Posted on | November 27, 2014 | No Comments
Last evening, the night before Thanksgiving Day, I went to sleep shaking my head. I had just watched the 1974 documentary, “Hearts and Minds”, which documented the behaviors of five American presidents from Eisenhower to Nixon, as they distorted the truth and led our country into a disastrous war.
Of the many images that refused to disappear as I drifted off to sleep, there were two, juxtaposed that were front and foremost. The first was a distraught and weeping 8 year old Vietnamese boy, holding a picture of his handsome father, as he refused to let go of his flag-draped father’s coffin being lowered into the ground. His full fledged grief, his defiance, his honest and human reaction to the shock and inhumanity of it all, reminded me of my own four children at this age. In his grief, he expressed love and honored his father’s memory forever.
The image was then starkly followed by a matter of fact interview, again in 1974, of the seersucker suit draped William Westmoreland who explained that “Well, the Oriental doesn’t put the same high price on life as the Westerner. And as the philosophy of the Orient expresses it, life is not important.”
Thinking of him and those years again, which in many ways I’d sooner forget, and realizing that to some extent, we have managed to repeat our mistakes, and embrace the same types of biases, in our actions in Iraq and Afghanistan, well, you can understand why I sighed a bit for the human race last evening.
But this morning, I came across Coral Davenport’s report in the New York Times, which seemed sent to deliver a Thanksgiving message that said, “Yes, but…” It make me offer thanks to Presidents Nixon, Bush(41), and Obama. And here’s why.
1. In 1970, the Senate passed the Clean Air Act 73-0, and President Nixon, who had created the EPA, signed the bill into law. This landmark legislation was intentionally writ large to allow the head of the EPA broad latitude in addressing future needs.
2. In 1990, another Republican president, George Bush, signed legislation that further strengthened the law after 89 senators, including Mitch McConnell supported the changes. Of this action, our new incoming Majority Leader, who has recently decried actions of the EPA as attempts to destroy “Big Coal”, has stated, “I had to choose between cleaner air and the status quo. I chose cleaner air.” President Bush’s action allowed the EPA to first begin to measure levels of ozone and mercury in our air.
3. Finally, faced with an inability to sign on to any new legislation, President Obama has made the most of the gifts that his two predecessors have provided him, and focused on mining the full potential of that far reaching, now nearly half-century old act. Most notably, it has become the leading edge of an attack on global warming. It’s chief instruments? Significant tightening of standards on coal-fired power plants to take effect next year and a new fuel-economy standard of 54.5 miles per gallon on automobiles by the year 2025. This last step alone helps explain why hybrid and electric technology is on a tear, and why Canadian tar sand and cross-territorial pipelines are really so “old school”.
So this Thanksgiving, I choose to see the world for what it is, endless shades of grey, imperfect, and yet hopeful. And I thank Presidents Nixon, and Bush, and Obama, for these wise actions, and for the good they continue to provide for each of us, wherever we are, and for our planetary patient.
Posted on | November 21, 2014 | 1 Comment
Parent Alert: Baby products giant Graco has recalled 5 million strollers like those above after babies have lost fingertips in the framing. To check whether your stroller is safe, contact Graco Children’s Products at (800) 345-4109 or online at gracobaby.com.
Posted on | November 19, 2014 | No Comments
Thanks to Consumer Reports, most Americans are at least somewhat aware that there are issues with rice – specifically arsenic. Their initial report from 2012 has just been updated with a 2014 Report with hundreds of measurements and testing of alternate grains as well. What do you need to know?
Arsenic is a naturally occurring toxic metallic element found in soil and water. In large enough concentrations in its’ inorganic form, it’s a proven carcinogenic substance. Arsenic concentrates differently in varied plants. One of the foods that concentrates arsenic at the highest levels is rice. The use of “arsenic-based pesticides, drugs and rice byproducts in agricultural production” has artificially elevated the concentration of arsenic in food and water in parts of the U.S. This, in turn, has continued to elevate arsenic levels in rice plants from some areas of our country. Brown rice, which naturally retains the grains outer sheath covering and has nutritional advantages compared to white rice, is higher in arsenic than white rice which has had the sheath removed. This is because the outer coverings of rice absorb arsenic at the highest levels. Rice is not only a popular food for adults in America but also extensively used in processed baby cereals, crackers and rice cakes, and as a milk alternative in childhood beverages. Babies and young children are especially vulnerable to arsenic.
