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Just Business - Employee Control Fraud, Gresham's Dynamic, and the Race to the Bottom in Health Care

Since Enthoven called for the break up of the physicians' "guild," and handing over its supposed power to managers, (see post <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-breaking-physicians.html">here</a>) managers have taken over from physicians and other health care professionals as leaders of health care organizations.  Unfortunately, most of these managers are <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic</a>, often lacking knowledge and experience in health care, and understanding of its core values.  Instead, such generic managers may rely on the current management dogma.  The perils of doing so are illustrated by an analysis of the recent expose of conditions at Apple manufacturing plants in China. The Apple Expose The New York Times summarized in a <a href="http://www.nytimes.com/2012/01/26/business/ieconomy-apples-ipad-and-the-human-costs-for-workers-in-china.html">landmark article</a> how bad it is to work in factories building Apple products under contract in China.  Workers endure harsh conditions, toiling up to six days a week, 12 hours a day.  Meanwhile, banners remind them to "work hard on the job today or work hard to find a job tomorrow."  Workers may be exposed to hazardous, even poisonous materials (like n-hexane used to clean components).  Workers have died in explosions due to inadequate control of combustible dust. Over 18 workers at one factory attempted or committed suicide within two years. The article suggested that while Apple managers may be well-intentioned, and "want to improve conditions in factories," the bottom line is more important: <blockquote>that dedication falters when it conflicts with crucial supplier relationships or the fast delivery of new products.</blockquote> In fact, because of its rigid insistence on cost control, its suppliers are sorely tempted to push their workers too hard: <blockquote>Apple typically asks suppliers to specify how much every part costs, how many workers are needed and the size of their salaries. Executives want to know every financial detail. Afterward, Apple calculates how much it will pay for a part. Most suppliers are allowed only the slimmest of profits. So suppliers often try to cut corners, replace expensive chemicals with less costly alternatives, or push their employees to work faster and longer, according to people at those companies. 'The only way you make money working for Apple is figuring out how to do things more efficiently or cheaper,' said an executive at one company that helped bring the iPad to market. 'And then they’ll come back the next year, and force a 10 percent price cut.' </blockquote> So, <blockquote>'You can set all the rules you want, but they’re meaningless if you don’t give suppliers enough profit to treat workers well,' said one former Apple executive with firsthand knowledge of the supplier responsibility group. 'If you squeeze margins, you’re forcing them to cut safety.' </blockquote> William Black's Analysis: Employee Control Fraud and the Race to the Bottom Writing <a href="http://www.huffingtonpost.com/william-k-black/apples-ethical-blindness-_b_1244410.html">in the Huffington Post</a>, William K Black showed how Apple executives' relentless focus on cost could drive a race to the bottom. He began by analyzing Apple executives' explanation for out-sourcing their production: <blockquote>'We shouldn't be criticized for using Chinese workers,' a current Apple executive said. 'The U.S. has stopped producing people with the skills we need.' </blockquote> He noted that it is absurd to suggest that the US does not have workers with the technical skills necessary to build Apple products. He suggests, however, that these are not the skills that matter. <blockquote>The suppliers want engineers and managers who will selectively apply their substantive skills. American engineers and managers cannot be counted on to provide the necessary selectivity. Apple's suppliers' often seek managers willing to order their workers to exceed the lawful workweek, to refuse to pay them for significant portions of the wages they have earned, to unlawfully employ child labor, and even to coerce abortions.</blockquote> So, in the n-hexane example, <blockquote>The engineer did not order the workers to use the nerve poison because he hated the workers. It was 'just business.' The nerve poison reduced cleaning time, so an engineer knowingly ordered the workers to use it and scores of other engineers did nothing to prevent the usage. </blockquote> Note that Black calls this employee control fraud, deceiving the employee that he or she is working in a reasonably safe environment, and that employee health and safety is a concern, when in truth the only concern is the bottom line. So what Apple executives, and by analogy, other multi-national corporate executives want are underlings, particularly middle and line managers who will do anything, anything to cut costs and improve the bottom line. This will produce the race to the bottom: <blockquote>What we are observing is the essence of a Gresham's dynamic in which bad ethics drives good ethics out of the market. Two aspects of this Gresham's dynamic are obscene, and both are produced by neoclassical economics dogma. Calling this process 'creative destruction' is baseless and dishonest. It is the fraudulent destruction of honest businesses, professions, and labor.