Doctors Wrestle With A.I. in Patient Care, Citing Lax Oversight

Christina Jewett

The New York Times

Originally posted 30 October 23

In medicine, the cautionary tales about the unintended effects of artificial intelligence are already legendary.

There was the program meant to predict when patients would develop sepsis, a deadly bloodstream infection, that triggered a litany of false alarms. Another, intended to improve follow-up care for the sickest patients, appeared to deepen troubling health disparities.

Wary of such flaws, physicians have kept A.I. working on the sidelines: assisting as a scribe, as a casual second opinion and as a back-office organizer. But the field has gained investment and momentum for uses in medicine and beyond.

Within the Food and Drug Administration, which plays a key role in approving new medical products, A.I. is a hot topic. It is helping to discover new drugs. It could pinpoint unexpected side effects. And it is even being discussed as an aid to staff who are overwhelmed with repetitive, rote tasks.

Yet in one crucial way, the F.D.A.’s role has been subject to sharp criticism: how carefully it vets and describes the programs it approves to help doctors detect everything from tumors to blood clots to collapsed lungs.

“We’re going to have a lot of choices. It’s exciting,” Dr. Jesse Ehrenfeld, president of the American Medical Association, a leading doctors’ lobbying group, said in an interview. “But if physicians are going to incorporate these things into their workflow, if they’re going to pay for them and if they’re going to use them — we’re going to have to have some confidence that these tools work.”

The info is here.

My summary: 

This article delves into the growing integration of artificial intelligence (A.I.) in patient care, exploring the challenges and concerns raised by doctors regarding the perceived lack of oversight. The medical community is increasingly leveraging A.I. technologies to aid in diagnostics, treatment planning, and patient management. However, physicians express apprehension about the potential risks associated with the use of these technologies, emphasizing the need for comprehensive oversight and regulatory frameworks to ensure patient safety and uphold ethical standards. The article highlights the ongoing debate within the medical profession on striking a balance between harnessing the benefits of A.I. and addressing the associated uncertainties and risks.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

Zulman DM, Haverfield MC, Shaw JG, et al.
JAMA. 2020;323(1):70–81.
doi:10.1001/jama.2019.19003

Key Points

Question  What are the most promising practices to foster physician presence and connection with patients?

Findings  This mixed-methods study identified 5 practices that may enhance physician presence and meaningful connection with patients in the clinical encounter: (1) prepare with intention; (2) listen intently and completely; (3) agree on what matters most; (4) connect with the patient’s story; and (5) explore emotional cues.

Meaning  For busy clinicians with multiple demands and distractions, 5 recommended practices have the potential to facilitate meaningful interactions with patients.

Abstract
Importance  Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

Objective  To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

Evidence Review  Preliminary practices were derived through a systematic literature review (fromJanuary 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (−4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Finalrecommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

Findings  The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions).

Conclusions and Relevance  This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

The research is here.

Professional Self-Care to Prevent Ethics Violations

Claire Zilber
The Ethical Professor
Originally published December 4, 2017

Here is an excerpt:

Although there are many variables that lead a professional to violate an ethics rule, one frequent contributing factor is impairment from stress caused by a family member's illness (sick child, dying parent, spouse's chronic health condition, etc.). Some health care providers who have been punished by their licensing board, hospital board or practice group for an ethics violation tell similar stories of being under unusual levels of stress because of a family member who was ill. In that context, they deviated from their usual behavior.

For example, a surgeon whose son was mentally ill prescribed psychotropic medications to him because he refused to go to a psychiatrist. This surgeon was entering into a dual relationship with her child and prescribing outside of her area of competence, but felt desperate to help her son. Another physician, deeply unsettled by his wife’s diagnosis with and treatment for breast cancer, had an extramarital affair with a nurse who was also his employee. This physician sought comfort without thinking about the boundaries he was violating at work, the risk he was creating for his practice, or the harm he was causing to his marriage.

Physicians cannot avoid stressful events at work and in their personal lives, but they can exert some control over how they adapt to or manage that stress. Physician self-care begins with self-awareness, which can be supported by such practices as mindfulness meditation, reflective writing, supervision, or psychotherapy. Self-awareness increases compassion for the self and for others, and reduces burnout.

The article is here.

The patient called me ‘colored girl.’ The senior doctor training me said nothing

By Jennifer Adaeze Anyaegbunam
Stat
Originally posted April 11, 2016

Medicine struggles with a chronic disease: racism.

Medical schools try to combat this disease with diversity initiatives and training in unconscious bias and cultural sensitivity. I’m about to graduate from the University of Virginia School of Medicine, so I’ve been through such programs.

