Fraud in a Labcoat

By Gareth Cook

The Boston Globe

MARC HAUSER has plenty of company when it comes to scientific misconduct.  (See our prior blog post.)

Hauser, you’ll recall, had built a brilliant career at Harvard. He directed a primate lab and published a long list of scientific papers on topics like the cognitive nature of morality, and the similarities between human and animal behavior. He was a popular teacher, and author of the hit book “Moral Minds.’’ And then it turned out that he was taking liberties with his scientific data. One paper was retracted, others were corrected, and, earlier this month, he left the university.

Also this month, federal authorities announced that a cancer researcher at the Boston University School of Medicine was inventing data. Two papers have been retracted. The scientist, and I use the term loosely, was shown the door.

These two cases are part of a remarkable flood of scientific retractions. Between 2001 and 2010, the number of retractions increased more than 15-fold, according to a recent investigation by the Wall Street Journal. There were 22 retractions in 2001, and 339 last year, according to the Journal, over a period of time when the number of publications increased by only 44 percent.

It would seem a grim development, this sudden scourge of epic sloppiness and outright fraud in the halls of science. But it’s actually news we should all welcome: We are not witnessing an explosion of misconduct, but a new openness about it.

There are some forces, including easy access to image manipulation software like Photoshop, that are making it easier to fake results. But the problem has festered for decades, and now, finally, science is beginning to get serious about dealing with it.

The most spectacular recent case of scientific fraud came out of South Korea. In early 2004, researchers there announced that they had cloned a human cell, earning front-page headlines around the world, and tantalizing the public with the prospect of future disease treatments. Invitations to collaborate poured in from top biologists. The South Korean government ensured that the lead scientist, Hwang Woo-suk, had every resource at his disposal. He was a national hero.

The rest of story can be found here.

Nearly 1 in 10 U.S. Kids Diagnosed With ADHD

By Alan Mozes
MedicineNet.com

Over the last decade, an increasing number of American children have been diagnosed with attention-deficit hyperactivity disorder (ADHD), a new government survey reveals.

Researchers from the U.S. Centers for Disease Control and Prevention found that between 2007 and 2009, an average of 9% of children between the ages of 5 and 17 were diagnosed with the disorder. This compared with just under 7% between 1998 and 2000.

The survey also indicated that previously notable racial differences in ADHD incidence rates have narrowed considerably since the turn of the millennium, with prevalence now comparable among whites, blacks and some Hispanic groups.

"We don't have the data to say for certain what explains these patterns, but I would caution against concluding that what we have here is a real increase in the occurrence of this condition," stressed study author Dr. Lara J. Akinbami, a medical officer with the National Center for Health Statistics. The findings appear in an Aug. 18 report from the agency.

"In fact, it would be hard for me to argue that what we see here is a true change in prevalence," Akinbami added. "Instead, I would say that most probably what we found has a lot to do with better access to health care among a broader group of children, and doctors who have become more and more familiar with this condition and now have better tools to screen for it. So, this is probably about better screening, rather than a real increase, and that means we may continue to see this pattern unfold."

According to the National Institutes of Health, ADHD is the most common behavioral disorder among children.

Children with ADHD are apt to have problems staying focused, and often suffer learning and behavioral problems as a result of a tendency to engage in hyperactive and/or impulsive behaviors.

The entire article can be here.

Angela Dean: Winner of the Patricia M. Bricklin Award

The PPA Ethics Committee presents the annual Patricia M. Bricklin Award to a Pennsylvania graduate student who submits the best work product (such as a paper) on ethics.  This year, Angela Dean, a student at Catham University earned the award.  Her professor is Anthony Goreczny, Ph.D.

The award comes with $500 that is funded by the Pennsylvania Psychological Foundation. 

The Ethics Committee invited Ms. Dean to our annual Ethics Educator Conference to be held in October, 2011.  Additionally, Ms. Dean will have a version of her paper published in The Pennsylvania Psychologist.


The title of the paper is Facebook for Psychologists: "Friend"ship Ethics.  It can be reviewed or downloaded from docstoc (below).


