Oncologist Pays for Patient's Meds: A 'Boundary' Crossed?

Nic Mulcahy

medscape.com

Originally posted 4 Nov 20

It was an act of kindness: while overseeing a patient through a round of chemotherapy, an oncology fellow at Johns Hopkins University's Kimmel Comprehensive Cancer Center in Baltimore, Maryland, paid a modest amount of money (about $10) for that patient's antiemetic medication and retrieved it from the center's pharmacy.

Co-fellow Arjun Gupta, MD, witnessed the act and shared it with the world September 23 on Twitter.

"Just observed a co-fellow pay the co-pay for a patient's post-chemo nausea meds at the pharmacy, arrange them in a pill box, and deliver them to the patient in the infusion center. So that the patient could just leave after chemo."

Healthcare professionals applauded the generosity. "Phenomenal care," tweeted Carolyn Alexander, MD, a fertility physician in Los Angeles.

It's a common occurrence, said others. "Go ask a nurse how many times they've done it. I see it happen weekly," tweeted Chelsea Mitchell, PharmD, an intensive care unit pharmacist in Memphis, Tennessee.

Lack of universal healthcare brings about these moments, claimed multiple professionals who read Gupta's anecdote. "#ThisIsDoctoring. This is also a shameful indictment of our medical system," said Mary Landrigan-Ossar, MD, an anesthesiologist at Children's Hospital, Boston, Massachusetts.

However, one observer called out something no one else had ― that paying for a patient's medication is not allowed in some facilities.

The info is here.

Systemic racism and U.S. health care

J. Feagin & Z. Bennefield
Social Science & Medicine
Volume 103, February 2014, Pages 7-14

Abstract

This article draws upon a major social science theoretical approach–systemic racism theory–to assess decades of empirical research on racial dimensions of U.S. health care and public health institutions. From the 1600s, the oppression of Americans of color has been systemic and rationalized using a white racial framing–with its constituent racist stereotypes, ideologies, images, narratives, and emotions. We review historical literature on racially exploitative medical and public health practices that helped generate and sustain this racial framing and related structural discrimination targeting Americans of color. We examine contemporary research on racial differentials in medical practices, white clinicians' racial framing, and views of patients and physicians of color to demonstrate the continuing reality of systemic racism throughout health care and public health institutions. We conclude from research that institutionalized white socioeconomic resources, discrimination, and racialized framing from centuries of slavery, segregation, and contemporary white oppression severely limit and restrict access of many Americans of color to adequate socioeconomic resources–and to adequate health care and health outcomes. Dealing justly with continuing racial “disparities” in health and health care requires a conceptual paradigm that realistically assesses U.S. society's white-racist roots and contemporary racist realities. We conclude briefly with examples of successful public policies that have brought structural changes in racial and class differentials in health care and public health in the U.S. and other countries.

Highlights

• A full-fledged theory of structural (systemic) racism for interpreting health care data.

• A full-fledged developed theory of structural (systemic) racism for interpreting public health data.

• Focus on powerful white decision makers central to health-related institutions.

• Importance of listening to patients and physicians of color on health issues.

• Implications of systemic racism theory and data for public policies regarding medical care and public health.

The info is here.

Patients aren’t being told about the AI systems advising their care

Rebecca Robbins and Erin Brodwin
statnews.com
Originally posted 15 July 20

Here is an excerpt:

The decision not to mention these systems to patients is the product of an emerging consensus among doctors, hospital executives, developers, and system architects, who see little value — but plenty of downside — in raising the subject.

They worry that bringing up AI will derail clinicians’ conversations with patients, diverting time and attention away from actionable steps that patients can take to improve their health and quality of life. Doctors also emphasize that they, not the AI, make the decisions about care. An AI system’s recommendation, after all, is just one of many factors that clinicians take into account before making a decision about a patient’s care, and it would be absurd to detail every single guideline, protocol, and data source that gets considered, they say.

