Sunday, April 27, 2014

Security vs Freedom: TSA Airline Security Gave me a Free Pass

I’m writing this aboard a United Airlines flight on route to Chicago.  I haven’t had this much leg room since I was inside my mother’s womb.   I am now in fear that if the gentleman in front of me reclines his seat, that it will disfigure me.  If this occurs, I wonder if United would be liable for my pain and suffering.   Now that I think about, throw that seat back, buddy!

Stretch out and relax!

I shouldn’t carp on United as I received an unexpected prize from the airline.  When I passed through the TSA checkpoint, I was told that I had been awarded a Pre-Check status, which conferred valuable privileges.  This meant that I did not have to remove my shoes or my jacket.  Somehow, the airline had determined that the Whistleblower posed no flight risk.  Luckily, the airline had not read some of my scathing Whistleblower posts on their pricing strategy and their deep commitment to customer service.

Do you think that they profiled me to determine that my shoes likely contained only my feet?  For law enforcement novices, profiling is a technique that everyone knows is effective, but we are not permitted to utilize.   One of the reasons that I feel so safe on El Al is because they use profiling, among other techniques, to identify individuals who warrant enhanced scrutiny.

Civil liberty champions, who argue vociferously for civil rights in classrooms, textbooks and on the airwaves, should consider that I have a right not to be blown up.  This is not a law school seminar.  We’re contemplating mass murder.

The dark and evil forces that are plotting against us and others are not constrained by societal laws and norms.   President Obama has rightly recognized this and has not only continued President Bush’s security policies, but has intensified them.  I suspect that there are many stealth security operations and practices that are operating without adequate oversight, or even without knowledge of the White House.  Familiar with the phrase plausible deniability?

The high stakes of our world warrant a recalibration of the balance between security and civil liberties, as has properly occurred.   My motto is, read my e-mails and save an airplane. 

Look at what is already public knowledge. 
  • The president authorized the killing of an American citizen in a foreign country.  Good idea?
  • An accused terrorist was essentially kidnapped from Libya, a sovereign nation, and transported to the United States to stand trial.   What would our response be if another country infiltrated the U.S. and grabbed a person of interest?  Would we shrug it off?  I doubt it.
  • We still have a pile of prisoners in GITMO whom we won’t try in court, but we won’t release.   While I understand why President Obama back flipped on his promise to close the place down, the continued existence of the place doesn’t seem to conform to our values, even if it is legal.
  • It’s against the law to torture, but the descriptions I’ve read about our enhanced interrogation techniques sound like torture to me.   And, I’m sure we’re doing stuff that I haven’t read about.
  • Lots of warrantless intrusions going on, despite what we hear about the robust FISA court.
Yeah, I know this is a medical commentary blog, and arguably I’m off message on this post.   I’ve awarded myself a Whistleblower Pre-Check, entitling me to certain privileges.

So, do you think the balance leans too far now in favor of security?  Perhaps, you feel it should tilt even further in this direction?  Name a policy that you would strengthen or weaken and the risks of this recommendation.

Sunday, April 20, 2014

Can We Survive an Epidemic of Corporate Wellness?

I’m a physician and I’m against wellness.  Let me explain.

Wellness is the new health mantra that has much more to do with marketing than with evidence-based medicine.  Wellness institutions and practitioners are omnipresent promising benefits that are often untested or rejected scientifically.   Hospitals that years ago would have shunned new age healing arts, now offer yoga, meditation, Reiki and massotherapy.  Do they do so because they have had a Damascus Road experience and now believe that these techniques are effective?  Guess again.

Ahead of His Wellness Time?
100 Years Ago Metchnikoff Suggests Probiotics 

Wellness is no longer restricted to medical campuses, costly weekend retreats for emotional and physical catharses and ubiquitous yoga storefronts.  Wellness is now championed by corporate America.   Business leaders argue that keeping employees well is not only a demonstration of good corporate citizenship, but is also good business.   Healthy employees, they claim, will reduce health care costs.  I agree, but not for the reasons they offer.

Their premise that wellness program participants will use fewer medical resources sounds rational, but it may not be true, despite claims from human resource professionals who want to justify these programs.  Here’s the argument.  “If we lower employees’ blood pressure, bring their weight down and control their diabetes better, than these folks will avoid heart attacks, strokes and surgeries which will save mega bucks and improve productivity.”  

Sure it sounds right, but is it really true?  Shouldn’t corporations that know the cost of every paper clip be able to prove that this strategy is sound?   Just earlier this year, a major study on obesity published in the prestigious Journal of the American Medical Association concluded that overweight individuals live longer.  My point?  Just because something sounds like it should be true, doesn’t make it so. 

Many companies are now coercing employees with financial rewards and penalties depending upon their success and enthusiasm in participating in company wellness programs.  If you don’t make their health grade, then the employee will lose serious cash, which may be far in excess of actual medical costs incurred.  In other words, an unstated motivating factor here may be simply to get employees pay more health care costs.

Indeed, two studies published earlier this year in Health Affairs, a peer-reviewed journal, strongly suggested that corporate wellness programs save company money simply by cost-shifting to employees.  Is this what is meant by corporate ‘wellness’?

The Cleveland Plain Dealer (PD) reported on April 20th that CVS Caremark is requiring employees to participate in its wellness program by May 1st or they will have to fork over $600 more for health care next year.  Do we really know that non-participants would drain the company’s coffers?   Realize that many employees change jobs every few years, and that adverse health effects of being obese or having elevated blood pressure may take decades to develop.   A CVS worker with a pair of love handles or modest hypertension, isn’t likely to consume more medical resources in the short term.  Yet, he would be docked on day 1 next year.  Does this policy pass the fair and reasonable test?

