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Serious leak of top secret classified information: physicians find health IT clunky and unresponsive to their needs

In news that must have been leaked by anonymous spies after being kept at a level of "Top Secret" and not acted upon for decades, Healthcare IT News reports on the <a href="http://www.healthcareitnews.com/news/docs-may-be-using-it-they-dont-love-it">healthcare IT user experience</a>: <blockquote> Healthcare IT News (3/10, Merrill) reported, a survey conducted by the American College of Physician Executives found "that although more physician leaders are using healthcare information technology, they still find it clunky and unresponsive to their needs." The survey of 1,000 ACPE members "revealed that the biggest source of frustration is a lack of input from physicians when designing and implementing healthcare information technology systems. Many said involving clinicians at the planning stages would pre-empt many of the problems that crop up later." [ya think? -ed.] One respondent noted that "systems are chosen according to administrative criteria rather than what physicians need." </blockquote>The Top Secret material has this been revealed. Call in the FBI ... Seriously, it almost seems there must have been an industry agreement to keep this information a secret before now, since people in my field, Medical Informatics, have been writing this for a long time, decades in fact. Yet nothing much has occurred as a result of those writings. In my case, a decade. See my HIT difficulties site at <a href="http://tinyurl.com/hit-misadventure" title="http://tinyurl.com/hit-misadventure">http://tinyurl.com/hit-misadventure</a> and my recent posts on health IT's mission hostile user experiences at <a href="http://tinyurl.com/hostileuserexper" title="http://tinyurl.com/hostileuserexper">http://tinyurl.com/hostileuserexper</a> . In other cases, people in this field have been writing on this for not a decade, but several decades. As far back as 1969, EMR and Medical Informatics pioneer Donald A. B. Lindberg, M.D., now Director of the U.S. National Library of Medicine at NIH, made the following observation. He wrote that "computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21). Only an industry lost in arrogance and unaccountability, and physicians demoralized into a state of (as one lawyer termed it) "<a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">learned helplessness</a>" could create such a ludicrous and in fact dangerous scenario, after 30+ years of effort.Was the industry learning nothing during that time? Physicians should refuse to use Health IT that has not undergone documented, rigorous user experience testing and that might have hundreds or thousands of unremediated defects and deficiencies that healthcare systems may be contractually obligated not to disclose. Interestingly, at yesterday's <a href="http://www.burnesscommunications.com/new/new_show.htm?doc_id=824981">Health Affairs-sponsored health IT briefing</a> "Stimulating Health Information Technology" in Washington, DC, kicking off a special HIT-focused issue of Health Affairs (Mar/Apr 2009), the only speaker who even mentioned the deficient health IT user experience and the need to improve it was self-described "only a software guy" Peter Neupert of Microsoft. Mr. Neupert mentioned the issue almost in passing during his talk. When I spoke to him afterward, he did not