Internist Karyn Baum, who’s leading M Health Fairview’s rollout of the tool, said she doesn’t bring up the AI to her patients “in the same way that I wouldn’t say that the X-ray has decided that you’re ready to go home.” She said she would never tell a fellow clinician not to mention the model to a patient, but in practice, her colleagues generally don’t bring it up either.

Four of the health system’s 13 hospitals have now rolled out the hospital discharge planning tool, which was developed by the Silicon Valley AI company Qventus. The model is designed to identify hospitalized patients who are likely to be clinically ready to go home soon and flag steps that might be needed to make that happen, such as scheduling a necessary physical therapy appointment.

Clinicians consult the tool during their daily morning huddle, gathering around a computer to peer at a dashboard of hospitalized patients, estimated discharge dates, and barriers that could prevent that from occurring on schedule.

The info is here.

When a Patient Regrets Having Undergone a Carefully and Jointly Considered Treatment Plan, How Should Her Physician Respond?

L. V. Selby and others
AMA J Ethics. 2020;22(5):E352-357.
doi: 10.1001/amajethics.2020.352.

Abstract

Shared decision making is best utilized when a decision is preference sensitive. However, a consequence of choosing between one of several reasonable options is decisional regret: wishing a different decision had been made. In this vignette, a patient chooses mastectomy to avoid radiotherapy. However, postoperatively, she regrets the more disfiguring operation and wishes she had picked the other option: lumpectomy and radiation. Although the physician might view decisional regret as a failure of shared decision making, the physician should reflect on the process by which the decision was made. If the patient’s wishes and values were explored and the decision was made in keeping with those values, decisional regret should be viewed as a consequence of decision making, not necessarily as a failure of shared decision making.

(cut)

Commentary

This case vignette highlights decisional regret, which is one of the possible consequences of the patient decision-making process when there are multiple treatment options available. Although the process of shared decision making, which appears to have been carried out in this case, is utilized to help guide the patient and the physician to come to a mutually acceptable and optimal health care decision, it clearly does not always obviate the risk of a patient’s regretting that decision after treatment. Ironically, the patient might end up experiencing more regret after participating in a decision-making process in which more rather than fewer options are presented and in which the patient perceives the process as collaborative rather than paternalistic. For example, among men with prostate cancer, those with lower levels of decisional involvement had lower levels of decisional regret. We argue that decisional regret does not mean that shared decision making is not best practice, even though it can result in patients being reminded of their role in the decision and associated personal regret with that decision.

The info is here.

Structural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge

Jonathan M. Metzl and Dorothy E. Roberts
Virtual Mentor. 2014;16(9):674-690.
doi: 10.1001/virtualmentor.2014.16.9.spec1-1409.

Here is an excerpt:

The Clinical Implications of Addressing Race from a Structural Perspective

These brief case examples illustrate the complex ways that seemingly clinically relevant “cultural” characteristics and attitudes also reflect structural inequities, medical politics, legal codes, invisible discrimination, and socioeconomic disparities. Black men who appeared schizophrenic to medical practitioners did so in part because of the framing of new diagnostic codes. Lower-income persons who “refused” to eat well or exercise lived in neighborhoods without grocery stores or sidewalks. Black women who seemed to be uniquely harming their children by using crack cocaine while pregnant were victims of racial stereotyping, as well as of a selection bias in which decisions about which patients were reported to law enforcement depended on the racial and economic segregation of prenatal care. In this sense, approaches that attempt to address issues—such as the misdiagnosis of schizophrenia in black men, perceived diet “noncompliance” in minority populations, or the punishment of “crack mothers”—through a heuristic aimed solely at enhancing cross-cultural communication between doctors and patients, though surely well intentioned, will overlook the potentially pathologizing impact of structural factors set in motion long before patients or doctors enter exam rooms.

Structural factors impact majority populations as well as minority ones, and structures of privilege or opulence also influence expressions of illness and health. For instance, in the United States, research suggests that pediatricians disproportionately overdiagnose ADHD in white school-aged children. Until recently, medical researchers in many global locales assumed, wrongly, that eating disorders afflicted only affluent persons.

