Category Archives: General Health

Why Dr. Oz Has Not Lost His Medical License

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An interesting article from Vox (link from retweet by Eric Benchimol) provides insight on why Dr. Oz can make numerous false claims of ‘miracle’ cures and not lose his medical license.

Here’s an excerpt:

The fact that Oz hasn’t lost any credentials speaks to a larger challenge in modern medicine: Once you get a medical license, its actually really difficult to lose it.

“This has been a longstanding complaint with medicine and the professional regulation. You either need to have sex with patients who file a complaint, be a really bad substance-using person… or you’re malpractice-level bad as a doctor,” David Jones, professor of culture of medicine at Harvard University, says. “Nothing in Dr. Oz’s conduct is even close to getting the attention of the state boards because they are dealing with sex criminals, alcoholics, and gross misconduct.”

Ouch!

The article details why the American Medical Association, New York State Dept of Public Health, Columbia University, and the Federal Trade Commission are all unable to take action against Dr. Oz.

Related blog posts:

Here’s John Oliver’s takedown of Dr. Oz: Dr. Oz on Last Week Tonight 

An Inside Look at the VA: “Hidden Lists” and “Watershed Moment”

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Here’s a different view of the VA, from a practicing physician, and an excerpt:

“Nowhere else than at the VA have I felt as much that I was a part of something greater than myself. We “care for him who shall have borne the battle” in a system that, for all its woes, remains a singular presence in the confused patchwork of medical care that is American medicine. Enter the VA medical system and you know that your critical medical data are available to every provider at every VA hospital in the country in ways unimaginable in the private sector; you know that care delivered in the VA system often meets or exceeds the quality standards of the private sector.1You know, moreover, that you and the person sitting next to you in the waiting room will get the same level of care, because there is no mysterious and fickle insurer to reckon with at the end of the appointment.

I don’t know what happened in Phoenix or elsewhere, what those hidden lists hold, what grief lies there. I wish those reporting on this scandal would do more to separate issues of access to care from problems with the quality of care. I do know that, all around the country, physicians who trained at the VA or who have chosen to live out their medical career with the VA have their own hidden lists, their indelible memories of men and women who entrusted their care to us. Let us continue to work for them.”

A second article “Watershed Moment,” summarizes the current problems and what needs to be done.  Here’s an excerpt:

“Yet access to care, particularly to outpatient appointments, has been an enduring problem for the VA, as documented in multiple reports from the OIG and the Government Accountability Office (GAO)… A key reason was inconsistency in the recording and tracking of wait times according to the “desired date,” defined as the date by which a patient wants to be seen or a health care provider wants him or her to be seen.1 A preliminary VA audit showed that 13% of scheduling staff — at 64% of the 258 surveyed facilities — had been instructed to enter a different desired date than that requested by the veteran, though it remains unclear what proportion of these changes represents willful falsification.2

There is anecdotal evidence that scheduling issues led to adverse health outcomes for veterans in Phoenix and elsewhere; more systematic assessments are under way. However, there is precedent for concern, since a September 2013 OIG report concluded that delayed gastroenterology consultations for colon-cancer screening had led to delayed diagnoses for more than 50 veterans, some of whom ended up dying of colon cancer.3

Beyond access to care, health system performance should be evaluated on the basis of health outcomes, the quality and safety of the care delivered, patient satisfaction, and costs. In many of these domains, the VA has kept pace with or surpassed private-sector health systems

 

The VA is a historic institution with a long tradition of providing care to former military service members. In recent years, the agency has made progress in addressing a backlog of disability claims and in sharply reducing veterans’ homelessness. In the 1990s, VA health care, facing a similar crisis of confidence and bipartisan calls for privatization, was transformed into a more technologically advanced, decentralized, and quality-oriented system. Now it needs to protect the best elements of its infrastructure, built around longitudinal, holistic care of each veteran, while embarking on another round of reforms.“

 

“Do Unto Others”

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A recent article from NY Times discusses the topic of advance directives and how physicians are likely to choose a “no code” status for themselves rather than heroic measures if faced with a terminal illness.