1. “Children (up to 70 pounds) should rarely eat hot rice cereals or rice pastas. Those products all had some of the highest measured levels of total inorganic arsenic.” According to Consumer Reports: “The FDA should immediately address the risk for children consuming rice and commonly consumed rice-based foods, including rice cereals, pastas, and beverages, by setting standards for inorganic arsenic in those food.”
2. “Rice labeled as from the U.S. or from Arkansas, Louisiana, or Texas …has the highest levels of total inorganic arsenic compared with rice from elsewhere.” This contrasts with rice from California which generally has much lower levels of arsenic.
3. Brown rice has higher levels than white rice, but also some nutritional advantages. Specifically, brown Basmati rice from California, India and Pakistan, and sushi rice from the U.S. had the lowest levels of arsenic of all varieties tested. Amaranth, millet, and quinoa are also safer alternatives.
In lieu of FDA action, Consumer Reports has created a point system to help guide consumer choice and behavior. Each product was assigned a number of points with differentiation of children and adults. Over a course of one week, CR recommends that neither child nor adult exceed 7 points.
The Full Report is available HERE.
For Health Commentary, I’m Mike Magee.
Posted on | November 13, 2014 | No Comments
The New England Journal of Medicine asks this week, “Where is the Surgeon General?”
In their words: “As an unchecked Ebola epidemic moves out of West Africa to touch the United States and the rest of the world, we should rightfully ask, ‘Where is the Surgeon General?’ The answer is, quite simply, that we do not have one. We face a growing crisis of confidence in our ability to protect patients and health care workers, and the position of the chief public health officer of the United States remains unfilled. How did this happen?”
In 2007, Health Commentary asked , “Do Americans know there is (or ever was) a Surgeon General, and do they care? Do they recall specific Surgeons General and what are their opinions (favorable and unfavorable) regarding those individuals? Are younger generations as aware of this position as older Americans?”
To answer these questions, a nationwide study with Yankelovich in September 2006 was commissioned – involving more than 1,000 Americans — that addressed these issues. The findings:
1. Most Americans, 71%, said they did know whether or not the United States had a Surgeon General.
2. At the same time, only one in three (32%) was able to recall unaided the name of any particular Surgeon General.
3. C. Everett Koop was by far the most commonly recalled Surgeon General, with 28% volunteering his name on an unaided basis, and an additional 24% recalling him when aided. This was especially remarkable since he had been out of the office for 17 years.
4. Jocelyn Elders, perhaps based on her highly publisized comments on masturbation, was the next highest at 3% unaided, and 33% aided.
5. Knowledge and awareness of Surgeons General was highest among older Americans. Younger Americans – those under 35 years of age – were generally unaware of any Surgeon General.
6. Men were more aware than were women.
In 2001, I interviewed a large number of Christian Conservatives (nearly 20), including Pat Robertson, about the Surgeon General position. To my surprise, they universally viewed the disposition of this position as among their most important issues. The primary take-aways were:
1. They continued to harbor deep anger and resentment toward C. Everett Koop, a well known fundamentalist Christian pediatric surgeon from the University of Pennsylvania, who they felt had betrayed their trust. These feelings were connected to Koop’s refusal to state that abortion carried with it substantial physical and psychological risk to women, as well as his activist promotion of condoms and the distribution of his HIV/AIDS Report by mail to American households. Koop had produced and distributed tens of thousands of copies of the report, which included the recommendation that AIDS education “be started at the earliest grade possible”, without prior clearance from the Reagan White House. He also refused to support mandatory testing for HIV which conservatives like Bill Bennett and Phyllis Schafly we’re pushing with a vengeance.
