Why Did Susan Warren Die?

By KIP SULLIVAN (23)

On April 17, the Minnesota Supreme Court published an opinion holding that doctors who deny services to patients may be sued even if they did not have a doctor-patient relationship with the patient. The decision drew expressions of surprise and consternation from observers inside Minnesota. Many malpractice experts had expected the court to conclude that patients cannot sue doctors unless the doctor had actually treated the patient. But in this case, Warren v. Dinter , the court held that a hospitalist [1] who refuses to admit a patient to the hospital may be sued for causing the death of the patient even though the hospitalist never laid eyes on the patient. 

The court sent the case back to the district court for trial. 

The defendants listed in this case are both the hospitalist, Dr. Richard Dinter, and the Fairview Range Medical Center in Hibbing, a small town on Minnesota’s Iron Range. The plaintiff is Justin Warren, the son of Susan Warren, a woman who died at the age of 54 one day after being denied admission to the Fairview hospital.

This is an odd case, and a complex case. It raises at least three questions worthy of extensive public debate. In the next section I will recite the basic facts of this story as they were reported by the opinions of the Minnesota Supreme Court and the Court of Appeals. In the section after that, I will discuss the three issues.

What we know about the death of the plaintiff’s mother

On the morning of Friday, August 8, 2014, Susan Warren visited Essentia Health Clinic in Hibbing. The clinic is part of the 15-hospital-75-clinic chain called Essentia Health that extends over much of northern Minnesota and Wisconsin. The clinic is about a block away from the Fairview Range Medical Center, the only hospital in Hibbing, one of 12 owned by Fairview Health Services a hospital-clinic chain that sprawls over the eastern half of Minnesota. 

Warren was suffering from fever, chills and stomach pain. A nurse practitioner at the Essentia clinic, Sherry Simon, drew some blood from Warren and sent it to a lab. That afternoon the lab reported that “Warren had unusually high levels of white blood cells, as well as other abnormalities,” as the court put it (p. 3). (Unless I note otherwise, “the court” refers to the Supreme Court, not the Court of Appeals.) Simon concluded, naturally enough, that Warren had an infection and needed to be hospitalized immediately. However, rather than send Warren straight to the ER of the Fairview Range Medical Center, Simon called the hospital “to seek Warren’s admission.” (p. 3) Simon’s call was routed to Dr. Richard Dinter, one of three hospitalists on call that day. 

Continue reading

Why Mentors Matter: Navigating When There Are Many Alternatives

By JEFF GOLDSMITH

For people starting out in their careers or contemplating a mid-career change, an honest conversation with a mentor can make a big difference. Mentoring seems to have gone out of fashion in a tech-driven world where nearly instantaneous feedback from wide networks of “friends’ seems to have taken the place of confidential conversation with older people. But reflecting on my own career, I can say with certainty that mentors made a huge difference. And I was lucky enough to have three of them, at different stages of my career. I am grateful to them for helping me navigate in a changing world.

Graduate School

As an undergraduate at Reed College in the late 1960’s, I became interested in social science research, specifically how institutions selected out types of people by their personalities and interests. While my academic work focused on classics and psychology, a research project on Reed’s brutal attrition rate (only a little more than a third of people who entered Reed as freshmen graduated in four years) that sought out the selection factors that predicted “success”, at least surviving the four years of a very intense undergraduate experience.

This work brought me in contact with Professor David Riesman at Harvard, whose 1954 book “The Lonely Crowd” made him a leading public intellectual and social critic (and landed him on the cover of Time). “Lonely Crowd” decried the erosion of individualism and the rise of the “other directed” personality in America. This work eerily presaged (by a mere fifty years) today’s obsessive internet-driven hunger for the approval of strangers. Reisman, who was then in his early 60’s, had come to Harvard, and had become a leading sociologist of higher education. I sent him my Reed research to see what he thought, and the correspondence led to a friendship that stretched over the next thirty years.

Continue reading

Congress Needs to Support a Competitive Healthcare Market

By RICHARD HARRIS, MD

With the 116th Congress actively discussing several healthcare topics, now is an opportune time to discuss how we can move our country to a truly value-based healthcare system that better serves patients’ needs. One of the most pressing issues affecting where and how patients access care remains the unchecked pace of hospital mergers and acquisitions. Not only are physicians like me concerned with this trend, most Americans are worried about the rate at which hospitals are purchasing independent physician practices, which they see as a threat to affordable care.