Here’s a link:  What doctors would choose and an excerpt:

Young doctors… 88.3 percent would choose a do-not-resuscitate or “no code” status. An allow-me-to-die status, in other words.  “Doctors see a lot,” Dr. Periyakoil told me later that day. Resuscitation attempts are so aggressive — likely to break an older patient’s ribs but unlikely to restore them to their previous state of health or function —that after witnessing several, “you know too much and you’re much more wary,” she said.

Perhaps readers here remember a much-circulated web essay by Dr. Ken Murray, a retired family practitioner, called “How Doctors Die.” He claimed that his fellow physicians largely reject the sort of high-tech care they routinely dispense to their patients.

Take-home message: Physicians frequently provide high-intensity heroic measures to many of their patients which they usually would reject for themselves.  Even in pediatrics, frequently parents demand that “everything be done” when many physicians would advise otherwise.

When “All-Natural” Really Isn’t

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A recent tweet from David Kessler provided this link, fooddive.com/news/the-case-…, regarding all-natural products and recent spate of lawsuits:

Here’s an excerpt from “The case against ‘all-natural’:

But how “natural” is the “natural” label? It might be a bit more misleading than you think. The U.S. Food and Drug Administration admits it doesn’t even have a hard-and-fast definition on what the term means. The agency also doesn’t object to a product being labeled as such, so long as “the food does not contain added color, artificial flavors, or synthetic substances.”

However, some consumers just aren’t buying that “all-natural” claim, and there have already been many notable court cases to prove it. Here’s a roundup of five recent lawsuits forcing food producers to cough up cash and remove labels after products didn’t live up to their farm-to-store promise.

Five recent lawsuits -highlighted in article

  • Kashi
  • Nature Valley
  • PopChips
  • Naked Juice
  • Tropicana Orange Juice

In a related post, ClarkHoward.com discusses how labels are misleading:

Here’s the link: 5 Label Tricks

“Food labels like “organic,” “free range,” “all natural,” and “multigrain” don’t necessarily mean what you think.”  He provides specific advice to avoid buying a misleading product.

“ProCESS” for Improvement or Reason for Caution

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“There is no such thing as the world of letters apart from the world of men…The scholar without this vision is a pedant.  He mistakes learning for an end in itself, instead of seeing that it is only a weapon in a wise man’s hands.” (Seth Low, 1890 -quoted in NEJM 2014; 370: 1679).

While sepsis, “the syndrome of dysregulated inflammation that occurs with severe infection,” is not frequent among pediatric gastroenterology patients, it does occur. Pediatric GI patients at risk include patients receiving immunosuppression medications, patients with inflammatory bowel disease, and patients with central lines.  So, it is not simply an academic exercise to understand the efforts to improve sepsis treatment. A recent study and related editorials discuss the role for protocols in treating sepsis, and likely have broader implications [NEJM 2014; 370: 173-76 (editorial-http://nej.md/1hYoAXc ), 1683-93 (article-http://nej.md/1qvKwBc ), 1750-51 (editorial-http://nej.md/1gkt6D2 )].

Overall, sepsis was reported as the 11th leading cause of death in the U.S. in 2010 and was the single most expensive condition treated in hospitals.  Nevertheless, the diagnosis is in part subjective and these statistics rely on insurance claims.

Key points:

  • Policymakers in New York require hospitals to adopt sepsis protocols (“Rory’s regulations”) following the death of a 12 year-old boy who died from unrecognized sepsis.  Other agencies, like the National Quality Forum (NQF), have recommended this as well. The Centers for Medicare and Medicaid is considering whether to adopt the NQF metric.
  • The ProCESS (Protocolized Care for Early Septic Shock) study (31 centers) enrolled 1341 patients (average age 61 years) into 3 randomized separate arms: protocol-based goal-directed therapy bundle, protocol-based standard therapy, and usual care. Conclusion: protocol-based resuscitation did not improve outcomes.
  • Sepsis mandates are not without risks.  Overdiagnosis can lead to unwarranted antibiotics, excessive testing, excessive blood transfusions, diversion of scarce ICU resources, and complications from central line placement.
  • Two more multicenter studies are underway (ARISE and ProMISE) which will further determine the utility of protocoled sepsis care

While the ProCESS trial did not identify improvements in protocol-driven care, most patients (76%) in all three groups received antimicrobials by the time of randomization (mean of ~3 hours).  Thus, early recognition of sepsis with treatment, particularly antibiotics and volume resuscitation, remain critical.  The editorial (pg 1750) imparts some useful advice from Machiavelli: “the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure.”

