternatives. Drugs, medical devices, and other interventions were usually portrayed positively; potential harms were minimized, and costs were ignored. 

Here were the standards applied during this seven-year period:

Ten review criteria were used to assess each news story reviewed. The review criteria addressed whether the story (1) adequately discussed the costs of the intervention; (2) adequately quantified the benefits of the intervention; (3) adequately quantified the harms of the intervention; (4) evaluated the quality of the evidence; (5) widened the diagnostic boundaries of illness and promoted public awareness of these widened boundaries, which may expand the market for treatments, a practice that has been termed disease mongering; (6) quoted independent sources and identified the conflicts of interest of sources; (7) compared the new approach with existing alternatives; (8) established the availability of the intervention; (9) established whether the approach was truly novel; and (10) appeared to rely solely or largely on a news release as the source of information.

The one type of mistake that I have seen all too often is described in the article as "the tyranny of the anecdote."  Gary explains: 

Stories may include positive patient anecdotes but omit trial dropouts, adherence problems, patient dissatisfaction, or treatment alternatives. In one example, 4 major US news sources used the same “breakthrough” patient anecdote of one man’s reported improvement from a heart failure stem cell experiment. This example illustrates another common problem: patient anecdotes provided by public relations representatives for medical centers or industry that put an overly positive spin on an intervention. 

How perfectly these stories coincide with the anecdotes used by firms and hospitals in promoting their products or services.  How much more so when the reporter works in a small or medium size community whose hospital has decided to buy into a firm's technology. It becomes quite evident that the journalist is often taken in by the jingoism of the hospital and "finds" the anecdotes that support the joint marketing campaign of the suppplier and the hospital.   Gary suggests that "fawning coverage of new technologies" is the result:

Journalists often do not question the proliferation of expensive technologies, such as proton beam radiation machines and robotic surgical systems. The use of new technologies can increase the costs of medical care but may not improve care.

Gary suggests:

Our findings can help journalists improve their news stories and help physicians and the public better understand the strengths and weaknesses of news media coverage of medical and health topics. 

I hope so. These reporters, often younger men and women on the staff of newspapers, need to understand that their reports can have a substantial impact on the public perception of new medical devices, therapies, and hospitals.  They owe it to the public to be diligent and rigorous in their coverage. Are they up to the task?

A reprise: Is this the free part, or the fair part?

Back in 2009, I wrote a story about an agreement between the Service Employees International Union and a major health care chain in Massachusetts which pretended to offer workers "free and fair elections."  It was nothing of the sort, of course.  In fact, it was a gag agreement that precluded an open debate about the merits of organizing those hospitals.

Five years later, we read this article in Modern Healthcare about a deal between the SEIU and the California Hospital Association.

The partners hailed the accord as a potential model for labor-management relations.

Boy, this must be good and really important.  We read further that the deal creates an organizing “code of conduct.”

The new deal, which was signed Monday night, includes facilities that operate a majority of the state's hospital beds. The hospital association declined to name the hospitals that signed the agreement, which will end Dec. 31, 2017. 

The code of conduct, which will govern organizers' communication with hospital employees, would seek to transform historically tense and negative conduct by unions and employers into more constructive and positive relationships... The partners declined to publicly release the code of conduct.

Wait, so unnamed hospitals signed a code of conduct that is being held confidential.

What a breakthrough for workers and managers! They don't know if their hospital signed the agreement.

What a victory for transparency! A code of conduct that is supposed to govern union-management relations is being kept secret from workers and managers.  Further, nothing was said as to how the code would be adopted or enforced.

So we have to assume that either the whole agreement is a nullity or that it contains elements that would be so abhorrent to workers or managers that the partners are afraid to announce what it says.  We can be confident, though, that it will offer workers "free and fair elections."  Whatever that means.

Partnering with patients on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Partnering with Patients for Safety: The Next Phase of Work and Commitment — will take place on Thursday, May 8, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Tejal K. Gandhi, MD, MPH, CPPS, President, National Patient Safety Foundation and Lucian Leape Institute
• Susan Edgman-Levitan, PA, Executive Director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital
• Maureen Bisognano, President and CEO, Institute for Healthcare Improvement (IHI)
• Linda K. Kenney, Executive Director and President of MITSS (Medically Induced Trauma Support Services, Inc.)

Health care is at a tipping point with respect to patient engagement — from something that’s “nice to do” (or even “the right thing to do”) to something that’s absolutely necessary. Research and experience are making it clear that no health care organization can operate in a reliably safe way without the involvement of patients and families. And without their involvement, any organization’s safety agenda is bound to encounter diminishing returns. Patients and family members offer extra eyes and ears to events unfolding around them, and have crucial knowledge about and perspectives on what kinds of changes will help them the most.

To frame what a vision of patient engagement needs to encompass, and what an across-the-board implementation of that vision needs to embrace, The National Patient Safety Foundation’s Lucian Leape Institute (LLI) has just published a comprehensive report that lays it all out: Safety Is Personal: Partnering with Patients and Families for the Safest Care. The contents of the report and how to make it actionable are our focus on the May 8 WIHI: Partnering with Patients for Safety — The Next Phase of Work and Commitment.

