Doctored

Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else:  insecure, discontented and anxious about the future.”  In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.

Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.

I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine:  income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”

The next paragraph, though, I read with astonishment.  Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout?  Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?

If so, I’m afraid he doesn’t understand the problem that he set out to solve.

The truth behind “quality” metrics

There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others.  In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer.  They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain.  But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates.  They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.

Let’s take, for example, a common operation such as laparoscopic cholecystectomy:  removal of the gallbladder using cameras and instruments inserted through small incisions in the abdomen.  This is a procedure which most general surgeons perform often, with few complications.

When complications occur, there are almost always factors involved other than surgical error.  Patients with diabetes are more likely to develop wound infections, for instance.  Surgery on patients who have had prior abdominal operations may take longer and could cause bleeding or damage to other internal organs because of scar tissue.  Morbid obesity and advanced age are risk factors too.

The surgeon whose mortality rates are higher, or whose patients are more likely to be readmitted to the hospital, may be dealing with a much different patient population from the surgeon with the lowest rates.  An inner-city hospital may admit more patients as emergency cases, in more advanced stages of disease.

It’s difficult for statistics to reflect accurately the dramatic differences among patients that affect surgical outcome.  A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon.  Trying to distinguish among surgeons with “outcomes data” will only result in more surgeons refusing to operate on high-risk patients.

Emphasizing 30-day readmission rates as a quality measure puts pressure on hospitals too.  CMS now plans to link hospital payment to readmission rates and hospital-acquired complication rates.  Community hospitals inevitably will feel pressure to funnel complicated, frail, or high-risk patients to the nearest major medical center which can’t bar them from the ER.

In my own line of work, anesthesiology, I often take care of patients who need chest surgery.  They have serious illnesses such as lung cancer, emphysema, and ALS–the bucket-challenge disease.  These high-risk patients don’t all have good outcomes, though I like to think that my management of their anesthesia care helps most of them return safely home.

My scores are fine on the meaningless “quality” metrics that the Joint Commission and CMS use to rate anesthesiology performance, despite their scant relation to clinical excellence.  (I’ve written before on how many of these metrics are flawed–see “The Dark Side of Quality“.)

But the best measure of whether or not I’m a good anesthesiologist isn’t either my outcomes data or my “quality” scores.  It’s the fact that surgeons and OR staff members at my hospital, who watch me work every day, often request me when they or their family members need anesthesia.  That’s a measure you won’t find in any report.

I can’t think of a worse way to address physician burnout than to publicize flawed “quality” or outcomes data that would unfairly pit physicians against one another. Dr. Jauhar’s further recommendation to link doctors’ pay to health outcomes (“pay for performance“) would only make matters worse.

The perils of patient satisfaction scores

Dr. Jauhar writes that his hospital sends quarterly reports to physicians, telling them how their patients rate them on different points such as communications skills and time spent with them.  I’m guessing that his reports must be good, or he wouldn’t consider patient satisfaction scores to be an incentive that could reduce physician malaise.

I’m also guessing that Dr. Jauhar’s colleagues in emergency medicine and primary care might feel differently.  Those physicians are under daily pressure to give narcotics to any patient who complains of pain, to prescribe antibiotics to patients who don’t need them, and to order expensive tests like CT scans at the slightest indication.  To do otherwise is to risk poor patient satisfaction scores.

The Atlantic published a recent article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.”  It highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.”  Patients often visit multiple emergency rooms and doctors’ offices asking for narcotics, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.”  They’ll be angry if their narcotic requests are denied.  Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.

Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A recent study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs.

prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality.  I can easily see how that could happen in the treatment of pain after surgery.  If you gave every patient enough morphine or Demerol, you wouldn’t hear complaints of pain. But the patients would be sleepy, wouldn’t want to get out of bed, and would run a higher risk of breathing problems and blood clots due to inactivity.

A recent Forbes article, “Why Rating Your Doctor Is Bad For Your Health,” concluded that “giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.” Many doctors would agree.

“Managing hopes”

Dr. Jauhar concludes that the solution to satisfaction as a physician is to settle for less.  He looks to medical students, who are “not so weighed down by great expectations”, to be the physicians of the future who won’t mind less money and prestige.

But here is where Dr. Jauhar misses the heart of the issue.  Most physicians didn’t go into medicine thinking to make a fortune–we leave that to the entrepreneurs and investment bankers.  Most of us never expected to be treated like gods, with the possible (tongue-in-cheek) exception of our colleagues in cardiac surgery and neurosurgery.

