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Sociology and Language of Medicine

Skin in the Game – Hospitalists Resisting Outsourcing

by Jen Jenkins

There was a time not long ago, circa the mid-1990s, when the term “hospitalist” did not exist. Doctors worked in hospitals only periodically, attending to their patients when necessary. It wasn’t until economic pressures and a push for efficiency in healthcare created “the hospitalist boom” that we started seeing doctors working in hospitals full-time. It became clear that having doctors based at every hospital was significantly better for both efficiency and for hospital profits. According to this article in the New York Times, the discipline grew rapidly from 2003-2011, jumping from 11,000 hospitalists nationwide to 50,000 respectively. Doctors began enjoying the additional time they were now afforded to spend with their patients and for a time hospitals were so happy with the advantages in efficiency that it all seemed too good to be true. And sure enough, the initial advantages began to wear off.  A huge consequence of the constantly changing healthcare market is the necessity for more and more efficiency. In yet another shift, doctors began having their quality time with patients limited due to a push for a focus on metrics, documentation, and hospital management.

Dr. Rajeev Alexander is a hospitalist at PeaceHealth Sacred Heart Medical Center in Springfield, OR. In his practice, Dr. Alexander believes in taking the time to go through every minute detail with his patients and he dislikes the style of medicine so carelessly flaunted in pop culture television. “Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.” His method of treating patients happened to be negatively juxtaposed against the new direction his hospital wanted to take. In 2014, Sacred Heart announced that they planned on requesting bids to outsource their hospitalists to a management company. Outsourcing has recently become more popular across the country as hospitals realize it may be an excellent way for them to measure quality without being responsible for the complicated data collection that is involved. Working in our modern hospitals means being preoccupied with money constantly; this new shift was targeting that bottom line.

Here, the overarching problem for Dr. Alexander’s group is that hospitalists are not a “profit center” for hospitals. Dr. Alexander and his colleagues at Sacred Heart were outraged by the very idea of outsourcing, convinced that this would mean seeing many more patients per shift in the interest of profits. They did not want to lose their jobs by resisting this change but they also knew that it would be the patients that were significantly affected. Then, the idea of unionizing was brought up. It is rare, but there are hospitals around the country whose doctors are unionized, although no union is composed of a single group of specialists. Feeling increasingly bitter after seeing no better options, the group shed their doubts and held a union election. The decision to form a union was voted in overwhelmingly. They had won a battle but not the war. Although the industry has seen a retreat in outsourcing for the time being, that does not mean that hospitals aren’t still keen on getting more out of their doctors. Just how they do so, we shall continue to see.

 

Sugar Pills & Saline Solutions

by Jen Jenkins, Market Analyst

By definition, the Placebo Effect is a remarkable phenomenon in which a placebo – a fake treatment using an inactive substance such as sugar, etc. – can in some cases improve a patient’s condition simply because the person has the expectation that it will. Recent studies have investigated the power of placebos specifically in athletic performance, and this New York Times article asks, “Can a shot of salt water make you a faster runner?” The answer? Yes, why yes it can.

Previous studies have shown that lying to an athlete and telling them they are moving slower than they are will cause them to speed up past what they originally thought possible. Same with lying and telling them that the pill they just took contains caffeine or steroids when it does not. These studies, however, were never done in competitive situations. The difference between isolating a study done during training from one done during real-life competition is that most athletes are already exerting what (they believe) is their maximum physical capability during a competitive race. By testing the theory of the Placebo Effect during competition, researchers aimed to find out if this phenomenon would still apply, or if athletes were indeed at their maximum physiological ceiling.

In a study to test this, 15 male recreational runners were told they’d be given erythropoietin, or E.P.O., which increases the number of red blood cells in the human body. The runners were under the assumption that this drug would not only improve their athletic performance, but that it was also a formulation that was legal and that the amount administered would not be considered “doping.” In reality, the runners were given an injection of a saline solution. The study rotated the runners between receiving injections one week and not receiving them the next. After a few different phases, nearly unanimous results showed that the injections made training easier, recovery faster, and motivated runners to push harder. Most significantly, all the runners saw an improvement in their race by approximately 1.5 percent during a 3K race.