NPSF’s Dr. Tejal Gandhi, IHI’s Maureen Bisognano, Susan Edgman-Levitan, and Linda Kenney will walk us through the report’s recommendations, anchored by some of the latest research on the link between patient engagement and health outcomes; identify barriers that must be overcome; and describe a clear set of responsibilities that need to be owned and shared by health care leaders, clinicians and staff, and policy makers. Patients and families cannot be held responsible for safety, but they can assist at every level with redesigning care and shaping an organization’s safety agenda. WIHI host Madge Kaplan welcomes you to this discussion. Please tune in! ​

I hope you'll join us! You can enroll for the broadcast here.

The medium that delivers the next message

Passing through the airport the other day, I bought a New York Times and the clerk kindly put the newspaper in this plastic bag.  I was appalled later when I saw this advertisement on the bag.

Irony arrived when I took out the newspaper and found this article by Matt Richtel.  The lede:

Electronic cigarettes appear to be safer than ordinary cigarettes for one simple — and simply obvious — reason: people don’t light up and smoke them.

With the e-cigarettes, there is no burning tobacco to produce myriad new chemicals, including some 60 carcinogens.

But new research suggests that, even without a match, some popular e-cigarettes get so hot that they, too, can produce a handful of the carcinogens found in cigarettes and at similar levels.

And later in the article:

[N]ew research suggests how potential health risks are emerging as the multibillion-dollar e-cigarette business rapidly evolves, and how regulators are already struggling to keep pace.

Which sends a stronger message to the young audience targeted by these e-cigarette companies, a sex-laden graphic with a subtext about rebellious behavior, or a thoughtful newspaper story.  Not even close, no?

Goal Play: Closing in on 10,000

I'm extremely pleased to note that cumulative sales of my book Goal Play! Leadership Lessons from the Soccer Field are close to reaching the 10,000 mark.

According to BK Publishers:

The average U.S. nonfiction book is now selling less than 250 copies per year and less than 3,000 copies over its lifetime.  Only 62 of 1,000 business books released in 2009 sold more than 5,000 copies, according to an analysis by the Codex Group (New York Times, March 31, 2010).

One of the great moments in my writing life was when Edgar Schein, author of Helping and many other leadership and management books, offered to write a foreword for Goal Play!

I am delighted that people around the world have found the leadership lessons of Goal Play! to be valuable to them.  If you have not yet had a chance to enjoy the stories from the girls soccer teams I have coached and the adult leadership lessons that emerge from them, I invite you try a copy (paper, ebook, and even audiobook.)  Also, if you know graduating college students or young professionals who might benefit from the book, I'd be honored if you considered it as a gift for them.

I've also been invited to address corporations and institutions around the world on the ideas contained in the book.  You can see this website for some examples.  If I can be part of your company's leadership training program or the like, please contact me at goalplayleadership [at] gmail [dot] com.  Thanks!

Letter from Barro Colorado Island and STRI

For a change of pace, I'm happy to present a short summary of a tour today to Barro Colorado Island, on Panama's Gatun Lake, home of a portion of the Smithsonian Tropical Research Institute (STRI.)  Our guide was Dr. Helene Miller-Landau, a staff scientist with research interests in ecology and evolution.

Under an arrangement with the Panamanian government, STRI manages the island and oversees the research taking place there.  It has been preserved in a natural state for many decades and offers an excellent laboratory to study flora and fauna.  A 50 hectare plot of land has been set aside to permit the complete mapping of virtually all the plants, providing a baseline against which to compare changes during the coming decade.  (Indeed, based on this precedent, several such plots have been established in other countries, and an effort is ongoing to coordinate research programs across these widely divergent sites.)

Beyond spending time with Helene, we had a chance to meet the panoply of scientists on the island.  They included Don Feener, from the University of Utah, who was a long-time resident years ago and stops by now for occasional visits.  His field is social insects, and particularly army ants, and he has been focusing on the variety of parasites that feed on this species.  But what gins up Don as much as the ants is the chance to meet with the young researchers on the island, graduate students and post-docs, who have come to carry out their own portion of the world's extensive study of tropical forest wildlife and plants.

We had a chance to spend time with several of these folks, and their enthusaism and desire to share what they have learned and to learn from one another is infectious.  I pointed out that such a spirit of collaboration and sharing is often missing from the world of medical research in the esteemed halls of academic medical centers and university biology departments.  Helene and others pointed out that the small likelihood of another researcher being able to "steal" a research finding, given the need to be "on the ground," might be one reasons people are more open about their progress and frustrations.  Also, there is more uncertainty in this field as to what direction of research is likely to be successful, so there is not a race to a certain conclusion, as there might be in more established biomedical research.  Whatever the reasons, it was a refreshing change from some places I have frequented.

This is truly a special place, in terms of flora and fauna, as you see from several pictures I've included.  But it is also a special place for the expansion of human knowledge, and it is a tribute to parties in both Panama and the US that it has been allowed to flourish.