The PD article quotes CVS as claiming that their policy is “the most effective way to encourage our colleagues to take control of their own health…”  This statement breaks the needle on the hypocrisy meter.  The gall that CVS wants to serve as a health guardian, or should I say health police, while it sells cigarettes, alcohol, junk food and the sugary beverages that New York City Mayor Michael Bloomberg has outlawed for health reasons.  This is chutzpah of the first order.
If CVS wants to adopt a sincere health mission, then let them get rid of their Camels, Marlboros and Lucky Strikes.  Otherwise, their flimsy argument goes right up in smoke. 

If a company truly believes that wellness is right for workers and business, then create a corporate culture that encourages this and provide leadership.   If it’s really as good an idea as they say, then folks over time will be persuaded to do join in.   Leave the financial rewards and penalties off the field. 

I’m not a wellness antagonist.   I support any activity that is safe and makes people feel better.  But making folks pay-to-play in the wellness game, doesn’t make me feel good.  Perhaps, I need to meditate more on this.  

First published in Crain's Cleveland Business, May 13, 2013

Sunday, April 13, 2014

Sued for Medical Malpractice - Again

Folks who have wandered through the Legal Quality category of this blog understand my views on our perverted and unfair medical malpractice system.  I've been in the arena many times, and always walked away unharmed.   If this system were presented in front of a fair minded and impartial jury, it would be dismantled.  Sure, there are positive elements present, but they are dwarfed and suffocated by the drawbacks. The self-serving arguments supporting the current system are far outweighed by the financial and emotional costs that innocent physicians unfairly bear.  Tort reform should not be controversial. 

You may wish to peruse a few of my medical malpractice posts before spewing forth vitriol in the comments section.

Beyond the medical arena, who wants to defend the crushing volume of litigation in the United States?   Let me be bold.  I think we have too much litigation and fear of litigation in this country.  Put that item up for a vote anywhere in the country except at an American Bar Association convention, and you don’t need to be a soothsayer to predict the outcome.  You just need to be breathing.

About two years ago, I was sued months after the death of a patient for whom I provided appropriate care.  Being sued is not a lonely process.  I was among many defendants, including several doctors, a hospital and other corporate entities. 

I reviewed the medical record and reached two conclusions:

    (1)    My care was appropriate and proper
    (2)    The record documented the above.

In the medical malpractice arena, it is much more important what has been documented than what has been done.  Meditate on this statement for a few moments.

The complaint against me didn’t offer a single specific allegation of a breach of my care.   Instead, there was a general statement, which used against every defendant, that we were negligent.  My attorney also could not divine from the complaint an actual allegation against me.   Isn’t there an obligation to state to the accused what the alleged negligence is?

In Ohio, a physician not involved with the case must sign an affidavit of merit swearing that there is a reasonable basis that malpractice occurred before a case can go forward.  While this sounds like a filter, it functions as a sieve.  Shockingly, this single physician swore that every physician deserved to be sued.  I suspect that if a hamster were sued, that this doctor would have put the little varmint in the dock also.
Many of these physician ‘experts’ earn a substantial portion of their incomes by serving trial attorneys.  Anyone spot a conflict of interest here?

The case was dropped against everyone, presumably as the plaintiff’s attorney couldn’t find real experts to support the claims of negligence. 

I thought I was in the clear until the case was refiled a few months ago.   My attorney petitioned the court to dismiss me as the physician who signed the affidavit of merit was not in my specialty.  The court agreed.  For all I know, this doctor may have been a psychiatrist.

What a system.  Consider that I’m only one defendant who was drawn into the legal labyrinth.  My malpractice carrier informed me it cost $11,750.22 to defend me, and my case never even reached the discovery phase.  How's that for money well spent?

I wonder what the financial costs are from all of the unnecessary litigation that our country endures in a year.  Probably, enough to truly reform the health care system.  Hey, this gives me an idea…

Sunday, April 6, 2014

Hospital Medicine Threatens Quality of Care with Communication Lapses

To those brave souls who have returned after digesting last week’s cheerleading on hospitalists, here is the Achilles’s heel of the system.  While the advantages are clear and substantial, there are serious vulnerabilities which have not yet been adequately remedied. 

Achilles Held by the Heel Being Dipped into the River Styx
  • Hospitalists cannot appreciate the medical nuances, personality, family dynamics, life events and prior experiences that may be well known by the out-patient physician.   
  • There are serious communication lapses, all of which cannot be bridged.  The out-patient doc may know that the patient’s chest pain is his typical anxiety and that it is not necessary to repeat the cardiac evaluation that was done 2 years ago.  The hospitalist may take a different tack here. 
  • Despite their best efforts, hospitalists know that they will not be seeing the patients after discharge.  As they are not permanently vested,  they may not address certain patient concerns, punting these  to the outpatient arena.  While this may be medically acceptable, it may be frustrating for some patients.
  • The hand off back to the out-patient doc after hospital discharge can be a minefield.   Patients may be on new medications.   They may have had a variety of laboratory and radiology tests.  Some of these results might be ‘pending’ at the time of discharge.   How does the out-patient physician reliably receive these results and understand their context?   Did medical specialists on the case leave recommendations that the primary physician now has to track and implement?   When the primary care doctor resumes care of a patient who had a complex hospitalization, is he now responsible to search out and address every loose end contained within the voluminous hospital record?   Could a single laboratory abnormality buried in the record that was totally unrelated to the medical illness become a medico-legal issue years later?  Do we really think that the hospitalists discharge summary to the primary care physician is airtight? 
A primary care physician recently complained to me that the local hospitalists never call him when his patient is admitted when he might provide useful information about his patient that only he know.   This is a legitimate gripe.

No system is perfect
So, over the past 2 weeks you have been offered a fair and balanced presentation on hospital medicine.   Which side of the issue has the better argument?