We did expect, though, to have a certain amount of autonomy in our daily working lives.  We expected to want to come to work every day and take the best possible care of our patients. We expected to have our education and opinions valued and respected, not second-guessed at every step by bureaucrats with clipboards.

Here is what I see as the downhill slide of 21st century medicine:

1.  The surge of uncritical belief in “evidence-based medicine” has led to rigid algorithms–cookbook recipes, really–for patient care. Experienced physicians know these algorithms are often a poor fit for patients with multiple medical problems, and must be ignored or subverted for the good of the patient.  At the same time, the physician may face criticism or sanctions for not following protocol.

2.  Bureaucrats and regulators seem convinced that if only we can produce enough care protocols, we can cut out physicians altogether and save money by having advanced practice nurses take care of everyone.  They encourage the devaluation of physician education and expertise. This seems to be the philosophy behind the proposed new VA rules which would eliminate physician supervision of veterans’ health care. (I’ll be curious to see if physician-free care will be considered good enough for the President and the Congress.)

3.  The unchecked power of regulatory agencies–including CMS and the Joint Commission–is growing, while their reason for being is the constant creation of new rules that get pettier by the day.  These proliferating rules have become a dangerous distraction to physicians and nurses, and take time away from their patients.

Where to go from here?

The way forward out of this mess won’t be easy, but a good place to start is this set of policy recommendations:  “The 2014 Physician’s Prescription for Health Care Reform.

In the meantime, it’s helpful to keep a few basic principles in mind.

Fee-for-service pay isn’t the chief culprit.  The best physicians stay busy because they have respect and referrals from their peers.  As they develop a base of satisfied patients and colleagues who recognize clinical excellence, they achieve financial success and have no wish to perform unnecessary procedures.  Price-fixing of physician services by third-party payers is the root cause of financial pressure to increase the number of services provided.

Limited provider networks benefit only insurers and the government.  They destroy long-standing patient-physician relationships, and prevent physicians from referring patients to other physicians whose work they know and trust.

Encouraging the medical students of today to settle for less isn’t the way to get the best and brightest to become the physicians of tomorrow. As a society, we need to push back hard against today’s flawed rules, laws, algorithms and metrics that promote mediocrity and standardization, and provide all the wrong incentives in healthcare.  That’s the only way that all of us–physicians and patients–will be able to enjoy the experience of individualized, personal patient care.

After all, the “human moments”, as Dr. Jauhar rightly points out, are the best part of medicine.

There’s no mystery about why the July 23 execution of Joseph Wood in Arizona took so long. From the anesthesiologist’s point of view, it doesn’t seem surprising that the combination of drugs used—midazolam and hydromorphone—might take nearly two hours to cause death.

Here’s why.

The convicted murderer didn’t receive one component of the usual mixture of drugs used in lethal injection: a muscle relaxant. The traditional cocktail includes a drug such as pancuronium or vecuronium, which paralyzes muscles and stops breathing. After anyone receives a large dose of one of these powerful muscle relaxants, it’s impossible to breathe at all. Death follows within minutes.

But for whatever reason, the Arizona authorities decided not to use a muscle-relaxant drug in Mr. Wood’s case. They used only drugs that produce sedation and depress breathing. Given enough of these medications, death will come in due time. But in the interim, the urge to breathe is a powerful and primitive reflex.

So-called “agonal” breathing, which precedes death, may go on for minutes to hours. The gasping or snoring that eyewitnesses described would be very typical. People who are unconscious after overdoses of heroin try to breathe in a similarly slow, ineffective way, before they finally stop breathing altogether or are rescued by emergency crews.

More about the drugs

Midazolam is a member of a class of drugs called benzodiazepines. The common “benzos” that many people take include Valium, Xanax, and Ativan. What these drugs have in common is that they produce relaxation and sleep. You might take a Xanax pill, for instance, to help you nap during a long flight.

In anesthesiology, we use benzodiazepines for another important reason: because they produce amnesia. There are stories of people taking a Valium to relax a little before they give an important talk, and the next day panicking because they can’t remember if they actually showed up and gave the talk.

Amnesia can be very helpful in my business. Many of my patients don’t want to remember coming into the operating room and seeing the bright lights and surgical instruments. After I inject one or two milligrams of midazolam into the IV, they’re often smiling and relaxed, and they have no memory later of coming into the operating room at all.  The next thing they know, surgery is over and they’re waking up.