Celebration of Women in Healthcare

12th Annual Celebration of Women in Healthcare

Thursday, May 8, 2014

5:00 - 7:30pm

Tufts Health Plan

705 Mount Auburn Street, Watertown

 

Featuring award-winning journalist Robin Young, co-host of Here & Now on WBUR/NPR, who will emcee a “story slam” about compassionate healthcare. Storytellers, who will share their own personal experiences, will include:

• Dianne Anderson, President and CEO, Lawrence General Hospital
• Consuelo Donohue, long-time nursing supervisor at Tufts Medical Center and interim nursing manager of the NICU, and mother of Richard Donohue, Jr., the MBTA officer who was injured in the aftermath of the Boston Marathon bombings
• Sharon McNally, Chief of Staff, Dovetail Health, and Co-Chair, Schwartz Center Leadership Council
• Joyce Murphy, Executive Vice Chancellor, UMass Medical School, and Member, Schwartz Center Leadership Council
• Charlotte Yeh, Chief Medical Officer, AARP Services, Inc

We’ll also be asking one or two audience members to share their stories of compassionate care, so please come prepared!

Ticket Price: $125 per person. Please RSVP by May 5
Corporate and Individual Sponsorship opportunites are available.
Click here to register!

In memoriam: Frank Scarcella

Wicked Local photo by Matthew Healey

Francesco “Frank” Scarsella died this week.  He was a fellow soccer referee in our region.  Here's a good sense of him from the local newspaper a couple of years ago:

If you’ve been to a youth, high school, college or semi-pro soccer game in New England in the last 40 or so years, you’ve probably seen Francesco “Frank” Scarsella out on the pitch.

Although he loves to play, Scarsella is best known among New England soccer fans as the preeminent referee in the state

At 68, Scarsella said he’s not only refereed thousands of games, but he’s probably trained tens of thousands of referees since 1978.

“Sometimes I’ll be out on the field and someone will come up to me and tell me that I was the one who trained him,” he said.

Scarsella emigrated from Italy at age 13 and he says that his love of the game is in his blood.

A friend writes:

Frank was one of those people who impacts other people’s lives in subtle ways.  He worked with my teenage daughter during a tournament as she took her first steps beyond the little cocoon of our town league.  He was supportive and kind, in his own way, to a young referee.  And he always, always retained his sense of humor.  We need more like him.

Another colleague noted:

We can see Frank’s true grit. There is something to be said about living life the way he wanted to. He told me at the time, he was given a five year window, when diagnosed. He exceeded that through fearless force of his will.

Frank trained all of us, regardless of our age.  We'll miss him.

It's working!

We're so excited to be getting feedback on our job negotiation book.  Please consider buying copies for your own college graduate or others you know.  Here are two recent reviews.  The first deals with the gender issues we cover in the book.  The second suggests that the advice we offer is helpful not only to first-timers in the job market, but other young professionals, too:

Take note, Females!
I went to a talk that Paul and Farzana gave at Tufts University School of Medicine a couple of weeks back. I was concerned because as a young student about to graduate grad school, I expressed to them that I was worried about negotiating because I'm young and don't have much experience. They assured me that once I've been offered a job, the company has already decided that they want me. Furthermore, they explained (and the book does too) that as a woman, I must go about the negotiation differently. I won't spoil the book, but I'll just say that I used the methods that the book suggests for women. Long story short, I was able to get my employer up $14k!!! I would recommend this book to anyone, but especially females. Sadly, our world can still be quite sexist. After accepting this sad truth, Paul and Farzana do a great job of describing how to deal with the hand that we, as women, are dealt.

Amazing book!
This book seriously increased my pay significantly, changed my job description to reflect a more senior role, AND enabled me to maintain a respectful and positive relationship with my future employer! This book was a helpful, fast read, and provided several examples and useful language that I was able to incorporate in my negotiations. This is by no means by first job - this book is helpful to anyone and everyone who is looking to create a mutually beneficial relationship with their future employer!

I highly recommend this to any graduating student or working professional.

The book is available on Amazon in paper and ebook form and is also on every other ebook platform.

POTUS is the topic for TT

Here my nomination for today's Throwback Thursday, a post from 2009 on medGadget.  Perhaps it strikes my fancy because of the uptick in health care expenses for the country:

During Barack Obama’s healthcare reform tour, while touting cheaper clinical and technological approaches for medicine, the President got a hands-on experience with the Da Vinci robotic surgical system from Intuitive Surgical. The Cleveland Clinic, perhaps having an odd sense of humor, touted to the President one of the most expensive pieces of equipment used in the OR.

Spring cleaning over at the blogroll

I spent some time cleaning up my blogroll (the list of blogs on the right side of this page.)  I deleted the ones that no longer link to a working website, that have been transformed into commercial enterprises, and that have gone dormant (defined as no posts since January.)  If you see that yours has been taken down in error, please let me know and I'll restore it.

The exception to my rule about inactivity is that I've retained two sites in remembrance of two wonderful women who died from cancer. It makes me happy to go back and read them.