seem to understand the criticality of the point he made, even when I reminded him of how much time and resource Microsoft devotes to improving the user experience of its operating systems. In fact, the sine qua non of health IT is the enabler of healthcare, the clinician. Health IT that presents a poor user experience is not optimally helping healthcare enablers, nor, I might add, healthcare facilitators (i.e., everyone else in healthcare who does not see patients), healthcare payers, and finally the "customers" of healthcare, namely, all of us.It troubles me that in this special issue of Health Affairs, even sober articles critical of HIT in its present form carried subtitles somewhat detached from reality. Jos Aart and Ross Koppel's article "Implementation of Computerized Order Entry in Seven Countries" carried the curious subtitle "Although hospital's uptake of CPOE is generally low, nothing diminishes CPOE's promise for patient safety and cost savings."Nothing at all, except these, as mentioned in the article itself, starting off with our old friend: <ul><li>Poorly designed user experience hindering clinician performance of certain tasks</li><li>Poorly designed, bull in a china shop, fatiguing decision support alerting systems</li><li>Increased time to enter orders</li><li>Decreased communications among doctors and nurses</li><li>Low levels of integration with clinician workflow and with other HIT</li><li>Unanticipated outcomes (of a negative nature), which were found to be the rule, rather than the exception</li></ul>I asked Koppel about the ebullient subtitle. To the best of his memory, he did not recall writing it.Dr. Farzad Mostashari of New York City’s <a href="http://www.nytimes.com/2009/03/01/business/01unbox.html?_r=1&scp=1&sq=Mostashari&st=cse" target="_self">Primary Care Information Project </a>(PCIP) described how 25% of the physicians mandated to use EHR "hate it", with many others suffering significantly longer workdays as servants of the computer data overlord. I am sad to say that the overall attitude at the Health Affairs meeting, with a few exceptions such as from privacy rights advocate <a href="http://www.patientprivacyrights.org/site/PageServer?pagename=Board_Of_Directors">Dr. Deborah Peel</a> of <a href="http://www.patientprivacyrights.org/">patientprivacyrights.org</a>, seemed one of physicians as indentured servants. The purpose of HIT as expressed seemed to be to make the indentured service better and cheaper, with little thought given to the life and comfort of the servant, the optimal leveraging of his or her training, experience and judgment, or the usability of his or her accouterments.Physicians need to extend the <a href="http://en.wikipedia.org/wiki/Phrygian_cap">Phrygian cap</a> and stand up for a far better HIT user experience than is provided now. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwM4z0uWuYXcV-9UrcqiNEzV3JS3nJu2SHMugu3ka0ypRyC7EBNA5rNtPSUASPoyPt8yifiTHvjtkbtKD2W9dFP_ebJ6QVv8eQhp3Dn2uf0hrqzy7Fn0LRQX0MdvEIGtMCjy0L4mB_JR2A/s1600-h/1794_liberty_cap_large_cent_obv.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5314239358940228210" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwM4z0uWuYXcV-9UrcqiNEzV3JS3nJu2SHMugu3ka0ypRyC7EBNA5rNtPSUASPoyPt8yifiTHvjtkbtKD2W9dFP_ebJ6QVv8eQhp3Dn2uf0hrqzy7Fn0LRQX0MdvEIGtMCjy0L4mB_JR2A/s320/1794_liberty_cap_large_cent_obv.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 162px; height: 170px;" /></a> -- SS