Yet of late, medicine and medical education have struggled most with addressing ways that structural forces impact and disadvantage communities of color. As sociologist Hannah Bradby rightly explains it, hypothesizing mechanisms that include the micro-processes of interactions between patients and professionals and the macro-processes of population-level inequalities is a missing step in our reasoning at present…. [A]s long as we see the solution to racism lying only in educating the individual, we fail to address the complexity of racism and risk alienating patients and physicians alike.

The info is here.

Immunity to Covid-19 could be lost in months, UK study suggests

Ian Sample
The Guardian
Originally posted 12 July 20

People who have recovered from Covid-19 may lose their immunity to the disease within months, according to research suggesting the virus could reinfect people year after year, like common colds.

In the first longitudinal study of its kind, scientists analysed the immune response of more than 90 patients and healthcare workers at Guy’s and St Thomas’ NHS foundation trust and found levels of antibodies that can destroy the virus peaked about three weeks after the onset of symptoms then swiftly declined.

Blood tests revealed that while 60% of people marshalled a “potent” antibody response at the height of their battle with the virus, only 17% retained the same potency three months later. Antibody levels fell as much as 23-fold over the period. In some cases, they became undetectable.

“People are producing a reasonable antibody response to the virus, but it’s waning over a short period of time and depending on how high your peak is, that determines how long the antibodies are staying around,” said Dr Katie Doores, lead author on the study at King’s College London.

The study has implications for the development of a vaccine, and for the pursuit of “herd immunity” in the community over time.

The immune system has multiple ways to fight the coronavirus but if antibodies are the main line of defence, the findings suggested people could become reinfected in seasonal waves and that vaccines may not protect them for long.

The info is here.

Can COVID-19 re-invigorate ethics?

Louise Campbell
BMJ Blogs
Originally posted 26 May 20

The COVID-19 pandemic has catapulted ethics into the spotlight.  Questions previously deliberated about by small numbers of people interested in or affected by particular issues are now being posed with an unprecedented urgency right across the public domain.  One of the interesting facets of this development is the way in which the questions we are asking now draw attention, not just to the importance of ethics in public life, but to the very nature of ethics as practice, namely ethics as it is applied to specific societal and environmental concerns.

Some of these questions which have captured the public imagination were originally debated specifically within healthcare circles and at the level of health policy: what measures must be taken to prevent hospitals from becoming overwhelmed if there is a surge in the number of people requiring hospitalisation?  How will critical care resources such as ventilators be prioritised if need outstrips supply?  In a crisis situation, will older people or people with disabilities have the same opportunities to access scarce resources, even though they may have less chance of survival than people without age-related conditions or disabilities?  What level of risk should healthcare workers be expected to assume when treating patients in situations in which personal protective equipment may be inadequate or unavailable?   Have the rights of patients with chronic conditions been traded off against the need to prepare the health service to meet a demand which to date has not arisen?  Will the response to COVID-19 based on current evidence compromise the capacity of the health system to provide routine outpatient and non-emergency care to patients in the near future?

Other questions relate more broadly to the intersection between health and society: how do we calculate the harms of compelling entire populations to isolate themselves from loved ones and from their communities?  How do we balance these harms against the risks of giving people more autonomy to act responsibly?  What consideration is given to the fact that, in an unequal society, restrictions on liberty will affect certain social groups in disproportionate ways?  What does the catastrophic impact of COVID-19 on residents of nursing homes say about our priorities as a society and to what extent is their plight our collective responsibility?  What steps have been taken to protect marginalised communities who are at greater risk from an outbreak of infectious disease: for example, people who have no choice but to coexist in close proximity with one another in direct provision centres, in prison settings and on halting sites?

The info is here.

Racial bias skews algorithms widely used to guide care from heart surgery to birth, study finds

Sharon Begley
statnews.com
Originally posted 17 June 20

Here is an excerpt:

All 13 of the algorithms Jones and his colleagues examined offered rationales for including race in a way that, presumably unintentionally, made Black and, in some cases, Latinx patients less likely to receive appropriate care. But when you trace those rationales back to their origins, Jones said, “you find outdated science or biased data,” such as simplistically concluding that poor outcomes for Black patients are due to race.