Hydromorphone is a member of a different class of medications: narcotics. These include powerful pain relievers such as morphine, Demerol, heroin, oxycodone, and hydrocodone. These medications, in large doses, will slow or even stop breathing altogether. That’s why the risk of overdose is emphasized so strongly, and why narcotics cause so many accidental overdose deaths.

When you put benzodiazepines and narcotics together, the risk of death by overdose rises sharply. These drugs in combination were implicated in the deaths of actors Heath Ledger and Phillip Seymour Hoffman. There’s no question that if you take enough of these drugs, your breathing will slow and eventually stop if no one steps in to help you.

Why were other executions faster?

The original cocktail designed for lethal injection consisted of sodium pentothal, potassium chloride, and pancuronium. Sodium pentothal produced sleep, potassium chloride stopped the heartbeat, and pancuronium paralyzed the muscles so that the convict was unable to move or breathe. To all appearances, the convict would go to sleep and within a matter of minutes would be pronounced dead.

But opponents of capital punishment argued that there was no guarantee with this recipe that the convict was ever truly unconscious. There could be a chance that the dose of sodium pentothal would be insufficient or would wear off before the other drugs had time to take effect. Being awake and paralyzed during the dying process would truly be cruel and inhumane, they claimed. Of course, there is no way of knowing if this ever occurred, but there is equally no way of knowing that it didn’t.

I’ve written before about the clearly botched execution of Clayton Lockett in April, where the lethal injection drugs worked slowly because they were probably not injected into a vein at all. Unfortunately, he seems to have been conscious at least during the early stages.

In Mr. Wood’s case, the combination of midazolam and hydromorphone appears to have produced sleep and depressed breathing, exactly as predicted. As time went on, and his breathing became slower and less effective, the amount of oxygen in his bloodstream inevitably decreased to dangerous levels, and the amount of toxic carbon dioxide increased. When that happens, the heart eventually starts to beat erratically, and cardiac arrest leading to death is the end result.

How long it will take to die from the effects of midazolam and hydromorphone is impossible to predict, because there are so many variables:  the age and size of the person, how sensitive the person may be to the effects of sedatives, and how much medication was given.

The only thing we can be reasonably sure of is this: Mr. Wood was asleep and unaware during the process of dying.

Since midazolam and hydromorphone don’t paralyze muscles, if Mr. Wood had been awake he would have been able to open his eyes and move around. The fact that he didn’t move or writhe, as Mr. Lockett did, makes a strong case that he was asleep. While Mr. Wood’s slow demise may have been excruciating for witnesses to watch, there appears to be no evidence that he was conscious after the injection took effect.

The cases of Mr. Wood and Mr. Lockett underscore the fact that even with lethal injection, execution may not be fast or painless for observers to watch. As pharmaceutical companies become even more reluctant to provide medications for the purpose of execution, we can expect to see more experiments with different combinations of drugs.

No one should be surprised if these experiments don’t go smoothly.

Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

American surgeons in 1918 started a system of reviewing hospitals because they were rightly concerned about serious differences in quality of hospital care and standards of practice. They wanted to evaluate hospitals objectively and motivate substandard ones to improve. In 1951, the American College of Surgeons joined forces with the American Medical Association, the American Hospital Association, and other corporate members to form the Joint Commission for Accreditation of Hospitals (JCAH).

As the organization’s scope of activities expanded, the name was changed in 1987 to the “Joint Commission for Accreditation of Healthcare Organizations” (JCAHO), commonly referred to as “Jay-co”, and then shortened to “The Joint Commission” in 2007.

The federal government didn’t pay much attention to healthcare quality until President Johnson signed the law creating Medicare and Medicaid services in 1965. Since the Joint Commission was already in the business of accrediting hospitals, the government decided to take advantage of the private sector’s expertise. Any hospital which passed Joint Commission review would be “deemed” worthy to take part in the Medicare and Medicaid programs.

Paying the Joint Commission to review their hospitals became much more attractive to hospital administrators once Medicare dollars were at stake, so more and more hospitals signed up. Today, the Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs, encouraging them to feature its “Gold Seal” on their websites and advertisements.

A few competitors, such as the international firm DNV GL, have started to make inroads in the lucrative business of accrediting hospitals, but for the time being the Joint Commission holds a virtual monopoly in the U.S.

As recently as 20 years ago, a Joint Commission review was a benign experience for hospitals. The reviewers identified flaws or oversights that weren’t obvious, and made recommendations that actually improved processes of delivering care. Reviewers wouldn’t have dreamed of coming into the operating room during surgery.

