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Clinical Issues

Hospitals With Robots Do More Prostate Cancer Surgery

Hospitals that buy surgical robots end up performing more prostate cancer operations, suggesting that technology has become a driving force behind decisions about men’s cancer care, new research shows.

The study, published in the journal Medical Care and explored in the New York Times, is the latest report to suggest that how men are treated for prostate cancer appears to be influenced by a variety of factors, including the technology and marketing goals of hospitals and doctors, rather than scientific evidence on benefits and risks.

The new study, conducted by researchers at New York University and other institutions, was a fairly large one, tracking surgical robot purchases at 554 hospitals, along with the treatment given to more than 30,000 men given a prostate cancer diagnosis from 2001 to 2005.

Interesting notes:

  • Buying a robot led to an average increase of 29 operations a year per hospital.
  • Hospitals that own a surgical robot may be that the technology helps a hospital lure potential surgical patients away from the competition.
  • The data also suggest that once a hospital obtains a robot, patients who might be candidates for non-surgical options are more likely to be steered toward robotic surgery instead.
  • A surgical robot used for prostate cancer costs $1 million to $2.25 million, according to the N.Y.U. study. In addition, hospitals spend $140,000 annually for a service contract and $1,500 to $2,000 per patient on disposable instruments.

The researchers found that treatment patterns varied markedly across the clinical sites studied, and those differences could not be explained by measurable factors like severity of disease or patient age. Read more…

Revisiting IME Ethics and standards

Revisiting IME Ethics and standards

As founder of MCN and a practicing physician, I am proud of what we do as a company and hold high expectations for ourselves, our consultants and indeed our clients. I write this note with a bit of trepidation, but I have never been known as one to shrink from issues.

What I am addressing is by no means the norm in many or most cases, but there are ethical situations that should not be part of our industry, even at the smallest level. Please review this post in the spirit that it is meant – to improve what we do. Please don’t shoot the messenger. But by all means, feel free to comment on this posting, or privately to me.

It has been almost two years since a major expose in the New York Times regarding certain practices in that region.  For those who wish to read this series, please visit:

http://topics.nytimes.com/top/reference/timestopics/subjects/w/workers_compensation_insurance/index.html this page has all the links. Here are links to the individual articles over 3 days:

http://www.nytimes.com/2009/03/31/nyregion/31comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/01/nyregion/01comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/02/nyregion/02comp.html?ref=workerscompensationinsurance

To my knowledge the matter to a large degree “blew over” in that I am not aware of any significant regulatory or other outcomes on this issue or sanctions against the company featured, though I have heard that they have changed names.

I believe that it may be time to revisit standards in performance of IMEs, especially in regions of the country where we have observed that certain practices that we regard as improper and indefensible may indeed continue to be practiced by certain consultants and IME companies. Not asking, for example, how it can be that they receive and accept examination reports at price points, length and quality that would not be possible elsewhere in the country.  All clients deserve the highest quality standards from those they rely upon for important services, which in the case of IME’s means unbiased, thorough, evidenced-based assessments performed by engaged and dedicated consultants.

With recent disruption in the industry, including a very large consolidation of a number of smaller companies, it is our hope that those who oversee large numbers of IMEs will endorse some or all of the points we are raising, and take appropriate actions in their own companies to insure integrity in all exams. Likewise all doctors who examinations must perform at the highest medical standards and not allow a lower standard for IME’s.

The basic principle is to do right by clients, claimants and society. And since we facilitate medical examinations, let doctors do their jobs properly and insist that high standards be followed and maintained.