They’re not enough.

Every one of us needs to own the principles that protect us and our patients from racism and bias. That means learning to see prejudice and speaking up against it. But that is far, far easier said than done.

Again and again during my four years of training, I encountered racism and ignorance, directed either at patients or at me and other students of color. Yet it was very hard for me to speak up, even politely, because as a student, I felt I had no authority — and didn’t want to seem confrontational to senior physicians who would be writing my evaluations.

The article is here.

Losing Informed Consent

By Paul Burcher
Bioethics Blog
Originally posted November 11, 2015

Here is an excerpt:

This case exemplifies the ambiguity around “informed consent.”  The nurse was referring to a document, a signed piece of paper; I was referencing a conversation, a process involving sharing information and answering questions. From a legal perspective, informed consent would seem to represent the document, whereas from an ethical perspective it is the process, not the paper that embodies informed consent.  Of course, ultimately, both have a role to play, and in the case of a significant procedure it is best to have both sides of this informed consent coin documented.  But what I would like to suggest is that the signed document represents an artifact—a physical symbol that two parties agree that the real nature of informed consent has been fulfilled.  The piece of paper is derivative, and a signed document that lacks the ethical underpinning of a complete and valid consent discussion is meaningless. A lawyer would probably give a slightly different answer, but this is an ethics blog, not a discussion of medical malpractice.

So if the signed document is not an essential aspect of informed consent, but rather evidence of the process that has supposed to have had occurred, what then represents the essential elements of informed consent? The standard answer is really not bad:  all relevant information regarding the procedure, its risks, and alternatives have been discussed, and the patient’s questions have been answered.  But the devil is always in the details, and in this case the detail of importance is how we define relevant.

The entire blog post is here.

Re-engineering shared decision-making

By Muriel R Gillick
J Med Ethics 2015;41:785-788
doi:10.1136/medethics-2014-102618

Abstract

Shared decision-making is widely accepted as the gold standard of clinical care. Numerous obstacles to achieving shared decision-making have been identified, including patient factors, physician factors and systemic factors. Until now, the paradigm is seldom successfully implemented in clinical practice, raising questions about the practicality of the process recommended for its use. A re-engineered model is proposed in which physicians elicit and prioritise patients’ goals of care and then help translate those goals into treatment options, after clarifying the patient's underlying health status. Preliminary evidence suggests that each step of this revised process is feasible and that patients and physicians are comfortable with this strategy. Adoption of this model, after further testing, would allow the goal of shared decision-making to be realised.

The entire article is here.

Laws that Conflict with the Ethics of Medicine: What Should Doctors Do?

By Dena S. Davis and Eric Kodish
Hastings Center Report 44, no. 6 (2014): 11-14.
DOI: 10.1002/hast.382

Here is an excerpt:

Medical ethics has always asked doctors to put their patients first, even at some risk to themselves. “Medicine is, at its center, a moral enterprise grounded in a covenant of trust,” writes Christine Cassell. “This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times.”[19] Physicians are expected to care for patients with infectious diseases, even at risk of their own health. Physicians are expected to do some pro bono work, to take on some patients who are not financial assets, and so on. Physicians should be advocates for the health of all people, above and beyond even their own patients. The AAP is “dedicated to the health of all children.”[20] The imperative to act on this ethical norm clearly suggests that physicians should challenge these types of laws. On rare occasions, individual doctors may be ethically justified in disobeying or breaking the law.

The entire article is here.

New test measures doctors' ability to deliver patient-centered care

University of Missouri-Columbia
News Release
Originally released December 29, 2014

When health care providers take patients' perspectives into consideration, patients are more likely to be actively engaged in their treatment and more satisfied with their care. This is called patient-centered care, and it has been the central focus of the curriculum at the University of Missouri School of Medicine since 2005. Recently, MU researchers have developed a credible tool to assess whether medical students have learned and are applying specific behaviors that characterize patient-centered care.

The researchers first worked with real patients to identify a list of specific behaviors that demonstrated physicians were providing patient-centered care. By defining these detailed, specific patient-centered behaviors, the researchers have been able to tailor the educational experience at the MU School of Medicine to help students gain these skills.

MU medical students now are assessed on their ability to deliver the care in ways the patients expect; students must perform at a satisfactory level on the patient-centered care exam to graduate from the MU School of Medicine.

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From this authentic assessment, researchers learned students were picking up on many key factors in patient-centered care. Most MU medical students had strong, effective communication skills, didn't use medical jargon, actively listened to the patient, showed empathy and were in charge of the situation when they needed to lead a critical conversation.