2. In the wake of these “betrayals”, their top preference regarding the position was that President Bush dissolve it or at least leave it unfilled.
3. Their second choice, if it had to be filled, was that it be done with a candidate who would be dormant and inactive in that position – ceremonial only.
In this week’s article, the editors of the Journal list a number of highly qualified candidates from the ranks of academia, public health, and government, urging the President to act now. As they say in their final sentence, “We urge the President to nominate and the Senate to confirm a strong leader and trusted voice as the nation’s next Surgeon General.”
While this is sound advise, I believe that, were I to interview the same individuals today that I did in 2001, I would find that their views were unchanged, and their passion for elimination or deliberate vacancy of the position would be even more entrenched and passionate today than it was back then.
For Health Commentary, I’m Mike Magee
Posted on | November 11, 2014 | 4 Comments
Veterans Day Invitation from Mike Magee
This Thursday, November 13, after 45 years, I will be returning to Syracuse. The trip is in response to an invitation from my Jesuit Alma mater, LeMoyne College. I spent four snowy years there, in the shadow of Vietnam and the Berrigan Brothers, from 1965 to 1969. I added four more years, a marriage and our first child, from 1969 to 1973, attending SUNY Upstate Medical School before heading South with the family to Chapel Hill. By the time we returned to New England in 1978, the war was over, but the human toil – physical, mental, spiritual – was visible in plain sight. It still is.
On Thursday, from 4:00 to 5:15 PM, I will be addressing student, faculty and guests at the college. My subject is WW II and how it defined U.S. health care for the next half century. My guides on this “tour” are three WW II veterans – all decorated, and all influential in my personal and professional life. There is a doctor, my father; an injured soldier and patient, Bob Dole; and a maverick economist and advisor to presidents on the health professional workforce during war and peace, Eli Ginzberg. In conversations with each of them, (and with the help of a bit of research), I have pieced together this story.
Consider this an Open Invitation, for any of you in the region Thursday, to join the conversation.
Here are the details:
Location: LeMoyne College – 1419 Salt Springs Road, Syracuse, NY, 13214. (315) 445-4100.
Site: SCA 318
Posted on | November 9, 2014 | 1 Comment
So it’s Sunday – and for many Americans (130 million when it comes to “Super-Bowl Sunday”) that means football. But as one post-election commentator opined today, “Politics determines who has the power, not who has the truth”.
Discussions around the future of NFL football are just about as fractionated and passionate as our deeply entrenched two party system. But at the end of the day, in the arena of science and diagnostic health care (at least as doctors, nurses and health professionals of all stripes espouse), truth = power.
When there is an impasse between reality and denial, lawyers eventually surface. That is one of the stop gates in the management of our civil society. There is an ample supply in this country of 300 million – about a million and a quarter lawyers from which to choose. In the NFL case, one spoke up.
Back in 2002, a physician in Allegeny County, PA, shared a beer with his friend, a young “working class” lawyer with a family passion for football. Dr. Bennet Omalu was a forensic pathologist at the county’s medical-examiner’s office. The friend was Jason Luckasevic, recent graduate from law school in 2000, then gainfully employed by a firm in Pittsburgh whose motto was “Working Lawyers for Working People”. For Luckasevic, whose godfather was president of the United Steelworkers local, that felt about right.
Dr. Omalu was anxious that day to share some findings from earlier in the week. He had done an autopsy on a 50 year old man who had for the past few years exhibited eratic behavior that had complicated his family life, and for a brief period, led to his seeking shelter in his pick-up truck. To Omalu’s surprise, the brain biopsy was filled with the tangled neurons and Tau protein deposits emblematic of Alzheimer’s disease.
That first patient was Pittsbugh Steeler Hall of Fame linesman Mike Webster. Omalu drew a straight line of cause and effect that day. And Luckasevic looked for further confirmation. Over the next two years, by word of mouth and inside referral, Omalu examined the brains of five other NFL players who had suffered early deaths and had some history of behavioral changes. All five showed the same characteristic neuropathologic findings.
