The Ethics of Money in Medicine

Many doctors have patients that are not able to manage the expense of drugs prescribed to them. The sad truth is that some of these patients end up in the emergency department with an exacerbation of their illness or condition because they could not afford their medicines and therefore did not take them. Providers, having a responsibility to care for patients, cannot ignore this problem. Controversial relationships created by drug company representatives, outrageous expenses for advertisements of public policy, and outlandish executive compensation are driving healthcare costs up and providers cannot merely ignore or accept these factors. It's easy to fall into the trap of wanting to patronize someone who's buying you lunch or giving you new pencils, but this can put patients at a great disadvantage. For example, when a physician prescribes medications of questionably better efficacy (name brand drugs) that are more costly than generic drugs, just because they choose to support the drug rep who brings them breakfast once per week, this is not good for the patient.

Prices of some top-selling prescription medications have increased astronomically in a short span of time. For instance, 60 Minutes reported about the rise in the price of Gleevec, a cancer drug from Novartis, that rose to $90,000 per year from $24,000 per year. What could have caused such a leap? Bloomberg Business reports that some top-selling prescription drugs have increased as much as 841% over the past seven years. Are you aware that after the FDA approves a drug, Medicare is legally mandated to pay the drug company's asking price? Picture the lobbying that was behind that legislation!

What do you think of the increasing costs of prescription drugs? What is your alternative? Let us know!

Some Good News: Hospitals become Healthier

In 1999, The Institute of Medicine issued a study highlighting the dangers of hospitalization, particularly illness or injury caused by treatment or by medical evaluation. The report called for a comprehensive effort to lessen hospital errors that resulted in death by 50% in five years. Five years later, the goal wasn't satisfied; nonetheless awareness of the situation rallied the healthcare industry to make modifications which are finally showing results.
Measurements of patient safety have been set up to properly gauge the issue. To ensure continuing improvements, we must be able to assess the expenses of patient injury along with the reliability of existing techniques. Patient safety targets must be measured using solid data from the field.
A recent report from the Agency for Healthcare Research and Quality showed that we are improving.  Iatrogenic events (illness caused by medical evaluation or treatment) decreased 17% between 2010 and 2013.  The report revealed considerable declines in pharmacy errors including preventable allergic reactions and dosing with the incorrect medication. Pharmacy errors were reduced by 40% in the 2010-2013 time frame. Another significant section of enhancement was in a decreased likelihood of catheter infections and bedsores. Unfortunately, it remains unclear which important modifications contributed most towards the decrease in iatrogenic harm; though the cost savings are obvious. The savings to Americans were more than 12 million dollars throughout the reporting period. Closer investigation into what factors led to the most improvements in patient safety will hopefully lead to improvements and cost savings for the entire healthcare system.

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Trending: The Opioid Free Emergency Department

The epidemic of opioid abuse in the USA is undeniable. Prescriptions of opioid pain relievers have grown to approximately 207 million prescriptions in 2013 from 76 million in 1991. The United States is the biggest global consumer accounting for 81% of oxycodone prescriptions and nearly 100% of hyrocodone prescriptions internationally. The amount of deaths from prescription drug overdose has more than quadrupled since 1999 and is now one of the leading causes of death in the United States estimated at 114 deaths daily. Therefore, prevention is key to halting this alarming tendency.
Public policy reform of prescribing practices is necessary to reduce the out of control use of addictive analgesics. Physicians seem ready to face these pain management practices and explore non-opioid strategies to pain relief in the emergency department according to discussions at a recent conference of the American Academy of Emergency Medicine 21st Annual Scientific Assembly. A totally opioid ED is probably not realistic, however exploration of alternatives may supply a solution to the routine prescription of opioids in the ED and beyond.

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Recording Your Doctor Visit – Is that OK?

Anyone with a Smartphone can record their doctor's appointment with or without the physician knowledge or the physician's permission. There are lots of reasons that patients have to record a visit including to share the information with a caregiver or family member, to remember or refresh the recommendations given, and to review it in a more relaxing environment. Many doctors are opposed to being recorded for fear that the recording will be used in a lawsuit (possibly even edited to present only part of the dialogue), along with the very fact that the doctor-patient relationship is confidential. Most doctors say they'd refuse to be recorded if asked.

In most states it is legal to record an in-person conversation without getting consent from everyone present. Thus, even if your physician refuses to be recorded, you can legally still do it (check your state laws first). Some doctors feel trust is violated by these recordings and they would immediately terminate the doctor-patient relationship if they caught a patient recording an appointment. Some offices have posted warning signs or have written statements regarding the office's "no recorded visits" policy. Other physicians, however, do allow recordings and some even encourage it. These physicians believe that if you're practicing good medicine you have nothing to worry about. Patients that can review a recording later may follow recommendations and guidance more thoroughly. In some physician offices, all appointments are being recorded for the patient. In such instances, problems about partial or edited recordings being presented in court no longer apply. Having these recordings that are complete could prove useful in defense of any malpractice lawsuit as the advice to document everything will ultimately have been completely complied with.