Serious leak of top secret classified information: physicians find health IT clunky and unresponsive to their needs

In news that must have been leaked by anonymous spies after being kept at a level of "Top Secret" and not acted upon for decades, ...

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Making ads more interesting

At Google, we believe that ads are a valuable source of information — one that can connect people to the advertisers offering products, services and ideas that interest them. By making ads more relevant, and improving the connection between advertisers and our users, we can create more value for everyone. Users get more useful ads, and these more relevant ads generate higher returns for advertisers and publishers. Advertising is the lifeblood of the digital economy: it helps support the content and services we all enjoy for free online today, including much of our news, search, email, video and social networks. That's why Google has worked hard to create technology that makes the advertising on our own sites, and those of our partners, as relevant as possible. To date, we have shown ads based mainly on what your interests are at a specific moment. So if you search for [digital camera] on Google, you'll get ads related to digital cameras. If you are visiting the website of one of our <a href="http://adsense.google.com/">AdSense</a> partners, you would see ads based on the content of the page. For example, if you're reading a sports page on a newspaper website, we might show ads for running shoes. Or we can show ads for home maintenance services alongside a YouTube video instructing you on how to perform a simple repair. There are some situations, however, where a keyword or the content of a web page simply doesn't give us enough information to serve highly relevant ads. We think we can make online advertising even more relevant and useful by using additional information about the websites people visit. Today we are launching "interest-based" advertising as a beta test on our partner sites and on YouTube. These ads will associate categories of interest — say sports, gardening, cars, pets — with your browser, based on the types of sites you visit and the pages you view. We may then use those interest categories to show you more relevant text and display ads. We believe there is real value to seeing ads about the things that interest you. If, for example, you love adventure travel and therefore visit adventure travel sites, Google could show you more ads for activities like hiking trips to Patagonia or African safaris. While interest-based advertising can infer your interest in adventure travel from the websites you visit, you can also choose your favorite categories, or tell us which categories you don't want to see ads for. Interest-based advertising also helps advertisers tailor ads for you based on your previous interactions with them, such as visits to their websites. So if you visit an online sports store, you may later be shown ads on other websites offering you a discount on running shoes during that store's upcoming sale. Our advertisers and publisher partners have been asking us for a long time to offer interest-based advertising. Advertisers need an efficient way to reach those who are most interested in their products and services. And publishers can generate more revenue when they connect advertisers to interested audiences. This kind of tailored advertising does raise questions about user choice and privacy — questions the whole online ad industry has a responsibility to answer. Many companies already provide interest-based advertising and they address these issues in different ways. For our part, we're launching interest-based advertising with three important features that demonstrate our commitment to transparency and user choice. <ul><li>Transparency - We already clearly label most of the ads provided by Google on the AdSense partner network and on YouTube. You can click on the labels to get more information about how we serve ads, and the information we use to show you ads. This year we will expand the range of ad formats and publishers that display labels that provide a way to learn more and make choices about Google's ad serving.</li><li>Choice - We have built a tool called <a href="http://www.google.com/ads/preferences/">Ads Preferences Manager</a>, which lets you view, delete, or add interest categories associated with your browser so that you can receive ads that are more interesting to you.</li><li>Control - You can always opt out of the advertising cookie for the AdSense partner network <a href="http://www.google.com/privacy_ads.html">here</a>. To make sure that your opt-out decision is respected (and isn't deleted if you clear the cookies from your browser), we have designed a <a href="http://www.google.com/ads/preferences/plugin">plug-in</a> for your browser that maintains your opt-out choice. </li></ul>To find out more about what Google is doing in this important area, please visit our <a href="http://googlepublicpolicy.blogspot.com/2009/03/giving-consumers-control-over-ads.html">Public Policy blog</a> and <a href="http://www.google.com/privacy">Privacy Center</a>. Keyword advertising has been so successful because it's useful to users, advertisers and publishers — everyone's interests are aligned. We believe that interest-based ads will create the same virtuous cycle, by giving users more relevant ads, while generating higher returns for advertisers and publishers. Posted by Susan Wojcicki, VP, Product Management