As a urologist who has fought for the rights of independent physicians for years, it is clear we can no longer allow hospitals to monopolize the conversation about care delivery, the organization of resources and the best reimbursement strategies. For too long, Americans have considered hospitals to be benevolent organizations more concerned with patient health and community service. The truth, as any informed observer of healthcare knows, is quite the contrary: hospitals are no different than any other business seeking to monopolize its service area and increase revenues. Multiple studies show that hospital consolidation in a market increases prices and reduces options for purchasers of health services, which includes self-insured businesses, insurers, government programs and individual patients.

For our patients, the increasingly rapid rate of hospital consolidation is leading to fewer and fewer options for care. Across the country, patients are less satisfied, less trusting and more concerned about the future of their healthcare than ever. In fact, a recent poll found that the majority of patients (65 percent) trust an independent physician to give them the best recommendation over those employed by hospital systems. Even worse, lesscompetition due to mergers has been shown to affect care quality. For example, Medicare beneficiaries who experienced a heart attack were more likely to die within one year of treatment if they were treated by a hospital that faced few potential competitors, compared to patients in the most competitive areas.

Continue reading

The Day a Disabled Child Walked Into My Exam Room And I Discovered She Was Pregnant

By NIRAN AL-AGBA, MD (7)

I will never forget her face.  She was only thirteen.  She had a significant cognitive disability, a result of an anoxic injury at birth.  She found her way to my clinic one late Friday afternoon in July almost two decades ago.  Her mother was a nurse and noticed her daughter had not had a period in the last two months.  Her pregnancy test came back positive.  I wanted to cry.  

The questions I had to ask this young girl were agonizing.  When asked if she had sex, she looked at me and shook her head back and forth, to say no, she had not had sex before.  She was telling the truth.  Having sex implies consent.  When I asked if someone had touched her private area, she nodded her head up and down and said there were two boys.  She thought they might have been about her age. She did not know who they were.  She had never seen them before or since. I asked if she could remember their faces.  She could not.  

The two boys pushed her down on a grassy area next to the high school football field when she was walking home one day.  She remembered it was raining because she had been looking up at the sky until they stopped hurting her.  She told me about the pain she experienced, down there, and she pointed to her vaginal area.  She told me there was some bleeding afterward at home.  She did not tell anyone about what had happened, even her mother.  I am not sure if she really understood what had been done to her.  I tried to put myself in her place to understand how hard it must be to be telling me her story now.  

Taking her small hand in mine, I told her she was pregnant.  Her shoulders slumped forward and she looked at the floor.  “Do you know what that means?”  She nodded her head up and down, then said “there is a baby in here” gesturing toward her abdomen.  It was more question than answer.   She was not capable of understanding how horrifying it was that she never made a choice to become a mother.  

She was still a child herself.  

Continue reading

Policies Like the Hospital Readmissions Reduction Program are Killing Patients & Harming Care. It’s Time to End Them.

By STEPHEN SOUMERAI and KIP SULLIVAN (29)

Federal programs designed to cut costs and improve health by penalizing doctors and hospitals are failing at an alarming rate. Some of them actually harm patients, and many don’t cut costs. One in particular, the Hospital Readmissions Reduction Program (HRRP), may have caused thousands of deaths instead of preventing them, and probably hasn’t saved money during its seven years in operation.

The Centers for Medicare and Medicaid Services began reviewing the safety of this program on Jan. 19. It shouldn’t take CMS nearly four months to err on the side of caution and pull the plug on it.

The HRRP was imposed upon Medicare by the Affordable Care Act. Its goal makes sense: reduce the number of patients readmitted to hospitals soon after being discharged. But its approach — penalizing hospitals millions of dollars if their rate of readmissions within 30 days exceeds an arbitrary threshold — makes no sense at all.