As time passed, though, the low-hanging fruit was picked. Hospitals made major corrections, and national standards for many processes, such as sterilization of surgical instruments, were implemented. Hospitals across the country embraced the concept of continuous performance improvement.

Moving the targets

How could the Joint Commission stay in business? One answer is obvious: it can reinvent itself indefinitely by changing the rules and moving the targets.

Here’s a real-life example.

The Joint Commission decrees that syringes containing medications should be labeled with the name of the drug. No, that’s not good enough. All syringes should be labeled with the exact concentration in mg/cc as well as the name of the drug. That’s not good enough either. All syringes should be labeled with the drug name, the concentration of the drug, and the date and time they were drawn up. No, wait. They should be labeled also with the initials of the person who drew them up. And some medications should be labeled not with the time the drug was drawn up, but with the time it expires.

There is nothing to stop the Joint Commission from changing its rules ad infinitum,  guaranteeing reviewers jobs for life, and worsening the stress on hospital staff. While an external review could serve a useful function by sharing ideas and offering solutions, today it only scans for inconsequential details to cite as flaws.

Follow the recipe or treat the patient?

The Joint Commission benefits from the popularity of “evidence-based medicine” as a healthcare concept. Certainly it’s wise to use research evidence to guide healthcare decisions. But when the Joint Commission declares that evidence supports one treatment or medication as a standard of quality in healthcare, it forces clinicians to follow that recipe. If they don’t, the hospital will score poorly on its next review.

What if the quality of the evidence turns out to be poor?

Experienced physicians tend not to change their time-tested practices based on the latest study, as they’ve seen over and over that new data often fail to support an initial widely-publicized finding. They wait to see if the evidence can stand up to larger studies and closer scrutiny.

When you are a patient, you expect your physician to treat you as an individual. It makes sense to use research evidence as a guideline, not as a standard. For example, one Joint Commission standard of care is to give antibiotics for only 24 hours after surgery. This standard is tracked, and doctors are held accountable for meeting it.

But if you are a patient with diabetes or a poorly functioning immune system, you might be at higher risk for infection. You might prefer to trust your doctor’s judgment about how long you should be on antibiotics, without the specter of a Joint Commission review affecting the decision.

Physicians are pushing back against inflexible rules, realizing that they are management-driven, not patient-centered. Many patients have more than one medical problem. The application of a standardized protocol for one disease or condition may worsen another one. It takes physician judgment, and the knowledge of the patient as an individual, to make the best decision under the circumstances.

Meanwhile, at my hospital, the level of tension is rising as we anticipate Joint Commission review within the next few weeks. Experienced nurses are pulled away from patient care to make mock review rounds. Department chairs circulate memos about minute details that could trip us up. One chairman concluded succinctly, “These people are not your friends.”

As you think about the amount of the American GDP that is devoted to health care, remember that physicians and nurses would rather spend their time looking after patients than worrying about the next Joint Commission review.

And take my advice–stay out of the hospital if you possibly can when the Joint Commission’s reviewers ride into town.

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The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license.”

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time. Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which many non-medical people wouldn’t consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart. This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

(Just for fun, I sent an email one day to the head of environmental services at my hospital, asking if the cleaning crew could attach a new suction canister to the anesthesia machine after they remove the dirty one from the previous case. The answer was no. His reasoning was that this would delay the workflow of the cleaning crew.)

Then I checked the circuit on the anesthesia machine, assembled syringes and needles, and drew up medications for the case. To each syringe, I attached a stick-on label with the name of the medication, and wrote by hand on each label the date, the time, and my initials. These tasks, as you might guess, don’t require an MD degree either. A pharmacy can issue pre-filled syringes, and clever machines can generate labels with automatic date and time stamps.

It was now 7 a.m., and I moved on to the preoperative area to meet my first patient. I introduced myself, and started to interview her. Then I noticed that no one had started her IV yet. I asked the patient’s nurse if he would set up the IV fluid, which had already been ordered via the electronic medical record. “If I have time,” he replied.

The nurse, in fairness, was busy with his own tasks—few of which required a nursing degree. He was doing clerical data entry in the computer, recording answers to a host of questions such as whether or not the patient had stairs in her home. In between, he was answering the phone, as there is no desk clerk to pick up the phone or check for incoming faxes.