</blockquote> Black concluded: <blockquote>firms that are anti-employee control frauds are likely to commit other forms of control fraud. Apple and its Western counterparts have driven the creation of an Asian network of fraudulent firms that has distorted international trade, hollowed out U.S. manufacturing, and created a bizarre hybrid: quasi-communist crony capitalism. It boggles the mind that theoclassical economists celebrate the corrupt result as the essence of creative destruction. The network is corrupt. It will not play by the rules. Firms like Apple help create the perverse incentives that encourage the network to cheat. Surviving U.S. manufacturing firms are whipsawed by the powerful Gresham's dynamic that the frauds produce. U.S. firms and workers are constantly pressured to reduce wages and workforce to try to compete with the foreign frauds. This is the 'Road to Bangladesh' strategy that has caused U.S. working class wages to stall for decades. Europe is retreating along this same road at an even more rapid rate. The Gresham's dynamic tilts the world in favor of fraudulent firms operating in fraud-friendly nations. </blockquote>The Race to the Bottom in Health Care Note that we have written about numerous examples of executives of US health care organizations putting revenue ahead of the health care mission, ahead of workers' morale, ahead of patients' and the public's health. Some of these examples involve executives of nominally non-profit organizations that are supposed to have charitable purposes. (Look under our heading of <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">mission-hostile management</a>.) In fact, just yesterday, Dr Carl Elliott, <a href="http://chronicle.com/blogs/brainstorm/working-the-assembly-line-at-the-human-experimentation-factory/43646">writing</a> for the Chronicle of Higher Education, summarized how pharmaceutical companies have out-sourced clinical research. The resulting commercial clinical research have generated conditions as bad for the research subjects as those endured by the Chinese electronics workers above: <blockquote>If the past decade had an emblematic moment for clinical research, it was probably November 12, 2005, the day when Bloomberg Markets published its cover story, “Big Pharma’s Shameful Secret.” In that issue, Bloomberg reporters laid out the story of SFBC International, a contract research organization in Miami that was paying undocumented immigrants to test the safety of new drugs in a seedy motel. The SFBC owners had converted the lobby into a large waiting area with plastic chairs, and they were housing their research subjects six to a room. The medical director of the research site was unlicensed to practice medicine; the Institutional Review Board that approved many of the studies was owned by the wife of the company vice-president; and the converted motel, which had been cited for fire and safety violations, was eventually demolished. Nonetheless, SFBC had become an astonishingly successful enterprise. Just a few years before the Bloomberg Markets report, Forbes had named SFBC one of the most admired small businesses in America. Virtually every major pharmaceutical company had tested drugs with the company. In fact, with 675 beds, the converted motel was the largest research facility in North America.</blockquote>Note: see our relevant posts here on <a href="http://hcrenewal.blogspot.com/search/label/SFBC%20International">SFBC International</a>, and on <a href="http://hcrenewal.blogspot.com/search/label/contract%20research%20organizations">contract research organizations</a>. Moreover, such out-sourcing has produced the sort of race to the bottom described by Black, but this time involving one of the US most important health care institutions, academic health care: <blockquote>the more important reason is money. In medical schools, faculty members are often expected to generate their own salaries, either by seeing patients or getting grants and contracts. Likewise, academic departments are often expected to be financially self-sufficient, with as little support as possible from central administration. 'Eat what you kill' is the phrase used, without irony, by medical school deans and department heads. And if you are not killing it with NIH grants, you probably need to be killing it with AstraZeneca or Pfizer. This system has not been good for human subjects, but it has not been good for academic physicians either. According to a recent study of over 5,000 faculty members at U.S. medical schools, 51 percent of respondents said that the administration is only interested in me for the revenue I generate.' Thirty-one percent said that their institution discourages altruism; 27 percent said that it does not reward clinical excellence; and over half said that it does not value teaching. Nearly half of respondents were considering leaving their current jobs; almost a third were considering leaving academic medicine altogether. Asked if their values lined up with the medical schools where they worked, over half said no. And just in case you are wondering why these physicians are not standing outside the building with picket signs, protesting the injustice of the system, the survey offers another clue. Thirty percent of respondents agreed with the statement, 'I am reluctant to express my opinion for fear of negative consequences.' [This was from an abstract by Pololi L et al.  See our relevant post <a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">here</a>.] Of course, this survey does does not exactly match up with the happy propaganda disseminated by the media-relations offices at most medical schools. Instead, it offers a picture of alienated, demoralized physicians, unhappy in their jobs, pressed to work according to values that repel them in order to prop up an institution that views them primarily as instruments to generate profit. In this environment, contract research makes perfect sense. It may not require much intellectual work, but it pays the bills and keeps the authorities happy. And if medical schools don’t really value intellectual work anyway, that may well be enough.</blockquote>So the pressures on medical school faculty are little different from those on corporate middle management.  Their only role is to make money, mainly so that the top leaders can become multi-millionaires, and woe unto them if they object. Summary What is missing in all this is any organized opposition to the race to the bottom. As long as top executives can make<a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation"> nearly unlimited money</a>, as long as they can do so by making their subordinates put revenue ahead of all else, as long as there are no countervailing forces, the race to the bottom will continue. To stop it, we need some combination of efforts by honest government regulators, professional and trade organizations, civil society organizations including non-profit organizations and NGOs that really care about patients' and the public's health, and finally an activated, and properly outraged public. As long as we think that a laissez faire policy allowing continual market dysfunction to continue, the good times for executives will keep rolling, over all of the rest of us.