More Eloquently Stated Concerns Over MOC

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Recently, I stated my concerns over the MOC process: After I Passed The Test | gutsandgrowth

The same issues I discussed are articulated more precisely in a recent editorial, titled “Maintenance of Certification: Beauty is in the Eyes of the Beholder:”

Ann Intern Med. Published online 13 May 2014 doi:10.7326/M14-1014

Here’s the link: http://bit.ly/Centor 

Copy Forward: What Could Go Wrong?

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From GI & Hepatology News: “Copy and paste at your own risk”

Here’s an excerpt:

In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue…

When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her “accompanied by spouse” at every visit.

The Bigger Picture -Mammography as an Example

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This week, a commentary makes a strong case for eliminating mammography (N Engl J Med 2014; 370:1965-1967):  “Abolishing Mammography Screening Programs? A View from the Swiss Medical Board”

Here’s a link from the NEJM: nej.md/1hV8q0L

What is fascinating is how ingrained mammography has become in our medical culture and how most individuals believe that mammography is so beneficial.  Take a look at the figure in the link to get a better perspective.  While women think that mammography may save 80 lives out of a thousand screened, according to the commentary, the data suggest that 1 woman may be saved.  The main problem: “for every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.”

If a well-established screening measure like mammography is not so beneficial, what else could be on the chopping block?  As noted in a previous blog post (Do you know about the “Choosing Wisely … – gutsandgrowth), even the annual physical exam has been deemed a low-value service.

Another related blog post:

“There is More to Life Than Death” | gutsandgrowth

 

A Leading Cause of Mortality in U.S….

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Being uninsured.  A recent article in Annals of Intern Medicine (2014; 160: 585-93) explored the reduction in mortality associated with expansion of Medicaid.

Key result: “Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults).”  The control group consisted of similar patients from other states.

An editorial (advbd.co/1lWHfsu) on this subject (from Atul Gawande retweet), notes the following: “The takeaway: Every 830 additional people who got insurance under Massachusetts’ health reforms prevented roughly one death….

A 2012 Urban Institute report estimated that 15.1 million uninsured adults could gain coverage if every state expanded Medicaid. Using the 830 figure from the Massachusetts study, and acknowledging that the state’s coverage wasn’t exactly equivalent to Medicaid, that would translate to 18,193 deaths prevented per year.

For a sense of comparison—that would make the Medicaid coverage gap the number five leading cause of preventable death in the United States”

1 “Medicaid Coverage Gap” based on 2012 estimate; other causes based on 2010 data.

Bottomline: Not having health insurance can be very bad for your health.

Related blog post:

45,000 Unnecessary Deaths Per Year | gutsandgrowth

Questions and Answers about MERS

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Recently two cases of Middle Eastern Respiratory Syndrome (MERS) have been reported in the U.S.  For more information -the following link (thx to Mike Hart) may be useful:  www.cdc.gov/coronavirus/MERS/index.html<http://www.cdc.gov/coronavirus/MERS/index.html

From the CDC: Middle East Respiratory Syndrome (MERS) is viral respiratory illness first reported in Saudi Arabia in 2012. It is caused by a coronavirus called MERS-CoV. Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness. They had fever, cough, and shortness of breath. About 30% of these people died.

So far, all the cases have been linked to countries in the Arabian Peninsula. This virus has spread from ill people to others through close contact, such as caring for or living with an infected person. However, there is no evidence of sustained spreading in community settings.