The HRRP and other federal “pay for performance programs” were under fire before they began. Evidence suggested that some hospitals would try to avoid penalties by not readmitting patients within the 30-day window, or if they showed up in the emergency department during that time would treat them there and send them home or place them in so-called observation units rather than admitting them to the hospital. There were also indications that these kinds of programs would disproportionately harm socially disadvantaged individuals.

Influential health policy experts either ignored this evidence or downplayed it.

Continue reading

Measuring the Measurers

By PETER ELIAS, MD

I precipitated a recent online discussion about healthcare’s obsession with measurement (quality metrics is the current buzz phrase) when I quoted two aphorisms that highlight some problems with metrics and targets:

Goodhart’s Law: “When a measure becomes a target, it ceases to be a good measure,”

Campbell’s Law: “The more a metric is used, the more likely it is to “corrupt the process it is intended to monitor.”

One comment rubbed me the wrong way because it implied that measurement reduces harm:

“In my experience, what unites liberal and conservative doctors alike is their conviction that they are being measured unfairly….My view is that those who are upset about the burden on physicians of unnecessary measurement need to show that they understand the death and injury toll of lack of measurement caused before we trust them with the pruning knife.”

Measurement does not reduce harm or improve quality.

I love data (the result of measurement).  As a clinician I used measurement all day, every day. I couldn’t have practiced medicine without it. But measuring a patient’s blood pressure does absolutely nothing to change that patient’s blood pressure. What improves the blood pressure are interventions. If the right thing is measured correctly, and if the measurement contributes to well-tailored interventions, then improvement occurs. Measurements must be part of a process by which one can improve the quality of one’s interventions.

Continue reading

What Medicare For All Really Means (And Why It Ain’t Happening)

By MARGALIT GUR-ARIE (1)

I am going to make a prediction here. No matter who we elect in 2020, Bernie or Trump or anything in between, Medicare For All is not going to happen in America. One can run an electrifying campaign on the promise of Medicare For All, or indignantly against it, but this is pure theater on both sides. I don’t know if God can make a rock so big and heavy that even He can’t lift it, but I do know that government can make corporations so big and powerful that even government itself can’t break them.

For decades our government encouraged the health care industry to consolidate vertically, horizontally and obliquely so it can achieve economies of scale and therefore lower consumer prices. In the last couple of decades, the government also compelled the industry to computerize its operations, because technology makes everything better and cheaper. Once the resulting monopolistic behemoths were summoned into existence, it was time to nationalize the whole lot, into one super monopoly, with super technology and super economies of scale. The only other example of such government monopoly in America is the Military.

Obviously, our standing armies must be, by definition, a national monopoly, but note that the Navy is not building its own ships and the Air Force is not building its own planes and the Army is not manufacturing tanks. The government is contracting with private suppliers for pretty much everything, from butter to bullets. The Military Industrial Complex is a network of very large and utterly corrupt contractors for the government, yielding more power over foreign and fiscal policy than Congress, the President, and all citizens put together, while delivering practically nothing either on budget or on time. A powerful Military is essential to America’s safety and global success, so we grind our teeth and keep paying. And medical care for hundreds of millions of people is at least as important.

Continue reading

Health Apps, Data Sharing and the Trust Deficit

By SUSANNAH FOX (17)

There has been a steady drip-drip-drip of articles documenting how health apps are sharing data with third parties:

Data sharing practices of medicines related apps and the mobile ecosystem: traffic, content, and network analysis, by Grundy et al. (British Medical Journal, Feb. 25, 2019)

Is your pregnancy app sharing your intimate data with your boss?As apps to help moms monitor their health proliferate, employers and insurers pay to keep tabs on the vast and valuable data, by Drew Harwell (Washington Post, April 10, 2019)

You Give Apps Sensitive Personal Information. Then They Tell Facebook. Wall Street Journal testing reveals how the social-media giant collects a wide range of private data from developers; ‘This is a big mess’, by Sam Schechner and Mark Secada (Wall Street Journal, Feb. 22, 2019)

Assessment of the Data Sharing and Privacy Practices of Smartphone Apps for Depression and Smoking Cessation, by Huckvale, Torous, and Larsen (JAMA Network Open, 2019)

This post is my chance to share some relevant data, add my perspective, and ask for your input.

