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Use of Psychological Manipulation of Physicians to Sell Pharmaceuticals: The Drug Representative as "Den Mother"

We have discussed, most recently <a href="http://hcrenewal.blogspot.com/2013/09/vested-interests-and-their-influence-on.html">here</a>, how marketers of health care goods and services use <a href="http://hcrenewal.blogspot.com/search/label/deception">deception</a> and psychological manipulation to sell their goods.  Physicians, of course, are particular targets of marketers of drugs and devices.  A vivid anecdote showing how this works just <a href="http://well.blogs.nytimes.com/2013/10/03/for-med-students-love-from-the-drug-rep/">appeared</a> on a New York Times blog.  It may be easier to recall that psychological theories: <blockquote class="tr_bq">In the social and culinary wasteland that was residency training, it had been easy for Cheryl, a bubbly brunette in her mid-30s, to become our den mother. She never tired of listening to our grousing, had unerring taste in take-out, made it a point to come to our parties when invited and every so often brought in a plate of her homemade brownies. But Cheryl was no den mother. She was a pharmaceutical rep. That she managed to slip a plug for her wares into every conversation or tuck copies of studies promoting her product into our white coat pockets as we polished off her brownies was awkward. But we always overlooked the salesmanship because it was such a familiar part of our residency routine. As trainees in a large teaching hospital, we knew numerous sales reps by name and the products they peddled; and it was odd, even disappointing, to go to an educational conference where one of them was not standing next to a table laden with tchotchkes, information brochures and free take-out.  But in retrospect, such docile acceptance was problematic. In an environment where no one, including senior doctors, ever questioned the presence of sales reps, we didn’t think too hard about why they might have been as friendly and helpful as they were. We didn’t ask where the money for all these giveaways was coming from and we were rarely curious about who these reps actually were (I only ever knew their first names). It wasn’t that I or the other residents preferentially prescribed their products. But I do know that more than once when faced with a decision about what to prescribe, the first thought that came to mind was not what I needed to do to find the latest evidence-based recommendation, but what Cheryl had just told us over lunch.  All of this became painfully clear after Cheryl suddenly disappeared. At first, the other trainees and I thought she had been fired, so we avoided bringing her absence up with the rep who replaced her. But when I ran into someone from her company at a national medical conference a year later, I learned otherwise. 'Oh, she got promoted,' the rep said, smiling broadly. 'Now she’s an executive in the central office.' </blockquote> Since Ahari and Fugh-Berman wrote and testified about the cynical tactics used in the marketing of drugs and other medical products years ago (look <a href="http://hcrenewal.blogspot.com/2007/05/fool-me-once-shame-on-you-fool-me-twice.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/03/what-drug-reps-really-care-about.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2008/04/more-about-cynical-world-of-drug-reps.html">here</a>), it is now inexcusably naive for doctors to believe that drug (or device) representatives are their friends, no matter how friendly they appear.  Drug and device reps are trained to appear to be likable.  They may look like sympathetic friends, glamorous companions, or in this case, den mothers.  But as Sah and Fugh-Berman noted (look <a href="http://hcrenewal.blogspot.com/2013/09/vested-interests-and-their-influence-on.html">here</a>), likability is a ruse to sell products.  Brownies are supplied to give the appearance of warmth and comfort, and to generate feelings of reciprocity. How well it works appears above: "the first thought that came to mind was not what I needed to do to find the latest evidence-based recommendation, but what Cheryl had told us over lunch."  That it works well is demonstrated by Cheryl's promotion to an executive office. As long as physicians remain trusting, naive, or foolish in their approach to deceptive marketing, there will be more use of needlessly expensive, and sometimes needlessly toxic drugs, and more drug reps made into well-paid executives.

Use of Psychological Manipulation of Physicians to Sell Pharmaceuticals: The Drug Representative as "Den Mother"

We have discussed, most recently here , how marketers of health care goods and services use deception and psychological manipulation to sel...