One disturbing trend:  I used to have links to 24 sites that deal with transparency and Lean process improvement.  That has now shrunk to 14, a pretty sizable reduction.  I hope that doesn't reflect the status of either transparency or Lean in the health care world, but maybe it does.

And on a lighter note, check out this post by Freida McFadden on A Cartoon Guide to Becoming a Doctor and see if you can come up with the right answer!  Post it over there, not here!

An unleashed demand for health care services

It slipped by so fast that I almost missed it.  It wasn't, after all, the main point of this news report by NPRs John Ydstie on All Things Considered.  It was on the economy as a whole.  Here's the audio recording.

Listen at minute at 2:57 and hear the story of the one growth area of the economy:

It looks as thought the advent of Obamacare and the provision of insurance to people who previously didn't have it has unleashed demand for health care services that simply wasn't there before.

In fact, spending on health care grew in the first three months of the year at an astonishing annual rate of nearly 10%.

This is no surprise to many of us.  As we saw in Massachusetts when universal access was provided, if you give people health insurance, they will use it.  In fact, at heart, that's why we want to give them insurance.  In the past, people without health insurance would avoid important visits to the doctor, or important visits to the hospital, or important consumption of drugs.

There are some who might argue that the fee-for-service rate design by which many providers get paid accounts for this.  But, no.  There is actually less fee-for-service care than there was in the past, as a number of insurers and providers have moved to more risk-based payment plans.

There are some who might argue that consolidation in the health care industry accounts for upward price pressure.  While that should be a concern over the coming years, I don't believe that it has yet had the full effect that it will.

No, what's happening now is much more simple.  People are going to the doctor sooner when they have symptoms.  Some portion of those people are sick and need more extensive care.  In the past, this group would not have gone to the doctor, and they would not have gotten the extensive care.  Some percentage would have gotten sicker and sicker at home and eventually would have shown up in emergency departments.  Without the full course of treatment they are now getting as insured patients, we would have "saved" a lot of money in treatment. Some, though, would have died prematurely or suffered from extended morbidity.

Others are having regular preventative diagnostic tests, like mammograms.  Early detection of breast cancer results in earlier treatment--radiation, surgery, chemotherapy--adding to the nation's health care bill.  (We saw this in Massachusetts.)  In the past, their disease would not have been noticed until it was too late, again "saving" a lot of money in treatment.

The human cost under the old regime was unconscionable, and we have done the correct thing to give people access to insurance and care.  The dollar cost, though, had to increase.

The problem here is not the result.  The problem was that the Administration, as part of its political strategy to get the legislation passed, glossed over this fact.  In fact, the promise was that access to insurance would be paired with lower costs.  The Administration's plan, all along, was that these costs would be covered by the imposition of a value-added tax.  But the political environment has changed, and the chance of such a tax is very low.  So the tension between access and costs will grow.  Over time, choices will be made.

In the short run, the solution imposed will be to charge consumers directly for a greater portion of their health care costs, with high deductible health plans (HDHPs).  This direction creates important issues and can interfere with our achievement of several of the Institute of Medicine's six aims of care--safe, effective, patient-centered, timely, efficient and equitable.  As the American Academy of Pediatrics notes in this policy statement:

Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.

Letting ideological purity stand in the way of common sense

Health care policy is rife with fads, unsupported and analytically flawed approaches to try to influence the way care is delivered with simple--but wrong--metrics used to determine unwarranted penalties.

There, I've said it.  But please don't put me as an ally of nay-saying doctors and hospitals who really don't want to improve the quality of care.  I've been devoting many years to advocating for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.

The problem is that poorly thought through interventions of government policy not only fail to improve care, but they raise levels of resentment and cynicism among the people we need to engage in making changes in the system.  Those interventions also have harmful unintended consequences.

The latest validation of the dangers of wrong-headed thinking is summarized in Robert Pear's article in the New York Times.  The lede:

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.

More:

The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

“Factors far outside the control of a doctor or hospital — patients’ income, housing, education, even race — can significantly affect patient health, health care and providers’ performance scores,” said Dr. Christine K. Cassel, the president of the organization.

Sorry, but this isn't news.  Here's a related point noted by anyone who was paying attention three years ago: 

Karen E. Joynt and Ashish K. Jha from Brigham and Women's Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, "Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives." Excerpts:

Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001). 

Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

Look though, at the response of the Administration, as reported by Mr. Pear:

The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. 

The Obama administration has championed the idea of pay for performance, with financial penalties for hospitals where deaths, readmissions or complications occur at rates above the national averages. The administration has said adjusting the data for social or demographic factors would be equivalent to accepting a double standard, with lower expectations for the care provided to low-income patients.

“We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Sorry, but this is the response of a government that has let ideological purity stand in the way of common sense.  The issue is not about rewarding lower levels of care to poor patients.  It is about not penalizing hospitals that care for poor patients.

Sometimes, it really stinks

Doug Wojcieszak's passion is to get hospitals and doctors to see the value of apology and to have them make it part of their standard of care.  He often tells positive stories about places that have done this well, but every now and then he has a story that makes you cringe.