Just Business - Employee Control Fraud, Gresham's Dynamic, and the Race to the Bottom in Health Care

Since Enthoven called for the break up of the physicians' "guild," and handing over its supposed power to managers, (see post ...

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Siemens Healthcare on solving EHR usability problems: you can just call up your pal at the next hospital

In my Aug. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/08/why-siemens-healthcare-fails.html">Why Siemens Healthcare Fails</a>", I wrote: <blockquote>I note that I used to admire German engineering rigor, but after seeing ill conceived, misguided position ads like the following from Siemens Healthcare, I am having sincere doubts about that country's current prowess in that domain.</blockquote> My admiration fell another notch. I now see this, in a Feb. 1, 2012 article from HealthData Management entitled "<a style="font-weight: bold;" href="http://www.healthdatamanagement.com/issues/20_2/user-unfriendly-43946-1.html">User Unfriendly</a>" on the flaws in commercial health IT that present a poor user interface/user experience (at the expense, ultimately, of you, the patient). The article's browser title bar somewhat subliminally reads "Physicians gripe that EHR's are not easy to use but improvements are coming": <blockquote> ... There's also no mechanism for publicizing problems with EHR interfaces, unlike the FDA's process for issues with medical devices. [User interface expert Prof. Ben] <a href="http://www.cs.umd.edu/%7Eben/">Shneiderman</a> describes a case where a physician found a bug in an EHR that created a danger to patients. "He contacted the supplier because he thought it was something other users should know about, and the response was, 'Oh, we know-we're working on it,'" Shneiderman says. "The physician said, What? You know about it and you haven't notified everyone?' Contrast that with the Federal Aviation Administration, where problems with airplanes are publicized within hours." The IOM report calls for substantial loosening of those contractual restrictions. "The committee views prohibition of the free exchange of information to be the most critical barrier to patient safety and transparency," the report says. "The committee urges the [HHS] Secretary to take vigorous steps to restrict contractual language that impedes public sharing of patient safety-related details. Contracts should be developed to allow explicitly for sharing of health I.T. issues related to patient safety." The report also says there should be a central place to report and publicize known issues with EHR software.</blockquote> Siemens apparently has a different idea on taking responsibility for the user interfaces of their products: <blockquote>Siemens Healthcare Chief Medical Officer Don Rucker, M.D., says the secrecy issue is overblown. "There are trailer loads of information out there on each of these big systems, and there are so many end users that you can just call up your pal at the next hospital."</blockquote> There are trailer loads of information out there, and it's up to the end user physician to find the information and sort through it? ... Sounds perfectly reasonable to me. /not/ There are so many end users that you can just call up your pal at the next hospital [for guidance on user interface complexities and errors]? Also sounds perfectly reasonable. /not/ ... Except, I think most EMR vendors and user-organizations sort-of disable Remote Assistance, Remote Desktop and similar programs. Even "print screen" is usually either disabled or forbidden from sharing with that "pal at the other hospital." Might have something to do with security and IP protection. Ever try to guide someone through a complex computer interface over the phone, blind, with no real-time mutually viewed visuals? It's not easy, but ... physicians and nurses have PLENTY of time for such fritter, what with the little other work they have to do. I also think saying busy physician, nurse and other clinical customers should "depend on their pals at the next hospital" for information on health IT difficulties is a rather condescending and patronizing statement to make (to be charitable), a backyard-mechanic attitude, but that's just me. Why does Siemens fail? This type of statement is a very good clue. -- SS

