Retracted autism study an ‘elaborate fraud,’ British journal finds – CNN.com

(CNN) — A now-retracted British study that linked autism to childhood vaccines was an “elaborate fraud” that has done long-lasting damage to public health, a leading medical publication reported Wednesday.

An investigation published by the British medical journal BMJ concludes the study’s author, Dr. Andrew Wakefield, misrepresented or altered the medical histories of all 12 of the patients whose cases formed the basis of the 1998 study — and that there was “no doubt” Wakefield was responsible.

“It’s one thing to have a bad study, a study full of error, and for the authors then to admit that they made errors,” Fiona Godlee, BMJ’s editor-in-chief, told CNN. “But in this case, we have a very different picture of what seems to be a deliberate attempt to create an impression that there was a link by falsifying the data.”

via Retracted autism study an ‘elaborate fraud,’ British journal finds – CNN.com.

I’m guessing First Do No Harm isn’t in his lexicon…

Dr. Wes: Our Health Care Reform Illusion

The idea of a fit for all is an illusion. Justice and equity are seen differently. We imagine some public consensus at our own peril. But honesty has been in short supply. To paraphrase Oprah: what do we know for sure?

Some people want a relationship with a trusted doctor who knows them well. They want to pick the doctor, the neighborhood and the hospital they attend. Others want immediate access and have little trust or interest in a personal relationship with a doctor.

Some people want…

via Dr. Wes: Our Health Care Reform Illusion.

What, one-size-fits-all isn’t a good plan?  It’s almost like we’d need a market to fulfill these disparate desires…

Dr. Wes: The Need for Doctors’ Right To Investigative Free Speech

For medical device companies that pay doctors as consultants, they have to be willing to have the knife cut both ways during clinical testing of their devices, regardless of the implications to their investors

via Dr. Wes: The Need for Doctors’ Right To Investigative Free Speech.

Damn right.

AMA Policy on Social Media

New AMA Policy Helps Guide Physicians’ Use of Social Media

For immediate release:
Nov. 8, 2010

SAN DIEGO – Millions of Americans use social networks and blogs to communicate, but when those users are physicians, challenges to the patient-physician relationship can arise. New policy adopted today by the American Medical Association (AMA) aims at  helping physicians to maintain a positive online presence and preserve the integrity of the patient-physician relationship.

It’s not surprising there is some guidance on social media from the AMA.  I suppose the only surprise is that it took this long.

Follow the link above to read the policy, which I find remarkably reasonable.  I have some litle heartburn about this one:

(e) When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.

Plenty of thoughtful people disagree with things I’ve written (and a few unthoughtful folks disagree with everything), but I’m not a fan of giving AMA blessing to harass. 

Yes, there’s some things written out there I’m not a big fan of.  I take it as a sign of strength that we can disagree but not make a federal case of it.

And, for you aspiring to get into a professional school, f) is not just for practicing physicians:

(f) Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.

You’d have to go a long way to damage the medical profession, but it takes one facebook post to damage yours.  “Dude, I was so wasted when I…” doesn’t instill confidence in you or your judgement.  Just putting that out there.

So, rare kudos from me for the ever-shrinking AMA.

Another satisfied ABEM Diplomate

I get emails after bemoaning the inefficient / laughable requirements being imposed by ABEM for continuous certification, and while I thank them for writing I’m not interested in being the Lonely Critic who Wails at ABEM.

So, allow me to publish (with their permission) someone elses’ lament at the current state of ABEM:

Thank you so much about your column about ABEM! It is making me feel like I am not the only one going thru this. We have 150 hours of CME required now, 4 through my state, 8 through my insurance, and now I find we can’t count the LLSA’s as continuous ed! Plus the articles in LLSA are horrible.

I took my CONCERT this year and the scores still aren’t out 8 weeks later for a computerized test. Someone needs to rise up against ABEM, they are not our advocates. I felt like maybe ACEP can help but I don’t think they can. ABEM I think is run by a lot of ivory tower guys who work 4 shifts a month in a University Hospital with the residents doing all the work. Thanks again for your columns!