Here's the latest example of the latter. Lest you have a doubt about Doug's feelings, he titled it "Hospital’s PR Weasel Words After Tech’s Lies."  After I read the story, I felt that he might have been too kind in his choice of words.  An excerpt:
 

In summary, Perry Hospital technician Rachael Rapraeger lied about the results from over 1,200 mammograms.  In her plea deal with a criminal court, Ms. Rapraeger said she got behind in her work and created negative readings for over 1,200 mammograms….mammograms that were never reviewed by physicians.  Patients were lied to.  Ten patients actually had positive readings, and two have since died.   Ms. Rapraeger apologized for her conduct and was sentenced to six months in jail, 9.5 years of probation, a $12,500 fine, and is banned from the healthcare profession for 10 years.

Perry Hospital is currently facing 30 lawsuits from Ms. Rapraeger’s actions, and the hospital issued the following statement after her plea deal: “We are pleased this component of Ms. Rapraeger’s unfortunate action is concluded.”

Doug notes:

I am sure some PR person with the help of a gaggle of lawyers wordsmithed this doozy, and it really stinks.

Just right, Doug.  Thanks for your dedication to this cause.

CLER progress?

The ACGME, the body that certifies US residency training programs, notes:

As a component of its next accreditation system, the ACGME has established the CLER program to assess the graduate medical education (GME) learning environment of each sponsoring institution and its participating sites. CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements. The intent of CLER is “to generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation.”

One requirement of the program is supposed to include "opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care."

I've been looking for a "cler" presentation of the results of the site visits on this matter, but I can't find anything on the ACGME website or elsewhere.  According to this document, the ACGME has accredited 9516 programs in 2013-14, covering 121,778 full-time residents.  The page that indicates which programs are on probation (unfavorable status), shows the number to be 39, but it does not list the reasons.

Here are my questions. I know from personal visits and discussions with residents that many hospitals do not satisfy the requirement cited above. Have any of these programs been put on probation?  Whether on probation or not, will the names of hospitals that fail this test be made public?

If a patient-safety-oriented medical student applying for the residency match program wanted to know which hospitals do not satisfy this requirement, how could he or she find out?

Finally, I wonder if the CMS payments to hospitals for residency training should be based in some way on the extent to which core requirements and competencies are met, rather than the current fixed number of dollars per student?  (See the past part of this article by David Mayer on this topic.)

Women Leading

Last year around this time, I had the pleasure to tell you about a new book, The Orange Line, A Woman's Guide to Integrating Career, Family and Life, by Jodi Detjen, Michelle Waters, and Kelly Watson.  Now Jodi is offering a special three-day master class called "Women Leading" at Suffolk University on May 15-17 from 8:30AM to 4:30PM. Here's the description:

Take your career to the next level and become a key leader and influencer. This three-day course will teach you how to integrate your life and remove the self-imposed barriers that prevent success.
In small classes capped at 20, you’ll work in an intimate, team-building setting and develop lasting connections with your peers. 

As part of the course, you'll receive a copy of the book: The Orange Line™ - A Women’s Guide to Integrating Career, Family and Life, which was written by Professor Jodi Detjen. The book will help guide conversations about the work-life balance among women.

At the end of the course, you’ll have an over-the-phone coaching session in small groups. Professor Detjen will lead a discussion about achieving your goals, overcoming challenges, evaluating the 360 analysis, and adapting your plans for the future.

You’ll emerge from this course with a clearer understanding of yourself, including your leadership vision and values. You’ll learn how to negotiate, navigate difficult conversations, build lasting relationships, and much more.    

Register:            RSVP

Contact:             Mia Levitt, Program Manager, Center for Executive Education: mlevitt [at] suffolk [dot] edu

I want my money back

Like many people, I have been following the saga of the failed state health care exchanges, Massachusetts being one.  But a sentence in today's New York Times article about the Oregon exchange took my breath away:

Oregon has received $305 million in federal grants to build its exchange, according to the Congressional Research Service.

The Census Bureau reports the number of households in Oregon as 1.5 million. So we (yes, we) have spent about $300 per family to produce nothing.

As we look at that CRS report, we see that Massachusetts got $170 million for the same purpose and couldn't get its act together.  Hawaii, $205 million.  Maryland, $171 million.  And, in addition, according to the Pioneer Institute report, "Failure at the Connector will cost Massachusetts taxpayers over $100 million dollars this year" because 160,000 Massachusetts residents are on temporary public Medicaid coverage even though they don't qualify for MassHealth.

On Oregon, the Times reports:

[I]n February, the federal government delivered a devastating critique of the Oregon exchange, saying it had “no integrated project schedule” and no “overarching dedicated project manager” to keep work on track. Moreover, it said, the state did far too little to supervise its main information technology contractor, Oracle.

I strongly support the goals and purposes of the Accountable Care Act, but this level of managerial incompetence is breathtaking.  Shouldn't we as federal taxpayers ask for the failed states to return the US grants they received?  Perhaps, then, the states will have an incentive to recover the spent funds from the contractors they hired.