So I got hold of a liter bag of IV fluid, spiked it with sterile tubing, and flushed the air out of the tubing. Then I did my first clinical care of the day, inserting an IV catheter into a vein in the patient’s hand. For the record, IV starts are well within the scope of nursing practice and don’t require a physician.

Finally, at 7:07, I began my clinical assessment of the patient’s readiness for anesthesia, which was the first activity that approached working at the top of my license. Multiply the 22 minutes I had already spent doing lower-level tasks by hundreds of cases per year per physician, and you’ll start to see what a colossal waste of resources is occurring every day.

Not just at my hospital but also at hospitals nationwide, administrators have pared back support staff in an effort to cut costs.  Their reasoning appears to be that lower-level support staff can’t do more advanced tasks, but their work can be “rolled into” what physicians and nurses do.

A nurse, so this thinking goes, can easily answer a telephone during idle moments, though most nurses I know would laugh bitterly at the idea that idle moments occur very often. A physician can type on a computer keyboard and enter data while doing a patient’s physical exam, regardless of how much extra time this takes compared to dictating the same information. Don’t think about how much the need to focus on the computer screen detracts from the doctor’s personal interaction and eye contact with the patient.

Bureaucrats and administrators advocate “practicing at the top of the license” as a not-too-subtle way of enabling healthcare workers with lower-cost skills to replace physicians. An alarming example of this is the Veterans Health Administration’s recent attempt to change VA rules so that advanced practice nurses could work without any physician supervision at all. Vigorous opposition from veterans’ advocates has stymied this initiative so far, but it could rise again.

These same bureaucrats and administrators eliminate lower-paid personnel—desk clerks, transport orderlies, and dictation typists, for instance—to trim their budgets.  Apparently they have no concern for how much they prevent physicians and nurses from truly practicing at the top of their licenses.  Someone still has to do the tasks that were previously done by those employees, and that someone, too often, is a physician or nurse.

The next time you wonder where your healthcare dollars are going, remember this: your physicians and nurses would like to spend more time taking care of you. But they may be too busy doing other things.

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I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

Not for amateurs

Though lethal injection is supposed to be more humane than the electric chair or the gas chamber, often it doesn’t work as planned. Mr. Lockett died on April 29 after the injection of midazolam, vecuronium, and potassium chloride into his system. It is unclear from media reports how much of which drug he actually received. Apparently, prison staff had difficulty finding a vein. The drugs were injected, they thought, into the large femoral vein in Mr. Lockett’s groin, and should have killed him within moments.

But witnesses reported that Mr. Lockett was still groaning and trying to breathe for over 40 minutes before he died. The medications probably were deposited into his muscles and soft tissues rather than entering the bloodstream directly. As they were slowly absorbed, they probably caused muscle weakness, air hunger, agitation, and gradual suffocation before Mr. Lockett’s heart finally stopped.

Lethal injection, to be done right, should be done by physicians who are experts in getting needles into veins, and in giving anesthesia drugs. Logically, anesthesiologists would be the first choice. A bipartisan panel of criminal justice experts in Washington just released a major study on the death penalty, and says, “The proper administration of anesthesia is crucial to the humane execution of an inmate.” But the American Society of Anesthesiologists and the American Medical Association agree that a physician, “as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

I can’t imagine intentionally doing harm to a helpless person under my care, no matter how vicious a crime he might have committed, any more than I could harm one of my children. When a gunshot victim—usually a young man—is rushed to surgery, I don’t want to know if the police think he was an innocent victim or a shooter himself. My task is to take care of him, not to judge.

So if lethal injection is to continue, the task will fall to others, not to anesthesiologists. Some well-meaning people want to make the process better. They argue in favor of using a single anesthetic drug, such as thiopental, in a large enough dose to produce death without needing other drugs to paralyze breathing or stop the heart. But that would still be practicing medicine. The drugs must be obtained under a physician’s prescriptive authority, and the technique of injecting them into a vein requires medical training even if it’s delegated to a nurse or a technician.

Other options?

No doubt some readers will think that I must be a bleeding-heart Los Angeles liberal. They would be wrong. I’m a Texas native, and earned the rank of major in the US Army Reserve. I know how to shoot a gun, and am not a bit squeamish. There’s no doubt in my mind that I would be capable of violence against anyone who physically threatened my family.

My purpose is not to argue for the abolition of the death penalty. The Constitution leaves that decision up to each state. My argument is that capital punishment should not involve either the misuse of medical techniques and drugs, or the practice of anesthesiology by people who are not qualified to do so. Anyone who supports the death penalty shouldn’t flinch at considering other options, and I’m sure modern technology could come up with an electric chair far superior to the ones of the past.