Typically, developers based their algorithms on studies showing a correlation between race and some medical outcome, assuming race explained or was even the cause of, say, a poorer outcome (from a vaginal birth after a cesarean, say). They generally did not examine whether factors that typically go along with race in the U.S., such as access to primary care or socioeconomic status or discrimination, might be the true drivers of the correlation.

“Modern tools of epidemiology and statistics could sort that out,” Jones said, “and show that much of what passes for race is actually about class and poverty.”

Including race in a clinical algorithm can sometimes be appropriate, Powers cautioned: “It could lead to better patient care or even be a tool for addressing inequities.” But it might also exacerbate inequities. Figuring out the algorithms’ consequences “requires taking a close look at how the algorithm was trained, the data used to make predictions, the accuracy of those predictions, and how the algorithm is used in practice,” Powers said. “Unfortunately, we don’t have these answers for many of the algorithms.”

The info is here.

Reframing Clinician Distress: Moral Injury Not Burnout

W. Dean, S. Talbot, and A. Dean
Fed Pract. 2019 Sep; 36(9): 400–402.

For more than a decade, the term burnout has been used to describe clinician distress. Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population. Massive information technology investments, which promised efficiency for health care providers, have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers, diverted the time and attention of those already engaged in patient care, and done little to improve patient outcomes. Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day. As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise. It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.

Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace. The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.

In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care. The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation. On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.

The article is here.

The Moral Determinants of Health

Donald M. Berwick
JAMA
Originally posted 12 June 20

Here is an excerpt:

How do humans invest in their own vitality and longevity? The answer seems illogical. In wealthy nations, science points to social causes, but most economic investments are nowhere near those causes. Vast, expensive repair shops (such as medical centers and emergency services) are hard at work, but minimal facilities are available to prevent the damage. In the US at the moment, 40 million people are hungry, almost 600 000 are homeless, 2.3 million are in prisons and jails with minimal health services (70% of whom experience mental illness or substance abuse), 40 million live in poverty, 40% of elders live in loneliness, and public transport in cities is decaying. Today, everywhere, as the murder of George Floyd and the subsequent protests make clear yet again, deep structural racism continues its chronic, destructive work. In recent weeks, people in their streets across the US, many moved perhaps by the “moral law within,” have been protesting against vast, cruel, and seemingly endless racial prejudice and inequality.

Decades of research on the true causes of ill health, a long series of pedigreed reports, and voices of public health advocacy have not changed this underinvestment in actual human well-being. Two possible sources of funds seem logically possible: either (a) raise taxes to allow governments to improve social determinants, or (b) shift some substantial fraction of health expenditures from an overbuilt, high-priced, wasteful, and frankly confiscatory system of hospitals and specialty care toward addressing social determinants instead. Either is logically possible, but neither is politically possible, at least not so far.

Neither will happen unless and until an attack on racism and other social determinants of health is motivated by an embrace of the moral determinants of health, including, most crucially, a strong sense of social solidarity in the US. “Solidarity” would mean that individuals in the US legitimately and properly can depend on each other for helping to secure the basic circumstances of healthy lives, no less than they depend legitimately on each other to secure the nation’s defense. If that were the moral imperative, government—the primary expression of shared responsibility—would defend and improve health just as energetically as it defends territorial integrity.

The info is here.

Scathing COVID-19 book from Lancet editor — rushed but useful

Stephen Buranyi
nature.com
Originally posted 18 June 20

Here is an excerpt:

Horton levels the accusation that US President Donald Trump is committing a “crime against humanity” for defunding the very World Health Organization that is trying to help the United States and others. UK Prime Minister Boris Johnson, in Horton’s view, either lied or committed misconduct in telling the public that the government was well prepared for the pandemic. In fact, the UK government abandoned the world-standard advice to test, trace and isolate in March, with no explanation, then scrambled to ramp up testing in April, but repeatedly failed to meet its own targets, lagging weeks behind the rest of the world. A BBC investigation in April showed that the UK government failed to stockpile neccessary personal protective equipment for years before the crisis, and should have been aware that the National Health Service wasn’t adequately prepared.