First, the data from a 2018 Hopelab/Well Being Trust study I helped write:

  • 71% of female teens and young adults say they have tried mobile apps related to health, compared to 57% of males. Three in ten (30%) females say they currently use a health app, compared to two in ten (20%) males.
  • Fully 48% of females ages 18- to 22-years-old and 25% of teen girls say they have used a period tracking app, compared with 2% of males.
  • Sixteen percent of females use a meditation app, compared with 5% of males.

Continue reading

N of 1

By CHRIS DWAN (7)

We are living through an uncomfortable period in the practice of medicine.

The dialogue between patient and physician is critically underserved, both in terms of tools for patients and physicians, and also in terms of the data context where that conversation takes place. This is unfortunate, because those are the moments of human to human care. Whether it’s a clinic visit, a lab test, a counseling or physical therapy session, the patient / provider meeting is when the full breadth of the caregiver’s experience and training can be brought to bear. At these moments, the subtle observations and pattern recognition that constitute diagnostic expertise come into play. These are are also the times when the nuance and detail of the patient’s lived experience can be shared to influence the course of diagnosis and treatment.

Population health turns into personal medicine at the bedside.

That conversation between patient and physician ought to be a first class citizen in terms of tool development, but it is not. It is within our reach to build a clinical care environment that retains high standards of data integrity and privacy while also focusing on empowering the human beings in the room rather the interests outside the door.

Continue reading

Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other

By KIP SULLIVAN (25)

Two bills that are called “Medicare for all” bills by their supporters have just been introduced in Congress. On February 27, Representative Pramila Jayapal introduced the Medicare For All Act of 2019, HR 1384 , in the House of Representatives. On April 10, Senator Bernie Sanders introduced a bill bearing the same name in the Senate, S 1129. The cost-containment section in Representative Jayapal’s bill will cut health care costs substantially without slashing the incomes of doctors and hospitals. Senator Sanders’ bill cannot do that. 

In this article, I explain the differences in the cost containment sections of the two bills and call upon Senator Sanders to correct two defects in his bill that minimize its ability to reduce costs. Defect number one: S 1129 authorizes a new form of insurance company called the “accountable care organization” (ACO). Defect number two: S 1129 fails to authorize budgets for hospitals. Representative Jayapal’s bill, on the other hand, explicitly repeals the federal law authorizing ACOs, and it authorizes budgets for individual hospitals. 

I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders. Bernie’s enthusiastic support for a “single payer” solution to the American health care crisis has added millions of new supporters to the single-payer movement. But precisely because he is now the most recognizable face of the single-payer movement, it is extremely important that all of us, whether we’re already in the single-payer movement or we just long for a sane and humane health care system, encourage Bernie to fix the defects in his bill. 

To explain the two defects in S 1129, I must first explain why a single-payer bill like Representative Jayapal’s will be effective at cutting the high cost of American health care. I begin by explaining the origin and meaning of the “single payer” label. I will then describe the two defects in S 1129 in more detail.

Continue reading

Life After Twitter

By DAVID SHAYWITZ, MD (8)

Quitting carbs last year was hard. Quitting Twitter this year has proved delightfully easy.  You might even want to try it for yourself.

Twitter has tremendous upside. Most notably, it provides the chance to connect and engage with more, and more varied, people than you otherwise might, and in the process, learn things you didn’t know, and hear about interesting articles you might have missed. A real highlight of the medium was getting to know so many extraordinary people in the healthcare and biotech communities.

My Tech Tonics podcast co-host Lisa Suennen (@VentureValkyrie) and I originally met on Twitter, for example.  I’m impressed by the ability of colleagues like Bruce Booth (@lifescivc) to use Twitter strategically and effectively, sharing thoughts on science and investing while steering clear of politics.  Many top scientists also enjoy the engagement of Twitter, as rock star Stanford chemist and Twitter newbie Carolyn Bertozzi (@CarolynBertozzi) recently highlighted on her captivating Long Run podcast with Luke (@ldtimmerman).

And yet.

As my economist friends (who, I acknowledge, I mostly met through Twitter) incessantly emphasize, everything is about trade-offs. The relevant question about Twitter isn’t whether there are benefits, but rather, whether the benefits are worth the costs. This analysis presumably will differ for each person.  For me, the calculus was pretty easy, and I’m hardly alone (indeed, “How I Improved My Life By Quitting Twitter” feels like a blogging subgenre at this point).