Siemens Healthcare on solving EHR usability problems: you can just call up your pal at the next hospital

In my Aug. 2009 post " Why Siemens Healthcare Fails ", I wrote: I note that I used to admire German engineering rigor, but after s...

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KevinMD: How algorithm driven medicine can affect (make more dangerous, actually) patient care

Reposted from KevinMD blog on another aspect of the health IT <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience</a>. Emphases and comments in [red italics] are mine: <blockquote><a style="font-weight: bold;" href="http://www.kevinmd.com/blog/2012/01/algorithm-driven-medicine-affect-patient-care.html">How algorithm driven medicine can affect patient care</a> by <a href="http://www.kevinmd.com/blog/post-author/jeffrey-parks" rel="tag">Jeffrey Parks, MD</a> Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a “pre-op checklist” to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. <a href="http://www.ashp.org/Import/PRACTICEANDPOLICY/PracticeResourceCenters/QualityImprovementInitiativeQII/LearnMoredup092253224960/SurgicalCareImprovementProjectSCIP.aspx">SCIP guidelines</a> mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.Let me explain. For most elective surgeries I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don’t want to give antibiotics inappropriately or continue them indefinitely.But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right? [No - wrong - the idiots who designed your CPOE/Pharmacy IT system forgot that robotic medicine is bad medicine - ed.] Well, you’d be surprised. [No, actually, I'm not. I'd have been more surprised to see a system not impeding critical medical decisions tailored to the individual patient - ed.] You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered [presumably cybernetically - ed.] in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes “please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis [that sounds a bit like begging - ed.] ,” the antibiotic will not be sent to the patient’s floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on “protocol” and “quality care metrics.”Similarly, the 60-minute timeline for pre-operative antibiotic administration can be problematic. I have had patients come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 10:30am. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn’t administered until 60 minutes before the scheduled OR time, just like the algorithm dictates — despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology. [This is how EHR-induced malpractice occurs, readers. Guess who bears liability? - ed.] And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened [this time, due to luck - ed.], but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It’s just astounding. [It's astounding the surgeons don't simply use a scalpel on the computer terminal network and power cables to protect their patients - ed.] As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements [a workaround to a 'feature' that turns medical judgment on its head - ed.] for therapeutic antibiotics because the default mode is to override a licensed physician’s clinical judgment. [Not mentioned is who is overriding that judgment through cybernetic proxy - ed.] This is what I’m talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.Jeffrey Parks is a general surgeon who blogs at <a href="http://ohiosurgery.blogspot.com/" target="_blank">Buckeye Surgeon</a>.</blockquote> I will simply add that these issues sound like poor IT/protocol design and implementation, getting in a physician's way regarding tailoring of care to the individual patient. An inviolable rule in health IT is - or needs to be - <div style="text-align: center;">"You should not have to work around something that is not in the way." </div> There is nothing to debate or discuss on this issue. -- SS Feb. 3, 2012 addendum: Some IT person (anonymously, of course) tried to argue and debate anyway; however, they did not even do basic homework. See their comments in the comments box. Feb. 5, 2012 addendum: More in the comments section by someone saying they made the aforementioned comments, stating they are a hospitalist, and still trying to advance the same arguments in favor of physicians adapting to mission-hostile HIT and/or protocols rather than 'protesting too much.'