Making ads more interesting

At Google, we believe that ads are a valuable source of information — one that can connect people to the advertisers offering products, serv...

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More Gravity Defying Compensation for Not-for-Profit Health Care Leaders

Two recent articles featured more about gravity-defying compensation given to the leaders of not-for-profit health care organizations. We had recently <a href="http://hcrenewal.blogspot.com/2009/03/43-million-dollar-ceo-for-not-for.html">posted</a> about how the CEO of one not-for-profit health care insurer rose while the organization's revenue and enrollment fell. Similarly, <a href="http://www.detnews.com/apps/pbcs.dll/article?AID=/20090310/BIZ/903100328/1040">from the Detroit News</a>, <blockquote> Blue Cross Blue Shield of Michigan -- the state's largest insurer -- gave pay hikes to six top-level executives in 2008 and doled out generous retirement packages for four former senior vice presidents, despite the nonprofit organization's loss of $144 million last year. The organization's deteriorating financial health, a justification for Blue Cross officials wanting to raise rates on its line of individual insurance policies, had prompted widespread job cuts at the Detroit-based insurer. In January, Blue Cross said it needed to eliminate about a 1,000 positions. Despite those cuts, CEO Daniel Loepp received a compensation package of base salary, bonuses and other compensation totaling $1.8 million in 2008, up from $1.7 million in 2007. The CEO's bonus last year was $727,575, up from $696,777 in 2007, according to documents filed last week with the Michigan Office of Financial and Insurance Regulation. Blue Cross spokesman Andrew Hetzel said the 2007 to 2008 increase was to help bring Loepp's total compensation in line with CEOs at other comparable-size Blue Cross organizations nationwide. The retirement packages -- ranging from $3.1 million to $994,132 depending on the executive -- were for four senior vice presidents who'd each been with the organization an average of nearly two decades, Hetzel said. Hetzel added that all the senior level executives are taking pay cuts this year -- including a 5 percent reduction in their base salary. And the compensation packages for 2008 were set by the Blue Cross board at the end of 2007, Hetzel added, well before the organization saw need to cut its work force. </blockquote> Note how the pay of the top leaders of many health care organizations seems to defy gravity, going up faster than inflation, going up even when the organizations lose money, going up even when the organizations have to lay off workers. There is always an excuse. But in this case, once the miserable results of 2008 became clear, why could the board not re-assess the CEO's pay? Finally, note that even if there is a decrease in 2009, it is a decrease only compared to the elevated 2008 level. Locally, the <a href="http://www.blogger.com/thephoenix.com/Boston/News/76685-Health-cares-big-moneyman-in-New-England/?page=1#TOPCONTENT">Boston Phoenix assessed </a>the pay of the CEOs and other top leaders of all the states not-for-profit hospitals. Some of its main findings were - The compensation of the CEO of the state's biggest hospital system is higher than any other New England hospital CEO: <blockquote> Receiving almost $3 million in annual salary and benefits in each of the last two years, Lifespan CEO George Vecchione is the highest-paid health-care executive in New England. Vecchione collects almost $1 million more each year than the CEO at the region’s largest health care network, Partners HealthCare System in Boston, although Lifespan is much smaller than Partners, and New England’s second largest network, Caritas Christi Health Care, also in Boston. In 2007, only Lahey Clinic CEO David Barrett approached Vecchione’s compensation, thanks to a one-time supplemental retirement benefit of $1.5 million; even with that payment, Barrett received $300,000 less than the Lifespan leader. </blockquote> The compensation of many RI hospital CEOs, and of other RI hospital leaders is high compared with peers in other states, and has risen much faster than inflation: <blockquote> Modern Healthcare's executive compensation survey suggests that Vecchione is not the only Rhode Island health-care CEO who is paid well above the national median. When benefits, expenses, and long-term incentive plan payments are subtracted from Care New England CEO John Hynes's compensation package, the remaining $911,562 is well above the $570,000 median base pay and bonus paid to the 60 CEOs of small hospital networks surveyed in 2007. Once benefits, long-term incentive pay, and terminated life insurance payments are subtracted, Women & Infants Hospital CEO Constance Howes received $481,625 in 2007, and Kent County Memorial Hospital's Mark Crevier collected $551,799. Meanwhile, salary and bonuses for Rhode Island Hospital's Amaral ($693,477) and Miriam's Hittner ($572,132), were more than $100,000 above the national median. Several other Lifespan administrators received more than $500,000 in compensation in 2007: general counsel Kenneth Arnold ($623,902); treasurer Mary Wakefield ($672,057); chief physician Arthur Klein ($935,291); senior vice president for shared services Frederick Macri ($569,777); and Lifespan Physician Service Organization CEO Joel Kaufman ($542,162). No other Rhode Island hospital executives listed on the tax returns received more than $500,000. Salaries at the smaller community hospitals present a mixed picture. Modern Healthcare's 2007 median compensation at independent hospitals with revenues under $200 million is $350,500. The CEOs of Westerly and South County hospitals and Roger Williams Medical Center were well below the median, while St. Joseph's John Keimig was slightly above. The 2007 