Politicians are easy targets, though. Horton goes further, to suggest that although scientists in general have performed admirably, many of those advising the government directly contributed to what he calls “the greatest science policy failure for a generation”.

Again using the United Kingdom as an example, he suggests that researchers were insufficiently informed or understanding of the crisis unfolding in China, and were too insular to speak to Chinese scientists directly. The model for action at times seemed to be influenza, a drastic underestimation of the true threat of the new coronavirus. Worse, as the UK government’s response went off the rails in March, ostensibly independent scientists would “speak with one voice in support of government policy”, keeping up the facade that the country was doing well. In Horton’s view, this is a corruption of science policymaking at every level. Individuals failed in their responsibility to procure the best scientific advice, he contends; and the advisory regime was too close to — and in sync with — the political actors who were making decisions. “Advisors became the public relations wing of a government that had failed its people,” he concludes.

The text is here.

My Bedside Manner Got Worse During The Pandemic. Here's How I Improved

Shahdabul Faraz
npr.org
Health Shots
Originally published 16 May 20

Here is an excerpt:

These gestures can be as simple as sitting in a veteran's room for an extra five minutes to listen to World War II stories. Or listening with a young cancer patient to a song by our shared favorite band. Or clutching a sick patient's shoulder and reassuring him that he will see his three daughters again.

These gestures acknowledge a patient's humanity. It gives them some semblance of normalcy in an otherwise difficult period in their lives. Selfishly, that human connection also helps us — the doctors, nurses and other health care providers — deal with the often frustrating nature of our stressful jobs.

Since the start of the pandemic, our bedside interactions have had to be radically different. Against our instincts, and in order to protect our patients and colleagues, we tend to spend only the necessary amount of time in our patients' rooms. And once inside, we try to keep some distance. I have stopped holding my patients' hands. I now try to minimize small talk. No more whimsical conversational detours.

Our interactions now are more direct and short. I have, more than once, felt guilty for how quickly I've left a patient's room. This guilt is worsened, knowing that patients in hospitals don't have family and friends with them now either. Doctors are supposed to be there for our patients, but it's become harder than ever in recent months.

I understand why these changes are needed. As I move through several hospital floors, I could unwittingly transmit the virus if I'm infected and don't know it. I'm relatively young and healthy, so if I get the disease, I will likely recover. But what about my patients? Some have compromised immune systems. Most are elderly and have more than one high-risk medical condition. I could never forgive myself if I gave one of my patients COVID-19.

The info is here.

Suicides of two health care workers hint at the Covid-19 mental health crisis to come

Wendy Dean
statnews.com
Originally posted 30 April 2020

Here is an excerpt:

Denial, minimizing, and compartmentalizing are essential strategies for coping with a crisis. They are the psychological tools we reach for over and over to get through harrowing situations. Health care workers learn this through experience and by watching others. We learn how not to pass out in the trauma bay. We learn to flip into “rational mode” when a patient is hemorrhaging or in cardiac arrest, attending to the details of survival — their vital signs, lab results, imaging studies. We learn that if we grieve for the 17-year-old gunshot victim while we are doing chest compressions we will buckle and he will die. So we shut down feeling and just keep doing.

What few health care workers learn how to do is manage the abstractness of emotional recovery, when there is nothing to act on, no numbers to attend, no easily measurable markers of improvement. It is also hard to learn to resolve emotional experiences by watching others, because this kind of intense processing is a private undertaking. We rarely get to watch how someone else swims in the surf of traumatic experience.

Those on the frontlines of the Covid-19 pandemic, especially those in the hardest-hit areas, have seen conditions they never imagined possible in the country with the most expensive health care system in the world. Watching patients die alone is traumatic. Having to choose your own safety over offering comfort to the dying because your hospital or health care system doesn’t have enough personal protective equipment to go around inflicts moral injury. When facing the reality of constrained resources and unthinkable choices, working to exhaustion, and caring for patients at great personal risk, the only way to get through each shift is to do what is immediately at hand.