The entire press release is here.

Can Our Brains Handle the Information Age?

An Interview with Daniel Levitin
By Bret S. Stetka
Medscape
Originally posted September 24, 2014

In his new book, The Organized Mind, best-selling author and neuroscientist Daniel Levitin, PhD, discusses our brain's ability—or lack thereof—to process the dizzying flow of information brought on us by the digital age. Dr Levitin also suggests numerous ways of organizing mass information to make it more manageable. Medscape recently spoke with Dr Levitin about the neuroscience of information processing as well as approaches potentially useful to overworked clinicians.

The Fear of Information

Medscape: Your new book discusses how throughout history humans have been suspicious of increased access to information, from the printing press back to the first Sumerian writings. But I think most would agree that these were positive advancements. Do you think the current digital age weariness expressed by many is more of the same and that today's rapid technological progression will end up being a positive development for humanity? Or has the volume of data out there just gotten too big for the human brain to handle?

Dr Levitin: I have two minds about this. On one hand, there is this "same as it ever was" kind of complaint cycle. Seneca complained at the time of the ancient Greeks about the invention of writing—that it was going to weaken men's minds because they would no longer engage in thoughtful conversation. You couldn't interrogate the person who was telling you something, meaning that lies could be promulgated more easily and passed from generation to generation.

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If we look back at our evolutionary history, the amount of information that existed in the world just a few thousand years ago was really just a small percentage of what exists now. By some estimates, the amount of scientific and medical information produced in the last 25 years is equal to all of the information in all of human history up to that point.

The human brain can really only attend to a few things at once, so I think we are reaching a point where we have to figure out how to filter information so that we can use it more intelligently and not be distracted by irrelevant information. Studies show that people who are given more information in certain situations tend to make poorer decisions because they become distracted or overwhelmed by the irrelevant information.

The entire interview is here.

Rethinking Hospital Restraints

Thousands of patients are physically restrained every day for their own safety—but evidence suggests that the practice may be ineffective and even harmful.

By Ravi Parikh
The Atlantic
Originally published August 18, 2014

Here is an excerpt:

Most of us who have been hospitalized have never seen physical restraints, as they are rarely used outside the ICU. Examples include wrist and ankle belts, vests, mitts, and full-length side rails attached to the bed. According to Medicare guidelines, restraints should only be used to ensure the safety of patients and staff and should be removed as early as possible. There are only a handful of situations where Medicare and other physician groups recommend using restraints, including patient violence towards himself or others and a threat of a patient disrupting his or her life-saving therapy, such as a breathing tube.

The entire article is here.

Doctors and empathy: Teaching Doctor Empathy

A Better NHS

Originally posted December 20, 2013

Here is an excerpt:

If at one level empathy can be demonstrated by a ‘banal social convention’ such as acknowledging my patient’s suffering, at another, empathy is inseparable from the moral obligation to care. When we say that doctors and nurses lack empathy, at one level we might actually mean that they simply lack basic courtesy and at another deeper level we mean that they don’t actually care.

Perhaps etiquette is a thinner version of empathy as ethicist Anna Smajdor, in an excellent paper about the limits of empathy in medical education and practice concludes. She suggests that we should settle for teaching this stripped down version of empathy. After all, it is clearly in short supply as any patient or health professional will testify. Kate Granger’s experiences of being a patient with cancer, led to her powerful call for healthcare professionals to introduce themselves. #hellomynameis has made a great and lasting impression.

The entire post is here.

Talking with Patients about Other Clinicians' Errors

By Thomas H. Gallagher, Michelle M. Mello, and others
The New England Journal of Medicine
Originally published November 6, 2013

Here is an excerpt:

The rationales for disclosing harmful errors to patients are compelling and well described. Nonetheless, multiple barriers, including embarrassment, lack of confidence in one's disclosure skills, and mixed messages from institutions and malpractice insurers, make talking with patients about errors challenging. Several distinctive aspects of disclosing harmful errors involving colleagues intensify the difficulties.

One challenge is determining what happened when a clinician was not directly involved in the event in question. He or she may have little firsthand knowledge about the event, and relevant information in the medical record may be lacking. Beyond this, potential errors exist on a broad spectrum ranging from clinical decisions that are “not what I would have done” but are within the standard of care to blatant errors that might even suggest a problem of professional competence or proficiency.

The entire article is here.

Thanks to Gary Schoener for this information.

VA tries quality improvement approach to medical ethics

Tools to evaluate how health care facilities perform ethically are in their infancy. The VA Health Care System hopes others can benefit from its experience.