FB_Psychological_Ethics -

OCR Data Breach Tally Passes a Milestone

Dom Nicastro for HealthLeaders Media

Covered entities have reported breaches of unsecured protected health information affecting 500 or more individuals to the Office for Civil Rights (OCR) nearly once every other day since the HIPAA privacy and security enforcer began posting the information 18 months ago.

The list, posted on the OCR breach notification website, hit the 300 mark this week. OCR went live with the site in February 2010, recording breaches that date back to September of 2009.

That's about 13 breaches per month dating back to the fall of 2009.

The website is part of the breach notification interim final rule, in effect since September 2009. OCR withdrew the rule a little more than one year ago from the hands of the Office of Management and Budget (OMB), which reviews rules for government agencies. OCR wanted more time to pursue changes to the rule.

The rest of the story can be read here.

HIPAA Auditor Involved in Own Data Breach

Dom Nicastro, for HealthLeaders Media

The company hired by the Office for Civil Rights (OCR) to conduct nationwide HIPAA privacy and security compliance audits was responsible for a breach that includes the loss of an unencrypted flash drive and affects more than 4,500 patient records.

OCR’s request for audit proposals came in February 2011, about eight months after KPMG, LLP, reported its breach to the New Jersey healthcare system.

KPMG, which won OCR’s $9.2 million contract for HITECH-required HIPAA audits in June 2011, told the Saint Barnabas Health Care System of West Orange, NJ, in June 2010 that a KPMG employee lost an unencrypted flash drive that may have contained a list with some patient names and information about their care, Saint Barnabas reported on its website. 

The potential breach affected individuals at two facilities—3,630 patients at Saint Barnabas Medical Center in Livingston, NJ, and 956 patients at Newark Beth Israel Medical Center in Newark, NJ—according to a report on the OCR breach notification website. The website lists entities reporting breaches affecting 500 or more individuals, a HITECH requirement that went live in February 2010.

The flash drive did not include patient addresses, Social Security numbers, personal identification numbers, dates of birth, financial information, or other identifiable information, according to the report on the Saint Barnabas website.

KPMG reported the matter to the New Jersey healthcare system June 29, 2010. KPMG believes the flash drive was misplaced on or about May 10, 2010, according to Saint Barnabas.

When EHRs Meet Malpractice Suits: New Concerns

By Neil Versel InformationWeek

An electronic health record (EHR) is more than just an electronic representation of a paper chart. It is a legal representation of a patient's medical condition and treatment at a given point in time, one that could be admissible in court. And that could present a whole new set of challenges for healthcare organizations.

"There is no guide out there to walk people through all that changes with an EHR," Adam Greene, a Washington, D.C.-based partner in the law firm of Davis Wright Tremaine, said this week at the American Health Information Management Association (AHIMA) Legal EHR Summit in Chicago.

EHRs make patient information more readily accessible to far more people than any paper chart stashed away in a filing room. They also change how and to what extent medical professionals document patient encounters and add in safety-related features such as clinical decision support.

"There are all sorts of liability fears with all these improvements," Greene told InformationWeek Healthcare. The Health Insurance Portability and Accountability Act privacy and security rules require anyone that handles electronic healthcare data to keep an audit log of access to any personally identifiable information, and records have helped organizations catch employees taking unauthorized looks at patient records--sometimes also landing the organizations themselves in hot water.

Indeed, some worry that audit logs can reveal too much. "There are concerns by providers that access reports could be used in malpractice suits," Greene said.

In fact, such reports already are, according to Stacey Cischke, an attorney with Chicago firm Cassiday Schade who teaches a course in legal issues in e-health at Loyola University Chicago. "The scope of traditional discovery is expanded," Cischke said. "More and more courts are finding that metadata and access to the inner workings of the EHR system is relevant and discoverable."

The general public and even plaintiffs' attorneys do not always comprehend how EHRs work, Cischke added. Because there is so much to chart, physicians and nurses are rushed and things get missed. From the patient's perspective, all the doctor should have to do is click and check off boxes in a list, but, according to Cischke, physicians often are "overwhelmed" by time and economic pressures, and skip steps or simply forget to check some boxes. "The metadata will show this," Cischke said.

Cischke said she prepares clinicians for trial by making sure they understand what each piece of metadata means. Knowing when something happened then opens up questions of why the doctor took a certain action.