Clients who order exams generally receive quality exams, but they should still ask questions if they see possible issues, and use common sense. Doctors who do exams, whocan’t or won’t practice in a way that treats each claim and claimant as individuals, with respect and dignity, give the process enough time, write original reports where critical thinking is employed, and remember why they entered (or should have entered) the profession, should not do exams. There are certain acts that MCN finds unacceptable. We believe all involved in the business should feel likewise and take appropriate measures to ensure that substandard performance does not occur. In no particular order they include:

Exams that are too brief: We believe that a reasonable rule of thumb is that an IME should take no less than 30 minutes— and often much longer—to perform. We generally schedule an hour in our own facilities, sometimes a bit less, but never more than two an hour, and we question at times whether this is optimal. The time must allow for review of appropriate records, a history from the claimant, a focused and appropriate physical or mental status examination, and an original report. We have observed with our own eyes the extreme of the company cited in one of the articles I liked cited above scheduling 12 exams in an hour, with an expectation of perhaps 4 no shows and therefore approximately 8 exams to be done. This timeframe is simply impossible. Further, I think that it is also impossible to do 4 proper exams in an hour. Attempting to cut corners on time does not work; it leads to claimants who feel rushed and not heard, reports that are shoddy, and conclusions that are inarticulate if not inaccurate.

Use of Boilerplate in substantive content areas: The history, examination and conclusions must be original. Templates can provide a framework to follow or serve as an introduction or disclaimer. But the words used in an exam should be original. Measurements should be real and reflect human variation. Normal findings if quantified should reflect a range of normal. While a 90 degree flexion for example, might be normal, normal flexion will be vary from 90 degrees, while still in a normal range. So the number would be expected to not be 90. Yet I have observed reports where normal variation appears absent. No two exams should ever look the same in language when it comes to the history, examination or conclusions.

Reports that are too brief: I am not prepared to state how long an exam should be, but can state with a high level of comfort that an assessment of a complex injury with records to review, a history to cite and an examination and assessment to record generally ought to be more than 2-3 pages.

Ghost-writing of reports or examination performance: It is the physician’s job, and his/her’s alone, to take the history, review records, perform a substantive examination and issue the final report. And it should be the physician contacted for the exam who completes this work. It may not be delegated. While rare, we have seen instances where this is not followed, despite clear guidelines on the matter. The physician must not sign their name on the work of others. While it may be the practice of a particular physician to delegate certain practice tasks, that is not the standard in IMEs, and certainly not something to be imposed upon an unaware client or IME company.

Ordering unnecessary tests, especially when personal or corporate gain may be involved: It is no secret that society has been looking very carefully at real or perceived conflict of interests in medical services. Fortunately our clients call us and ask for exams and we don’t drive the demand. But we do expect that consultants make a determination as to whether a particular study is needed. Interestingly, when it comes to typical orthopedic type examinations, we find that the common frequency of ordering of studies in situations where testing is not on site is less than 5%. However we have learned that in situations where physician practices or certain IME companies have X-ray equipment on site, the incidence of use increases to approximately 35%. This is a massive variable and suggests that something may be amiss. The only indication for a study should be if it is necessary for a quality report. Often it is not, or prior studies are more than adequate. If a consultant is ordering common films uncritically, or clients see this taking place, questions should be asked. We believe that clients should consider exercising the option of requiring approval for studies, to insert a bit of friction in the process, especially if X-rays appear to be a norm with a particular setting, consultant or company.

Think about the New York Times test: The homily that one should never do something that they would not mind seeing on the front page of the New York Times holds true. And as you can see above, aberrant behavior in our field made the front page two years ago. Or to frame this in another manner, don’t do anything in our businesses or tolerate practices that we would not subject our immediate family members and best friends to. Some of what I have observed over the years would suggest that if this were the case, some people really dislike their friends and families, to allow certain practices to not only take place, but persist.

Some of these practices have been defended on the basis that questionable claims and claimants may justify them. To this I only can shake my head. Yes there are questionable claims and claimants but this in no way justifies lowering our standards of dignity and respect for what we do as physicians and companies.

Other justifications have included the belief that this is what the client wants and that they are price sensitive and therefore a hurried approach, done cheaply and below standard is therefore acceptable. I don’t believe that clients want claimants to be mistreated, and while price may be an issue, clients realistically understand that quality does carry a price and one can’t cut corners in key areas and achieve a defensible and acceptable product. I believe there may be business risk in the long-term if questionable practices are tolerated. Also, the practice of medicine is the province of physicians, and just as a client would not tell a doctor how to provide treatment, the client hopefully should rely upon ethical and trained physicians to be the final arbiter on examination performance and quality.