If a needle is still preferred, I’m surprised no one has considered the option of air embolism. The injection of a large volume of air into the heart will stop the circulation very effectively, just like an air lock in your fuel line. The technique is quite simple; it involves no drugs and little teaching. Find a large syringe and attach a long needle—three inches or so is best. Draw air into the syringe. Insert the needle under the breastbone in the direction of the left shoulder, aiming down at a 30-45 degree angle. When blood starts to fill the syringe, inject the air forcefully into the heart. Repeat if necessary. (For a practical demonstration of the injection technique, see the movie “Pulp Fiction”.)

Too gruesome? I thought it might be, but let’s face facts. No execution—taking the life of an unwilling person by force—can be truly humane.

Lethal injection has the highest failure rate of all methods of execution due to its technical complexity. Today it is often difficult to obtain the proper medications since many corporations don’t want to supply drugs for that purpose. No other method of execution attempts to hide behind white-coat respectability and pretend that it’s neither cruel nor gruesome. No other method of execution dishonors the profession of medicine and the pledge to do no harm.

Perhaps life imprisonment without parole isn’t such a bad alternative.

The Dark Side of Quality

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Nobody stands up to argue against quality and value in healthcare. You might as well argue against motherhood, or puppies. Yet many physicians are inherently skeptical of definitions of “quality” that are imposed from above, whether by outside evaluators like The Joint Commission, or (worse) by the government.

There’s good reason for skepticism. Some of the “evidence” behind “evidence-based medicine” has turned out to be flawed, tainted by financial conflict of interest, or outright fraudulent. Any experienced physician knows that there are fads in healthcare just as there are in fashion, and today’s evidence-based medicine may be tomorrow’s malpractice. Let’s take a closer look at what’s really going on in the world of quality metrics, and why it matters if payments to you and your hospital are increasingly linked to how you score.

Surgical Site Infections

The financial toll of surgical site infections (SSIs) is huge, estimated in the U.S. at more than $10 billion a year.(1)  A recent retrospective review from the Veterans Affairs Surgical Quality Improvement Program showed that the majority of SSIs are diagnosed only after hospital discharge, and that 57% will require hospital readmission within 30 days.(2)  The Centers for Medicare and Medicaid Services (CMS) stopped paying for care related to SSIs in 2008 by designating them as “never events”, or non-reimbursable serious hospital-acquired conditions. Now SSIs are part of a long list of hospital-acquired conditions that can result in reduced CMS payments to hospitals, and will bring further reduction in payments over the next several years with the implementation of “value-based purchasing”. More than 1400 hospitals will see their Medicare payments cut by as much as 1.25% this year–a margin that could spell financial disaster for hospitals already struggling.(3)

You may already be among the more than 50% of anesthesiologists who have been reporting performance metrics to the Physician Quality Reporting System (PQRS), which is administered by CMS. When the system started in 2007, CMS offered a bonus payment of 1.5% for successful participation, but that soon shrank to 0.5% and will be discontinued after 2014. Starting in 2015, CMS will impose a 1.5% payment reduction for physicians who do not participate in PQRS, and will push the pay cut to 2% in 2016.

If you participate in PQRS reporting, you know that two of the measures that anesthesiologists report are directly aimed at SSI prevention: perioperative temperature management, and antibiotic timing. PQRS measure #193 specifies that the patient must receive “active warming” or have a temperature above 36C recorded within 30 minutes before or 15 minutes after anesthesia end time. Measure #30 specifies that prophylactic parenteral antibiotics must be administered within one hour before skin incision. Compliance with these two measures isn’t hard to achieve, though no one seems to question the cost to the American healthcare system of all those forced-air warming blankets and machines, or ask why giving antibiotics 61 minutes instead of 59 minutes before skin incision is an automatic “fail”.

But have CMS threats and PQRS compliance done any good? A just-published editorial in Anesthesiology concluded: “Despite early efficacy literature establishing the value of specific antibiotic timing and active warming, repeated large database analyses have not observed robust effectiveness across hundreds of hospitals.”(4)   Simply put, as many of us have noticed in our own hospitals, SSI rates have remained about the same.

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Nepal? I don’t know anyone in Nepal. Yet not long ago I received a courteous email from a physician there, asking my permission to translate an article of mine into Nepali. The topic: advice for older patients who need anesthesia. He wants to distribute it to patients and publish it in his local newspaper.