This is a very small study, but it does show that in this case the placebo did indeed enhance the performance of the runners, even in the most physiologically demanding circumstance such as a competition. For the everyday athlete or fitness guru, it is possible that even if you know you’re taking a placebo you may still achieve the desired effect of running faster or working out harder due to some “unconscious psychology going on.” To quote the popular Under Armour campaign: you will what you want.

Making (Common) Sense out of HIPAA

by Brian L. Grant MD

That HIPAA is misunderstood is an understatement. As this article in The New York Times describes, HIPAA is used as an excuse for absurd interpretations and ultimately a denial of rights to communicate by non-covered entities, a refusal to receive information from family members, churches who erroneously believe they can no longer share the fact that a congregant may be ailing, and other forms of nonsense.

If I had a quarter for every person who made declarative but incorrect statements about HIPAA, it would buy a lot of coffee, and some pastries to boot!

The goal of HIPAA is to maintain the privacy of medical information. But many questions remain. For example, why is unencrypted email apparently unacceptable but a fax is OK, though many senders or recipients of faxes send the faxed documents as Internet attachments? Is an email less secure than the US mail, which could result in a piece of paper lying on a desk in plain sight of the wrong people? I imagine that if the NSA or North Korea has an interest in the files of a medical practice, they may view them with minor effort. But does encrypting email actually solve a problem of files being compromised? The reality is that unencrypted email use is not prohibited. What is prohibited is accessing and reading such information by an individual or more who are not authorized. That raises the theoretical concern that people with time on their hands at Yahoo or Google are opening and viewing emails containing PHI (protected health information).

Protecting medical privacy is important and HIPAA is well-intended and to the degree it compels the profession to establish guidelines, training and evaluating of who and how one shares medical information, it is a good thing. But we have a ways to go to achieve clarity, reduce barriers to good care, and maintain compassion along with common sense.

Medicine is a Science, Medicine is an Art

by Jen Jenkins, MCN Market Analyst

An address first delivered in 1926 at Harvard Medical School, The Care of the Patient by Francis W. Peabody, MD explores a topic that seems to remain relevant in the practice of medicine today. Dr. Peabody (1881-1927) was renowned for setting himself apart from his colleagues throughout his career by treating each patient as a real person and not just according to their disease or disorder. The premise of this essay is the belief that “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” 

As science and technology improved then, and continue to improve now, the practice of medicine puts a greater emphasis on the science and less on the actual care of patients. Students are exiting medical school with excellent knowledge where medicine is concerned but the actual practice of medicine has been somewhat neglected.  Dr. Peabody believed caring for patients is something learned over time, not necessarily in the 4 to 5 years it takes to complete medical school, but he also believed it to be the medical institution’s job to provide the foundation for this type of care. The pressure to effectively diagnose and treat often overlooks the necessity of conversation and the vital importance of creating a personal relationship with the patient. The fundamental sciences will always be imperative but intimately knowing a patient as a human being and not just as a sick individual is the practice of medicine in the broadest sense.

The diagnosis and treatment of disease is a very limited aspect of practicing medicine. A quote that stood out was “The art of medicine and the science of medicine are not antagonistic but supplementary to each other.” Oftentimes, it is not just the disease that needs treating but the individual who needs to be treated. This takes time, which more now than ever is a commodity difficult to obtain in most settings, and it also takes compassion and understanding. The practice of medicine is intensely personal and the more impersonal and clinical the profession becomes the further we stray from the main objective of it all – the actual care of the patient.

See the related 1984 commentary in the Journal of the American Medical Association (JAMA) on this article.