KevinMD: How algorithm driven medicine can affect (make more dangerous, actually) patient care

Reposted from KevinMD blog on another aspect of the health IT mission hostile user experience . Emphases and comments in [red italics] are...

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EHR Workstation Designed by Amateurs

Below is an actual workstation, in an ICU of a major regional hospital, to permit interaction with an already <a href="http://www.tinyurl.com/hostileuserexper">mission-hostile</a> EHR system: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKoy5uEINVofkrjR5_5G5ZrmzgCLArIt7CcdS5gk9wM-Qk7T-GFlFldfLqcLmUCunoYoyO67RRcsE0m8z8C9CURrpn6rUBQQJlV7kDx8oXLsYMoLGy1k5jVS78peWOw-fFcwgh_jEN40m0/s1600/EHR_workstation.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5704232947644786402" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKoy5uEINVofkrjR5_5G5ZrmzgCLArIt7CcdS5gk9wM-Qk7T-GFlFldfLqcLmUCunoYoyO67RRcsE0m8z8C9CURrpn6rUBQQJlV7kDx8oXLsYMoLGy1k5jVS78peWOw-fFcwgh_jEN40m0/s320/EHR_workstation.jpg" style="cursor: pointer; display: block; height: 222px; margin: 0px auto 10px; text-align: center; width: 367px;" /></a></div><div style="text-align: center;">How many things are wrong here? (Click to enlarge) <div style="text-align: left;">I can charitably say this workstation, in this recent picture, was designed by amateurs. Less charitably, I would use the words 'glaring incompetents.' How many things are wrong here? For starters (commenters are welcome to suggest additions to the list): <ul><li>Small square (4x3) monitor, when large 16x9 monitors are available quite cheaply, even at retail let alone in bulk;</li></ul><ul><li>Monitor in front of window so on sunny days, glare causes eye strain;</li></ul><ul><li>Monitor forces user to look away from the patient, with their back facing the patient behind them;</li></ul><ul><li>Standard keyboard and mouse to help spread infection, not medical-specialty devices such as membrane-based or membrane-covered keyboards and easily cleanable trackpads;</li></ul><ul><li>Very slow, small, toy-ish <a href="http://en.wikipedia.org/wiki/Nettop">nettop computer</a>, to facilitate responsiveness delays;</li></ul><ul><li>Height of ledge with keyboard/mouse and of elevated monitor on ledge does not facilitate comfortable ergonomics when sitting, note chair in background (or standing as is intended, either, although I don't recall ever making entries in the permanent paper chart on my feet). It seems nobody ever heard of an appropriate moveable workstation desk;</li></ul><ul><li>Tangle of wires behind setup, without any protective sheath or shield, facilitates "accidents."</li></ul> There are probably a few more "issues" I'm missing. There is nothing to argue here and nothing to debate. Combined with the mission hostile virtual user interfaces presented by health IT software itself, this is inexcusable. Apart from designers, any physicians (and nurses) who would accept such poor choices - and the cause of this workstation's problems were, in fact, deliberate choices - are either weak-kneed victims of "<a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">physician's learned helplessness</a>" themselves, or enjoy EHR-induced medical errors and lawsuits. The workstations are poorly designed like this all throughout this hospital, including the ED. This is not the first time I've observed this type of amateurism in hospitals. I observed similar issues in <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">another ICU</a> - over a decade ago. Hospitals are truly an IT backwater. -- SS</div></div>

EHR Workstation Designed by Amateurs

Below is an actual workstation, in an ICU of a major regional hospital, to permit interaction with an already mission-hostile EHR system: H...

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What is Life is Really Like in Pharma? - These xtranormal Video Cartoons Come Close.