salary and bonuses, however, for Memorial Hospital's Francis Dietz ($572,000), Landmark Medical Center's Gary Gaube ($673,164), and Rehabilitation Hospital of Rhode Island's Richard Charest (440,593) were considerably above the median. Not only are compensation packages high, they have increased at incredible rates for some executives. Two Care New England executives watched their pay more than double over the last seven years, in part due to long-term incentive plan payments in 2007. Butler Hospital CEO Patricia Recupero's compensation grew 117 percent, while Hynes' pay increased 107 percent. In addition, Landmark Medical Center CEO Gaube's compensation increased 107 percent as his hospital slid into financial insolvency. The compensation for three other CEOs, Memorial Hospital's Dietz, Emma Pendelton Bradley Hospital's Daniel Wall, and Lifespan's Vecchione, increased between 90 and 99 percent over the last seven years. Three CEOs of Lifespan hospitals received lesser raises since 2000: Amaral (65 percent), Hittner (62 percent) and Newport Hospital's Arthur Sampson (55 percent). St Joseph Health Service CEO Keimig, who, like Amaral and Gaube, has resigned, received a 72 percent pay increase over seven years. </blockquote> CEO compensation has risen quickly even at institutions whose finances are failing: <blockquote> Increases in compensation for Gaube and Charest are among the most notable. In a December 2008 report, the state Department of Health labeled Landmark Rhode Island's financially weakest hospital. Landmark ran a small profit in 2004, but starting in 2005, the Woonsocket hospital slid into insolvency. In June 2008, the Rhode Island Superior Court appointed a special master to run the troubled institution. Landmark also owns 50 percent of the Rehabilitation Hospital of Rhode Island, where Charest served as president, as well as second in command to Gaube at Landmark. While the hospital ran in the red, however, Gaube and Charest continued to receive raises. A review of the hospital's tax returns indicates that Gaube's compensation increased 37 percent, or almost $200,000, from 2005 to 2007. Over the same two-year period, Charest's pay increased 32 percent, or more than $100,000. </blockquote> The article does provide some insight into the thinking of those in charge of awarding these bloated pay packages. For example, regarding the pay received by the Care New England CEO: <blockquote> 'John Hynes earns every penny,' says Care New England board chairman Jonathan Farnum, adding, that few people have the skill set to handle the job. He describes Hynes and Vecchione as workaholics who are always on call and constantly handling crises. 'The people are well-served,' Farnum says. 'I don't think they're [the CEOs] driven to maximize their own personal salaries.' </blockquote> What a peculiar argument to make in a health care context. Lots of people in health care work long hours and are on call frequently, and unlike a hospital CEO, may have to handle life and death decisions in the wee hours of the morning. And most of them make far less than Hynes, who was still not the highest paid leader in the Phoenix article. What really seems to be the rationale, in my humble opinion, is the belief that the work of executives is somehow much harder and more deserving than the work of anyone else, including physicians. Those who set executive pay were unmoved by the arguments that medicine and health care are callings, and that not-for-profit should not pay their executives comparably to the richest for-profit corporations: <blockquote> With 10,000 employees and $1 billion in revenue, Lifespan is more like a for-profit health-care institution, [Lifespan board chairman Alfred] Verrecchia says, adding, 'We wouldn't be paying any different if we were for-profit or not-for-profit.' Verrecchia also disputes the idea that high CEO salaries may discourage donations to the hospital. 'We're not receiving funds to manage day-to-day operating procedures at the hospitals,' he says. Fundraising pays for specific programs, he explains, like a new emergency or operating room. </blockquote> In response, let me just quote more of the Phoenix article: <blockquote> 'They may be able to persuade donors of that,' counters Alan Sager, a Boston University professor of health policy and management, 'but money is fungible. Money can be moved.' Sager adds, 'If the CEO gets $2.9 million, that's money the hospital can't use to underwrite care for uninsured or underinsured people.' Sager notes that 30 nurses could be hired with Vecchione's salary. 'Does this person do as much good in the world as 30 nurses?' he asks. 'I find that hard to believe.' </blockquote> The follow up to that may make the most important point of all: <blockquote> As president and CEO at Pawtucket-based toymaker Hasbro, Verrecchia was paid $8.4 million in 2006, and $16.5 million in 2007, according to Security and Exchange Commission documents. This is another part of the problem, says Sager: The corporate lawyers and executives who sit on hospital boards form 'a club' with the hospital executives, in which six- and seven-figure salaries are normal. The result, he says, is a 'financially combustible combination' for nonprofit hospitals. </blockquote> That really seems to be the bottom line. As hospitals become more like big businesses, their leaders identify more with the power elite, or the "superclass," than with their staff, much less their patients. Their sense of entitlement grows, and their understanding of the problems of ordinary people wanes. Whether their devotion to the healing (and sometimes academic) missions of their organizations can survive under these circumstances is open to question. (Note, for full disclosure: I am a part-time voluntary teaching attending at one of the Lifespan hospitals, if my position survives this posting.)