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Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse.  In effect, when under orders to only speak positively about a hospital or its technology, saying anything bad could very likely get clinicians labeled as 'troublemakers' or 'disruptive clinicians.'  Sometimes - in a sadly real example at Affinity Health - it may even get threats of having complaints plastered to one's forehead (see <a href="http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html">http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html</a>), a threat answered to by a judge. The 'disruptive' label usually does not have a good effect on one's evaluations and job (or, for doctors, even career) longevity.  See, for example, the resources at <a href="http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/">http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/</a> on sham peer review. At <a href="http://www.uahealth.com/">University of Arizona Health Network (UAHN)</a>, clinicians are being told to promote the EPIC EHR. The campaign is under the aegis of executives who know, should know, or should have made it their business to know the mayhem caused at other medical centers by EPIC and other major clinical IT systems (see for example query links <a href="http://hcrenewal.blogspot.com/search/label/EPIC">http://hcrenewal.blogspot.com/search/label/EPIC</a> and <a href="http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties">http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties</a>). Here's what clinicians are bring told in the Oct. 3, 2013 "Weekly update for UAHN employees": <blockquote class="tr_bq"> <h1 style="color: #606060 !important; display: block; font-family: Helvetica; font-size: 40px; font-style: normal; font-weight: bold; letter-spacing: -1px; line-height: 125%; margin: 0; text-align: left;"> Words that Work </h1><div style="color: #505050; line-height: 13px;"> Talking positively to our patients about our new Electronic Health Record system is important! Here are some key words and phrases you can use to emphasize the many benefits of the new system:</div><ul><li style="color: #505050; line-height: 13px;"> Electronic health record (not ‘Epic’ or ‘EHR’)</li><li style="color: #505050; line-height: 13px;"> One comprehensive record</li><li style="color: #505050; line-height: 13px;"> Coordinated care</li><li style="color: #505050; line-height: 13px;"> Improves patient safety & quality</li><li style="color: #505050; line-height: 13px;"> Convenient, easy patient portal </li><li style="color: #505050; line-height: 13px;"> Private and secure</li></ul><div style="color: #505050; line-height: 13px;"><a href="https://www.uahealth.com/pdf/Epic_Words_That_Work.pdf" style="color: #1c3e71; font-weight: normal; text-decoration: underline; word-wrap: break-word !important;" target="_self">Click here</a> for more words and behaviors to inspire confidence in our patients (and ourselves) as we transition to this new system.</div></blockquote> The link to "more words" produced this PDF: <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OOVivF_6D2GEFgUm6ujfKdJjMf4UMwoxX7ZECU7351gCph46CpKY7tryUY2qq63Q7Snl9fy1SNKk9QOxUyXfhgON7lm2W2MO_Sgin5pPxl4Rf6OR78MIdzjuQrxPDCBQ4ri6BeN3YxKn/s1600/words+that+work.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OOVivF_6D2GEFgUm6ujfKdJjMf4UMwoxX7ZECU7351gCph46CpKY7tryUY2qq63Q7Snl9fy1SNKk9QOxUyXfhgON7lm2W2MO_Sgin5pPxl4Rf6OR78MIdzjuQrxPDCBQ4ri6BeN3YxKn/s400/words+that+work.jpg" width="311" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">"Words that Work" - If I worked there, I would be concerned that that using "words that don't work" about a project that probably cost hundreds of millions of dollars would likely injure my career.  Click to enlarge.</td></tr></tbody></table> This is shameless.  Many of these claims are unsubstantiated or in significant doubt in the literature. First: They left out issues such as these: <blockquote class="tr_bq">• The software is tested and validated for safety by nobody, including traditional medical device safety testers. • No postmarket surveillance for problems, either. • Transparency about problems that can cause patient harm is severely impeded by systematic impediments to information flow (as per IOM's 2012 study of health IT safety at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>, FDA via their leaked Internal Memo on HIT safety as at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>, the Joint Commission in their Sentinel Events Alert on Health IT as at <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html">http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html</a>, and others.) • Problems known are only the "tip of the iceberg" (FDA, ECRI Institute), as at <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html">http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html</a> and <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a> </blockquote><blockquote class="tr_bq">(Mar. 2014 addendum: add to that list the revelations of med mal insurer CRICO, that EHR technology has contributed to a substantial fraction of the medical malpractice suits in Massachusetts: <a href="http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html">http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html</a>)</blockquote> Of the claims they do make: <blockquote class="tr_bq">• Efficient - see aforementioned links as well as "Common Examples of Healthcare IT Difficulties" at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a> • Convenient - as above.  According to whom?  Compared to what?  Pen and paper? • Improves patient safety and quality - see IOM report post at <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html">http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html</a> .  We as a nation are only now studying safety of this technology, and the results are not looking entirely convincing, e.g. ECRI Deep Dive Study of health IT safety at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>.  171 health IT mishaps in 36 hospitals, voluntarily reported over 9 weeks, with 8 reported injuries and 3 reported possible deaths is not what I would call something that "improves patient safety and quality" without qualifications. • The Cadillac of its kind - according to whom? • Patients at hospitals using this system love it -  Do most patients even know what it, or any EHR, looks like?  Have they provided informed consent to its use? • Exciting - clinician surveys such as by physicians at <a href="http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html">http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html</a> and by nurses at <a href="http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html">http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html</a> shed doubt on that assertion.  </blockquote><blockquote class="tr_bq">(Addendum: also see what nurses think about these systems at "Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications Only a Matter of Time in Open Letter", <a href="http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html">http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html</a>) • The best thing for our patients - again, according to whom? • Sophisticated new system - "New"?  Not so much, just new for U. Arizona Health.  "Sophisticated", as if that's a virtue?  Too much "sophistication" is in part what causes clinician stress and burnout, raising risk; see this summary of a new, not-free JAMIA article "Electronic medical records and physician stress in primary care: results from the MEMO Study", J Am Med Inform Assoc amiajnl-2013-001875 at <a href="http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html">http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html</a>.   From that summary: <blockquote class="tr_bq">... Compared with physicians at clinics with low-function EMRs, physicians at clinics with moderate-function EMRs experienced significantly more stress and had a higher rate of burnout. Additionally, physicians at clinics with moderate- or high-function EMRs felt less satisfied with their current position overall. </blockquote>and: <blockquote class="tr_bq">... Results also showed a significant relationship between time pressure and physician stress in the cohort with high-function EMRs, and only in this cohort, suggesting physicians at these clinics may be particularly pressured for time during patient encounters in the face of a large number of EMR functions. "This 'made sense' to us in thinking about the possibility that those in the high-use group had more to do in the EMR" [say the authors]. </blockquote> • Smartest program out there - "Smartest" meaning what, exactly?  According to whom?  Who performed the comparison? • Streamlined - compared to what? • Thank you for your patience - even if the effects on clinicians gets you or your loved ones maimed or killed? • Safe and secure network - really?  No break ins, ever, considering multiple breach stories like those at <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy</a>? • Keeping you informed is our priority - informed of what? • Specially trained staff - like these:  <a href="http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html">http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html</a>?</blockquote> and this: <blockquote class="tr_bq">• Take Responsibility - I ask, should clinicians "take responsibility" for IT-related disruptions that impair care such as "use error" (as opposed to user error), i.e., what the National Institute of Standards and Technology has called operator error due to poor usability and other features of bad health IT?  (See "NIST on the EHR Mission Hostile User Experience" at <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a>.)  What about "glitches" and bugs that corrupt or lose data?  Should clinicians also 'take responsibility' for those?  (See for example the posts on the wild things that happen when IT malpractice leads to clinical mayhem at <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>.)</blockquote> It appears to me that this vendor is using its client hospitals' management to enforce an "acceptable point of view" clinicians must proffer to patients about EHRs (which they must call "health" records), despite well-known contradictory findings.  This is, in effect, forced marketing of a device. Trying that for a drug or a conventional medical device (e.g., a particular stent) would be on its face unethical and likely illegal. Finally, critical thinking is what keeps patients alive and safe.  Marketing measures like this (some might call it "propaganda"), espousing and enforcing 'EHR exceptionalism', in my opinion, damage critical thinking and expression, and are thus unacceptable to push on clinicians and on patients. I add that requiring clinicians to promote deceptive propaganda the clinicians themselves know is untrue, from painful experience, is degrading, intimidating and destroys morale.  It is axiomatic that clinicians (or anyone) operating under such conditions cannot perform at their best. Thus the management geniuses who came up with these instructions (if not outright vendor-ghostwritten as at the Aug. 2012 "Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists", <a href="http://www.tinyurl.com/epic-stealth">http://www.tinyurl.com/epic-stealth</a>) are by their actions increasing risk of patient harm. The nurses' unions at at <a href="http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html">http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html</a> have it right, in my view:  complain about the disruptions this technology causes, and complain loudly, if at the very least to make sure the problems are out in the open. -- SS Note: also see the followup Nov. 2013 post "We’ve resolved 6,036 issues and have 3,517 open issues: extolling EPIC EHR virtues at University of Arizona Health System" at <a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html</a>

Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse. In ...

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Round and Round Spins the Revolving Door, Unimpeded by "Obamacare," Nor By Those Protesting "Obamacare"

On this day of government dysfunction in the US, it is time for our latest installment on the "<a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">revolving door</a>," the interchange of insiders among government legislative offices that affect health policy and agencies that implement it, and large health care corporations and the lobbyists and attorneys who represent them.  While we have been discussing this issue since March, 2011 (look <a href="http://hcrenewal.blogspot.com/2011/03/those-big-doors-keep-revolving.html">here</a>),  it got major media attention in the form of a New York Times <a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html?pagewanted=all">article</a> two weeks ago. We have accumulated several other relevant stories since late August, 2013, which we will group by the type of government offices and agencies affected, and within them, by the date the story first came out.. Regulatory and Law Enforcement Agencies Health Care Antitrust Leader at the Federal Trade Commission to Arnold & Porter  From the MainJustice.com <a href="http://www.mainjustice.com/2013/09/09/ftc-senior-antitrust-attorney-joins-arnold-porter/">site</a>, <blockquote class="tr_bq">Peter J Levitas, a former senior antiturst attorney at the Federal Trade Commission, is joining Arnold & Porter LLP in Washington, D.C.... Levitas has spent the past four years as deputy director of the FTC's Bureau of Competition and oversaw investigations and litigation for mergers and conduct cases in numerous industries.  </blockquote> So, <blockquote class="tr_bq">Levitas joins the firm's antitrust practice with experience3 addressing complex merger and conduct investigations, particularly in the healthcare, pharmaceutical and technology industries.</blockquote> Leader of Health Care Fraud Enforcement for US Attorney New Jersey Office to Lowenstein Sandler From the ComplianceWeek.com <a href="http://www.complianceweek.com/former-health-care-fraud-chief-rejoins-lowenstein-sandler/article/311549/">site</a>, <blockquote class="tr_bq">Maureen Ruane, a former health care fraud chief at the U.S. Attorney's Office for the District of New Jersey, has rejoined the law firm Lowenstein Sandler to lead its new health care litigation, investigations and compliance practice. The new practice will help the firm's healthcare and life science clients strengthen their regulatory and compliance programs, as well as defend corporate and individual clients who become the subjects or targets of government investigations or enforcement actions.  Prior to rejoining Lowenstein Sandler, Ruane most recently served for more than three years as the Chief of the Health Care & Government Fraud Unit at the U.S. Attorney's Office for the District of New Jersey.</blockquote> Health Policy Implementation Counsel for Department of Health and Human Services to Sidley Austin <a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html?pagewanted=all">Per</a> the NY Times,  <blockquote class="tr_bq">Dr. [Dora] Hughes, a former Obama administration official, has something Washington lawyers and lobbying shops covet: an insider’s understanding of the new health care law. After nearly four years as counselor to Health and Human Services Secretary Kathleen Sebelius, she left government last year to work for Sidley Austin, which represents insurers, pharmaceutical companies, device makers and others affected by the law. </blockquote> Previously, <blockquote class="tr_bq">she  began a decade ago, first as a health policy adviser to Senator Edward M. Kennedy, and later to Mr. Obama, then a senator. </blockquote> Deputy Assistant Secretary of Department of Health and Human Services to Glover Park Group Also from the NY Times, <blockquote class="tr_bq"> Elizabeth Engel, who oversaw health legislation and served as a liaison to Congress when she was a deputy assistant health secretary under Ms. Sebelius, is now advising health care clients for the Glover Park Group. </blockquote> White House to Avenue Solutions <a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html">From</a> the NY Times, <blockquote class="tr_bq">Yvette Fontenot, a mother of three who began her Washington career in 1997, analyzing Medicare for the Office of Management and Budget. Ms. Fontenot worked on the health bill as a Finance Committee aide and later moved to the White House. Four months ago she joined Avenue Solutions, a boutique lobbying shop. </blockquote> White House "Health Czar" and Deputy Chief of Staff to Consonance Capital, and CVS While we <a href="http://hcrenewal.blogspot.com/2013/08/the-door-revolves-again-former-white.html">noted</a> this in August, 2013, the NY Times reported in September as part of its larger article,  <blockquote class="tr_bq">   <a href="http://m.healthcarefinancenews.com/news/aca-architect-returns-private-equity">Nancy-Ann DeParle</a>, Mr. Obama’s former 'health czar' and later his deputy chief of staff, now guides health care investments as a partner in a new private equity firm, Consonance Capital, with colleagues from her pre-White House days. </blockquote> Actually, as we <a href="http://hcrenewal.blogspot.com/2009/03/meet-new-boss-same-as-old-boss-health.html">discussed</a> in 2009, Ms DeParle has been oscillating back and forth through the revolving door for a while.  She  was the administrator of the Health Care Financing Administration in the Department of Health and Human Services under President Clinton from 1997-2000.  She left to become managing director of a private equity firm, CCMP Capital.  She also served on the boards of directors of Boston Scientific, Cerner, and Medco.  Then she went back to the executive branch as noted by the the Times above. Furthermore, as reported by AP, <a href="http://news.providencejournal.com/breaking-news/2013/09/cvs-caremark-board-adds-former-white-house-adviser.html">via</a> the Providence Journal, <blockquote class="tr_bq">Drugstore chain CVS Caremark has added to its board of directors a former top adviser to President Barack Obama on the health care overhaul. The Woonsocket, R.I., company said Wednesday after markets closed that Nancy-Ann M. DeParle, 56, will be an independent director who serves on the board's audit committee.