Seven years later, in 2011, Luckasevic filed a law suit against the N.F.L., on behalf of 75 players. That number would grow. As for Dr. Omalu, in 2005, he published his findings in the journal, Neurosurgery. The N.F.L. was not amused, sensing an existential threat. They came at the accomplished Nigerian born pathologist with all guns blazing. In their attack, they mirrored tactics reminiscent of tobacco, chemical and pharmaceutical, agribusiness, and energy companies before them who had battled regulation and liability. They led with “medical experts” on their payroll. These “physician-experts” (a collection of team doctors) lied with straight faces on camera and in depositions, and enjoyed the opportunity to publish, in equal balance, “counter-claims” in reputable medical journals and in print and broadcast media.
The human and professional toll on Omalu is painfully documented in the remarkable PBS Frontline documentary, “League of Denial: The NFL’s Concussion Crisis.”
Besides utilizing familiar New York based, crisis intervention PR firms, the NFL went after media. As occurred a half century earlier when Monsanto and other chemical companies attempted to shut down the New Yorker serial publication of Rachel Carson’s “Silent Spring”, NFL pressured Frontline and Disney to not broadcast. And to the broadcast industry’s credit, they followed the New Yorker’s early lead and held tough.
The NFL has now admitted in legal documents that they believe up to 28% of their players have or will incur significant brain injury. They have tentatively agreed to a settlement that will provide around $1 billion in damages. But their future, and the futures of their players and fans, remain at great risk.
Watching Dr. Omalu on camera, I was filled with conflicting emotions – great sadness for the pain and suffering he has endured, and great pride for his courage and fortitude in the pursuit of his patient’s welfare, even at a tremendous financial and emotional cost. He is, after all, the doctor, the scientist, we intended to be when we each began this journey.
Which brings me back to the election. This morning, I saw a photo of my good friend and fellow physician, orthopedist and Pennsylvania native, John Barrasso, walking side by side, next to incoming Majority Leader Mitch McConnell. He was providing council, as they walked toward the White House yesterday. Of late, he has stepped back from the camera, where for a brief time he had been positioned by his party as a expert voice, a physician legislator, opposing the Affordable Care Act.
Watching him, I continue to see the potential for legislative greatness. His father, and his father’s father, ran a cement and masonry business in rural Pennsylvania. He learned at his father’s knee, how to build, how to constuct lasting foundations. But his Dad had larger dreams for John and his two younger brothers. Twenty years ago, John told me his father had told him, “God gave you one brain and it’s bigger than both your hands.” I thought of that quite literally when I listened to Dr. Omalu on Frontline. What is clear to the viewer is that this Nigerian born physician honored his profession and honored the truth. And in return he confronted power, and, for that, he deserves our eternal gratitude.
For Health Commentary, I’m Mike Magee.
Posted on | November 1, 2014 | No Comments
The finding is in. Malpractice awards against physicians are falling dramatically. The only two questions are “Why?” and “What does this have to do with quality health care, if anything?”
First the numbers. The JAMA study this week found:
1. Physicians paid claims decreased from 18.6 to 9.9 paid claims per 1,000 physicians between 2002 and 2013.
2. That translates into an annual decrease of 6.3 percent for MD’s and a 5.3 percent decrease forDO’s.
3. From 2007 to 2013, median payment’s have declined to $195,000 from $218,400 or average annual decreases of 1.1 percent per year.
During the years of the Obama Presidency we have seen significant changes in physician human resources including major shifts toward organizational employment vs. private practice, increased use of team approaches to care delivery, expanded use of “intensivists” and in-house Nurse Practitioners and Physicians Assistants, widespread expansion of EMR’s, and continued focus on Quality Improvement, including financial incentive systems tied to performance.
Is that what’s going on here, and what will the future hold? Study authors share there predictions.
