Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Sunday, February 3, 2013

High court rules online posts didn't defame doctor

The closely watched case tested the boundaries of First Amendment rights vs. reputation.

By ABBY SIMONS
Star Tribune
Originally posted January 30, 2013

Dennis Laurion fired off his screed on a few rate-your-doctor websites in April 2010, along with some letters about what he saw as poor bedside manner by his father's neurologist. He expected at most what he calls a "non-apology apology."

"I really thought I'd receive something within a few days along the lines of 'I'm sorry you thought I was rude, that was not my intent' and that would be the end of it," the 66-year-old Duluth retiree said. "I certainly did not expect to be sued."

He was. Dr. David McKee's defamation lawsuit was the beginning of a four-year legal battle that ended Wednesday when the Minnesota Supreme Court ruled the doctor had no legal claim against Laurion because there was no proof that his comments were false or were capable of harming the doctor's reputation.

The unanimous ruling reverses an earlier Appeals Court decision and brings to an end the closely watched case that brought to the forefront a First Amendment debate over the limits of free speech online.

It's a frustrating end for McKee, 51, who said he's spent at least $50,000 in legal fees and another $11,000 to clear his name online after the story went viral, resulting in hundreds more negative postings about him -- likely from people who never met him. He hasn't ruled out a second lawsuit stemming from those posts.

"The financial costs are significant, but money is money and five years from now I won't notice the money I spent on this," he said. "It's been the harm to my reputation through the repeated publicity and the stress."

He said he offered to settle the case at no cost after the Supreme Court hearing. Laurion contends they couldn't agree on the terms of the settlement, and said he not only deleted his initial postings after he was initially served, but had nothing to do with subsequent online statements about McKee.

Opinion vs. reputation

The lawsuit followed the hospitalization of Laurion's father, Kenneth, for a hemorrhagic stroke at St. Luke's Hospital in Duluth. Laurion, his mother and his wife were also in the room when McKee examined the father and made the statements that Laurion interpreted as rude.

After his father was discharged, he wrote the reviews and sent the letters.

On at least two sites, Laurion wrote that McKee said that "44 percent of hemorrhagic strokes die within 30 days. I guess this is the better option," and that "It doesn't matter that the patient's gown did not cover his backside."

Laurion also wrote: "When I mentioned Dr. McKee's name to a friend who is a nurse, she said, 'Dr. McKee is a real tool!'"

McKee sued after he learned of the postings from another patient. A St. Louis County judge dismissed the lawsuit, saying Laurion's statements were either protected opinion, substantially true or too vague to convey a defamatory meaning. The Appeals Court reversed that ruling regarding six of Laurion's statements, reasoning that they were factual assertions and not opinions, that they harmed McKee's reputation and that they could be proven as false.

The Supreme Court disagreed. Writing the opinion, Justice Alan Page noted that McKee acknowledged that the gist of some of the statements were true, even if they were misinterpreted.

Page added that the "tool" statements also didn't pass the test of defaming McKee's character. He dismissed an argument by McKee's attorney, Marshall Tanick, that the "tool" comment was fabricated by Laurion and that the nurse never existed.

Whether it was fabricated or not was irrelevant, the court ruled.

"Referring to someone as 'a real tool' falls into the category of pure opinion because the term 'real tool' cannot be reasonably interpreted as stating a fact and it cannot be proven true or false," Page wrote.

The entire story is here.


Diagnosis of ADHD on the Rise in this Study

Recent Trends in Childhood Attention-Deficit/Hyperactivity Disorder

Darios Getahun, MD, PhD; Steven J. Jacobsen, MD, PhD; Michael J. Fassett, MD; Wansu Chen, MS; Kitaw Demissie, MD, PhD; George G. Rhoads, MD, MPH
JAMA Pediatr. 2013;():1-7. doi:10.1001/2013.jamapediatrics.401.

Objective
To examine trends in attention-deficit/hyperactivity disorder (ADHD) by race/ethnicity, age, sex, and median household income.