More Gravity Defying Compensation for Not-for-Profit Health Care Leaders

Two recent articles featured more about gravity-defying compensation given to the leaders of not-for-profit health care organizations. We ha...

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US President Advocates for Research Integrity

US President Barack Obama announced a new emphasis on the integrity of science used to help make public policy decisions. As <a href="http://www.nytimes.com/2009/03/10/us/politics/10obama.html">summarized by the NY Times</a>, <blockquote> President Obama’s directive on Monday to 'guarantee scientific integrity' in federal policy making could have a far-reaching impact.... The document orders Mr. Obama’s top science adviser to help draft guidelines that will apply to every federal agency. Agencies will be expected to pick science advisers based on expertise, not political ideology, the memorandum said, and will offer whistle-blower protections to employees who expose the misuse or suppression of scientific information. The idea, the president said in remarks before an audience of lawmakers, scientists, patients advocates and patients in the East Room, is to ensure that 'we make scientific decisions based on facts, not ideology'.... </blockquote> Here are some key parts of the <a href="http://www.whitehouse.gov/the_press_office/Memorandum-for-the-Heads-of-Executive-Departments-and-Agencies-3-9-09/">memorandum written by the President</a>: <blockquote> Science and the scientific process must inform and guide decisions of my Administration on a wide range of issues, including improvement of public health, protection of the environment, increased efficiency in the use of energy and other resources, mitigation of the threat of climate change, and protection of national security. The public must be able to trust the science and scientific process informing public policy decisions. Political officials should not suppress or alter scientific or technological findings and conclusions. If scientific and technological information is developed and used by the Federal Government, it should ordinarily be made available to the public. To the extent permitted by law, there should be transparency in the preparation, identification, and use of scientific and technological information in policymaking. The selection of scientists and technology professionals for positions in the executive branch should be based on their scientific and technological knowledge, credentials, experience, and integrity. By this memorandum, I assign to the Director of the Office of Science and Technology Policy (Director) the responsibility for ensuring the highest level of integrity in all aspects of the executive branch's involvement with scientific and technological processes. Specifically, I direct the following: 1. Within 120 days from the date of this memorandum, the Director shall develop recommendations for Presidential action designed to guarantee scientific integrity throughout the executive branch, based on the following principles: (a) The selection and retention of candidates for science and technology positions in the executive branch should be based on the candidate's knowledge, credentials, experience, and integrity; (b) Each agency should have appropriate rules and procedures to ensure the integrity of the scientific process within the agency; (c) When scientific or technological information is considered in policy decisions, the information should be subject to well-established scientific processes, including peer review where appropriate, and each agency should appropriately and accurately reflect that information in complying with and applying relevant statutory standards; (d) Except for information that is properly restricted from disclosure under procedures established in accordance with statute, regulation, Executive Order, or Presidential Memorandum, each agency should make available to the public the scientific or technological findings or conclusions considered or relied on in policy decisions; (e) Each agency should have in place procedures to identify and address instances in which the scientific process or the integrity of scientific and technological information may be compromised; and (f) Each agency should adopt such additional procedures, including any appropriate whistleblower protections, as are necessary to ensure the integrity of scientific and technological information and processes on which the agency relies in its decisionmaking or otherwise uses or prepares. </blockquote> Unfortunately, we rarely post about what could be called good news on Health Care Renewal. But I really think it is really good news when the President of the United States makes scientific integrity a headline issue; speaks for scientific integrity and specifically against suppression and manipulation of science; advocates specific standards for scientific integrity for every government branch and agency; advocates for the transparency of science and the scientific process used in policy decisions; and argues for the protection of whistle-blowers. We have again and again documented instances of threats to scientific integrity (specializing, of course, in the integrity of clinical and health services and policy research) including suppression of research, manipulation of research, and protection of whistle-blowers. It's nice to see these causes gain moral, and in this case legal support, especially from one of the most powerful political leaders in the world. Nice work, Mr President!

US President Advocates for Research Integrity

US President Barack Obama announced a new emphasis on the integrity of science used to help make public policy decisions. As summarized by t...

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BLOGSCAN - An Example of Spinning Clinical Research Results

BLOGSCAN - An Example of Spinning Clinical Research Results

On the Clinical Psychology and Psychiatry blog , the anonymous blogger did a great job analyzing an article supported by pharmaceutical comp...

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The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach?