1. Fights Over Status-Quo Will Continue and Be Non-Productive: “Debates and disagreement about traditional tort reforms, especially damages caps, will continue in the courts, in legislatures, and on ballot initiatives… They sap political energy and divert attention from alternatives…”
2. Communication/Resolution Programs Will Grow: “AHRQ is planning to support a nationwide scale-up of the communication-and-resolution approach. To that end, the agency recently awarded a contract for the development of a communication-and-resolution program implementation toolkit and training modules.”
3. Private Settlements: “There will be greater emphasis on laws that facilitate rapid private resolutions of medical injury disputes. Presuit notification, apology, and state-facilitated mediation laws can be adopted without vitiating traditional remedies to patients, and may encourage rapid dispute resolution.”
4. Creation of Safe Harbors: “The potential for safe harbors to improve safety and reduce cost through greater standardization of care will likely also keep them in the mix of attractive policy options. In February 2014, safe harbor legislation was introduced in Congress as part of the Saving Lives, Saving Costs Act.”
5. Physician Employment + ACO’s = Better Claim Resolution: “Tighter relationships between physicians and organizations enhance organizations’ ability to affect physicians’ behavior in ways that promote safety, transparency, and early resolution of injuries. These relationships also make it sensible to unify liability insurance under a single policy offered through the organization…”
6. Watch Out For Cycles: “…the lack of volatility in liability insurance costs may not last; it is reasonable to expect another increase in insurance premiums within the next few years.”
Now to the second question – “What does this have to do with quality of care?” Well. to begin with, there’s been pretty good evidence for awhile that even though medical malpractice law was intended to address poor quality by compensating patients for injuries resulting from negligence, and making future malpractice occurrences less likely, it has never really delivered.
In theory, this law made sense. Courts provide oversight when professional oversight breaks down. Doctors and hospitals are insured and therefore assured that a claim will not lead to financial ruin. Patients show restraint. And lawyers pursue only claims that have merit. But in practice, reality does not come close to this theory.
Three well-known scholars noted in 2004, the medical malpractice system “has internal logic but falls far short of its social goals of promoting safer medicine and compensating wrongfully injured patients.”1
The biggest problem? The medical malpractice system is fundamentally adversarial and built on a culture of blame. Doctors, hospitals, insurers, and lawyers have until recently been locked in battle with each other. Patients were routinely caught in their crossfire.
As a result, the status-quo didn’t bring relief to those who deserved it. A famous study conducted in 1984, at Harvard, examined 30,000 medical records and 3,500 malpractice claims. Only two percent of the patients who had suffered from negligence filed claims. Only seventeen percent of the claims that were submitted were in any way tied to negligence.(1,3)
The second big problem was that the tort system used litigation as its lever for change, while the safety movement uses quality improvement analysis. Tort law focuses on the individual. Safety focuses on the process. The tort system’s punitive style drives information down, encouraging secrecy. The safety movement requires a collaborative approach. This encourages openness, transparency, and continuous improvement. With tort law, exposing oneself can end one’s career and harm one’s mental health. In the safety movement, contributing is career-enhancing and therapeutic.(2)
So one should not be surprised that malpractice numbers are declining. As we move to a more organized approach to care delivery – based on expanded insurance, rationale teamwork, constantly improving processes, more home-based vs. hospital-based care, greater patient and family education/empowerment, and employed vs. independent physicians – we will continue to see these numbers improve.
That is what we should expect to happen. Why? Because the weaknesses in our health delivery system were never really based on fears of malpractice – that was a cop out. They were structural. And we’re finally doing what we should have done all along.
For Health Commentary, I’m Mike Magee
1.Studdert DM, Mello MM, Brennan TA. Medical malpractice. NEJM. 2004; 350: 283-292.
2.Leape LL, et al. Promoting patient safety by preventing medical error. JAMA. 1998; 280:1444-1447.
3.Robinson GO. The malpractice crisis of the 1970’s: a retrospective. Law Contempt. Probl 1986; 49:5-35.