One of my colleagues recently took the recertification test, which is now computer-based, and his description was less than flattering. “It’s like they scanned a photograph of a slide, and then uploaded that for the test”. He’s also about 8 weeks out from the test, and awaiting his scores…

I don’t want to be the anti-ABEM forum (is EMED-L still around?) but when I get emails like this it tells me I’m not alone in wanting ABEM to perform better. Significantly better.

retired doc’s thoughts: What are the plans of Don Berwick’s “leaders with plans”?

retired doc’s thoughts: What are the plans of Don Berwick’s “leaders with plans”?.

Wow.  I’m speechless.

Thanks to Retired Doc for getting this out in a cogent summary.

Eye Dr DeLengocky: A second medical school in Fort Worth is a misplaced priority

…It is obvious that the priority of addressing physician shortages in the area is to develop new residency opportunities, not increasing the number of medical students. Therefore, the push for a second medical school on campus with a class size of 100 students is a travesty and misplaced effort.

via Eye Dr DeLengocky: A second medical school in Fort Worth is a misplaced priority.

A good article by a DO against a Fort Worth MD School, with a good point: what we need more are residency slots, not a new school.

This also ignores the elephant in the room, that hospitals don’t want Osteopathic residencies as there’s still a stigma (which is not justified but that is real).  I believe that’s the reason behind the allopathic push, with the not unreasonable belief that hospitals will be more amenable to opening MD residencies.

Still, a good blog post by a medblogger I was unaware of, and it makes very good points.

Lawmakers Discussing Dropping Health Care Program — Health Reform and Texas | The Texas Tribune

Some Republican lawmakers — still reveling in Tuesday’s statewide election sweep — are proposing an unprecedented solution to the state’s estimated $25 billion budget shortfall: dropping out of the federal Medicaid program.

via Lawmakers Discussing Dropping Health Care Program — Health Reform and Texas | The Texas Tribune.

Hmmm.

Welcome to entitlement reality, Texas-style.  Currently 20Bn/year and going to go up with expanded eligibility, the article does say the Feds pay 60%, but doesn’t say: 1) it’s temporary, then the Federal contribution goes down or away, and 2) the Federal component doesn’t come from magical money fairies, it’s money takes from taxpayers then funneled back into a particular program.

Medicaid is not loved or respected in Medicine.  Decreasing reimbursements coupled to increasing requirements mean it’s at a minimum inefficient for both patients and providers.

I’m not against kicking Medicaid to the curb PROVIDING the state has some kind of replacement program.  Which I’m not sanguine about.

Destitute Companies Get Health Insurance Pass From Feds | WhiteCoat’s Call Room

Why repeal the new health care law? Just get a waiver so you don’t have to comply.

via Destitute Companies Get Health Insurance Pass From Feds | WhiteCoat’s Call Room.

Terrific post.

It’s also a disgrace.  It’s disgraceful that big companies continue to get anything they want from our increasingly dysfunctional government.

I am not an Obamacare fan, and would like it repealed, with smaller, more focused Bipartisan fixes, but if the government is going to pass something then roll over this easily to special interests… it’s already worse than useless.

Standard of Care Project at EP Monthly

The Power of Agreement

We can stop baseless malpractice suits before they get started. How? By having a majority of practicing emergency physicians go on record as to the baseline “standard of care,” beneath which is negligence.

via Standard of Care Project at EPMonthly.

This has been rolling for a while, and I’ve been late to blog it.  That does not, in any way mean I’m not 100% FOR it.

The idea is beautifully simple: the Standard of Care in Emergency Medicine should be set by practicing EM physicians, not case-by case in courts before lay juries with battling experts.  (AAEM had the ‘remarkable testimony’ series as a retrospective attempt to shame ‘experts’ who gave, well, remarkable statements under oath, which to date has two cases in it).

This has the very real advantage of being a clear, concise peer statement that this is / is not the Standard of Care.