A <a href="http://www.nytimes.com/2009/03/09/opinion/l09harvard.html">letter to the NY Times </a>by Dr Daniel Becker in response to the recent controversy at Harvard Medical School over financial relationships among industry and faculty (see our post <a href="http://hcrenewal.blogspot.com/2009/03/harvard-medical-students-against.html">here</a>) brought up an interesting point: <blockquote> I take issue with the implicit assumption that faculty members who accept drug money are driven exclusively by greed; this issue is much more complicated than it may seem at first. Harvard Medical School’s 'drug money' problem relates, in part, to a little-known fact: Harvard rarely pays the salaries of its medical faculty directly. Despite substantial revenue from tuition, most faculty members teach medical students on a volunteer basis. Similarly, the salaries of research faculty are not paid by Harvard, but rather by grants from the National Institutes of Health, private foundations and in some instances, grants from pharmaceutical companies. If these financing sources dry up, professors are often forced to find a new job. </blockquote> Wait a minute, it's a medical school, so shouldn't the faculty be paid to teach and do research? That's what faculty are supposed to do. The above letter, although it may be a bit simplistic, fits in with other anecdotal evidence that, in fact, medical schools do not pay faculty much to teach or do research. Instead, they are mainly tasked with raising money from external sources to "cover" the academic work one would think should be central to their jobs. Failing that, they must bring in fees for their clinical work. In 2005, we <a href="http://hcrenewal.blogspot.com/2005/01/medical-schools-charge-more-for.html">quoted</a> the editor of JAMA as saying, "few medical schools provide adequate, if any, reimbursement for teaching time." In 2007, we <a href="http://hcrenewal.blogspot.com/2007/03/flash-harvard-medical-school-to-start.html">noted</a> that it was news when Harvard Medical School pledged to actually start paying hospital-based faculty meaningful amounts for teaching medical students. Previously, they were paid an average of $30/hour for doing so. However, I have not seen any follow-up as to whether the school carried out the promise. Moreover, at that time, we noted that Harvard required its faculty "to teach or volunteer on committees 50 hours a year, but Harvard does not track how many hours doctors teach and does not actively enforce the policy." Again, one might be forgiven for thinking that a faculty member generally should spend a substantial amount of time teaching. But at Harvard, they only apparently need to spend about 2% of their time doing so. Later in 2007, we <a href="http://hcrenewal.blogspot.com/2007/04/medical-schools-to-faculty-show-me.html">discussed</a> a medical school dean's revelation that his school primarily judge faculty was by how much external funding (grants, contracts, practice income, etc) they brought in, not by how well or how much they taught, or the quality and quantity of their research. Finally, in 2009, we <a href="http://hcrenewal.blogspot.com/2009/03/were-only-in-it-for-money.html">discussed</a> how two-thirds of the salary of one university president seemed to come from his medical school, even though that school accounted for only one-eighth of his students. Putting it all together, it seems that the "faculty" at some, maybe most medical schools are not faculty in the ordinary sense. There is little expectation that they teach. Instead, they are supposed to do research funded by external grants, or failing that, collect fees from direct patient care. They are judged by how much money these pursuits provide, not by the quality of their research, and certainly not the quality of their teaching. The money they provide disproportionately goes to fund parts of the university outside of the medical schools. Presumably, the pressure to bring in ever more money drives "faculty" entanglements with pharmaceutical, biotechnology, device and other corporations. If one must constantly pursue grants, now mostly available from industry, one must constantly interact with industry representatives. Under this sort of pressure, is it any wonder that "faculty" might find it hard to turn down consulting work, speakers' fees, and offers to serve on advisory boards from the same people they must please to obtain grants? So I believe Dr Becker is right. The problem is simply not the greed of "faculty" members (although some, of course, can become greedy.) Much of the problem appears to be the greed of university administrators who see their medical schools and academic medical centers as cash cows, and see nothing wrong with hiring "faculty" who scarcely teach, as long as they keep bringing in the cash.

The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach?

A letter to the NY Times by Dr Daniel Becker in response to the recent controversy at Harvard Medical School over financial relationships am...

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The Minneapolis...Or Is It Hartford?...Two-Step

