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Demystifying Medicine One Month at a Time

Category: uncertainty (page 1 of 12)

# This is Our Lane

Dr. Judy Melinek

The American College of Physicians recently released an updated position paper on “Reducing Firearm Injuries and Deaths from Gun Violence in the United States.”

The College’s recommendations center around the notion that gun violence should be treated as a public health epidemic, and that it’s well within the purview of doctors and other health professionals to ask their patients about firearms—namely, do you own them, and if so, are they safely stored? Are they kept in a place where your children can’t get to them?

This makes sense to me, but I’m a doctor. I don’t hunt, nor have I ever owned a gun.

The College’s position makes some very uncomfortable—it’s not a medical issue, they say. This is about personal behavior. Choice. Individual rights.

The NRA sent a tweet in response to the position paper:

Told to “stay in our lane,” doctors have loudly declared #ThisisOurLane, and now have a Twitter handle and thousands upon thousands of tweets stating that it’s medical professionals who care for gunshot victims. Many sent pictures of themselves spattered with blood from taking care of gunshot victims in emergency rooms and operating suites.

One doctor, a forensic pathologist and medical examiner in Oakland, tweeted back to the NRA:

Understandably, Dr. Melinek’s tweet went viral, and she was interviewed the world over—from Africa to Australia—even on Amanpour.

Dr. Melinek was kind enough to speak with me—our interview occurred recently for #MedicalMonday on KWGS-Public Radio Tulsa, and drew a tremendous response.

Like Dr. Melinek, I find it frustrating that the NRA’s strong advocacy has had such a chilling effect on research into gun safety and gun violence in the U.S.

Shutting down attempts to gather more detailed information is a bully tactic of someone or something afraid of truth. How can people make informed decisions without really knowing the effects of gun ownership and use?

Advocate for gun rights all you want. But let the research be done.

Questioning a Health Care Sacred Cow

If you’ve worked in U.S. health care for any length of time, you’ve no doubt lived through a period of impending ‘inspection’ by the Joint Commission at your hospital or health care organization. Stress levels amongst all staff inevitably rise in the runup.

Everyone needs to look sharp, have their protocols down, and most importantly, where to find organizational policy information if it’s not available by quick memory retrieval.

One of the 800 lb. gorillas of the U.S. health care world, the JC (as it’s known) audits, inspects and accredits nearly twenty-one thousand U.S. health care enterprises.

I was always under the impression that the JC had a complete monopoly in its market–that is, if your health care organization wanted to be accredited (the vital ‘seal of approval’ for your organization’s public relations and safety standards, but also key for reimbursement through CMS) than you had to play ball with them.

In 2012, one of the hospitals at which I worked decided to go in a different direction, choosing instead to work with the accrediting agency DNV, which has its origins in the world of Norwegian shipping. For real. As in, ocean liners need a ton of regulation and safety standards so that they don’t run into each other and sink. We’re always comparing health care to airlines, right? Maybe it’s not such a big stretch after all.

Like most of my physician colleagues who’d lived through years of JC audits, we were a bit flabbergasted: “You mean the JC actually has competition?” As it turns out, the JC only controls a mere 80% of the market. Turns out it’s only a 785 lb. gorilla.

Even though this whole issue is a little bit “inside baseball,” I wrote an essay about it for NPR. My reasoning was that there’s always value in questioning monolithic conformity. And I had been really surprised to learn that there was actually competition to the JC.

Now comes a study in BMJ, led by Harvard researcher Ashish Jha. The study compared more than 4000 U.S. hospitals and the outcomes generated for 15 common medical conditions and six common surgical conditions between the years 2014-2017 in a Medicare population data set of more than four million patients.

What did the study find?

Interestingly, there was no statistical difference in 30-day mortality or readmission rates in the patients that were seen at JC-accredited hospitals vs. those at hospitals accredited by ‘other independent organizations.’ There was a slight but not statistically significant benefit in mortality and readmission rates for JC-accreditation vs. hospitals reviewed and accredited by state survey agencies.

The study raises the reasonable question: if there aren’t patient outcome differences in hospitals accredited by JC vs. those accredited by either state review (government) or other independent agencies (other privates), then should the JC enjoy such a massive industry dominance?

After all–many health care leaders cite the JC’s regulatory and inspection processes as burdensome, and argue that the whole preparation game and citation-fixing business is expensive and distracting from the core hospital mission: taking care of people.

Other JC critics cite the fact that the organization is less than optimally transparent, electing to keep its inspection reports private, despite the fact that many health care enterprises flagged for violations are able to stay accredited.

Congress has even begun an investigation into possible lax oversight.

Apparently Jha’s work has struck a chord, as there was some notable media coverage about the BMJ piece. For one, the Wall Street Journal ran a story about it, which it kept in front of its paywall, while noting that hospitals pay on average $18,000 for an inspection and annual fees of up to $37,000 to the Commission.

Cardiologist and prolific blogger John Mandrola also wrote an opinion piece titled “Joint Commission Accreditation: Mission Not Accomplished.” In his piece, Mandrola compares JC accreditation to medications or surgery that fail to live up to evidence-based standards and subsequently fall out of practice. He concludes, “If the JC’s brand of accreditation can’t show benefit, than it too needs to be de-adopted.”