</blockquote> White House to health care venture capital Also from the NY Times story, <blockquote class="tr_bq">Bob Kocher, a doctor, management consultant and former member of Mr. Obama’s economics team, is a California venture capitalist, helping finance health start-ups. </blockquote> Legislative Offices Senate Finance Committee Staff, then Department of Health and Human Services Staff to Avenue Solutions As <a href="http://thehill.com/business-a-lobbying/318577-architects-of-obamacare-reap-windfall-as-washington-lobbyists">reported </a>by The Hill bog, <blockquote class="tr_bq">The firm Avenue Solutions, for instance, recently hired Yvette Fontenot, a former staffer for both the Senate Finance Committee, which wrote ObamaCare’s tax-related provisions, and HHS's Office of Health Reform, which is assisting the implementation. Since her hire in April, the four-woman firm has picked up Health Care Service Corp. as a client, and Fontenot is now lobbying for the Blue Cross Blue Shield Association</blockquote> Congress to Alston & Bird In the same report, <blockquote class="tr_bq">Former Rep. Earl Pomeroy (D-N.D.) joined Alston & Bird in 2011 after dealing with healthcare and tax issues as a member of the House Ways and Means Committee. Now Pomeroy and his one-time chief of staff, Bob Siggins, are lobbying on ObamaCare for clients such as clients such as Vision Service Plan, the National Coordinating Committee for Multiemployer Plans and Medicare — a health insurance provider.</blockquote> Health Counsel for Senate Finance Committee from WellPoint, Now to Johnson & Johnson Note that we touched on part of this story back in 2010<a href="http://hcrenewal.blogspot.com/2010/04/pay-for-hypocrisy-for-health-insurance.html"> here</a>.  Now <a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html?pagewanted=all">from</a> the New York Times,  <blockquote class="tr_bq"><div itemprop="articleBody">Liz Fowler, a onetime executive with WellPoint, the insurer, helped draft the legislation as the chief health counsel for the Senate Finance Committee and later joined the administration. Now she runs global health policy for Johnson & Johnson, the medical equipment and pharmaceutical giant, which strongly backed the health bill and stands to benefit from it. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">Ms. Fowler is not a registered lobbyist, but she does provide in-house advice on the bill — work that has drawn criticism from publications like the British newspaper <a href="http://www.theguardian.com/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1">The Guardian</a> and the Web sites <a href="http://www.salon.com/topic/liz_fowler/">Salon</a> and <a href="http://www.huffingtonpost.com/bill-moyers/watch-washingtons-revolvi_b_2316245.html">The Huffington Post</a>, where the journalist Bill Moyers singled out Ms. Fowler, asserting that 'when push comes to shove, corporate interests will have the upper hand.'</div></blockquote><div itemprop="articleBody"> </div><div itemprop="articleBody">Summary</div><div itemprop="articleBody"> </div><div itemprop="articleBody"> It's enough to make one's head spin: all that traffic through the revolving door reported just in the last five weeks.</div><div itemprop="articleBody"> </div><div itemprop="articleBody">As we have said many times before, the constant interchange of health care insiders among government offices, lobbying and legal firms, and large health care corporations certainly suggests that health care, like many other sectors, seems to be run by an amorphous group of insiders who owe allegiance neither to government nor industry.  The NY Times tried to explain this in a benign way,</div><div itemprop="articleBody"> </div><blockquote class="tr_bq"><div itemprop="articleBody">Yet the progression from government to the private sector is also predictable, a window into the peculiar rhythms of life in the capital. Young aides, often fresh out of college or graduate school, acquire highly specialized knowledge but eventually settle down, build lives and long for jobs that pay more and let them see their children at night. </div></blockquote><div itemprop="articleBody"> </div><div itemprop="articleBody">While the private sector may offer good pay, is it just for these poeples' skills and expertise?  Or are these offers only for those who while in government service evinced friendship to private vested interests?  Do government workers who think longingly of higher pay and shorter hours wonder what it would take to please those that might offer such opportunities?</div><div itemprop="articleBody"> </div><div itemprop="articleBody">Yet those who work in government are supposed to be working for the people, and those who work on health care within government are supposed to be working for patients' and the public health.  If they are constantly looking over their shoulders at potential private employers who might offer big checks, who indeed are they working for?</div><div itemprop="articleBody"> </div><div itemprop="articleBody">Attempts to turn government toward private gain and away from being of the people, by the people, and for the people have no doubt been going on since the beginning of government (and since the Constitution was signed, in the case of the US).  However, true health care reform  would require curtailing the severe sorts of conflicts of interest created by the revolving door.  This might require both improving pay and working conditions for government regulators, law enforcers, and legislative staffers; and specific laws to prevent immediate transitions from being a regulator, law enforcer, or legislator to handling corporate responses to or defenses against such regulation and enforcement. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">That bit does not seem to be part of the current Affordable Care Act, yet it was hardly to enact such restrictions on conflict of interest that certain members of Congress have shut down the government.   </div><div itemprop="articleBody"> </div>

