Research suggests physicians are concerned about becoming known as a tattler and losing referrals
By Marshall Allen
Propublica
Originally published November 12, 2013
Patients don’t always know when their doctor has made a medical error. But other doctors do.
A few years ago I called a Las Vegas surgeon because I had hospital data showing which of his peers had high rates of surgical injuries – things like removing a healthy kidney, accidentally puncturing a young girl’s aorta during an appendectomy and mistakenly removing part of a woman’s pancreas.
I wanted to see if he could help me investigate what happened. But the surgeon surprised me.
Before I could get a question out, he started rattling off the names of surgeons he considered the worst in town. He and his partners often had to correct their mistakes — “cleanup” surgeries, he said. He didn’t need a database to tell him which surgeons made the most mistakes.
The entire story is here.
Thanks to Gary Schoener for this article.
Showing posts with label Treatment Outcomes. Show all posts
Showing posts with label Treatment Outcomes. Show all posts
Friday, November 29, 2013
Wednesday, April 10, 2013
Viewpoint: We Need to Rethink Rehab
By David Sheff
Time
Originally published April 3, 2013
Here are some excerpts:
I’ve already written about my experience with Nic, but for my new book, Clean, I wanted to understand why so many suffer and die. So I undertook an investigation of the treatment system that so often fails. I learned that no one actually knows how often treatment works, but an oft-quoted number of those who abstain from using for a year after rehab is 30%. Even that figure is probably high. “The therapeutic community claims a 30% success rate, but they only count people who complete the program,” according to Joseph A. Califano Jr., the founder of the National Center on Addiction and Substance Abuse and former U.S. Secretary of Health, Education, and Welfare. “Seventy to eighty percent drop out in three to six months.” Over the course of my research, I did hear one statistic that I trusted. Father John Hardin, chair of board of trustees at St Anthony’s, a social services foundation with an addiction recovery program in San Francisco, told me, “Success for us is that a person hasn’t died.”
The treatment system fails because it’s rooted in an entrenched but inaccurate view that addicts are morally bereft and weak. If they weren’t, the belief goes, they’d stop using when drugs begin to negatively impact their lives. Most treatment centers in America are based on an archaic philosophy that’s rooted in the Twelve-Step model of recovery. Twelve-Step programs have saved countless lives, but they don’t work for a majority of people who try them. It’s not a fault in the program itself. Its founder, Bill Wilson, wrote, “These are but suggestions.” But many rehabs require them. This is particularly problematic for teenagers and young adults, the very people most susceptible to addiction. Twelve-Step programs require people to accept their powerlessness and turn their lives over to God or another higher power. Many adolescents question religion and in general teenagers aren’t going to turn their lives over to anyone.
In many of these Twelve-Step-based programs, patients are berated and yelled at if they don’t “surrender” and practice the steps. They’re warned — in some cases, threatened — that if they don’t they’ll relapse and die. It can become a self-fulfilling prophecy.
The entire story is here.
Time
Originally published April 3, 2013
Here are some excerpts:
I’ve already written about my experience with Nic, but for my new book, Clean, I wanted to understand why so many suffer and die. So I undertook an investigation of the treatment system that so often fails. I learned that no one actually knows how often treatment works, but an oft-quoted number of those who abstain from using for a year after rehab is 30%. Even that figure is probably high. “The therapeutic community claims a 30% success rate, but they only count people who complete the program,” according to Joseph A. Califano Jr., the founder of the National Center on Addiction and Substance Abuse and former U.S. Secretary of Health, Education, and Welfare. “Seventy to eighty percent drop out in three to six months.” Over the course of my research, I did hear one statistic that I trusted. Father John Hardin, chair of board of trustees at St Anthony’s, a social services foundation with an addiction recovery program in San Francisco, told me, “Success for us is that a person hasn’t died.”
The treatment system fails because it’s rooted in an entrenched but inaccurate view that addicts are morally bereft and weak. If they weren’t, the belief goes, they’d stop using when drugs begin to negatively impact their lives. Most treatment centers in America are based on an archaic philosophy that’s rooted in the Twelve-Step model of recovery. Twelve-Step programs have saved countless lives, but they don’t work for a majority of people who try them. It’s not a fault in the program itself. Its founder, Bill Wilson, wrote, “These are but suggestions.” But many rehabs require them. This is particularly problematic for teenagers and young adults, the very people most susceptible to addiction. Twelve-Step programs require people to accept their powerlessness and turn their lives over to God or another higher power. Many adolescents question religion and in general teenagers aren’t going to turn their lives over to anyone.
In many of these Twelve-Step-based programs, patients are berated and yelled at if they don’t “surrender” and practice the steps. They’re warned — in some cases, threatened — that if they don’t they’ll relapse and die. It can become a self-fulfilling prophecy.
The entire story is here.
Tuesday, April 9, 2013
A Texas Senate Bill Would Revise the State’s End-of-Life Procedure
By Becca Aaronson
The Texas Tribune/The New York Times
Originally published March 31, 2013
Texas lawmakers have grappled year after year over whether families or medical professionals should decide when to end a terminally ill patient’s life-sustaining care. This year, they seem closer to a compromise.