On the other hand, with an EHR, users can't "fudge" charts as they could with paper, since EHR systems generally won't allow any modifications after a physician signs off on the record of a patient encounter. But plaintiff's attorneys do not always consider this. "It's logistically challenging," Cischke said. It is hard for the layperson to understand individual records, flow sheets, and audit trails.

Thus, Cischke recommended that providers adopt a multidisciplinary approach to identifying potential lawsuits, and promote consistency in how they produce reports and respond to threatened legal action. Both in-house and outside counsel and staff need to learn how the EHR works and how to navigate through electronic records before they find out the hard way, after being sued.

The rest of the story can be round here.

Assisted suicide could be 'legalised' in groundbreaking case

Sarah Boseley, Health Editor

guardian.co.uk

A 46-year-old-man who wants to die after a stroke that left him almost completely paralysed is bringing a groundbreaking legal action that could effectively lead to the legalisation of assisted suicide in the UK.

Martin, as he has agreed to be called to preserve his anonymity and that of his family, was a fit and active man who enjoyed rugby, cars and socialising with friends in the pub before suffering a brainstem stroke three years ago. Now requiring round-the-clock care, his mobility is limited to moving his eyes and small movements of his head. He communicates by staring at letters on a computer screen which the machine recognises and forms into words spoken by a digitised voice.

Martin has been asking to die since six months after the stroke but says he has no one willing to assist him and cannot on his own organise a trip to the Swiss clinic Dignitas, where he could end his life legally. His wife, who chooses to be known as Felicity, says she will be with him if he dies but will not help bring about his death.

Human rights lawyers at the firm Leigh Day in London have taken the first step in an action on Martin's behalf that, if successful, could have massive implications. One possibility is that the case could lead to a court ruling that Martin has the right to help not only from a paid professional to assist him get to Switzerland, but also to the services of a palliative care doctor in the UK to ease his death, should he decide to end his life by refusing food and drink.

Such a ruling would dramatically alter the current options for seriously ill and severely disabled people who wish to end their own lives in the UK. "There would be no more planes to Switzerland," said Richard Stein of Leigh Day. "Why would you bother?"

However, Stein added that beginning this legal action would potentially put the lawyers working on it in legal difficulty, since both they and any doctor or psychiatrist who came to examine Martin for the case could be considered to be assisting his suicide, thus exposing them to potential prosecution or disciplinary action from professional bodies.

The rest of the story and the video can be found here.
A prior post on assisted suicide can be found here.

Malpractice Risk According to Physician Specialty

Blog Editor Note:

According to this study, only 1 in 5 malpractice claims against doctors leads to a settlement or other payout. While doctors and their insurers may be winning most of these lawsuits, there still remains a high amount of legal actions in medicine. This study indicates that, each year, about 1 in 14 doctors is the target of a claim, and most physicians and virtually every surgeon will face at least one in their careers. While these numbers may support those who believe there are a high number of frivolous lawsuits, the authors seek to understand the complexity of these issues.  Also, psychiatrists have one of the lowest lawsuit rates of the medical specialities and one of the lowest number of payouts.

------------------------------

Anupam B. Jena, M.D., Ph.D., Seth Seabury, Ph.D., Darius Lakdawalla, Ph.D., and Amitabh Chandra, Ph.D.

The New England Journal of Medicine

Abstract


Despite tremendous interest in medical malpractice and its reform, data are lacking on the proportion of physicians who face malpractice claims according to physician specialty, the size of payments according to specialty, and the cumulative incidence of being sued during the course of a physician's career. A recent American Medical Association (AMA) survey of physicians showed that 5% of respondents had faced a malpractice claim during the previous year. Studies estimating specialty-specific malpractice risk from actual claims are much less recent, including a Florida study from 1975 through 1980 showing that 15% of medical specialists, 34% of obstetricians and anesthesiologists, and 48% of surgical specialists faced at least one claim that resulted in an associated defense cost or payment to a claimant (an indemnity payment) during the 6-year study period.

Each of these earlier studies has limitations, including the use of older data with limited geographic coverage, reliance on self-reports with limited sample size and low response rates, limited information on physician specialty, and a lack of information on the size of payments. Although the National Practitioner Data Bank includes most cases in the United States in which a plaintiff was paid on behalf of a licensed health care provider, it does not report the specialties of physicians and does not record information on cases that do not result in a payment.