Acetaminophen Caution and Guidance

We often take Tylenol pills or other acetominophen products (like some night time cold remedies) without thinking of them as drugs with possible harmful side effects.  An article in Medscape by Charles Argoff, entitled "Acetaminophen Caution and Guidance," reminds us to be careful. He says doctors should advise patients to read the labels of the prescription and over-the-counter medications so that they do not take multiple acetaminophen-containing products at the same time. Also, they should advise patients not to drink alcohol while taking acetaminophen-containing products. Excerpts:

Between 1998 and 2003, acetaminophen was the leading cause of acute liver failure in the United States, with 48% of these acetaminophen-related cases of liver failure being associated with accidental overdoses. Summarizing data from 3 different surveillance systems, there were an estimated 56,000 emergency department visits, 26,000 hospitalizations, and 458 deaths related to acetaminophen-associated overdoses per year from 1990 through 1998. A study from 22 medical centers in the United States that was completed in 2003 and was confirmed in a separate study in 2007, demonstrated that a high percentage of instances of liver injury due to acetaminophen were related to unintentional overdoses. In other words, the patient took too much by mistake.

On January 14, 2014, the FDA recommended that healthcare professionals discontinue prescribing and dispensing prescription combination drug products that contain more than 325 mg of acetaminophen per tablet, capsule, or other dosing form. Even before that, in 2011 the FDA had asked manufacturers of prescription combination drug products containing acetaminophen to limit the amount of acetaminophen to no more than 325 mg in each tablet, capsule, or other dosing method by January 14, 2014.

In this particular directive, the FDA noted that severe liver injury with acetaminophen had occurred in patients who took more than the prescribed dose of an acetaminophen-containing product within a 24-hour period, took more than 1 acetaminophen-containing product at the same time, and/or who drank alcohol while taking acetaminophen products. While noting also that acetaminophen is widely used in many over-the-counter products, including over-the-counter cold products, the FDA directive did not provide any regulatory action regarding these particular products. The FDA did advise that many consumers are often unaware that many products contain acetaminophen, and, therefore, consumers could easily take too much by accident. But no actions were taken in regard to over-the-counter products.

GRACE: It all started by asking why, five times

Back in 2010, I reported on a protocol developed by Dr. Melissa Mattison and others called GRACE (Global Risk Assessment and Careplan for Elders). As noted then, this program was designed to improve the care of all hospitalized elders, with the hope of reducing the risk of delirium, falls, pressure ulcers, functional decline, etc.

But let's go back to the genesis of GRACE, when the staff wondered what might be the cause of many of the falls experienced by older patients.  As I noted in 2009:

Our review process often indicated that the staff had done just the right things with regard to fall prevention and supervision of patients. Using the "5 Why" process of Lean, they kept digging into the cause of these falls. A hypothesis emerged: Perhaps we were contributing to the likelihood of falls by over-medicating geriatric patients or missing important parts of their supervision and therefore causing them or allowing them to be disoriented.

The GRACE protocol was the result of this root cause analysis.  I'm now happy to provide a progress report, in the form of an article in the Journal of the American Geriatric Society. The program has been shown to make a difference.  Here are some excerpts.

Recognizing that older adults have specific care needs that are distinct from the needs of younger adults, a group of geriatricians, hospitalists, and nurses designed a supplemental checklist to accompany the standard bedside monitoring form.

Specifically, the bundle provides staff with a bedside checklist for individuals aged 80 and older admitted to the hospital and decision support in the CPOE system. The bedside check-
list prompts staff to screen for delirium and to implement delirium prevention and management strategies. The CPOE system provides decision support for antipsychotic and opioid analgesic ordering.

There were four main components of the intervention that were critical to its success. First, the intervention was targeted to a population likely to benefit from the intervention and that staff and the CPOE system are likely to identify easily. Units where individuals were already receiving specialized care plans (e.g., intensive care units, inpatient psychiatry) were excluded. Second, the decision support required for success of the intervention was carefully designed for this target population. Third, outcomes focused on critical intervention components were predetermined and monitored. Finally, throughout the intervention, educational curricula were created and offered to staff across clinical disciplines—including nursing, physician staff, and residents.

The findings indicate that the intervention improved prescribing of sedating medications—participants were significantly less likely to be prescribed haloperidol in excess of 0.5 mg or intravenous morphine in excess of 2 mg. There were more triggers for acute change in mental status, but this was seen in individuals receiving the intervention and in the concurrent controls. Significantly more individuals receiving the intervention were discharged to home than to ECFs [extended care facilities] than would have been expected, suggesting less in-hospital functional decline.

Tensions and Tempers on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Transforming Tensions and Tempers on Health Care Teams — will take place on Thursday, April 24, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Neil Baker, Principal, Neil Baker Consulting and Coaching
• Nan Cochran, MD, President, American Academy on Communication in Health Care (AACH); Director, On Doctoring
• Calvin Chou, MD, PhD, FAACH, Professor of Clinical Medicine, UCSF; Vice President for External Education, AACH

The last thing a patient needs to experience at a hospital or a clinic is tensions between staff members. Yet, we've all been there and seen and heard things that make us wonder “who isn’t getting along with whom” or, worse, are we getting the best care when we can tell providers are just barely disguising their frustrations with one another? It's a fair question, especially since health care is being redesigned at all levels to be more of a team effort. Doesn't that mean that the team has to be cohesive and everyone needs to get along?