I asked how he came across the article. He was browsing online among anesthesia blogs, and found mine, “A Penned Point“. Now “blog” isn’t a word Jane Austen would have recognized. It is a lumpish merger of “web” and “log”, and is generally defined today as a website on which an individual records opinions. The proliferation of blogs–like Tribbles–may be seen as a pernicious trend, but it demonstrates the power and reach of the Internet. Business Insider estimates that 22% of the people in the world own smartphones, an increase of 1.3 billion smartphones since 2009. In social media, once you put content out, you have no idea how far it will travel.

Many physicians consider social media a frivolous waste of time. Certainly they can be horribly misused–think of the cyber-bullying that goes on among teenagers. But used wisely, social media can be valuable communication tools. Here follows a brief guide to social media for physicians, admittedly subjective, with caveats included.

The doctor with an opinion

We all have opinions. Occasionally, we want the world to know about them. If you want to publish an opinion column and don’t want to create your own blog, there are online sites where your submission may be welcome. Probably the best-known public site for medical topics is KevinMD, which is curated by Dr. Kevin Pho, a New Hampshire internist. He came early to the game, starting his blog in 2004, and now has over 1000 regular contributors, myself included. You can submit a 500-700 word piece on almost any topic within medicine, aimed at an audience of physicians or at the general public. There’s a good chance that if you can put together a coherent sentence, Kevin will find a place for it. Brace yourself for the comments: Kevin’s readers tend to hold opinions as strongly as the writers do.
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“The creatures cause pain by being born, and live by inflicting pain, and in pain they mostly die.”–C. S. Lewis

The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic: “Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction. As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital. The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

Now hospital payments are at risk too.  Beginning in 2002, the Centers for Medicare & Medicaid Services (CMS) began work with the Agency for Healthcare Research and Quality (AHRQ) to develop a standardized survey of patients’ perceptions of hospital care, now known as the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Press Ganey submits HCAHPS data to the government on behalf of its many clients. At first, the HCAHPS survey was intended as a tool to allow objective comparisons of hospitals on topics important to consumers, including:

How well doctors and nurses communicate with patients
How responsive hospital staff are to patients’ needs
How well hospital staff manage patients’ pain
Whether key information is provided at discharge.

But since 2007, hospitals that fail to report “required quality measures”, which include HCAHPS results, receive less payment from CMS. The government’s “Value-Based Purchasing” program bases only 70% of hospital performance scores on actual clinical care, and a full 30% on the HCAHPS survey’s report of the “patient experience of care”–including patient satisfaction with pain management.

“Never deny a request”

A patient who isn’t pleased with the experience of care may give bad marks overall, whether the problem was a long wait or a doctor who doesn’t heed requests for a medication or a test.  But any physician who is associated with the low scores will earn the ill will of hospital administrators, who fear reduction of the hospital’s already slim Medicare/Medicaid payments, and of the CEO, whose salary incentive component may be at risk too.  Never mind that Press Ganey scores are often based on small numbers of returned questionnaires, too small to be statistically significant.

Do these pressures affect how physicians deliver care? It would be surprising if they didn’t. A family physician, Dr. William Sonnenberg, wrote recently, “The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” He believes Press Ganey “has become a bigger threat to the practice of good medicine than trial lawyers.”

The Atlantic published a recent article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.” The author, Richard Gunderman, highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.” Patients often visit multiple emergency rooms and physician offices asking for narcotics, Gunderman reported, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.” Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.

Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A recent study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs. A prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality.

Forbes writer Kai Falkenberg, in her article “Why Rating Your Doctor Is Bad For Your Health,” concluded that “giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.”

Today, over 12% of primary care visits and over 32% of emergency department visits involve opioid or benzodiazepine prescriptions, according to the results of a study presented last month at the American Academy of Pain Medicine’s annual meeting, and these rates are steadily increasing. The study’s co-author, Dr. Ming-Chih Kao, said that between 1999 and 2006 there was a 250% increase in fatal overdoses in the US, and more than half involved more than one drug, usually opioids and benzodiazepines. Patients may lack resources to cover services like physical therapy and mental health treatment, and they urge physicians to prescribe opioids and benzodiazepines instead.

Unintended consequences

The recent history of opioid use and abuse in the US illustrates how well-intentioned actions so often have unintended consequences. There was a time when physicians hesitated to prescribe opioids even for cancer pain, let alone non-malignant pain, for fear of addiction. That philosophy started to change in 1986, when Dr. Russell Portenoy published a paper in the journal Pain concluding that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.” Pharmaceutical companies began to promote new formulations including OxyContin for the treatment of pain.