Conjure yourself as a wallflower: You are a shy early-adolescent compelled by your parents (who at all times adhere to the operative cultural norms) to attend your first dance.  You would rather not be there at all.  Your life as it was was perfectly acceptable.  You were happy with the old, self-sufficient ways.  But now, along with your peers, you are entering a new phase.  From now on the world will work dyadically.  More and more, you will be required to operate in conjunction with a second party.  And this second party, in many respects, is not sympatico. Its motives and methods and  do not always align with yours.  Yet still you hope for the best...<div> </div><div>Bring up the music, turn down the lights - the moment has arrived.  Your expectations are shaped by what you believe you are owed: a polite and respectful pairing; civility, if nothing else.  Instead you are greeted with a rude awakening.  Your partner is an arrogant lummox, indifferent to your sensibilities. While the band plays waltz music you are dragged through a lumbering bump-and-grind.  In the process your hair is mussed, one foot is mashed,  an earring is dislodged. What's worse: at the end, there's no apology, no acknowledgement of the brutishness of what has just transpired; indeed, you are quite convinced that you are not alone - you are merely the first of many hapless victims for that evening alone.</div><div> </div><div>Welcome to the rhythms of "step therapy," yet another barbed arrow in the quiver of managed care, still seemingly in ascendency, a galling procedure whereby "prior authorization" for a prescriber's first choice of medication is "denied" until such time as (usually two) "preferred alternatives" from an insurance company's formulary have been tried and have proven either ineffective or intolerable.  I had thought it insult enough that patients be required to "fail" two trials of medications with inferior clinical profiles (e.g., adolescents in my psychiatric practice are now "required" to try two generic stimulants whose short or intermediate duration of action is guaranteed to leave them without any therapeutic benefit during the second half of the school day - unless, that is, they wish to submit to the stigma of presenting to the school nurse every day for their "stupid pill" - before they can receive the long-acting medication that is the standard of care recommended by the American Academy of Child and Adolescent Psychiatry) before gaining access to what, from the beginning, simple common sense held to be the proper choice.  Despite years of steeling myself to callousness of the managed care organizations, I was nonetheless appalled by my most recent encounter with step therapy requirements, since the process has been rendered EVEN MORE LUDICROUS by the inventive touches of faceless executives bent on achieving promotion, I would wager, through demonstrations of their ability to concoct ever more sociopathic obstructionistic schemes. Consider this excerpt: A new patient presents to my practice, having moved to Rhode Island from a different state.  For a year or more, she has been taking Strattera, with good results, for her ADHD, having experienced adverse effects from previous trials of methylphenidate and mixed amphetamine salt preparations.  In conjunction with her move, however, her health insurance has changed. When the first prescription for Strattera reimbursable under the new plan is presented to a Rhode Island pharmacy, a prior authorization form is faxed to us by the insurer.  The PA asks for documentation of failures on two formulary drugs, a condition which the patient's clinical history does satisfy.  My office submits the PA form, properly executed.  Several days later, we receive notification that the PA request has been denied, because, in the standard boilerplate, the Strattera is not "medically necessary."  I then instruct my office manager, as I do quite frequently these days, to request a "peer to peer" review in appeal of the decision.  More time passes.  Finally, I am called by a retired (probably on the basis of "burn-out," if he has had many such experiences as I am relating) psychiatrist NOW EMPLOYED BY THE INSURER (no conflict of interest there!).  After a little perfunctory back-and-forth, he informs me that the denial will have to stand because, as I have failed to note in the fine print, treatment failure with the formulary alternatives did not occur IN THE LAST SIX MONTHS.  My efforts to cajole him into a different opinion through the use of logic fail.  His decision is firm.  In essence, I am told: IT DOESN'T MATTER THAT THE FORMULARY PRODUCTS WERE ALREADY TRIED AND PRODUCED ADVERSE EFFECTS.  IF YOU WANT THIS PATIENT TO RECEIVE REIMBURSEMENT FOR STRATTERA UNDER OUR PLAN, WE WILL REQUIRE YOU TO AGAIN GIVE THE PATIENT MEDICATIONS WHICH, AS THE PATIENT HAS TOLD YOU, PRODUCED ADVERSE EFFECTS.  End of conversation.  Click.</div><div>Expletive deleted.</div><div> </div><div>How will the story end?  Happily, I predict.  The reason being that I will prescribe one tablet of Ritalin to the patient and, then, one tablet of Adderall.  The patient will be instructed to fill each prescription in sequence, and then flush each tablet down the toilet.  The insurer's preconditions will thus be satisfied and the patient will be able to use their insurance benefit.</div><div> </div><div>At least two lessons, it seems to me, can be derived from this anecdote.  Number one: the chaperones have failed at their task.  Which is to say, WHERE ARE THE INSURANCE REGULATORS?  How can this kind of grossly manipulative, illogical protocol be allowed to exist?  And sadly, number two: PLAYING THE SAME KIND OF MENDACIOUS LITTLE GAMES THAT THE INSURANCE COMPANIES PLAY OFTEN IS THE ONLY ETHICAL COURSE OF ACTION.  And so it goes - two-stepping with the Leviathan.</div><div> </div>

The Minneapolis...Or Is It Hartford?...Two-Step

Conjure yourself as a wallflower: You are a shy early-adolescent compelled by your parents (who at all times adhere to the operative cultura...

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