We're going to get into this important issue on the April 24 WIHI: Transforming Tensions and Tempers on Health Care Teams. The topic couldn’t be timelier, and we’ve brought together an expert group that spoke to a packed room about managing conflict on health care teams at IHI’s National Forum in December.

Neil Baker is familiar to many of you as an IHI faculty member who’s spent the past 30 years helping organizations and professionals better deal with the “people issues” that can not only stall improvement work but also jeopardize patient safety. Nan Cochran wears a lot of hats, including being President of the American Academy on Communication in Healthcare. Dr. Cochran does a lot of training in conflict management and negotiation, which we’ll tap into on the April 24 WIHI.

Calvin Chou at UCSF rounds out our panel. His work focuses on teaching medical students and residents humanistic clinical skills that are critical to communicating more effectively with patients. Some of these same skills can help health care teams better appreciate their differences and avoid overreacting to one another, to the detriment of the team and patients.

What are you and your colleagues learning about building rapport and resolving tensions? I hope you’ll tune into the April 24 WIHI to share your experiences, learn from our experts, and bring members of your health care team with you. And, if you sometimes wonder what’s behind some of the difficult behaviors on teams, here’s some interesting additional reading. See you on April 24!

I hope you'll join us! You can enroll for the broadcast here.

The slippery slope between academia and pharma

I want to be very careful about how I present the following information, as I mean to suggest no improper or illegal behavior on the part of any individual.  Instead, consistent with my previous columns on these matters, I mean to suggest that it is a slippery slope when people in academic medical centers join the boards of directors of pharmaceutical companies. The issue is not their honesty or expertise.  The issue is that we lose the expertise of key people in helping us resolve thorny public policy debates.  A further issue is that, in serving two masters, they contribute to the erosion of public confidence in the research and clinical activities of the health care sector.

We start with a story by Andrew Pollack in the New York Times.  The lede:

Record sales of a new hepatitis C drug pushed the first-quarter earnings of Gilead Sciences far beyond expectations, the company reported on Tuesday, but could also heighten concerns about the high cost of the drug, known as Sovaldi, and the ability of the health care system to pay for it.

He explains:

The rapid uptake of Sovaldi to some degree reflects pent-up demand, as many patients were holding off treatment until it was approved in December. The drug, a pill taken once a day, has a higher cure rate, a shorter duration of treatment and fewer side effects than previous treatments.

But Sovaldi, which has a list price of $1,000 per pill, or $84,000 for a typical course of treatment, has become a flash point in a debate over drug prices.

Paying for Sovaldi for all the patients who need it could put financial strain on insurers, state Medicaid programs, the Department of Veterans Affairs and prison systems. UnitedHealth Group, one of the largest insurers, said last week that its first-quarter earnings had declined in part because it had spent more than $100 million on hepatitis C treatments, including Sovaldi, far more than it expected.

Some doctors say there is a benefit to treating even early stages of the disease, to prevent scarring of the liver.

“If cost were not a factor, we would want to treat the entire population,” said Dr. Rena Fox, a professor of medicine at the University of California, San Francisco. She said it was frustrating that “we finally get this great treatment and then we withhold it.”

Now, let's look at the membership of the Gilead Board of Directors.  It is not atypical in including luminaries from many fields, and among the group is Professor Richard Whitley, from the University of Alabama at Birmingham. His compensation from Gilead has been reported as $425,000.  A truly impressive physician, Dr. Whitley is:

Distinguished Professor of Pediatrics, Professor of Microbiology, Medicine and Neurosurgery; Loeb Eminent Scholar Chair in Pediatrics; Co-Director, Division of Pediatric Infectious Diseases; Vice-Chair, Department of Pediatrics; Senior Scientist, Department of Gene Therapy; Scientist, Cancer Research and Training Center; Faculty, Gene Therapy Center; Associate Director for Drug Discovery and Development and Senior Leader, Pediatric Oncology Program, Comprehensive Cancer Center; Director, UAB Center for Emerging Drug Discovery; Co-Founder and Co-Director, Alabama Drug Discovery Alliance. 

He is also "responsible for the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group whose role is to perform clinical trials of antiviral therapies directed against medically important viral diseases of children and adults including viruses considered as threats to human health." 

A more detailed description follows:

Through the NIAID-CASG we perform clinical trials of antiviral therapies directed against medically important viral diseases of children and adults. These include studies of neonatal herpes simplex virus infection, herpes simplex encephalitis, herpes zoster, enteroviral infections of the newborn, therapeutic interventions for congenital cytomegalovirus infections, hepatitis C, and respiratory virus diseases in the immunocompromised host. Work in these areas includes protocol design, assessment of efficacy and toxicity endpoints, application of contemporary clinical trial methodology and monitoring principals, and evaluation of biologic specimens obtained from volunteers in these studies.  [Emphasis added.]