Round and Round Spins the Revolving Door, Unimpeded by "Obamacare," Nor By Those Protesting "Obamacare"

On this day of government dysfunction in the US, it is time for our latest installment on the " revolving door ," the interchange ...

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Another in the "Health IT Crashed, But Patient Care Was Not Compromised" Series - NHS Greater Glasgow and Clyde

We must have health IT to prevent stupid doctors and nurses from making mistakes.  Without it, patients are at the mercy of dreaded Paper Records, which by definition cannot ever be used to provide quality care. But when the IT goes down, Patient Care Has Not Been Compromised.  This line should be trademarked, as it's seen so often.  (I even have an indexing tag for it, see this query link: <a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised">http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised</a>.) Care is never, never compromised when the IT goes belly up en masse due to information technology malpractice.  Care is only compromised by paper, no matter how good the paper records and its human stewards are. Here's the latest example that made it to the news, in Scotland: <blockquote class="tr_bq">1 October 2013 BBC News <a href="http://www.bbc.co.uk/news/uk-scotland-glasgow-west-24358107">Appointments postponed after major IT failure at NHSGGC</a> (NHS Greater Glasgow and Clyde) Hundreds of outpatient appointments and a number of operations had to be postponed after computer systems failed at Scotland's biggest health board. NHS Greater Glasgow and Clyde said technicians were working through the night to fix a "major IT problem" which occurred on Tuesday morning. It affected staff access to clinical and administrative systems. </blockquote> Delaying hundreds of appointments and delaying surgeries at up to 10 major hospitals seems on its face to represent "compromised care." <blockquote class="tr_bq">The health board apologised to patients and said all appointments would be rescheduled. In total, 288 outpatient appointments, four planned inpatient procedures, 23 day surgery cases and 40 chemotherapy sessions were postponed. There was also some delay in calls to the switchboard being answered. The problem may have affected up to 10 major hospitals across the health board area.</blockquote> One wonders how these appointments and surgeries were triaged for delay.  Clearly the downed computer was of no help. Here's that wonderful line: <blockquote class="tr_bq">But emergency operations were not compromised - neither were community services.</blockquote> So when does computer failure actually compromise patient care?  I'd like to see some hospital executive with a spine for once admit that IT malpractice does disrupt patient care, create distractions, and thus create safety risk.  Considering the domain, however, I doubt I'll ever see that. <blockquote class="tr_bq">A spokeswoman said: "Our technical staff are working flat out to resolve this.</blockquote> It should never have happened in the first place. <blockquote class="tr_bq">"The problem relates to our networks and the way staff can connect to some of our clinical and administrative systems.</blockquote> Well, sick patients really appreciate that explanation. <blockquote class="tr_bq">It was not clear how long the disruption would last. NHSGGC said if it did continue, people who were scheduled for treatment would be contacted directly. </blockquote> Per a computer guru from my past:  "Either you're in control of your information systems, or they're in control of you." In this instance, the latter clearly applies. In healthcare, having your information systems in control of you is, sooner or later, going to be deadly. -- SS

Another in the "Health IT Crashed, But Patient Care Was Not Compromised" Series - NHS Greater Glasgow and Clyde

We must have health IT to prevent stupid doctors and nurses from making mistakes. Without it, patients are at the mercy of dreaded Paper Re...

