OP-ED

OP-ED

Is Pornography Creating a Public Health Crisis?

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flying cadeuciiWell, it’s not Zika and it won’t kill you, but pornography is being discussed—seriously—as a public health problem, even a “crisis.”

The path to this claim is a long one, with a slow burn over many years.  It was kicked into higher gear in recent months with:(a) legislative action in one state;(b) a coverstory in TIME magazine (April 11 issue);(c) a Washington Post op-ed piece by anti-porn advocate Gail Dines; (d) a response to that in Atlantic Monthly; and (e) the publication of two books that discuss at length the effect of porn and the new sexual culture on teen girls—American Girls-Social Media and the Secret Lives of Teenagers by Mary Jo Sales and Girls & Sex-Navigating the Complicated New Landscape by Peggy Orenstein.

The legislative action took place in Utah.  The Republican-led House of Representatives in that state became the first legislative body in the nation to pass a resolution declaring pornography “a public health hazard leading to a broad spectrum of individual and public health impacts and societal harms.” Dines and her fellow anti-porn crusaders want to carry that fight to other states.

This is going to be fun to watch! (Pun intended.)

Why I Left My Pharma-Sponsored Academic Research Gig

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flying cadeuciiNot long back, I departed a pharma-sponsored research project. I based my decision to leave in something I occasioned over a decade ago. I thought it was time to share the episode and the lessons learned given the attention being paid to physician conflict of interest nowadays (as well as the annual Open Payments review and dispute period approaching).

When I finished training, very few docs practiced hospital medicine—or even knew what the term hospitalist meant. Several forward-thinking medical centers hitched their wagons to the hospitalist model, as did some astute information technology and staffing companies.

However, few healthcare players embraced the hospitalist movement in a serious fashion like the pharmaceutical industry. They realized hospitalists prescribed a narrow band of products, in big lots, within a centralized location. The higher ups in the pharma sector saw the benefits in directing reps our way.

The Joint Commission Pain Standards: Five Misconceptions

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Baker_David_275In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.

The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain. The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.

Our foundational standards are quite simple. They are:

  • The hospital educates all licensed independent practitioners on assessing and managing pain.
  • The hospital respects the patient’s right to pain management.
  • The hospital assesses and manages the patient’s pain.

Requirements for what should be addressed in organizations’ policies include: 

The Pharma = Evil Narrative

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flying cadeucii“People hate pharma,” my Forbes colleague Matthew Herper observed recently–and at times I can understand why. There’s not much to admire about executives like Martin Shkreli, or businesses like Valeant.

But I’ve started to worry that the “pharma = evil” narrative has become so ingrained that it’s taking on a life of its own, as readers instinctively anticipate this storyline, and journalists reflexively provide it. Coverage of a recently announced innovative training collaboration between Johns Hopkins and MedImmune (a subsidiary of AstraZeneca ), for instance, focused primarily on potential conflicts of interest.

(Disclosure/reminder: I work at DNAnexus, a health data management company in Silicon Valley and Boston; our partners include universities, government agencies and private companies.)

This narrow view, however, not only fails to capture the urgent need for effective, new therapies, it overlooks entirely the vital role played by companies in translating fragile but promising scientific ideas into robust medicines for patients.

Climate Change and the Migration of Infectious Disease

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Zika is all over the news. Zika is surely dangerous, but it has its limitations and is likely to be well contained. However, its greater significance extends beyond any current spread. Instead, it exemplifies the crucial emerging trend of a novel infectious agent that has swiftly become a global threat.

The common phrase, ‘this time is different’, is almost always wrong. Yet, our modern circumstances are distinctly unlike any previous era. Humans possess a unique ability for rapid travel and we choose to journey with our favorite pets and plants. This unprecedented degree of mobility extends across every planetary habitat. Further yet, it now occurs during a phase of a rapidly shifting climate. Certainly, species migration or global climate change are not new but it is only in this present moment that these factors can amplify through instantaneous global travel in a singular manner.

In fact, the results of this unusual conjunction are already apparent. For example, Zika’s advance across Europe and to the Americas has been extremely rapid. This is such an extraordinary event that at the beginning of this year, the World Health Organization declared Zika a global emergency in recognition of its rapid spread from continent to continent. Its rising incidence mirrors our prior concerns about the global scope of other recent epidemics such as Ebola or SARS.

What Is Patient-Centered Care? What Isn’t Patient-Centered Care?

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Rob LambertsMy last post discussed the wide gulf between healthcare and the rest of the world in the area of customer service. To sum up what took over 1000 words to express: customer service in healthcare totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care. We get what we pay for.

But shouldn’t we judge the system for what it was build for: the quality of the care we give? Sure, the service is overwhelmed with serious suckitude, but that can be forgiven if we give good quality care for people, right?

Even if that was the case, there is no excuse for the lousy service people get from our system. The lack of respect we, as medical “professionals” show to our patients undermines the trust our profession requires. Why should people believe we care about their health when we don’t care about them as people? Why should they respect us when we routinely disrespect them? No, the incredibly poor service we have all come to expect from hospitals and doctors is, and never should be overlooked or forgiven.