A major upswing in the government’s interest in pain management followed in the 1990s, as the AHRQ issued guidelines advocating more aggressive treatment of pain. In 1998, the Veterans Health Administration premiered a national strategy intended to improve pain management for its patients, and defined “Pain as the 5th Vital Sign”. The new strategy required use of a numeric rating scale for pain in all clinical encounters. The Joint Commission quickly added the achievement of low pain scores to its measures of hospital quality, and issued a major monograph in 2003 called “Improving the Quality of Pain Management Through Measurement and Action.” CMS began to rate hospitals on the basis of patient satisfaction scores, and the rest is history.

Now political pressure in the opposite direction–against narcotic prescription–is escalating, as the Centers for Disease Control and Prevention is urging doctors to use opioids more sparingly. The state of Washington passed a law restricting opioid prescription, and other states are considering similar measures, while patients with chronic pain scramble to find treatment. In 2010, a new formulation of OxyContin was introduced in order to make it more difficult to dissolve or crush. The result, reported in the New England Journal of Medicine in 2012, was that the selection of OxyContin as a primary drug of abuse decreased, but the abuse of other opioids–including fentanyl, hydromorphone, and heroin–rose markedly.

Physicians are caught in the vise between patient satisfaction surveys and the epidemic of prescription drug abuse and overdose. Government and regulatory intervention, as well-intentioned as it may have been, has only led to worse problems and disastrous outcomes. Fed-up physicians are leaving clinical medicine for jobs in hospital administration, consulting, or industry wherever they can. Is anyone surprised?

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We hold these truths to be self-evident:

A hospital administrator with a clipboard is in search of a physician who isn’t following “evidence-based guidelines”.

There are fads in medicine just as there are in fashion—today’s “evidence-based medicine” may be tomorrow’s malpractice.

Did your hospital, like so many, abruptly switch from povidone-iodine antiseptic solution to ChloraPrep® for cleaning a patient’s skin before surgery?  If so, I’m sure the staff was told that ChloraPrep would be more effective and cheaper.  No doubt, they were also warned of the extra precautions that must be taken with ChloraPrep to prevent operating room fires, since ChloraPrep contains highly flammable 70% isopropyl alcohol in addition to chlorhexidine.  Even the fire risk apparently wasn’t enough to make hospitals think twice before switching antiseptics.

You (and your hospital’s staff) may not have heard this news. The US Department of Justice (DOJ) announced last month that CareFusion Corp. would pay the government a $40.1 million settlement to resolve allegations that the company violated the False Claims Act by paying kickbacks to boost sales of ChloraPrep and promoting it for uses that aren’t FDA-approved.

Who received kickbacks?  According to the DOJ’s press release, the complaint alleged that “CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses, and recommends standardized health care performance measures and practices.”  Another physician with close ties to CareFusion, Dr. Rabih Darouiche, was the lead investigator on a 2010 NEJM article which concluded (not surprisingly) that Chloraprep was “significantly more protective” than povidone-iodine against surgical site infections.

The Leapfrog Group, launched by the Business Roundtable in 2000, claims that its hospital survey is “the gold standard for comparing hospitals’ performance on the national standards of safety, quality, and efficiency.”  On January 30, Leapfrog announced that it accepted the resignation of Dr. Denham, who had served as chair of Leapfrog’s Safe Practices Committee since 2006, amid concerns that Dr. Denham had failed to reveal his “potentially compromising relationship with CareFusion.” At the same time, Leapfrog said it would undertake “a thorough scientific review of its full slate of endorsed safe practices.”

Are you still feeling good about evidenced-based medicine?

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No HIPAA for us in healthcare

badge of shame

We guard the privacy of patients in my hospital zealously—we take care of a lot of celebrities since we’re right in the shadow of Beverly Hills.  And of course we live in terror of HIPAA violations, those federally mandated HHS rules that protect individually identifiable healthcare information and could bring down “civil money penalties” upon us if we don’t keep our patients’ medical records strictly confidential.

But for healthcare workers—physicians, nurses, technicians, even medical supply vendors—in LA County, the usual privacy rules don’t apply any more.  Now everybody gets to know at least some of our medical history:  whether or not we’ve been vaccinated against influenza.

How will anyone know whether or not I’ve had this year’s flu vaccine?  Because policy dictates that I must publicly say so, whether I want to “out” that information or not.

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