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Vested Interests and Their Influence on Physicians- New Understanding from Cognitive and Social Psychology

<a href="http://hcrenewal.blogspot.com/search/label/evidence-based%20medicine">Evidence-based medicine</a> proposes patient care decisions based on the best evidence from critically reviewed clinical research, knowledge of biology and the biopsychosocial context, and patients' values and preferences.  Yet physicians often fail to make evidence-based decisions, despite many efforts to educate, or incentivize them to do so.  We used to think that the main reason was physicians' lack of knowledge and understanding of EBM, and human cognitive limitations that make such evidence-based thinking difficult.  However, now we realize that physicians are deluged by  attempts to influence their decisions so as to favor vested interests, whether or not that is good for patients. We have discussed various kinds of <a href="http://hcrenewal.blogspot.com/search/label/deception">deception</a> used in <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> meant to increase physicians' prescriptions for drugs, and recommendations for devices and health care services.  Physicians have not proved to be very resistant to these methods. Now a new article provides a different perspective on how marketers use cognitive and social psychology to manipulate physicians.(1)  Sunita Sah's and Adriane Fugh-Berman's introduction stated, <blockquote class="tr_bq">Physicians often believe that a conscious commitment to ethical behavior and professionalism will protect them from industry influence.  Despite increasing concern over the extent of physician-industry relationships, physicians usually fail to recognize the nature and impact of subconscious and unintentional biases on therapeutic decision-making. Pharmaceutical and medical device companies, however, routinely demonstrate their knowledge of social psychology processes on behavior and apply these principles to their marketing. </blockquote> The article then listed a number of findings from social (and cognitive) psychology that marketers may use to their advantage on naive physicians. Psychological Mechanisms Promoting Acceptance of Conflicts of Interest and Dubious Marketing Ploys First, marketers may take advantage of cognitive biases and psychological mechanisms that allow physicians to accept marketing maneuvers while denying the effect of marketing on their decision making. Confidence and Over-Confidence <blockquote class="tr_bq">People are strongly influenced by messages delivered with confidence and do not take the trouble to ascertain the accuracy of these messages if doing so requires effort or money.</blockquote> I would add that many humans, including physicians, are also over-confident in the accuracy of their own judgments.  (In 1989 we showed  that physicians often were excessively confident in their judgments of patients' outcomes, in particular, about survival of critically ill patients.)(2) Of course, marketers often state their messages with great confidence regardless of their accuracy. So physicians need to try to restrain their own over-confidence, and be more skeptical of the confidence of others. Maybe this would just be an exercise in simple humility. Self-Serving (or Ego) Biases People tend to believe that the results of their decisions, or of their groups' decisions, are better than average.  This can be called the Lake Wobegon effect (from Garrison Keilor's fictional town in which all the children are above average.) We and others have shown that physicians may be overly optimistic about the outcomes of their own (versus others') patients, or their clinical units' (versus others') outcomes, again in the context of predicting survival of critically ill patients.(3)  We have also <a href="http://hcrenewal.blogspot.com/2010/07/where-no-hospital-ceos-are-below.html">posted</a> about how corporate boards of directors seem to almost always think that their hired executives are better than average, at least when determining their executive compensation. Similarly, Sah and Fugh-Berman wrote, <blockquote class="tr_bq">Physicians believe that their own prescribing behavior is unaffected by industry influence, although they concede that other physicians are susceptible to such influence.</blockquote> Furthermore, <blockquote class="tr_bq">Social psychology research confirms that people have a 'bias blind spot,' namely, they are more likely to identify the existence of cognitive and motivational biases in other than in themselves.</blockquote>But, as Dana and Lowenstein wrote, <blockquote class="tr_bq">It cannot both be true that most physicians are unbiased and that most other physicians are biased.</blockquote> So, to put it bluntly, physicians ought to be more humble about their own ability to resist outside influences and the resulting biases. Again, some simple humility might help. Cognitive Dissonance Sah and Fugh-Berman pointed out that <blockquote class="tr_bq">While articulating and believing in the importance of scientific objectivity, physicians' biases to accept industry gifts create cognitive dissonance; that is, discomfort that arises from discrepancy between conflicting beliefs, or between beliefs and behaviors.</blockquote> So, <blockquote class="tr_bq">Cognitive dissonance theory specifies three methods - not mutually exclusive - by which people manage or reduce dissonance.  Changing one of the dissonant beliefs, opinions or behaviors (possibly a difficult or painful process that requires sacrificing a pleasurable behavior or treasured belief); Lowering the importance of one of the discordant factors which can be accomplished by denial - forgetting or rejecting the significance of one or more of the conflicting cognitions; and adding consonant elements that resolve or lessen the dissonance (this may involve rationalizations to buffer the dissonance between conflicting cognitions.)</blockquote> Physicians may use denial and rationalization to reduce cognitive dissonance caused by their concurrent desire for relationships with marketers and others with vested interests on one hand, and their professionalism and its obligation to put patients' needs first on the other hand.  Sah and Fugh-Berman cited Chimonas and colleagues, <blockquote class="tr_bq">Denial included (a) avoiding thinking about the conflict of interest; (b) rejecting the notion that industry relationships affect physician behavior, and (c) disavowing or universalizing responsibility for problems that arose from conflicts of interest ('there's always a conflict of interest...').  Rationalizations included (a) asserting techniques that would help maintain impartiality and (b) reasoning that meetings with drug reps were educational and benefited patients.</blockquote> We have discussed various public justifications for accepting conflicts of interest by physicians and other health care decision makers that employed a variety of <a href="http://hcrenewal.blogspot.com/search/label/logical%20fallacies">logical fallacies</a> along these lines. So physicians need to re-examine their treasured beliefs and the gratification they get from relationships with industry (as opposed to those with patients, colleagues, friends and families).  They could remember the advice that no one can serve two masters. Sense of Entitlement Physicians' sense of entitlement, especially given the increasing stress upon them, may be used to rationalize relationships with drug, device and biotechnology companies since these corporations seem to be among their few friends (versus insurance companies, government agencies, and sometimes hospital administrations whom physicians feel may be more burdensome.).  