Man's Best Friend – Some Insight into Why

Not everyone loves dogs of course, but most dog owners claim a strong bond with their pet. A new study from Japan sheds some light into the biochemistry of this relationship: Dogs who trained a long gaze on their owners had elevated levels of oxytocin, a hormone produced in the brain that is associated with nurturing and attachment. After receiving those long gazes, the owners’ levels of oxytocin increased, too.  This is similar to how bonding occurs between parent and newborns.

Researchers also tested oxytocin levels in wolves-to-owner gazes among a sample of wolves who had been raised by humans. Compared with dogs, the wolves scarcely gazed at their owners, and the owners’ oxytocin levels barely budged.

Dr. Takefumi Kikusui, professor in the School of Veterinary Medicine at Azabu University, suggested that “there is a possibility that dogs cleverly and unknowingly utilized a natural system meant for bonding a parent with his or her child.” Certainly one doesn’t have to search long to find examples which speak to this bond:

“My little dog—a heartbeat at my feet.” – Edith Wharton

“Children and dogs are as necessary to the welfare of the country as Wall Street and the railroads.” – Harry S Truman

“All knowledge, the totality of all questions and all answers is contained in the dog.” – Kafka

 

 

Dr. Oz to Respond to Criticism

Dr. Mehmet Oz will question the credibility of critics who sought to have him removed from his position at Columbia in a segment on his show on Thursday, a spokesman for the show said.

Why is this important, and why does MCNTalk care? Dr. Oz has noted on his Facebook page, “I bring the public information that will help them on their path to be their best selves. We provide multiple points of view, including mine which is offered without conflict of interest. That doesn’t sit well with certain agendas which distort the facts.”

But in the multi-billion dollar world of celebrity and supplement endorsement, is there such a thing as “without conflict of interest?” And, as we noted in 2013, “In medicine there is a continuum between hard science, that which can be objectively observed and tested, so-called ‘art,’ and unsubstantiated beliefs masquerading as science.”

There is certainly no harm in being a good person and given the nature of many illnesses, conveying warmth while the body heals itself may be more than enough. But promoting amulets, strange foods, and other hocus pocus presented by charlatans does a disservice to society. Oz appears to personally promote unproven products and their promoters in his show – conveying an irresponsible and unearned aura of legitimacy. It appears he has embraced celebrity at the expense of credibility and his millions of fans are none the wiser.

A Disease of Time

Post Traumatic Stress Disorder is a psychiatric disorder, the fourth-most-common one in America.  Over a decade into the global war on terror, PTSD purportedly afflicts as many as 30 percent of the conflict’s veterans. And the disorder’s reach extends far beyond the armed forces.

David J. Morris, who served in Iraq from 2004 to 2007, provides us with a new understanding in his recently released The Evil Hours: A Biography of Post-Traumatic Stress Disorder. PTSD, he notes, is “in a manner of speaking, a way of institutionalizing moral outrage.”

From Morris’s website is a brief summary of The Evil Hours: Drawing on his own battles with post-traumatic stress, David J. Morris — a war correspondent and former Marine — has written a humane, unforgettable book…Through interviews with people living with PTSD; forays into the rich scientific, literary, and cultural history of the condition; and memoir, Morris crafts a moving work that will speak not only to those with PTSD and their loved ones, but to all of us struggling to make sense of an anxious and uncertain time.

David Morris notes:

I first got interested in PTSD when I read a newspaper article about how some Iraq veterans felt “poisoned” by the war, as if it had fundamentally altered their existential position in the world. I am fascinated by this moral component of survivorship—how events in life can freeze us in time, seeming to render us unfit for the everyday world. This is essentially the same question confronted by Ishmael at the end of Moby Dick, as he looks out on the vast sea from Queequeg’s coffin: How does one live in the aftermath of the impossible?

The Evil Hours has been widely and quite favorably reviewed, from “an eye-opening investigation of war’s casualties” (Kirkus Reviews)  to “Well-integrated autobiographical elements make this remarkable work highly instructive and readable. (Publishers Weekly) Read more…

When Does a Behavior Become a Disease?