I voted (while at ACEP).  If you’re an Emergency Physician (and you have to cough up some information to determine your bona-fides before you can vote) go to the Standard of Care Project, and cast your vote.  They have set the bar at 30,000 votes, which is ambitious.  It’s also worth it.

Texas (National, really) issue: qualifications of your ER doc | Houston & Texas News | Chron.com – Houston Chronicle

Texas is at the center of a heated national battle over the training emergency physicians need in order to advertise themselves as board certified.

At stake is the welfare of patients requiring immediate medical attention. Leaders of the traditional board say allowing physicians without proper training to advertise themselves as board-certified would mislead the public. Leaders of the alternative board say the proposed rule change will undermine the ability of Texas’ rural hospitals to staff their emergency departments with board-certified ER physicians.

A final verdict may only come, given one board’s already delivered threat, in a court of law.

via Texas issue: qualifications of your ER doc | Houston & Texas News | Chron.com – Houston Chronicle.

At stake also are the careers of a lot of practicing Emergency Physicians, many of whom I’m proud to call friends and colleagues.  (And it’s not just docs at rural hospitals, they’re in nearly every ED in Texas, and your lesser state).  They practice high quality Emergency Medicine, and I have no qualms about the practice of those who are alternately boarded.

I’m a residency trained, BCEM doc, so I’m in the group that’s considered Board Certified by definition.  I’m also still in the minority in US ED’s.  The majority are ‘alternately trained’ docs, the vast majority of whom always wanted to practice EM but either there was no such training when they finished med school, or the few EM programs were full.

Most are FP or IM trained, have worked hard and have been and continue to be ED and hospital leaders.  Again, I’m proud to have them as friends and colleagues, and have no questions as to their abilities.  They’re not interested in practicing EM for a few years then establishing a private practice somewhere, they’re EM docs, who didn’t do EM residencies.

In an ideal world would I like all docs in the ED to be residency trained as a requirement?  Yes.  Is that at all practical?  Not unless you want to close a whole lot of ER’s across the country, and the rural ones (where there is arguably more need for an EM doc who knows what they’re about) would be the first to go.

EM is either the newest or the second newest specialty in medicine, and for a primer on the brief history of EM, look here, (and there appreciate the spirit and the gamble that made my specialty):

Unlike the residents of today, those physicians who pursued Emergency Medicine residency training in the early 1970′s faced an uncertain future. They had no opportunity to be certified by a specialty board, and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action.

Now, about the Board Certified thing…

The reason this is an issue is the recognition that physician credentials are important (they are), that it’s desirable for physicians to be Board Certified in their chosen specialty field (it is), and the public is becoming more sophisticated about who’s trained in what (good).  The reason this is a problem is that as of now the only ‘officially approved’ path to Board Certification in EM is to complete a residency, as the ‘practice track’ to grandfather other-trained docs closed in 1988.  It had to close eventually, there would always be some people stuck no matter the chosen date, but it’s done.  (I now think it was closed too early, but that’s not under my control).  Every medical specialty has had the same issue, the conversion from docs who filled a need to specialty-trained specialists in their field.

In 1990 Texas had one EM residency, taking either 6 or 8 residents per year (3 year program) in El Paso.  Texas then had a population of nearly 17 million.  Most EM docs I know work hard, but that seems like a pretty steep workload for those 6-8 grads a year.  (There are now 8 residencies in Texas, with at least one more opening in 2011).

Therefore, Texas ED’s have been staffed (mostly) with other-trained docs who only wanted to practice Emergency Medicine.  A few did the then accepted thing of working ED shifts to supplement their income while they built a private practice then bowed out of the ED, but most didn’t.  Most worked, many ‘grandfathered’ into a specialty that literally developed as they practiced, and more and more residencies in EM started.

So, the practice track closed several years ago when there were nowhere near enough EM training programs for the demand.  These docs worked hard, but needed to demonstrate they were EM pros.  Enter the ABPS which provides Board Certification through an alternate pathway, thus they’re often referred to as ‘alternate boards’.  per their website:

must have practiced Emergency Medicine on a full-time basis for five (5) years AND accumulated a minimum of 7,000 hours in the practice of Emergency Medicine and maintained currency in ACLS, ATLS, and PALS.