Sadly, the 'xtranormal' video cartoons at the following URL capture all too well what life is like in the pharmaceutical industry - buzzwords, neologisms, nouns turned into verbs, new paradigms, team players - and per the site, endless inane "initiatives" and related threats to sanity. I've been there; while a parody, these videos are uncomfortably close to reality. <a href="http://www.youtube.com/user/ZombieSymmetry/feed"> http://www.youtube.com/user/ZombieSymmetry/feed</a> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOjW3ZHtixsCfG9CBqzXYLcqBNdPxJfgRiMWhP1TfVsbPKNV6NDp0c-JUoAgxIMPsWulXxYRPYLY-gj7lra6MFhMEeztKzp0-SCnEJXtxVUCA56iMar4JHzQEluGSW11Qq3_GrgN-Rn7a9/s1600/future_of_pharma.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5704053254550054114" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOjW3ZHtixsCfG9CBqzXYLcqBNdPxJfgRiMWhP1TfVsbPKNV6NDp0c-JUoAgxIMPsWulXxYRPYLY-gj7lra6MFhMEeztKzp0-SCnEJXtxVUCA56iMar4JHzQEluGSW11Qq3_GrgN-Rn7a9/s320/future_of_pharma.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 382px; height: 260px;" /></a></div><div style="text-align: center;">"I'll have to ideate on that for awhile, Mike" </div> Even sadder are managers who believe their own babble. -- SS

What is Life is Really Like in Pharma? - These xtranormal Video Cartoons Come Close.

Sadly, the 'xtranormal' video cartoons at the following URL capture all too well what life is like in the pharmaceutical industry - ...

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How the Anechoic Effect Is Institutionalized - A Hospital Policy Against Unsupervised Discussion with the Media

In a single sentence, a short, obscure <a href="http://www.wbjournal.com/news50656.html">article </a>in the Worcester (MA) Business Journal on life at a community hospital after a for-profit corporate take-over: <blockquote>Several Nashoba employees, who didn't want their names used because it's against hospital policy to talk to the media without authorization, said they're happy with the new insurance plan.</blockquote> We have often discussed the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, how cases involving or discussions of the topics we address on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>, the concentration and abuse of power in health care, fail to produce any responses, or echoes.  It was almost an aside, but the sentence above provides evidence of the existence of apparently blanket hospital policies against unsupervised discussion with the media. Here is an example of the institutionalization of the anechoic effect. This example raises three immediate questions. How prevalent is this? How long has it been going on? What is it meant to hide? Prevalence This article is only about a single hospital. However, the context of the article is the take-over of Nashoba Hospital by Steward Health Care. <a href="http://hcrenewal.blogspot.com/search/label/Steward%20Health%20Care">Steward Health Care</a> is a for-profit health care corporation that grew out of the take-over of the formerly not-for-profit <a href="http://hcrenewal.blogspot.com/search/label/Caritas%20Christi">Caritas Christi</a> health system by the private equity firm <a href="http://hcrenewal.blogspot.com/search/label/Cerberus">Cerberus Capital Management</a>. Steward Health Care now comprises <a href="http://www.steward.org/our-hospitals.html"> eight hospitals</a>, and also owns physician practices (apparently including over 2000 doctors based on a quick search using its <a href="http://www.stewardhealth.org/doctorfinder/search_form">"doctor finder" function</a>.) Thus it is likely that the policy at Nashoba Hospital that prevents unsupervised discussion with the media also applies at seven other hospitals, and perhaps to the practices of over 2000 doctors. Thus it is very likely that this hospital gag policy is not unique, and may be widespread. However, recursively, the existence of such gag policies will make it hard to determine their own prevalence. Note that we have posted a few times about confidentiality clauses mainly within physicians' contracts <a href="http://hcrenewal.blogspot.com/search/label/confidentiality%20clause">here</a>. Duration This policy is likely relatively new, since the take-over of Caritas Christi by Cerberus occurred in 2010. My guess is that the rise of such policies may parallel the resurgence of for-profit hospitals and hospital systems, and perhaps the new involvement of <a href="http://hcrenewal.blogspot.com/search/label/private%20equity">private equity firms</a> in such organizations. In my humble experience, gag policies and confidentiality clauses at least within non-profit teaching hospitals were virtually unheard of from the time I began medical school (1974) to when I left my last full-time academic medical position (2005). Note that we<a href="http://hcrenewal.blogspot.com/2012/01/barbarians-at-gate-making-private.html"> recently found out</a> (because of investigative journalism about presidential candidate Mitt Romney's previous involvement with private equity firm Bain Capital) that such firms are generally rebranded leveraged buy-out firms. They have become known for their secretiveness. Therefore, maybe it should not be surprising that they have imposed such secretiveness on hospitals and health care professionals. Rationale  The big question is why should hospital employees not be allowed to talk to the media without management supervision? I can only speculate. In this case, perhaps such secretiveness is just the habit of the private equity executives who now run the hospital system. Even if this is the reason, they ought to reconsider. Hospitals and health care professionals due have a solemn obligation to keep confidential their patients' medical information. However, otherwise health care organizations and health care professionals ought to be as transparent as possible. Maintaining such a level of secrecy could lead to some suspicions, for example, that the generic managers of the organization distrust the professionals they hire who actually provide patient care; worse, that the managers fear discussion that might question their actions or abilities; worse, that the managers want to silence whistle-blowers; or even worse, that the managers have something unethical or illegal to hide. That is all speculation, of course. On the other hand, we have discussed again and again how the anechoic effect has stifled discussion of what is wrong with health care, and hence prevented meaningful health care reform. Gagging hospital employees is an obvious extension and institutionalization of the anechoic effect. It should not be done, because we need honest discussion of what is really wrong with health care so we can come up with some real solutions.