Design
An ecologic study of trends in the diagnosis of ADHD using the Kaiser Permanente Southern California (KPSC) health plan medical records. Rates of ADHD diagnosis were derived using Poisson regression analyses after adjustments for potential confounders.

Setting  
Kaiser Permanente Southern California, Pasadena.

Participants  
All children who received care at the KPSC from January 1, 2001, through December 31, 2010 (n = 842 830).

Main Exposure
Period of ADHD diagnosis (in years).

Main Outcome Measures
Incidence of physician-diagnosed ADHD in children aged 5 to 11 years.

Results  
Rates of ADHD diagnosis were 2.5% in 2001 and 3.1% in 2010, a relative increase of 24%. From 2001 to 2010, the rate increased among whites (4.7%-5.6%; relative risk [RR] = 1.3; 95% CI, 1.2-1.4), blacks (2.6%- 4.1%; RR = 1.7; 95% CI, 1.5-1.9), and Hispanics (1.7%-2.5%; RR = 1.6; 95% CI, 1.5-1.7). Rates for Asian/Pacific Islander and other racial groups remained unchanged over time. The increase in ADHD diagnosis among blacks was largely driven by an increase in females (RR = 1.9; 95% CI, 1.5-2.3). Although boys were more likely to be diagnosed as having ADHD than girls, results suggest the sex gap for blacks may be closing over time. Children living in high-income households were at increased risk of diagnosis.

Conclusions  
The findings suggest that the rate of ADHD diagnosis among children in the health plan notably has increased over time. We observed disproportionately high ADHD diagnosis rates among white children and notable increases among black girls.

The entire study can be found here.

Saturday, February 2, 2013

HHS Releases Final HIPAA Privacy and Security Update Final Rule


U.S. Department of Health & Human Services
FOR IMMEDIATE RELEASE
Thursday, January 17, 2013

The U.S. Department of Health and Human Services (HHS) moved forward today to strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The final omnibus rule greatly enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law.

“Much has changed in health care since HIPAA was enacted over fifteen years ago,” said HHS Secretary Kathleen Sebelius.  “The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age.”

The changes in the final rulemaking provide the public with increased protection and control of personal health information.  The HIPAA Privacy and Security Rules have focused on health care providers, health plans and other entities that process health insurance claims.  The changes announced today expand many of the requirements to business associates of these entities that receive protected health information, such as contractors and subcontractors. Some of the largest breaches reported to HHS have involved business associates. Penalties are increased for noncompliance based on the level of negligence with a maximum penalty of $1.5 million per violation. The changes also strengthen the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification requirements by clarifying when breaches of unsecured health information must be reported to HHS.

Individual rights are expanded in important ways.  Patients can ask for a copy of their electronic medical record in an electronic form.   When individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan.  The final omnibus rule sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of an individuals’ health information without their permission.

“This final omnibus rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented,” said HHS Office of Civil Rights Director Leon Rodriguez.   “These changes not only greatly enhance a patient’s privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a health care provider, or one of their business associates.”

The final rule also reduces burden by streamlining individuals’ ability to authorize the use of their health information for research purposes.  The rule makes it easier for parents and others to give permission to share proof of a child’s immunization with a school and gives covered entities and business associates up to one year after the 180-day compliance date to modify contracts to comply with the rule.

The final omnibus rule is based on statutory changes under the HITECH Act, enacted as part of the American Recovery and Reinvestment Act of 2009, and the Genetic Information Nondiscrimination Act of 2008 (GINA) which clarifies that genetic information is protected under the HIPAA Privacy Rule and prohibits most health plans from using or disclosing genetic information for underwriting purposes.

The Rulemaking announced today may be viewed in the Federal Register at https://www.federalregister.gov/public-inspection.


The final document is here.

More Using Electronics to Track Their Health

By MILT FREUDENHEIM
The New York Times
Published: January 27, 2013

Whether they have chronic ailments like diabetes or just want to watch their weight, Americans are increasingly tracking their health using smartphone applications and other devices that collect personal data automatically, according to health industry researchers.