According to this report, Dr. Whitley is an Editor of Antiviral Research, and is a member of the Editorial Boards of the Journal of Infectious Diseases, Sexually Transmitted Diseases, Reviews in Medical Virology, Antimicrobial Agents and Chemotherapy, Antiviral Chemistry and Chemotherapy, Infectious Diseases Watch for Pediatricians, Seminars in Pediatric Infectious Diseases, Gene Therapy, and Medscape Infectious Disease.

As we view all of this, we can only imagine the extent of Dr. Whitley's personal commitment to eradicating disease.  This is truly an outstanding record.  I'd bet, too, that he would strongly support expanded access to Sovaldi for humanitarian reasons.  But in all the searches I have done, I can find no public statements from him concerning the financial issue raised in Andrew Pollack's story.  Indeed, it would be very difficult for someone on the Gilead board to make a statement about such matters, as it would be viewed as inconsistent with the duty of loyalty and care required of corporate directors.

I note that Gilead has made the drug available at a dramatically lower cost in some other countries in the world.  As reported here,

The company’s reduced prices came after the World Health Organization worked with Gilead directly to help spread the drug's usage. So what determines who gets a discount and who doesn't? It's simple. Gilead admits their “global pricing model is based on a country’s ability to pay.”

As for the $1,000 a day American price for the extremely effective (and life-saving) medication, Gilead is holding firm that they “think the price is fair. It’s a one-time cost that is your lifetime cost.”

So, there we have the nub of the issue. An extremely respected scientist with Dr. Whitley's credentials could be among the most qualified in society to "referee" this kind of issue--to help us understand and balance the legitimate financial needs of the pharmaceutical industry with the equally important humanitarian concerns about a drug's availability and cost in America.  He cannot do so while on the board of the company producing the drug. The loss to society is that someone of Dr. Whitley's expertise and compassion is taken out of the public debate on these matters.

Beyond that, what does his silence on this issue say to the country about his duty to two masters, a federally subsidized drug research effort and a pharmaceutical company? What message does that send to the public about how they should view the relationships between academic medical centers and industry? I think it doesn't help either sector retain the public's confidence.

Distinguished Professor, Loeb Scholar Chair in Pediatrics, Professor of Pediatrics, Microbiology, Medicine, and Neurosurgery, University of Alabama at Birmingham - See more at: http://www.gilead.com/about/leadership/board-of-directors#sthash.f1uR5D5k.dpuf

Distinguished Professor, Loeb Scholar Chair in Pediatrics, Professor of Pediatrics, Microbiology, Medicine, and Neurosurgery, University of Alabama at Birmingham - See more at: http://www.gilead.com/about/leadership/board-of-directors#sthash.f1uR5D5k.dpuf

Distinguished Professor, Loeb Scholar Chair in Pediatrics, Professor of Pediatrics, Microbiology, Medicine, and Neurosurgery, University of Alabama at Birmingham - See more at: http://www.gilead.com/about/leadership/board-of-directors#sthash.f1uR5D5k.dpuf

Texting while "driving" in the OR

We all know we shouldn't text while driving, right? Because if you are going 30 miles per hour, your car has gone 44 feet for every second you are looking down at your iPhone. Bad things can happen even at that speed.  At 60mph, you go 88 feet per second.  Imagine how much damage you can do in that situation.  But remember the guy who said, "I only text on the highway"?

Well, now comes a new set of "drivers," doctors who text or otherwise use their electronic message devices while in the operating room. They are equally irresponsible.  Check out this article by Rebecca Buckwalter-Poza on Pacific*Standard. Excerpts:

In one ongoing malpractice case in Texas over the death of a 61-year-old woman following a low-risk cardiac procedure, attorneys for her family discovered that the anesthesiologist charged with administering anesthesia and monitoring the patient’s vital signs had been on his iPad throughout the operation. In his deposition, the surgeon testified that the anesthesiologist didn’t even notice the patient’s dangerously low blood-oxygen levels until “15 or 20 minutes” after she “turned blue.”

The anesthesiologist admitted to texting, accessing websites, and reading ebooks during procedures. He claimed, though, that “even when I’m doing so, I’m always listening to the pulse ox, always checking the blood pressure, always—you know, at least every five minutes.” It seemed lost on him that five minutes is an eternity in medicine: The brain begins to die after just a few minutes without oxygen.

While throughout the 1980s, most programs banned residents from so much as studying in operating rooms or on the ward, doctors now routinely do far more distracting things in these same settings, with no possible medical justification—from tweeting to texting to posting on Facebook.  

The term “distracted doctoring” doesn’t seem adequate to describe the phenomenon of health care providers who habitually use electronic devices for non-medical purposes during appointments and procedures. These doctors, nurses, and technicians aren’t momentarily distracted: They’re deciding to interact with Facebook friends or Twitter followers instead of the patient in front of them.

Perhaps hospitals should do what our local transit system does:  They prohibit even possession of cell phones by transit drivers while in buses and rapid transit vehicles.  Because if you have it, you will use it.