By Tanya Albert Henry
amednews.com
Originally posted May 20, 2013

How often does a physician have enough time to discuss a treatment recommendation with a patient?

Would a doctor be reluctant to raise concerns if he or she believes a colleague's clinical abilities are impaired?

How often are notes or papers with identifiable patient information left in areas where other patients, relatives or staff members might view the sensitive material?

These are just a few of the questions the National Center for Ethics in Health Care at the U.S. Dept. of Veterans Affairs is using to query its staff at the VA Health Care System. The goal is to help facilities see what they are doing well in terms of ethics and point out areas where they could be doing more.

The concept is similar to the recent push to evaluate quality of care by asking about procedural issues such as how well physicians are helping patients control hypertension or whether hospitals are keeping infection rates low.

Ethics evaluations, though, are not so common, and surveys do not tie payment to how well facilities score. However, the idea of measuring ethics as a component of quality of care is gaining momentum, and leaders in the field say its time has come.

“This is about managing ethics the same way you manage health care quality,” said Ellen Fox, MD, chief ethics in health care officer for the Veterans Health Administration. “Ethics quality is an important area that can have a dramatic effect on health care, including life-and-death decisions. … An effective ethics program promotes better patient care, better patient satisfaction, better efficiency.”

The entire story is here.

Should I Report My Ex-Wife for Sleeping With Her Patient?

By Chuck Klosterman
The New York Times - The Ethicist
Originally published April 26, 2013

My ex-wife is a physician. We divorced when I found out she was having an affair with one of her H.I.V.-positive patients. I feel compelled to tell the state medical licensing board and the professional societies to which she belongs about her affair. My reasons for doing so are that I feel an intense urge to retaliate her breach of trust and that she potentially exposed me to H.I.V. (fortunately, I tested negative). I also know that, as a physician myself, I should report her to protect other patients, so that she may get increased supervision at her workplace and treatment if needed. Should I report her even though my main motivation is revenge?

The entire article is here.

Patients should decide what the end of life is like, study says

By Mary VacVean
The Los Angeles Times
Originally published March 20, 2013

Finding out what dying patients want and treating them accordingly leads to happier patients who are in less pain and who use fewer healthcare dollars, UCLA researchers said Tuesday.

“You can improve care while reducing costs by making sure that everything you do is centered on what the patients want, what his or her specific goals are and tailor a treatment plan to ensure we provide the specific care he or she wants,” Dr. Jonathan Bergman, a Robert Wood Johnson clinical scholar at UCLA, said in a statement.

Bergman and colleagues wrote an article advocating for patient-centered care at the end of life in the journal JAMA Surgery.

People who are dying often receive care that is poorly coordinated and not in line with the patient’s values or goals, the journal authors said. That should change, they said.

The entire article is here.

Survey: Too many EHR alerts could lead to missing test results

By Andis Robeznieks
ModernHealthcare.com
Originally posted March 4, 2013

The information deluge unleashed by electronic health-record systems could cause physicians to miss notifications of abnormal test results, according to a survey of primary-care practitioners with the U.S. Veterans Affairs Department. Missing those notifications could delay needed care for patients, according to the physicians, nurse practitioners and physicians assistants surveyed.

Researchers from several Houston institutions—including the Houston VA Health Services Research and Development Center of Excellence—surveyed almost 2,600 VA primary-care practitioners from June 2010 through November 2010 regarding EHR-based alerts. Almost 30% acknowledged missing notification of test results that led to care delays, according to a research letter in the American Medical Association journal JAMA Internal Medicine (formerly the Archives of Internal Medicine).

The entire story is here.

U.S. proposes scrapping some obsolete Medicare regulations

By Reuters
Originally published February 13, 2013

The Obama administration on Monday proposed eliminating certain obsolete Medicare regulations, a move it said would save hospitals and other healthcare providers an estimated $676 million a year, or $3.4 billion over five years.

The Department of Health and Human Services described the targeted regulations as unnecessary or excessively burdensome and said their proposed elimination would allow greater efficiency without jeopardizing safety for the Medicare program's elderly and disabled beneficiaries.

"We are committed to cutting the red tape for healthcare facilities, including rural providers," Health and Human Services Secretary Kathleen Sebelius said in a statement.

"By eliminating outdated or overly burdensome requirements, hospitals and health care professionals can focus on treating patients," she added.

Industry representatives largely welcomed the changes, saying the proposed rule would help hospitals free up more resources for patient care.

"There are a number of particularly meaningful provisions in the proposed rule," said Chip Kahn of the Federation of American Hospitals.