“The explosion of mobile devices means that more Americans have an opportunity to start tracking health data in an organized way,” said Susannah Fox, an associate director of the Pew Research Center’s Internet and American Life Project, which was to release the national study on Monday. Many of the people surveyed said the experience had changed their overall approach to health.

More than 500 companies were making or developing self-management tools by last fall, up 35 percent from January 2012, said Matthew Holt, co-chairman of Health 2.0, a market intelligence project that keeps a database of health technology companies. Nearly 13,000 health and fitness apps are now available, he said.

The Pew study said 21 percent of people who track their health use some form of technology.

They are people like Steven Jonas of Portland, Ore., who uses an electronic monitor to check his heart rate when he feels stressed. Then he breathes deeply for a few minutes and watches the monitor on his laptop as his heart slows down.

“It’s incredibly effective in a weird way,” he said.

Mr. Jonas said he also used electronic means to track his mood, weight, mental sharpness, sleep and memory.

The entire story is here.

Friday, February 1, 2013

Clinical Psychologists’ Firearm Risk Management Perceptions and Practices

Andrea Traylor, James H. Price, Susan K. Telljohann, Keith King, and Amy Thompson

J Community Health. 2010 February; 35(1): 60–67.
Published online 2010 January 22.
doi:  10.1007/s10900-009-9200-6

Abstract

The purpose of this study was to investigate the current perceptions and practices of discussing firearm risk management with patients diagnosed with selected mental health problems. A three-wave survey was mailed to a national random sample of clinical psychologists and 339 responded (62%). The majority (78.5%) believed firearm safety issues were greater among those with mental health problems. However, the majority of clinical psychologists did not have a routine system for identifying patients with access to firearms (78.2%). Additionally, the majority (78.8%) reported they did not routinely chart or keep a record of whether patients owned or had access to firearms. About one-half (51.6%) of the clinical psychologists reported they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others. Almost half (46%) of clinical psychologists reported not receiving any information on firearm safety issues. Thus, the findings of this study suggest that a more formal role regarding anticipatory guidance on firearms is needed in the professional training of clinical psychologists.

The entire article is here.

Thanks to Dan Warner for this article.

Should Therapists Play Cupid?

By Richard A. Friedman
The New York Times Sunday Review
Originally published January 19, 2013

IF you are in psychotherapy, there’s a good chance your therapist knows more about your inner thoughts and secret desires than anyone else.

So, if you’re looking for a mate, wouldn’t your therapist be a more reliable matchmaker than eHarmony and Match.com and other sites that rely on impersonal algorithms?

The idea that therapists might play Cupid with patients tantalizes patients and therapists. An anecdotal survey of my psychiatrist colleagues suggests that the matchmaking impulse is very common.

A senior colleague, for example, tells me he was treating a young man who was struggling to find a partner. My colleague said he knew someone who was perfect for his patient and wanted to set them up on a date, but didn’t because he was afraid — there were too many ways even the most well-intentioned therapist fix-up could go wrong.

Why? Psychotherapy, especially insight-oriented therapy, is designed to conjure intense feelings — on the part of the patient and therapist. Much of what patients feel toward their therapists, the so-called transference, are unconscious feelings that are redirected from important early figures in their lives — parents, family members and teachers. Your therapist mirrors this phenomenon with his own countertransference.

One of psychotherapy’s aims is to use the patient-therapist relationship to better understand the patient’s relationships with others and to remedy problems in the little lab that is the therapeutic connection.

The entire story is here.

Thursday, January 31, 2013

Doctor Tells U.S. Judge He Created Fake L.I.R.R. Injury Claims


By THE ASSOCIATED PRESS
Published: January 18, 2013

An orthopedist who was accused of taking cash payments for fake diagnoses and billing health insurance companies for unnecessary medical treatment in widespread disability fraud involving Long Island Rail Road workers pleaded guilty on Friday to conspiracy charges.

The doctor, Peter J. Ajemian, admitted that between the late 1990s and 2008 he invented “narratives” to justify illness and injury claims for hundreds of workers seeking to retire on disability.