The consequences of inattention to ethical medical examination practices creates an uneven playing field in the provision of IME’s; those who do quality work and those who don’t. Some IME provider will take a pass on work at a price that could only be provided sub-optimally. Fortunately we at MCN and many of our ethical competitors are blessed with great consultants and clients who value integrity in the work they do and the examinations they expect. We as a company will continue to strive for the highest standards of integrity. We invite all consultants, clients and competing companies to set similar bars of expectation.

In closing, I invite a dialogue, comments, even respectful challenges to these ideas. We also may have missed some additional issue and areas bearing attention. Please raise them.

Brian L. Grant, MD

Chair and Medical Director, MCN

What’s in a Name? For Illnesses, it’s Fodder for Debate

A study of chronic fatigue syndrome, published last month in The Lancet, has highlighted how competing case definitions for illnesses and syndromes can lead to confusion rather than clarification — what you see depends on who’s doing the looking — and has stoked a fierce debate among researchers and patient advocates on both sides of the Atlantic as noted in this New York Times article.

“If you recognize something is happening, you need a case definition so you can count it,” said Andrew Moss, an emeritus professor of epidemiology at U. C. San Francisco and an early AIDS investigator. “You need to know whether the numbers are going up or down, or whether treatment and prevention work. And if you have a bad case definition, then it’s very difficult to figure out what’s going on.”

Once a disease can be diagnosed reliably through lab tests, creating an accurate case definition becomes easier. But when an ailment has no known cause and its symptoms are subjective — as with chronic fatigue syndrome, fibromyalgia, and other diseases whose characteristics and even existence have been contested — competing case definitions are almost inevitable.

What does this mean for the patient? Well, quite a lot. As the article notes, treatments could easily vary depending upon which diagnostic measurements a physician were using. In the case of chronic fatigue, some researchers believe that the syndrome is  a psychological condition and patients would benefit from exercise. Other researchers, however, are deeply convinced it is a viral disease and note that the exercise therapy advised by the Lancet study can cause major relapses in people with chronic fatigue syndrome — a claim supported by some patient surveys. Read more…

Sex, Lies and Videotape – and the Internet


We hesitated a bit before posting this. It is not often that we can see a combination in one event that includes the perils of the Internet, workers’ compensation, dishonesty, and perhaps human greed combined with ignorance.

We find these cases interesting on a social level. Typically the amount of money misappropriated in cases like this of probable malingering is in the tens or hundreds of thousands; an amount that would result in criminal charges if a person walked into their employer or someones else’s house and stole it. But in the case of clear and convincing evidence that an individual is faking injury or extent of injury, denial of subsequent benefits or as in this case, payback of prior payments seems more common. What is the difference between this situation and theft and why is prosecution not the norm?

While the majority of claims are valid and respond to appropriate treatment and rehabilitation, cases of fraud and malingering when they occur are costly and troublesome, and underscore at times larger social issues. This case also underscores the value of searching for information about claimants that are not under their direct control in the medical context. Historically this involved surveillance, but as this case demonstrates, the Internet – typically social networking sites, often provides a wealth of intentional or unintentional self-disclosure.

Full Face Transplant a “Success”

 

A man referred to only as Rafael was the recipient of the first full face transplant. The operation, which was done in March, was performed by 30 Spanish doctors in Barcelona. Mr. Rafael underwent the transplant after nine previous operations failed to help his neurofibromatosis, a genetic disorder that caused benign tumors to grow on his face.

Magnetic Brain Stimulation Fights Depression (for now)

When weighing electroshock treatment, one’s mind typically drifts to practices seen in popular films rather than curing depression, but studies going on right now are looking to change that. While all parties may not agree regarding the ethics of such treatments, the facts are in: 14% of patients recovered from depressions in the first trial and 30% in the second.