Using physician-level malpractice claims obtained from a large professional liability insurer, we characterized three aspects of malpractice risk among physicians in 25 specialties: the proportion of physicians facing a malpractice claim in a given year, the proportion of physicians making an indemnity payment, and the size of this payment. In addition, we estimated the cumulative career risk of facing a malpractice claim for physicians in high- and low-risk specialties.

Part of the Discussion Section

Our results may speak to why physicians consistently report concern over malpractice and the intense pressure to practice defensive medicine, despite evidence that the scope of defensive medicine is modest. Concern among physicians over malpractice risk varies far less considerably across states than do objective measures of malpractice risk according to state (e.g., rates of paid claims, average payment sizes, malpractice premiums, and state tort reforms). For example, 65% of physicians practicing in states in the bottom third of rates for paid malpractice claims (5.5 paid claims per 1000 physicians) express substantial concern over malpractice, as compared with 67% of physicians in the top third (14.6 claims per 1000 physicians). Although these annual rates of paid claims are low, the annual and career risks of any malpractice claim are high, suggesting that the risk of being sued alone may create a tangible fear among physicians.

The perceived threat of malpractice among physicians may boil down to three factors: the risk of a claim, the probability of a claim leading to a payment, and the size of payment. Although the frequency and average size of paid claims may not fully explain perceptions among physicians, one may speculate that the large number of claims that do not lead to payment may shape perceived malpractice risk. Physicians can insure against indemnity payments through malpractice insurance, but they cannot insure against the indirect costs of litigation, such as time, stress, added work, and reputational damage.  Although there is no evidence on the size of these indirect costs, direct costs are large. For example, a Harvard study of medical malpractice suggested that nearly 40% of claims were not associated with medical errors and that although a low percentage of such claims led to payment of compensation (28%, as compared with 73% of claims with documented medical errors), they accounted for 16% of total liability costs in the system.

The entire article can be read here.

New Resource: APA Handbook of Ethics in Psychology

The American Psychological Association recently published a wonderful two-volume set on ethics.  The Editor-in-Chief is Pennsylvania's Sam Knapp, EdD, ABPP. 

Here is the description from Amazon.com:

Discussions of ethics in psychology often focus primarily on misconduct, punishment, and legal sanctions, and too often ignore aspirations, values, principles, and virtues. The net effect of this unbalanced approach creates an atmosphere in which psychologists have viewed ethics as unpleasant and frightening, instead of inspiring and uplifting. Psychologists naturally must be concerned about laws, codes, and regulations, but these documents do not constitute the beginning and end of the conversation on ethics.

The editors of this 2-volume reference propose that ethics is best viewed as a striving toward the highest ethical ideals, not just as an injunction against rule violation--a perspective they refer to as "positive ethics" or "active ethics"--and they encourage psychologists to elevate their ethical observance above the minimal standards found in law and enforceable ethics codes.

Against this backdrop, handbook contributors investigate the complexities of ethical behavior in clinical, educational, forensic, health, and "tele-" psychology. Several chapters zero in on the teaching of ethics and on ethically minded research relevant to professionals working in experimental psychology.

By comparison with many ethics textbooks, this two-volume handbook covers a wider range of subjects and pursues them in greater detail. For instance, it reflects important recent advances in research and technology that present new opportunities and challenges for practice and scholarship. Also, it takes a serious look into some burgeoning new areas such as life coaching and providing services over the Internet. These are just two examples of developments that present fascinating, novel ethical questions that deserve attention.

Significant perspectives presented in the handbook include:

Ethics is more than the knowledge of the laws, rules, and regulations that govern the profession and discipline of psychology.

Competent psychologists rely on overarching ethical theories, as well as laws and regulations, when they live up to their highest ethical ideals.

Attention to ethical issues is especially important as psychologists move into new and increasingly complex areas of practice.

The Table of Contents can be found here, along with ordering from APA.

If you are not a member of APA, you can purchase this two volume compendium through Amazon.com by clicking here.

Full Disclosure: Drs. Gavazzi and Knapp are on the Ethics Committee, co-authored a chapter, and received $50 each to write it.  Authors do not receive any money based on sales of the handbook.