So, in one study, <blockquote class="tr_bq">Implicitly reminding physicians of the burdens of medical training and their working conditions more than doubled reported willingness to accept gifts....</blockquote>So physicians need to reconsider that to which they feel entitled.  This is the third instance in which some humility might help.  Principles of Influence Used by Marketers Markets seem to also be well acquainted with the six principles of influence and persuasion identified by Cialdini and colleagues. Reciprocity <blockquote class="tr_bq">The norm of reciprocity - the obligation to help those who have helped you - is one of the guiding principles of human interaction</blockquote> This is the foundation of the effect of relatively small conflicts of interest, such as giving of small gifts. <blockquote class="tr_bq">Physicians pay off industry gifts through changes in their practice</blockquote> Furthermore, <blockquote class="tr_bq">Gifts associated with a subtle implicit request may be more likely to achieve compliance than gifts that call for explicit reciprocation. </blockquote>So physicians need to be wary of Greeks, or anyone else bearing gifts, even those less conspicuous than wheeled horses. Commitment and Consistence <blockquote class="tr_bq">Consistency is highly valued in our society and associated with rationality and stability.  After committing to a decision or opinion, people justify that choice or opinion by remaining consistent with it.</blockquote> So marketers try to get physicians to make small commitments to leverage larger ones.  This is <blockquote class="tr_bq">why drug reps, ask, for example, 'will you try my drug on your next five patients?'</blockquote>So physicians should remember there is no virtue in commitment to erroneous beliefs.  "A foolish consistency is the hobgoblin of little minds." - Ralph Waldo Emerson Social Proof This is basically the deliberate deployment of the logical fallacy of the <a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html">appeal to common practice</a>. <blockquote class="tr_bq">Social proof, also referred to as social validation or conformity, is the practice of deciding what to do by looking at what others are doing. </blockquote> So, <blockquote class="tr_bq">If accepting industry gifts is a cultural norm in medicine, physicians will continue to do so.  The opinions of colleagues are often used by industry representatives to sway physicians to adopt a particular therapy.  </blockquote> This may be why industry works so hard to sign up health care academics. <blockquote class="tr_bq">Trainees in an institution, for example, are affected by the institution's stated policies but also - and sometimes more so - by what they see their mentors do.</blockquote>So physicians, who often pride themselves on independence, need to be skeptical about the need to follow the crowd. Liking or Rapport The more you like someone, the more you are apt to follow their advice, even if your feelings towards them have been manipulated. This is obviously why drug representatives, for example, are so nice to physicians. <blockquote class="tr_bq">Physicians often feel overworked, underpaid, and unappreciated [ed note -  and their is plenty of evidence, some of which we have discussed on this blog, that this is not unreasonable.]  Drug reps dispense sympathy, flattery, food, gifts, services and income-enhancing opportunities and seek to ask nothing in return but scholarly consideration of the benefits of drugs. </blockquote>So physicians need to reconsider who really are their friends, and be skeptical of "friends" with something to sell.  Authority and Security This is basically the deliberate deployment of the logical fallacy of the <a href="http://www.nizkor.org/features/fallacies/appeal-to-authority.html">appeal to authority</a>.  The best example is industry's efforts to recruit <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leaders</a>, that is health professionals who are perceived as authority figures, but have really been hired to market. <blockquote class="tr_bq">From an industry perspective, the best KOLs radiate status and authority while successfully convincing their peers (and perhaps themselves) of their illusory independence and lack of bias. </blockquote> Note that <blockquote class="tr_bq">KOL speakers not only influence audience members' prescribing behavior, but also - as predicted by cognitive dissonance theory - become more convinced themselves of the benefits of the products they endorse.</blockquote>So physicians need to be skeptical of those claiming to be authorities, especially when they are connected with people who have something to sell. Summary We used to strongly believe (and Dr Wally Smith and I used to teach a course to the effect that) the major barrier to true evidence-based practice was the cognitive limitations that physicians share with all humans.  We thought in terms of cognitive biases and the inappropriate use of cognitive heuristics leading physicians to inaccurately judge the probabilities of diagnoses and medical outcomes, and thus make less than optimal decisions. Now it seems apparent that the deliberate influencing of health professionals' judgments and decisions by external actors, mainly those interested in selling more products and services, but sometimes by those with ideological or political motives, is currently a much more important challenge to evidence based practice.  It looks like the influencers may be very knowledgeable about human cognitive limitations and how social psychology influences judgment and decisions, and may use this knowledge to pursue their vested interests, at the financial and physical expense of patients, and ultimately the public.  True health care reform would encourage professional education designed to increase resistance to external influences that put self-interest ahead of patients' and the public's health, and careful regulation that would decrease some of the more dangerous practices used.  Of course, much more resistance might be achieved if physicians used a little more common sense when dealing with people who are obviously trying to sell them on goods, services, or ideas.  A good proportion of the deceptive methods discussed above could be countered by remembering the usefulness of humility, skepticism, and a few simple aphorisms.    Again, as we have written repeatedly, not only should all conflicts of interest be disclosed for the sake of honesty, but physicians and other health professionals ought to consider repudiating most of all of them, maybe at some personal expense, but in the interest of re-establishing their commitment to putting the patient, not their own self-interest, or the vested interests of others, first.     References 1.  Sah S, Fugh-Berman A. Physicians under the influence: social psychology and industry marketing strategies.  J Law Med Ethics 2013; 14:  . Link <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2286433">here</a>: 2. Poses RM, Bekes C, Copare F, Scott WE.  The answer to "what are my chances, doctor?"  depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.  Crit Care Med 1989; 17: 827-833.  Link <a href="http://www.ncbi.nlm.nih.gov/pubmed/2752779">here</a>. 3. Poses RM,  McClish DK, Bekes C, Scott WE, Morley JN. Ego bias, reverse ego bias, and physicians' prognostic judgments for critically ill patients. Crit Care Med 1991; 19: 1533-1539.  Link here.