The info is here.

How Becoming a Doctor Made Me a Worse Listener

Adeline Goss
JAMA. 2020;323(11):1041-1042.
doi:10.1001/jama.2020.2051

Here is an excerpt:

And I hadn’t noticed. Maybe that was because I was still connecting to patients. I still choked up when they cried, felt joy when they rejoiced, felt moved by and grateful for my work, and generally felt good about the care I was providing.

But as I moved through my next days in clinic, I began to notice the unconscious tricks I had developed to maintain a connection under time pressure. A whole set of expressions played out across my face during history taking—nonverbal concern, nonverbal gentleness, nonverbal apology—a time-efficient method of conveying empathy even when I was asking directed questions, controlling the type and volume of information I received, and, at times, interrupting. Sometimes I apologized to patients for my style of interviewing, explaining that I wanted to make sure I understood things clearly so that I could treat them. I apologized because I didn’t like communicating this way. I can’t imagine it felt good to them.

What’s strange is that, at the end of these visits, patients often thanked me for my concern and detail-orientedness. They may have interpreted my questioning as a sign that I was interested. But was I?

Interest is a multilayered concept in medicine. I care about patients, and I am interested in their stories in the sense that they contain the information I need to make the best possible decisions for their care. Interest motivates doctors to take a detailed history, review the chart, and analyze the literature. Interest leads to the correct diagnosis and treatment. Residency rewards this kind of interest. Perhaps as a result, looking around at my co-residents, it’s in abundant supply, even when time is tight.

The info is here.

On the ethics of algorithmic decision-making in healthcare

Grote T, Berens P
Journal of Medical Ethics 
2020;46:205-211.

Abstract

In recent years, a plethora of high-profile scientific publications has been reporting about machine learning algorithms outperforming clinicians in medical diagnosis or treatment recommendations. This has spiked interest in deploying relevant algorithms with the aim of enhancing decision-making in healthcare. In this paper, we argue that instead of straightforwardly enhancing the decision-making capabilities of clinicians and healthcare institutions, deploying machines learning algorithms entails trade-offs at the epistemic and the normative level. Whereas involving machine learning might improve the accuracy of medical diagnosis, it comes at the expense of opacity when trying to assess the reliability of given diagnosis. Drawing on literature in social epistemology and moral responsibility, we argue that the uncertainty in question potentially undermines the epistemic authority of clinicians. Furthermore, we elucidate potential pitfalls of involving machine learning in healthcare with respect to paternalism, moral responsibility and fairness. At last, we discuss how the deployment of machine learning algorithms might shift the evidentiary norms of medical diagnosis. In this regard, we hope to lay the grounds for further ethical reflection of the opportunities and pitfalls of machine learning for enhancing decision-making in healthcare.

From the Conclusion

In this paper, we aimed at examining which opportunities and pitfalls machine learning potentially provides to enhance of medical decision-making on epistemic and ethical grounds. As should have become clear, enhancing medical decision-making by deferring to machine learning algorithms requires trade-offs at different levels. Clinicians, or their respective healthcare institutions, are facing a dilemma: while there is plenty of evidence of machine learning algorithms outsmarting their human counterparts, their deployment comes at the costs of high degrees of uncertainty. On epistemic grounds, relevant uncertainty promotes risk-averse decision-making among clinicians, which then might lead to impoverished medical diagnosis. From an ethical perspective, deferring to machine learning algorithms blurs the attribution of accountability and imposes health risks to patients. Furthermore, the deployment of machine learning might also foster a shift of norms within healthcare. It needs to be pointed out, however, that none of the issues we discussed presents a knockout argument against deploying machine learning in medicine, and our article is not intended this way at all. On the contrary, we are convinced that machine learning provides plenty of opportunities to enhance decision-making in medicine.

The article is here.

Which Legal Approaches Help Limit Harms to Patients From Clinicians’ Conscience-Based Refusals?