The costs of Twitter are consequent to the attention it demands and extracts, and the amount of mindshare you give over to it. Insidiously, it seemed to claim more and more of my time and emotional energy in the years since I first joined in 2011. You could say I became a very avid user. I tweeted around 45,000 times over an eight-year period, and had around 13,000 followers. Even though I carefully curated a group of just 40 accounts to follow, in effort to minimize distraction, it wasn’t working. By late February, I decided it was time to quit.

Continue reading

Q: How Do You Build a “Great Party of Healthcare?”
A: Build a Party of Doctors

By NIRAN AL AGBA, MD

The narrative goes like this:

The Democrats are the party of healthcare. The Republicans are the party that wants to take healthcare away from people. Dismantle the Affordable Care Act and we’ll have a disaster on our hands, millions will lose their healthcare coverage, middle class Americans will go bankrupt, the World will end

All this political propaganda ignores a fact that physicians have understood for some time now:   For doctors and millions of Americans, Obamacare already is a *total and unmitigated disaster*. From opening day when the administration’s Healthcare.gov web site symbolically blew up, it was clear that things weren’t going to be going according to plan.

Giving millions of people access to healthcare was a great thing and long overdue. But kowtowing to health insurers and pharmaceutical companies, obsessing about centralization, and endless digital paperwork all but guaranteed an epic fail.

Continue reading

The AMA Is Using Its Government-Granted Healthcare Data Monopoly to Power a Sketchy New Commercial Venture

By LEAH HOUSTON, MD (11)

Source: Health2047.com

Like many academic institutions and non-profits these days, the American Medical Association (AMA) decided not long ago to get into the innovation business, launching Health 2047, a new for-profit Silicon Valley-style venture innovation incubator.

One of the AMA’s first new ventures is Akiri, a blockchain-enabled data transmitting and sharing network built to efficiently transmit the data the AMA owns among patients, physicians, and health systems. According to a news brief filed at the time, Akiri’s data transmission network includes health information exchanges, and will allow the personal health records of patients to be transmitted. [1]

What most people don’t know is that Congress effectively granted the AMA a monopoly on healthcare data back in the sixties.

Continue reading

The Electronic Medical Mess

By CHRIS DWAN (47)

I posted a quick tweet about this a few months ago:

Over the years, I’ve worked with at least half a dozen projects where earnest, intelligent, diligent folks have tried to unlock the potential stored in mid to large scale batches of electronic medical records. In every case, without exception, we have wound up tearing our hair and rending our garments over the abysmal state of the data and the challenges in getting access to it at all. It is discordant, incomplete, and frequently just plain-old incorrect.

I claim that this is the result of structural incentives in the business of medicine.

What is a Medical Record?

Years ago the medical record was how physicians communicated amongst themselves. The “clinical narrative” was a series of notes written by a primary care physician, punctuated by requests for information and answers from specialists. Physicians operated with an assumption of privacy in these notes, since patients didn’t generally ask to see them. Of course they were still careful with what they wrote. If things went sideways, those notes might wind up being read aloud in front of a judge and jury.

Continue reading

In Defense of Pediatricians … (And a Few Words of Advice For Doctors and Other Public Health Types)

By NIRAN AL AGBA, MD (19)

Allow me to share a few select comments from Twitter with you.

“You people are awful.”

“This is just sick,” wrote another.

“All this to enrich yourselves. DISGUSTING!!”

“You endanger KIDS LIVES for a $400,000 a year salary and a Lexus???”

“This is just terrible, horrible behavior!!!”

Wow. What’s going on? What are these people talking about?

They’re taking me and my fellow pediatricians to task because of the perceived role pediatricians play in perpetuating the conspiracy that pediatricians, public health officials and greedy pharmaceutical companies encourage vaccinations in order to make money and are therefore willing to endanger the lives of children everywhere.

The anger toward pediatricians is real. How did things end up this way?

How did a medical specialty most people associate with sniffles and sore throats, reach the point where labels are thrown at us that are more commonly used to describe axe murderers and third world dictators?

Continue reading