There are plenty of behaviors which are bad for one’s health. Smoking and not getting enough exercise are two things which quickly come to mind. Binge eating. But are these disorders, or is it that their consequences can lead to disorders?

Is it that we create diseases to fit the profitable (and dangerous) cures? If binging is a disease, then so is anything done to excess. Recently binge eating, officially recognized as its own disorder in 2013 by the American Psychiatric Association, has received attention for a media campaign promoting the amphetamine Vyvanse to treat it. Retired tennis player Monica Seles has been hired by pharmaceutical company Shire as a paid spokesperson, appearing on talk shows from “Good Morning America” to “The Dr. Oz Show” to share her personal struggle with binge eating. And to plug Vyvanse.

One prominent eating-disorder specialist said that although Vyvanse showed promise, other treatments, like talk therapy, had more research behind them. And the use of Vyvanse is worrisome, with its classification by the federal government as having a high potential for abuse. In fact for decades, amphetamines, which suppress the appetite, were widely abused as a treatment for obesity.

“Once a pharmaceutical company gets permission to advertise for it, it can often become quite widely prescribed, and even tend to be overprescribed, and that’s a worry,” said Dr. B. Timothy Walsh, professor of psychiatry at the New York State Psychiatric Institute at Columbia University.

A Remarkable Man Confronts His Coming Death

By Brian Grant

I awoke to this op-ed piece in today’s New York Times by Oliver Sachs. Tears formed. Sachs is a man who has contributed to medicine, literature, and entertainment through his writing and clinical care. And he is dying as his article describes. He is 81 and continues to contribute to the world. And when he departs, his legacy will continue with his passing. I will let his article speak for itself. Readers might enjoy clicking on the comments and seeing how other readers value and cherish his many gifts.

Chronic Fatigue Syndrome Becomes Systemic Exertion Intolerance Disease

We have now seen another example of the medicalization of distress and the emergence of a new “disease” (as opposed to a group of symptoms) according to the linked article.

While we have not yet read the report and reserve full conclusions, the release suggests nothing new in terms of science, etiologic agents, or new findings that lend meaningful clarity and a path to recovery from the symptoms of Chronic Fatigue Syndrome (CFS). Rather, the deciding panel appears to have largely achieved a political goal of validating a syndrome of various symptoms that do not lean to any conclusions as to cause or cure. That those who claim to have CFS or whatever new name may be ascribed to it are suffering is not in question. What remains unknown is why, and whether this syndrome is caused by a lesion of some sort, a viral or bacterial pathogen. What is going on with this action?

Likely a number of things. One is that it addresses the anxiety and perceived stigma that often applies to experiences that are ill-defined and may be considered to have an emotional component, implying lack of validity for the sufferers. Noteworthy is that the panel is seeking responsive treatment and diagnostic codes. By validating a syndrome as a disease, the conversation changes to one of obligations and rights for the sufferers that they believe they lacked before.

And it implies and may create duties by others in the industry of treating diseases, including insurance carriers, employers, courts and the culture to increase the level of payment, support, acceptance and accommodation to those claiming the disease. And let’s not forget members of the medical profession, drug companies, hospitals and other parties who have a strong vested interest in adding to the list of issues for which they may/will receive payment.

The list of syndromes, new diagnoses or disorders with expanding numbers and those claiming them are many. In no particular order they include: Post-concussive syndrome, “Low-T,” erectile dysfunction (with a recent ad featuring a beautiful woman claiming that over 50% of men over 40 suffer from some form of it), Epstein Barr Virus, Autism, Post-traumatic stress disorder, Fibromyalgia, ADHD (attention deficit hyperactivity disorder), Lyme Disease, and others. Common to many are claims of financial, educational, occupational or legal entitlement, partial exculpation from responsibility, expensive and proprietary medications, strong advocacy groups and heated arguments in the media and professions.

In short, recent “clarification” on Chronic Fatigue Syndrome likely fits more into the realm of politics than science.