R. Kogan, K. Kraschel, & C. Haupt
AMA J Ethics. 2020;22(3):E209-216.
doi: 10.1001/amajethics.2020.209.

Abstract

This article canvasses laws protecting clinicians’ conscience and focuses on dilemmas that occur when a clinician refuses to perform a procedure consistent with the standard of care. In particular, the article focuses on patients’ experience with a conscientiously objecting clinician at a secular institution, where patients are least likely to expect conscience-based care restrictions. After reviewing existing laws that protect clinicians’ conscience, the article discusses limited legal remedies available to patients.

Potential Sites of Conflict

Clinicians who object to providing care on the basis of “conscience” have never been more robustly protected than today by state legislatures and federal law. Although US law as well as professional ethics allows clinicians to deviate from professional norms and standards when their religious or moral beliefs conflict with a requested service,1 the scope of legal remedies for patients harmed by these objections has shrunk as federal and state law has effectively insulated objecting clinicians from liability. This article outlines laws protecting clinician conscience and identifies questions that arise when a clinician refuses to perform a procedure consistent with the medical profession’s standard of care. We focus on patients seeking care at secular institutions where patients are least likely to have notice that care they receive could be restricted based upon an individual clinician’s refusal. As a result, patients may unknowingly receive substandard care from objecting physicians and even be harmed by their refusals. However, the legal remedies available to patients adversely affected by refusals are limited. We first discuss federal and state law governing refusals based on clinician conscience and then examine the remedies available to patients who suffer harm as a result of a physician’s refusal.

The info is here.

Virus lays bare the frailty of the social contract

Editorial Board
Financial Times
Originally published 3 April 20

If there is a silver lining to the Covid-19 pandemic, it is that it has injected a sense of togetherness into polarised societies. But the virus, and the economic lockdowns needed to combat it, also shine a glaring light on existing inequalities — and even create new ones. Beyond defeating the disease, the great test all countries will soon face is whether current feelings of common purpose will shape society after the crisis. As western leaders learnt in the Great Depression, and after the second world war, to demand collective sacrifice you must offer a social contract that benefits everyone.

Today’s crisis is laying bare how far many rich societies fall short of this ideal. Much as the struggle to contain the pandemic has exposed the unpreparedness of health systems, so the brittleness of many countries’ economies has been exposed, as governments scramble to stave off mass bankruptcies and cope with mass unemployment. Despite inspirational calls for national mobilisation, we are not really all in this together.

The economic lockdowns are imposing the greatest cost on those already worst off. Overnight millions of jobs and livelihoods have been lost in hospitality, leisure and related sectors, while better paid knowledge workers often face only the nuisance of working from home. Worse, those in low-wage jobs who can still work are often risking their lives — as carers and healthcare support workers, but also as shelf stackers, delivery drivers and cleaners.

The info is here.

Managing mental health challenges faced by healthcare workers during COVID-19 pandemic

Greenberg N., & others
BMJ 2020; 368 :m1211

Here is an excerpt:

Moral injury

Moral injury, a term that originated in the military, can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code.1 Unlike formal mental health conditions such as depression or post-traumatic stress disorder, moral injury is not a mental illness. But those who develop moral injuries are likely to experience negative thoughts about themselves or others (for example, “I am a terrible person” or “My bosses don’t care about people’s lives”) as well as intense feelings of shame, guilt, or disgust. These symptoms can contribute to the development of mental health difficulties, including depression, post-traumatic stress disorder, and even suicidal ideation. Equally, some people who have to contend with significant challenges, moral or traumatic, experience a degree of post-traumatic growth,3 a term used to describe a bolstering of psychological resilience, esteem, outlook, and values after exposure to highly challenging situations. Whether someone develops a psychological injury or experiences psychological growth is likely to be influenced by the way that they are supported before, during, and after a challenging incident.

Moral injury has already been described in medical students, who report great difficulty coping with working in prehospital and emergency care,4 where they were exposed to trauma that they felt unprepared for. This may be similar to the unprecedented nature of the challenges healthcare staff are currently facing. In the UK, most NHS staff may have felt, with some justification, that with all its faults, the NHS gives the sickest people the greatest chance of recovery. As such, staff should and usually do feel that it is something to be proud of.