Having learned that there’s an emerging marketplace of agencies equipped to inspect hospitals and health care enterprises it seems there’s an opportunity here: Perhaps the agency offering the greatest value in terms of cost, reporting, and public accountability will triumph against a behemoth that seems too complacent and entrenched in its ways.

Medical Marijuana: Not Up to the Standard

This year Oklahoma voters made a clear choice to legalize medical marijuana, joining thirty other states that permit cannabis for medicinal use.

Unsurprisingly, immediately in the vote’s aftermath, patients began asking me to ‘prescribe’ medical marijuana licenses, as the new law stipulates users must have as a precondition for legal purchase. The new law does not, however, specify qualifying diagnoses for which medical marijuana might be clinically indicated.

My answer thus far has been, “Not now. Likely never.”

This has not been a popular response. One patient looked at me as if I’d put a lump of coal in his Halloween bag.

I’m not a fan of medical marijuana for several reasons. The main issue is the lack of proven medical efficacy. I know there are thousands of anecdotes from people whose pain or anorexia has been diminished by marijuana–and I’m genuinely glad for them. But I’d like to see better powered controlled trials of cannabis products head-to-head with accepted therapeutic agents. Having the FDA weigh in on marijuana’s safety and efficacy would also go a long way toward legitimizing pot’s medicinal use.

Another major problem is smoking the stuff. If we had proven, standardized dosing of edibles, I’d be more supportive of medicinal use. But smoking anything–tobacco, marijuana, vapor juice–is not a healthy practice, and one I counsel patients to avoid. I hear the arguments about the purity of pot and how it’s ‘more natural’ than manufactured tobacco products. The bottom line is that inhaling burning plant matter into your lungs is a terrible idea–regardless of the herb.

If voters want to legalize marijuana for recreational use, I have no objection–provided we put in place a legal framework to make sure that people don’t get hurt. Standardized dosing and measures to assure product consistency would be integral. And we’d need adequate enforcement to make sure that people aren’t impaired when at work or in other situations in which their marijuana use could jeopardize others.

Putting doctors in the middle of what amounts to a political, legal, social, and economic debate steers the medical profession in a race to the bottom–and let’s face it–our profession has enough problems already without being the gatekeepers of grass.

Remember that marijuana is still scheduled by the Drug Enforcement Administration as a Class I narcotic, defined as having “no accepted medical use and high potential for abuse.” So even though medical weed is now legal in my state, I have no interest in violating or abetting violations of federal law.

In fact, as it turns out, since I work at a university, our legal counsel is of the opinion that no provider in our system shall recommend marijuana, since our institution has numerous federal grants and funding streams and must therefore comply with all federal rules and regulations.

Some have suggested that given our national opioid epidemic, marijuana can serve as a safer alternative for pain control. Since most cannabis is homegrown, and where legalized a tax revenue source–this does make medical marijuana a more appealing alternative to propping up the seemingly ubiquitous heroin/fentanyl drug cartels.

This argument makes pot part of a harm reduction strategy, which I’d be more supportive of if the evidence were stronger.

Right now I see the pot economy as a Wild West with hundreds of entrepreneurs and medical professionals looking to stake claims in this new quasi-legal economy.

Get back to me when we have more state/federal legal congruence and clarity on the stuff’s true medical benefits.

This essay originally appeared as a Doximity Op-(m)ed.

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

A Surprising Reason Some Still Don’t Like Obamacare

The Affordable Care Act (“Obamacare”) has slowly become more popular as Americans discover that the law has lowered the number of people without health insurance and provided baseline benefits to millions of us (preventive care, youth coverage under parents until age 26, doing away with pre-existing conditions, etc.), without causing massive social or health care disruption.

Critics of the ACA cite ideals like letting the marketplace sort things out, rather than relying on government intervention to do so. Of course, the individual mandate, the requirement to be insured, was scaled back by the late 2017 tax reform law–such that people on the individual insurance market will be able to opt out in 2018 and beyond if they choose without penalty (even though the US Supreme Court ruled in 2012 that the mandate is constitutional).

Recently, a reader sent me a fascinating article about why some evangelical Christians also dislike Obamacare. It’s known as crucicentrism.

Not all evangelicals hold this worldview. According to a source cited in the article, about one quarter of evangelicals espouse this viewpoint.

Still–what does it mean? From the aforementioned article:

To secure a permanent place at God’s side is far more important than any short-lived torment to the body. From this perspective, then, the greatest kindness one can show others is to help them reach the salvation of the Cross.

Such a crucicentrist view on compassion explains puzzling statements by white evangelicals like Mark Green, a Tennessee state senator. “Sickness,” Green told a church group, “is one of the main avenues that bring people to religion.” In the Gospels, he said, “every person who came to Christ came to Christ with a physical need. It was either hunger or a disease.” When the government created the ACA it did a “great injustice” because, Green explained, by helping people regain their health, it had limited “the Christian church’s role” and robbed sick individuals of the opportunity “to come to a saving knowledge of who God is.” People who fell ill would now look “to the government” instead of to God.

In this worldview, suffering is seen as a pathway to faith, which will lead to salvation. And, I presume, better health.

Maybe this shouldn’t be surprising. After all, institutions have always needed members, missions, and money to maintain their existence over millennia.

But I do find this inclination shockingly uncharitable.

What do you think?

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