How the Anechoic Effect Is Institutionalized - A Hospital Policy Against Unsupervised Discussion with the Media

In a single sentence, a short, obscure article in the Worcester (MA) Business Journal on life at a community hospital after a for-profit cor...

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Can You Sue the Government? FDA Whistleblowers Sue Over Surveillance of Personal e-Mail

From the Washington Post: <blockquote><a style="font-weight: bold;" href="http://www.washingtonpost.com/world/national-security/fda-staffers-sue-agency-over-surveillance-of-personal-e-mail/2012/01/23/gIQAj34DbQ_story.html?sub=AR">FDA staffers sue agency over surveillance of personal e-mail</a> Ellen Nakashima and Lisa Rein January 29, 2012 The Food and Drug Administration secretly monitored the personal e-mail of a group of its own scientists and doctors after they [the scientists - ed.] warned Congress that the agency was approving medical devices that they believed posed unacceptable risks to patients, government documents show. The surveillance — detailed in e-mails and memos unearthed by six of the scientists and doctors, who filed a lawsuit against the FDA in U.S. District Court in Washington last week — took place over two years as the plaintiffs accessed their personal Gmail accounts from government computers.</blockquote> While accessing Gmail from government computers was not a wise idea, since all traffic over an institutional PC and network can be monitored, these Gmails were apparently to members of Congress. <a href="http://www.washingtonpost.com/wp-srv/national/documents/fda-whistleblowers-3.html#document/p1/a43233"></a><blockquote><a href="http://www.washingtonpost.com/wp-srv/national/documents/fda-whistleblowers-3.html#document/p1/a43233">Copies of the e-mails</a> show that, starting in January 2009, the FDA intercepted communications with congressional staffers and draft versions of <a href="http://www.whistleblowers.org/">whistleblower complaints</a> complete with editing notes in the margins. The agency also took electronic snapshots of the computer desktops of the FDA employees and reviewed documents they saved on the hard drives of their government computers.</blockquote> See sample emails at link above. <blockquote>Information garnered this way eventually contributed to the harassment or dismissal of all six of the FDA employees, the suit alleges. All had worked in an office responsible for reviewing devices for cancer screening and other purposes.</blockquote> That's very unfortunate. It will be far more unfortunate if the warnings of the six, as in <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=lawsuit">this whistleblower case</a>, went unheeded, and patients are injured or die as a result. In that case, FDA bureaucrats might have been accessories to those injuries or deaths. <blockquote>“Who would have thought that they would have the nerve to be monitoring my communications to Congress?” said Robert C. Smith, one of the plaintiffs in the suit, a former radiology professor at Yale and Cornell universities who worked as a device reviewer at the FDA until his contract was not renewed in July 2010. “How dare they?” </blockquote> I, on the other hand, would have expected it. It would have been far more prudent to send such emails from a private home computer and ISP. <blockquote>The scientists and doctors denied sharing information improperly. The HHS inspector general’s office, which oversees FDA operations, <a href="http://www.washingtonpost.com/wp-srv/national/documents/fda-whistleblowers-2.html/#document/p1/a43237">declined to pursue an investigation</a>, finding no evidence of criminal conduct. It also said that the doctors and scientists had a legal right to air their concerns to Congress or journalists.FDA officials sought a second time that year to initiate action against the scientists and doctors. “We have obtained new information confirming the existence of information disclosures that undermine the integrity and mission of the FDA and, we believe, may be prohibited by law,” wrote Jeffrey Shuren, director of the FDA’s Center for Devices and Radiological Health, on June 28, 2010.The inspector general, after consulting with federal prosecutors, declined the second request, as well.