Vested Interests and Their Influence on Physicians- New Understanding from Cognitive and Social Psychology

Evidence-based medicine proposes patient care decisions based on the best evidence from critically reviewed clinical research, knowledge of...

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A Plague of Bureaucrats - Now 10 Per Physician in US Health Care

There seems to be a reasonable argument that the US health care system is more dependent on the private sector, and in particular the for-profit private sector, than systems in other developed countries.  Advocates of private, for-profit health care often tout the private sector as more efficient and less bureaucratic than government.   However, a <a href="http://blogs.hbr.org/2013/09/the-downside-of-health-care-job-growth/">post by Robert Kocher in the Harvard Business Review blog</a>, of all places, noted that US health care is increasingly inflicted by a proliferation - perhaps a plague - of bureaucrats. Dr Kocher looked at employment of physicians, other health care professionals and clinical workers, and bureaucrats in a more recent time frame, 1990-2012.  The key findings were: <blockquote class="tr_bq"> Using data from the Bureau of Labor Statistics (BLS) and the American Medical Association, my colleagues and I found that from 1990 to 2012, the number of workers in the U.S. health system grew by nearly 75%. Nearly 95% of this growth was in non-doctor workers, and the ratio of doctors to non-doctor workers shifted from 1:14 to 1:16.</blockquote> Furthermore, <blockquote class="tr_bq"> Today, for every doctor, only 6 of the 16 non-doctor workers have clinical roles, including registered nurses, allied health professionals, aides, care coordinators, and medical assistants. Surprisingly, 10 of the 16 non-doctor workers are purely administrative and management staff, receptionists and information clerks, and office clerks. </blockquote> So, in summary, for every doctor, there are 6 clinical workers (nurses, aides, etc) and 10 bureaucrats (including managers). Note that this data appears compatible with 1983-2000 employment data we <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">summarized</a> in 2005. During that period, the ranks of health care managers grew much faster than the ranks of physicians or nurses.  The growth rates from 1983 to 2000 were 1.39x (39%) for physicians, 1.54x (54%) for nurses, and a whopping 8.26x (726%) for managers. Another way to look at it is, in 1983 there was 1 manager for every 5.7 physicians and every 15.1 nurses. In 2000, there was 1 manager for every 0.96 physicians and every 2.9 nurses. Again, by 2000, the number of health care managers exceeded the number of physicians. There were more managers than any other species of health care worker other than nurses. So, by 2000, there was one manager per doctor.  By 2012, there were 10 bureaucrats, including managers, per doctor.  We have discussed the increasing power of managers, administrators and executives over health care.  Management gurus, such as Alain Enthoven, had advocated breaking the power of the supposed "physicians' guild" to reduce health care costs, and replacing physician leaders with managers (look <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-breaking-physicians.html">here</a>).  We have discussed the growing role of <a href="http://hcrenewal.blogspot.com/search/label/generic%20management">generic managers,</a> that is leaders trained only to manage, but not experienced in , and often not sympathetic to the values of health care.  Now there is increasing evidence that managers and bureaucrats are increasingly numerous in health care, the former somewhat and the latter greatly out-numbering physicians. We cannot scientifically prove that this plague of bureaucrats is responsible for US health care's mediocre quality and access, despite higher costs per capita than in any other developed country.  However, it does appear to be a reasonable hypothesis that increasing the relative numbers of health care professionals versus bureaucrats might produce at least more health care per dollar, if not also better health care per dollar.    This suggests that true health care reform requires decreasing the influence of generic management.  Health care leaders ought to be those with some knowledge of health care and some sympathy for its values. Such health care leadership might be less concerned with increasing bureaucracy, and more concerned with more and better actual care of actual patients.  (But do not expect such reforms to be popular with the very <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">well-paid</a> generic managers who now run health care, and hence do not expect such reforms to be easy to implement.)

A Plague of Bureaucrats - Now 10 Per Physician in US Health Care

There seems to be a reasonable argument that the US health care system is more dependent on the private sector, and in particular the for-pr...

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Should "Diagnosing While Texting" Be Illegal?

I saw an interesting comment at Medscape in the comment thread of the article "<a href="http://www.medscape.com/viewarticle/809237">Do Your EHR Manners Turn Patients Off?</a>" (MedScape subscription required). <div style="margin-left: 40px;">Dr. [redacted] | Neurology I live in a town that has passed legislation criminalizing texting and driving. A driver is more impaired and distracted when texting than when intoxicated.  EHR's and the practice of medicine should be no different. Do you really believe that your physician is actually concentrating on the patient in front of them while their attention is primarily focused on entering data on a computer? The reality is that EHR's true value is data collection for statistical analysis by our government and there is an obvious deficiency for enhancing the physician-patient collaborative experience. </div><div> </div><div> </div><div>Medicine, like driving, is a very cognition, thinking and concentration-intense activity.   Failures lead to injury and death (although not quite as dramatically in the former compared to the latter).</div><div></div><div> I think the point about distraction the commenter makes is valid, or at least worthy of healthy consideration. Unless you're a health IT hyperenthusiast, that is (see <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>).</div><div></div><div> -- SS </div>

Should "Diagnosing While Texting" Be Illegal?

I saw an interesting comment at Medscape in the comment thread of the article " Do Your EHR Manners Turn Patients Off? " (MedScape...

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