In any career, if you’ve been able to do it for 5 years full time you’re good enough to be recognized as able to do it long-term.  Alternate boards are the only path open to anyone who practices EM but wasn’t grandfatherable in the late 80′s.

(My issue with alternate boards is those 5 years of independent practice as an EM doc without EM training, which I’m not a big fan of, but I cannot come up with a reasonable / workable alternative.)  (And stop it with the ‘they should go back and do an EM residency’: it’s economically unfeasible both for the residency and the doc, and that would cause a shortage of EM docs as they’d be a) in residency and b) taking slots from new med-school grads who also want to do EM).

I think Texas should accept ABPS Boarding of EP’s for the foreseeable future, with the recognition that in 10-20 years it’ll need to be re-addressed as the number of residency grads is able to take up the slack in US ED’s.  There should not be a permanent need for an alternate pathway to EM boarding.

Pragmatism and practicality aren’t dirty words, they’re how life is lived, and in the ED they’re how lives are saved.  Let’s keep our experienced Emergency Medicine physicians.

Update: reminded by the comments, the standard should be residency training in EM for anyone getting new Board Certification today.  The above argument applies, IMHO, only to those who are already alternately boarded (and yes, there’s another group that’s excluded…)

2+2=7? Seven things you may not know about Press Ganey Statistics

…The time you spend with critically ill patients may make another department’s satisfaction scores better . . . while making yours worse…

via 2+2=7? Seven things you may not know about Press Ganey Statistics.

A nice evaluation of Press Ganey and its current application in the Emergency Department.

I have No Idea why hospitals pay for this service, when they could do it themselves for a lot less moolah, have much higher data capture rates, and get actually usable data.

amednews: Most ED patients willing to wait longer to avoid nondoctor care :: Aug. 30, 2010 … American Medical News

Nurse practitioners and physician assistants account for at least 10% of outpatient visits and increasingly are being used to handle patient care in emergency departments, according to previous research. 

But a new survey said 80% of patients expect to see a physician when they come to the ED. Fewer than half would be willing to see an NP or PA for an ankle injury — they would rather wait two more hours to be cared for by a physician.

via amednews: Most ED patients willing to wait longer to avoid nondoctor care :: Aug. 30, 2010 … American Medical News.

For the record, if I went to the ED with a straightforward, well defined problem I’d just as soon see a PA/NP if it’s quicker.  (And, per the article, I’d like to know who’s seeing me and my problem).

Also for the record, my ED doesn’t utilize midlevels at all, so my knowledge of working with them is from my residency and my prior job, over 8 years ago.

Nearly every discussion I have with colleagues from other departments has a time when they are surprised we don’t have midlevels, and tell me the benefits, which boils down to either a) ‘they make us money’ or b) they do all our procedures, so they’re better at them than we are.

I find ‘a’ objectionable, but that’s just me.  ‘B’ is somewhat more defensible as it at least implies an increased level of patient care, but at the cost of a physician voluntarily relinquishing skills, then using that lack of practice as evidence of the superiority of others.  This has a rather obvious answer, which I’m too polite to point out to them.

I’m not saying there are no roles for midlevels in some ED’s, but I have yet to hear a compelling argument for them from a patient care aspect.

So, school me BUT do it without denigrating anyone else.

Obamacare personal insurance mandate wildly popular in Missouri

Or not.

Millions spent on doctor ‘gagging orders’ by NHS, investigation finds – Health News, Health & Families – The Independent

Hospital doctors who quit their jobs are being routinely forced to sign “gagging orders” despite legislation designed to protect NHS whistleblowers, it is revealed today.

Millions of pounds of taxpayers’ money are being spent on contracts that deter doctors from speaking out about incompetence and mistakes in patient care.

via Millions spent on doctor ‘gagging orders’ by NHS, investigation finds – Health News, Health & Families – The Independent.

Wow.

I’m not being snarky here, I really have no idea: does this happen in the US?