The employees “were not in fact disabled and could have continued working in their railroad jobs, as they had no complaint right up to the time of their retirement date,” Dr. Ajemian told a judge in Federal District Court in Manhattan.

Prosecutors said that Dr. Ajemian, 63, received up to $1,200 for each of the fake assessments, as well as millions of dollars in health insurance payments. His patients received more than $90 million in disability benefits.

Dr. Ajemian was among 32 defendants who have been arrested in the past two years.

Three other retirees also pleaded guilty this week, bringing the number of guilty pleas in the case to 21.

Sentencing for Dr. Ajemian was set for May 24.

The story is here.

Accused gunman's doctor, university face lawsuits

By Jim Spellman,
CNN
Originally published January 17, 2013


The university psychiatrist who treated the accused gunman in last year's deadly Colorado theater rampage could face more than a dozen lawsuits that blame her and the school for not properly handling James Holmes' treatment.

At least 14 people have filed legal documents indicating they are planning to sue the University of Colorado Denver and Dr. Lynne Fenton for negligence.

Holmes, 25, was a doctoral student in neuroscience at the university.

Fenton has testified that her contact with Holmes ended on June 11, more than a month before he allegedly walked into a crowded movie theater in Aurora, Colorado, and opened fire, killing 12 people and wounding 58 others during a screening of the new Batman film.

She said she later contacted campus police because she was "so concerned" about what happened during her last meeting with him, but she declined to detail what bothered her.

The entire story is here.

Wednesday, January 30, 2013

Recovery from autism spectrum disorder (ASD) and the science of hope

Editorial in The Journal of Child Psychology and Psychiatry
Sally Ozonoff JCPP Joint Editor
Originally published January 16, 2013
DOI: 10.1111/jcpp.12045


The Journal of Child Psychology and Psychiatry, and the field of developmental psychopathology in general, is keenly interested in stability and change, continuities and discontinuities, and prediction of outcome. This issue of the journal presents several articles that examine influences and predictors of child difficulties, such as avoidant behavior (Aktar et al., 2012†) and antisocial behavior (Rhee et al., 2012). The effects of maternal depression and parental anxiety on child outcomes are also explored in this issue (Aktar et al., 2012; Hughes et al., 2012), as are the stability of symptoms in autism spectrum disorders (Corsello et al., 2012; Simonoff et al., 2012). All add to our understanding of the basic mechanisms and developmental pathways that underlie atypical child development. I call your attention to one article in particular that explores these concepts from a different angle and brings solid science to an understudied topic with a very controversial and contentious history, namely recovery from autism spectrum disorder (ASD).

Fein et al. (2012) recruited 34 children with clearly documented early histories of ASD who no longer met criteria for any autism spectrum diagnosis and, even further, had lost all symptoms of ASD. They compared these children to a group of typically developing participants and found no differences on multiple measures independent of the group classification process. They conclude, rather modestly, that these results “substantiate the possibility of optimal outcome,” demonstrating that some children with a clear early history and accurate diagnosis of ASD do indeed move into the entirely normal range of social and communication development later in childhood. Fein et al. use the word “recovery” only once in their paper, in reference to the findings and claims of another study. Their avoidance of the word is likely intentional. In fact, scientific papers have largely steered clear of this word, although it is alive and well on the Web. Why has recovery been such a provocative concept?

Lovaas (1987) was the first to use the term “recovery” in relation to ASD, describing the outcomes of children he had treated using the methods of applied behavior analysis. He did not provide an explicit definition of recovery, but described this group of children as having normal educational and intellectual functioning. His interpretation of this outcome as “recovery” was embraced wholeheartedly by some and scrutinized skeptically by others. It was pointed out that many children who meet criteria for ASD attain this level of functioning, but continue to display significant symptoms. Whether they had achieved “recovery” that fit with the Merriam-Webster definition of “regaining or returning to a normal or healthy state” was disputed. Researchers have generally avoided the term for fear of being viewed as naïve, idealistic, political, or simply just not good scientists. But recovery has remained a very powerful construct, one that many parents talk about and that has been the subject of much media and internet attention.

The entire article and issue can be found here.