We work at the intersection of medicine and the law.  Please don’t hesitate to contact us if you have any questions about our services!

Impaired Physicians: Whose Responsibility is it?

Addiction affects approximately 10% of the general population at any one time. Doctors are affected by addiction at a comparable rate. Addiction affects all facets of a person’s lifestyle – marriages are ruined, private lives crumble, and work performance suffers. It is the work performance that troubles people the most since an impaired physician may cause a whole lot of injury to others. Physician health plans (PHPs) have been in place in many states to aid doctors afflicted with substance abuse. They're able to give treatment and assistance to help the physician maintain his/her career. They also can offer future follow-up and monitoring of the physician. PHPs have a wonderfully high success rate for doctors around 80-90% long lasting success. The reasons for this large achievement rate involve highly motivated patients, rigid adherence, and long-term follow-up and monitoring. However, the use rates for these PHPs is quite minimal, most likely because of worry about these organizations reporting back to state licensing boards, concern with disciplinary action, losing one’s license, and career damage. Since PHPs do not generally report back to licensing boards such fears are unfounded.
Physicians often ignore or do nothing if they suspect there is a colleague suffering from substance abuse for concern with damaging his/her career. Physicians can also be very cautious to turn to a PHP by themselves. Generally, colleagues, businesses, or couples are the people to start the treatment. Luckily, following the development of PHPs, significant serious preventable events due to impaired physicians has dropped greatly and many physicians are referred to PHPs for before a major event can occur. If a major event does occur, the AMA established precedence a long time ago stating: “it is the physician’s ethical responsibility to take cognizance of a colleague’s inability to practice medicine adequately by reason of physical or mental illness including alcoholism and drug dependence.”

Please let us know what experiences you have had with repercussions of not reporting a physician who is impaired due to alcohol or drugs.

Physician Burnout Reaches Epidemic Proportions

Approximately 18 months ago I hung up my stethoscope and retired from my occupation as a primary care internist. I was miserable and disillusioned with my precious area of medicine. The increasing levels of bureaucratic tasks and documentation, too little time to spend with patients, and pay that was not consistent with my years of training and education made me, simply, burned out. According to a new report by Medscape, burnout is commonly signified by a loss of excitement for work, feelings of cynicism, and a low sense of achievement. Burnout happens when someone experiences constant stress with no capacity to recover from it day to day. By all measures, burnout is growing rapidly. Rates are being reported by survey results among doctors from 30 to 65%. Trends demonstrate that physicians in primary care or emergency medicine have the highest rates of burnout.
The effects of burnout are extremely real. Doctor suicide rates are higher than the overall public. Suicide is also the second leading cause of death among medical students. Other effects include diminished quality of care, loss of doctors in the profession, divorce, addiction, and severely diminished quality of life.
Many physicians are feeling the stress of bureaucratic pressure and the loss of autonomy resulting in animosity of the present practice environment. Political uncertainty, the danger of lawsuits, struggles for monetary compensation for services, and also the pressure to deliver the very best patient care despite these challenges, are some of the factors which may lead to burnout. Many physicians feel admission of depression or inadequacy can be career ending. The self reliant culture of medicine doesn't support taking care of oneself. There are methods to reduce stress, but it is unlikely that burnout will go away until doctors can recover some element of control over the system in which they work.

Please share your physician burnout experiences with us.  Can it lead to compromised patient care and medical malpractice

Attitudes Toward Medical Malpractice: A History

The first known case of medical malpractice involved a breach of contract litigation between a patient who sued a doctor that repaired a badly maimed hand, but did not meet expectations. The judge in that case set out some basic principles in medical malpractice:  If a patient is injured as a result of physician negligence, the physician is liable. However, simply being unable to heal a patient does not represent medical malpractice. The term "medical malpractice" wasn't coined until 1765 in England describing neglect or unskilled practice by a doctor that ultimately leads to harm.
Starting in the 1840s, malpractice lawsuits became more common as the physician started getting the blame for poor medical outcomes. Reasons for this included: the citizenry had discarded beliefs about God being in charge of poor outcomes, poor medical training, and also no medical standards.  The American Medical Association was formed in 1847 and began developing standards of medical care. The doctor's performance could then be measured against these standards which actually encouraged more patients to sue. Many patients began hoping for monetary judgments even if they did not actually believe the doctor was at fault.
Improvements in medicine fueled, and continue to fuel, malpractice lawsuits. Patients who before may have simply been thankful to survive, began to anticipate being cured, not just being happy to be alive -- being alive, but disabled wasn't good enough. Malpractice suits are likely when patient expectations exceed what medicine can produce. For example, lawsuits over obstetrics are considerably more common that litigation over geriatric medicine. Many folks acknowledge that modern medicine hasn't promised a cure for old age, but feel that a risk free delivery and a healthy infant is assured. Sadly, medical advances can lead to a rise in medical legal problems as patient become more demanding and unrealistic results are expected.

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