</blockquote> The IG office seemed to find the behavior legal, but FDA bureaucrats apparently did not like non-team players. <blockquote>The FDA scientists and doctors, all of whom worked for the agency’s <a href="http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CDRH/CDRHOffices/ucm115879.htm">Office of Device Evaluation</a>, said they first made internal complaints beginning in 2007 that the agency had approved or was on the verge of approving at least a dozen radiological devices whose effectiveness was not proven and that posed risks to millions of patients. Frustrated, they also brought their concerns to Congress, the White House and the HHS inspector general.Three of the devices risked missing signs of breast cancer, the scientists and doctors warned, according to documents and interviews. Another risked falsely diagnosing osteoporosis, leading to unnecessary treatments; one ultrasound device could malfunction while monitoring pregnant women in labor, risking harm to the fetus; and several devices for colon cancer screening used such heavy doses of radiation that they risked causing cancer in otherwise healthy people, the FDA scientists and doctors said.</blockquote> Permit me to wonder if <a href="http://hcrenewal.blogspot.com/search/label/regulatory%20capture">regulatory capture</a> played a role in these decisions. One might also wonder if complaints about electronic health records or other clinical IT, admitted by FDA to be a medical device "<a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html">political hot potato</a>" they elected to not regulate, were also involved. <blockquote>... The first documented FDA interception was of an e-mail dated Jan. 29, 2009, shortly after the letter from Ferry. In it, device reviewer Paul T. Hardy asked a congressional aide, Joanne Royce, for assurances that “it is not a crime to provide information to the Congress about potential misconduct by another Agency employee.”Royce replied: “[Y]ou and your colleagues have committed no crime. . . . you guys didn’t even provide confidential business information to Congress.”</blockquote> The only 'crime' was apparently not being a 'team player', which on Healthcare Renewal <a href="http://hcrenewal.blogspot.com/2011/12/ehr-mission-hostile-user-experience.html">has been defined as</a> someone who is silent, or silenced, or a co-conspirator regarding managerial mediocrity, malfeasance, or madness. <blockquote>Hardy, who is among the six employees who filed the suit, was fired in November after a negative performance review; an internal FDA letter obtained in separate litigation quoted managers saying they did not “trust” him. Of the other five scientists and doctors, the suit says two did not have their contracts renewed, two suffered harassment and werepassed over for promotions, and one was fired.</blockquote> Trust him to do - what, I ask? Read the whole WaPo article. Plaintiff's lawyers need to be aware of this event, and I intend to make them aware. -- SS Feb. 13, 2012 addendum: A link to Darrell Issa's letter to FDA Commissioner Hamburg is <a href="http://hcrenewal.blogspot.com/2012/02/congressman-darrell-issa-fdas-email.html">here</a>. -- SS

Can You Sue the Government? FDA Whistleblowers Sue Over Surveillance of Personal e-Mail

From the Washington Post: FDA staffers sue agency over surveillance of personal e-mail Ellen Nakashima and Lisa Rein January 29, 2012 The Fo...

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