The American Hospital Association, though, said it was disappointed the administration did not allow "hospitals in multi-hospital systems" to have single integrated medical staff structures.

"Hospitals are delivering more coordinated, patient-centered care and (the administration) should not let antiquated organizational structures stand in the way," AHA President Rich Umbdenstock said in a statement.

The entire article is here.

EHRs could mean fewer malpractice claims

By Mike Milard
IT Health News
Originally published August 3, 2012

A study by Harvard Medical School-affiliated researchers, published in June in the Archives of Internal Medicine, showed that Massachusetts physicians who used electronic health records saw a reduction in malpractice claims.

Correlation does not imply causation, of course. But the report's authors say their findings suggest, "implementation of EHRs may reduce malpractice claims and, at the least, appears not to increase claims as providers adapt to using EHRs."

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"We found that the rate of malpractice claims when EHRs were used was about one-sixth the rate when EHRs were not used," the researchers write. "This study adds to the literature suggesting that EHRs have the potential to improve patient safety and supports the conclusions of our prior work, which showed a lower risk of paid claims among physicians using EHRs. By examining all closed claims, rather than only those for which a payment was made, our findings suggest that a reduction in errors is likely responsible for at least a component of this association, since the absolute rate of claims was lower post-EHR adoption."

The entire article is here.

Hospitals Reaping Financial Benefits of Telehealth

By Karen Minich Pourshadi
Health Leaders Media
Originally published July 19, 2012

Here are some excerpts:

The passing of the years has softened resistance by patients to using this approach. Patients are now willing to forego an in-person visit with the doctor in order to get the care they need swiftly, without having to travel, and in some instances at a lower cost. Moreover, the reimbursement environment is changing. Whereas at one time payers rejected the notion of reimbursing e-health, now more are willing to pay for it. Plus, legislators nationwide are creating state laws requiring payers to reimburse for these services, though in many instances payers are doing so irrespective of mandate.

"Telemedicine can lower healthcare costs by reducing avoidable hospital visits and providing regular access to care in remote parts of the state, and it's more convenient for patients," says Georgia Partnership for TeleHealth CEO Paula Guy. The nonprofit telehealth provider works with more than 350 partners and 175 specialists and other healthcare providers and has handled some 40,000 patient encounters as of 2011.

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GPT has also placed telehealth into nursing homes. In 2011, using telehealth resulted in 160 ED visits being avoided, saving approximately $480,000 in ED cost, Guy says, "In the past, these older patients may have just called for an ambulance when they had a problem. But now patients can be seen by a doctor without an expensive ambulance trip to the ED. Plus they can use it for routine access to care, and by getting that they're less likely to end up in the hospital as frequently," Guy says.

Telehealth visits saved 310 miles and nearly six hours of traveling on average, according to a study by Children's Healthcare of Atlanta, a three-hospital system for children and teens. CHA reviewed 609 appointments over a nine-month period and noted that approximately 86% of patients would have missed school and more than 80% of parents would have missed a full day of work to go to the city for an in-office visit, according to data published in the Atlanta Journal-Constitution. Additionally, Guy explains that out of the 40,009 telehealth visits GPT tracked, a random sample showed an average savings of patient travel time of 124 miles per encounter and nearly $762,027 in fuel alone.

The entire article is here.

Damaged Fairview ousts exec

Mark Eustis was linked to firm behind high-pressure debt collections

by Maura Lerner and Tony Kennedy
The Star Tribune
Star Tribue Staff Writers
Originally published May 24, 2012

Mark Eustis, CEO of Fairview Health

Mark Eustis couldn't have known it at the time, but his downfall as president of Fairview Health Services began last summer with the report of a stolen laptop. Within 10 months, the incident had grown into a public relations nightmare that Fairview couldn't shake.

On Thursday, Eustis, 59, abruptly announced plans to retire, one day after Fairview's board voted not to renew his contract. It was just four weeks after Attorney General Lori Swanson released a scathing report about debt collectors badgering patients for money inside Fairview hospitals.

Initially, the board had said Eustis' job was safe. But criticism has mounted over Fairview's association with Accretive Health, the for-profit company Swanson blamed for the collection practices.

Eustis found himself at the center of the turmoil because he was instrumental in hiring Accretive and has a son who works for the firm.

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Dr. Steve Miles, a University of Minnesota physician and bioethicist, said the most disturbing revelations weren't just about heavy-handed debt collectors, but internal e-mails in which Accretive employees talked about patients as "lowlifes" and "deadbeats."

The entire article is here.

Thanks to Gary Schoener for this lead.