The big question is what to do next. Doctors can’t agree on how long treatment should last or what sorts of drugs to pair with treatment.

Silk Brain Implant Could Aid Spinal Injuries, Epilepsy

Reuters posted a very compelling article about a silk chip that adheres to the brain that has the potential to help people with epilepsy or spinal cord injuries. The water-soluble silk dissolves onto the brain leaving only the electrodes behind. Going forward, this technology could have the potential to help other disorders like Parkinson’s Disease and Multiple Sclerosis.

“Wellness” – A Word I dislike

The New York Times Magazine of April 18 carried this article that addresses one of my pet peeves – the abuse of our beautiful language. Actually the article is too kind to the word, focusing on the first use and evolution of the term. What benefit is there to a word that has a perfectly fine equivalent called – health?

Wellness has become a buzzword and a marketing term to promote all sorts of expensive maneuvers and services, often in the workplace, to improve the health of individuals, often involving incentives, paid consultants and the like. I have yet to see a scholarly report that establishes the effectiveness of such programs and their cost benefit. I believe it most likely that those who wish to be healthy need no external incentive or program, and are already taking care of themselves, and those who can’t or won’t engage in healthy choices in their lives are unlikely to be significantly persuaded by a workplace program.

How many people are in the dark about what it takes to be healthy, especially adults in the workforce?

Law May Do Little to Help Curb Unnecessary Care

Most of the effort in health reform remains on the payment and access side. The elephant in the room is the treatment side. I believe that this will move to the front of the debate in the very near future.

This recent NY Times article from March 29, 2010 nicely lays out the problem.

As prior postings have suggested, there is little incentive on the part of patients, insurers, or doctors to not over-treat, over-diagnose, use more costly options in general, and in general fail to exercise the common sense and cost/benefit analysis that all of us exercise every day as consumers when it comes to our own dollars. While many may believe that carriers may benefit from saying no, in the aggregate they say yes more than not, and merely pass on the costs in the form of premium increases. And to the degree that carriers are regulated, they may have incentive to pass on costs, which may translate into higher profit when they are accustomed to and permitted to bring a certain percentage of revenue to the bottom line. The more cash that flows through a company, in general the greater the impact and capacity to profit.

A significant flaw in a system that does not have the consumer spending and watching their own money, as the apparent absence of and resistance to regulations that will determine and enforce what will be paid for, if not how much will be paid when it comes to health spending.

I remember years ago when I did hospital work, I crossed out some routine orders on a patient, which included multiple vitamins. The nature of this patient’s problem was such that she had no need for these pills, which were being charged at a rate of dollars for each unit dose. I was called by the hospital administrator and asked to explain myself. I politely told him that I decided what was appropriate for my patient based upon clinical needs, not a routine set of orders. He was most unhappy with me, as I was obviously depriving the hospital of a massive mark-up on this drug, and by questioning and exercising judgment, was seen as a threat to its bottom line.

As gatekeepers physicians have the ability to say no to the optional, the more costly or the clearly not indicated interventions for their patients. If we treated each patient as if the patient was paying out-of-pocket, we would take better care of them. But we also know that we may face unhappy patients, defections from our practice, pressure from colleagues, hospitals, vendors and perhaps a decreased income. Threat to income is especially significant when it comes to the procedures that we perform ourselves.

So we will trash, dismiss, or ignore studies, guidelines and mandates that may bring common sense and cost-containment to medical care. The increases in premiums will keep on coming and the US health bill will remain a 6th of our economy rather than the more modest 9th or so of many other developed countries. To not go along to get along is a bit like tilting at windmills.

By the way, some will cite liability concerns as rationale for many of the excesses, especially diagnostic procedures. While this may be true in part, I believe it is a flip remark that at best is a small part of the problem. Physicians exercise discretion regularly, and accepted standards of care will support a well-reasoned decision to not do something just as it may require that something be done. That is the nature of malpractice litigation – physicians having to defend themselves for their decisions. Having reviewed many an NPDB report, the majority of lawsuits have to do with a bad outcome from something other than failure to perform a particular test.