The huge current effort to ensure adequate staffing and resources may be successful, but it looks likely that during the covid-19 outbreak many healthcare workers will encounter situations where they cannot say to a grieving relative, “We did all we could” but only, “We did our best with the staff and resources available, but it wasn’t enough.” That is the seed of a moral injury. Not all staff members will be adversely affected by the challenges ahead (table 1) but no one is invulnerable, and some healthcare workers will hurt, perhaps for a long time, unless we begin now to prepare and support our staff.

The info is here.

COVID-19 and the Impossibility of Morality

John Danaher
philosophical disquisitions
Originally published 16 March 20

The stories coming out of Italy over the past two weeks have been chilling. With their healthcare system overwhelmed by COVID-19 cases, Italian doctors are facing tragic triage decisions on a daily basis. In severe cases of COVID-19 patients need ventilators to survive. But there are only so many ventilators to go around. What if you don’t have enough? Who should you save? The 80 year old with COPD and other medical complications or the slightly healthier 50 year old without them? The 45 year old mother of two or the 55 year old single man? The 29 year old healthcare worker or the 38 year old diabetes patient?

Questions like these might sound like thought experiments cooked up in a first year ethics class, but they are not. Indeed, decision-making of this sort is not uncommon in crisis situations. For example, infamous tales are told about what happened at the Memorial Medical Center in New Orleans during Hurricane Katrina in 2005. With rising flood waters, no electricity and several critically ill patients who could not be evacuated, medical workers at Memorial had to make some tough decisions: abandon patients and leave them die in agony or administer euthanizing drugs to end their suffering more quickly? The suspicion is that many chose the latter course of action.

And medical decisions are just the tip of the iceberg. As we are all now being asked to isolate ourselves for the common good, many of us will find ourselves confronting similar, albeit less high stakes decisions. Which is more important: my duty to care for my elderly parents or my duty to protect them (and others) from potential transmission of disease? My duty to work to ensure that other people have the essential services they need or my duty to myself and my family to protect them from illness? We may not like to ask these questions, but we cannot avoid them.

But what are the answers? What should people do in cases like this? I don't know that I have much in the way of specific guidance to offer, but I do have a point that I think is worth making. It's at times like this that the essentially tragic nature of much moral decision-making reveals itself. This tragedy lurks in the background most of the time, but it is brought into sharp relief at times like this. Once we are aware of this ineluctable tragedy we might be inclined to change some of our common moral practices. We might be less inclined to blame others for the choices they make; and we might be more conscious of the pain of moral regret.

The info is here.

What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

K. Drabiak and J. Wolfson

AMA J Ethics. 2020;22(3):E221-231.
doi: 10.1001/amajethics.2020.221.

Abstract

Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics.

Fraud in Health Care

Growth in corporatization and profitization in medicine, insurance company payment rules, and government regulation have fed natural proclivities, even among physicians, to optimize profits and reimbursements (Florida Department of Health, oral communication, September 2019). According to the most recent Health Care Fraud and Abuse Control Program Annual Report, in one case a management company “pressured and incentivized” dentists to meet specific production goals through a system that disciplined “unproductive” dentists and awarded cash bonuses tied to the revenue from procedures—including many allegedly medically unnecessary services—they performed. This has come at a price: escalating costs, fraud and abuse, medically unnecessary services, adverse effects on patient safety, and physician burnout.

Breaking the cycle of bad behaviors that are induced in part by financial incentives speaks to core ethical issues in the practice of medicine that can be addressed through a combination of organizational and cultural enhancements and more transparent practice-based compliance and risk management systems that rely on front-end data analytics designed to identify, flag, and focus investigations on fraud and abuse at the practice site. Here, we discuss types of health care fraud and their impact on health care costs and patient safety, how this behavior is incentivized and justified within current and evolving medical practice settings, and a 2-pronged strategy for mitigating this behavior.

The info is here.