Still, I already wrote a post about that. Go back and read it if you missed it. This post isn’t going anywhere. Now I want to cover the actual care we give, and how it too has moved away from the needs of the people it is supposedly for. The people question how much providers care (verb) mainly based on the (lousy) service they get. The care (noun) we give is all about the quality of the product purchased by whoever pays for that (be they third-party or the patients themselves). The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.

The C Word

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flying cadeuciiThat we are experiencing a “consumer revolution” in healthcare is a durable meme in the media and in policy circles just now.  When you hear the word “consumer”, it conjures images of someone with a cart and a credit card happily weaving their way through Best Buy. It is, however, a less than useful way of thinking about the patient’s experience in the health system.

A persistent critique of our country’s high cost health system is that because patients are insulated from the cost of care by health insurance, they freely “consume” it without regard to its value, and are absolved of the need to manage their own health.  In effect, this view ascribes our very high health costs to moral failure on the part of patients.

Market-oriented policy advocates believe that if we “empower”patients as consumers by asking them to pay more of the bill, market forces will help us tame the ever rising cost of care. If patients have “skin in the game” when they use the health system and also “transparency” of health providers’ prices and performance, patients can deploy their own dollars more sensibly.

This concept played a major role in the otherwise “progressive” Affordable Care Act. The 13 million people who signed up for coverage this year through the Affordable Care Act’s Health Exchanges opted overwhelmingly for subsidized policies with very high deductibles and out-of-pocket cost limits. The “skin in the game” argument has also heavily influenced corporate health benefits decisions. More than 30 million workers and their families receive high deductible plans through employers.

Keep Calm and Save the NHS

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Keep Calm and Save the NHSIt was Boxing Day weekend. The consultant surgeon summoned the on-call team. “We face a calamity,” he said. The house officer had called in sick. The locum wasn’t going to arrive for another 12 hours. This meant that I, the senior house officer, would have to be the house officer. The registrar would take my place. The consultant, looking tense, would have to be the registrar—i.e. a junior doctor again.

“Junior doctor” is a misnomer because it implies a master and an apprentice. Running the National Health Service (NHS) are apprentices who become Jedis very quickly, and without a Ben Kenobi showing them the ropes.

I’ll never forget my first night on-call in the emergency room (ER). I was one of two junior doctors managing a busy inner city ER in London from midnight to 8 am. Just a year earlier, I was an errant medical student bunking lectures. Now I had to see people with heart attacks, strokes, and broken bones. Seeing the terror on my face, the senior nurse reassured me. “Just look as if you know what you’re doing. We’ll handle the rest.”

Financing Physicians: A Modest Proposal

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flying cadeuciiIn 1729, a bold and innovative thinker named The Very Reverend Jonathan Swift made “A Modest Proposal,” the subtitle of which was “For Preventing The Children of Poor People in Ireland From Being a Burden to Their Parents or Country, and For Making Them Beneficial to The Public.” One more thoughtful suggestion by Sir Jonathan was that Irish children, if prepared properly, made fine eating, having been assured by a “very knowing American…acquaintance” that at a year old, they are delicious, “whether stewed, roasted, baked, or boiled.”

While that suggestion never did catch on, it did represent a different insight as to a possible solution to a seemingly intractable problem, and it provoked quite a discussion. We have a new such problem, and it has to do with physicians. Today’s physicians, in their quiet moments, usually admit that their profession and they are in deep trouble.  Physicians too often work too hard for too little; they spend too little time on what they consider to be the “practice” of medicine; they believe they are disrespected by hospitals and insurers; primary care docs envy specialists; specialists despise hospitals; and worst, they just flat do not like their day jobs to the point that there is rampant burnout, anger, and depression. Not quite Marcus Welby.

It starts after med school, if not during. The plight of newly “minted” physicians is dire. Unless they come from families of wealth or get some miraculous form of a free ride, they end their education and training with debt often exceeding $200,000. And given the length of time it takes for them to start making decent income, they will have lost at least 8 years of saving and investing, plus the time they need to pay that debt back. They also have to purchase exorbitantly priced malpractice insurance. Meanwhile they do things like get married, have children, and buy houses and cars, like many other professionals. Their plight is well described in a recent article which should cause even the most idealistic young man or woman to think twice before entering medicine. The burnout and depression statistics of practicing physicians today are astounding.

A Guide to Top Medical Journals: A Primer For Journalists

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Charles Ornstein is an award-winning healthcare journalist who recently wrote an article in the Boston Globe about an ongoing controversy regarding a top medical publication. Yet Ornstein still wonders about the current status of medical journals:

To help answer Mr. Ornstein’s query, I have asked the editors of top medical journals to submit responses to a simple questionnaire. Here are their answers.

BMJ

What would an alternative title to your journal be? The Journal of Transparent Research

What is your tag line? “Leading the charge against conflicts of interest

What happened at your most recent editorial staff meeting? We discussed possible strategic partnerships with healthcare journalists to get Freedom-of-Information-Act orders. Independent observers should be able to get patient-level research data released from the clutches of industry and their puppet scientists and journals.