“If we were only making decisions based on medical facts, everything would be straightforward,” said Dr. Leigh Fredholm, the medical director of Seton palliative care at the University Medical Center Brackenridge in Austin. “But that’s not how we make decisions.” (Seton is a corporate sponsor of The Texas Tribune.)
State law allows physicians to discontinue treatment they deem medically futile. If a physician’s decision to end treatment contradicts the patient’s advance directive or the judgment of the patient’s surrogates, state law gives patients or their families 10 days to find another provider and appeal the doctor’s decision to a hospital ethics committee.
Advocacy groups that identify as “pro-life” say existing law does not go far enough to protect the interests of patients or their families. But they are divided on how legislators should change it. While support in the Legislature’s upper chamber seems to be coalescing around Senate Bill 303, which would tweak the process, some support bills that would bar doctors or hospital ethics committees from making the final decision to end treatment.
The entire story is here.
The Texas Tribune/The New York Times
Originally published March 31, 2013
Texas lawmakers have grappled year after year over whether families or medical professionals should decide when to end a terminally ill patient’s life-sustaining care. This year, they seem closer to a compromise.
“If we were only making decisions based on medical facts, everything would be straightforward,” said Dr. Leigh Fredholm, the medical director of Seton palliative care at the University Medical Center Brackenridge in Austin. “But that’s not how we make decisions.” (Seton is a corporate sponsor of The Texas Tribune.)
State law allows physicians to discontinue treatment they deem medically futile. If a physician’s decision to end treatment contradicts the patient’s advance directive or the judgment of the patient’s surrogates, state law gives patients or their families 10 days to find another provider and appeal the doctor’s decision to a hospital ethics committee.
Advocacy groups that identify as “pro-life” say existing law does not go far enough to protect the interests of patients or their families. But they are divided on how legislators should change it. While support in the Legislature’s upper chamber seems to be coalescing around Senate Bill 303, which would tweak the process, some support bills that would bar doctors or hospital ethics committees from making the final decision to end treatment.
The entire story is here.
Saturday, April 6, 2013
Looking for Evidence That Therapy Works
By Harriet Brown
The New York Times
Originally posted on March 25, 2013
Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.” Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.
The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.
C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.
Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called “therapist drift.”
The entire story is here.
The New York Times
Originally posted on March 25, 2013
Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.” Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.
The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.
C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.
Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called “therapist drift.”
The entire story is here.
Friday, April 5, 2013
Do Antipsychotics Worsen Long-term Schizophrenia Outcomes?
By Robert Whitaker
Mad in America Blog
Originally published March 26, 2013
Martin Harrow and Thomas Jobe have a new article coming out in Schizophrenia Bulletin that I wish would be read by everyone in our society with an interest in mental health. Harrow and Jobe, who conducted the best study of long-term schizophrenia outcomes that has ever been done, do not present new data in this article, but rather discuss the central question raised by their research: Does long-term treatment of schizophrenia with antipsychotic medications facilitate recovery? Or does it hinder it?
This is a paper that needs to be widely known. I wish every psychiatrist in the country would read it, and I wish that it would be widely discussed in the media too.
Now, Harrow’s study produced findings that belied common wisdom. He and Jobe followed schizophrenia patients for 20 years, and those who got off antipsychotics, as a group, had much better outcomes. Over the long term, they were much more likely to be recovered, much more likely to work; they were much less likely to be experiencing psychotic symptoms; and they had better cognitive function and they were much less anxious. So how can you square that finding with research showing that when patients are withdrawn from antipsychotic medications, they relapse at a much higher rate? That is the evidence for long-term use of antipsychotics, and here is what Harrow and Jobe write: “We view the results from these discontinuation studies as involving a paradox.”
Within six to 10 months following discontinuation, they write, 25% to 55% of schizophrenia patients withdrawn from their medications relapse. But, they note, “relapse rates are considerably lower subsequently in discontinued schizophrenia patients who remain stable during these 6-10 months,” and that “patients with schizophrenia not on antipsychotics for a prolonged period do not show this tendency to relapse when they remain unmedicated.”
So the puzzle is this: Why is there such a high relapse rate in the immediate months following withdrawal, compared to the relapse rate when patients “remain unmedicated” after this initial discontinuation period?
The entire blog post is here.
Mad in America Blog
Originally published March 26, 2013
Martin Harrow and Thomas Jobe have a new article coming out in Schizophrenia Bulletin that I wish would be read by everyone in our society with an interest in mental health. Harrow and Jobe, who conducted the best study of long-term schizophrenia outcomes that has ever been done, do not present new data in this article, but rather discuss the central question raised by their research: Does long-term treatment of schizophrenia with antipsychotic medications facilitate recovery? Or does it hinder it?
This is a paper that needs to be widely known. I wish every psychiatrist in the country would read it, and I wish that it would be widely discussed in the media too.
Now, Harrow’s study produced findings that belied common wisdom. He and Jobe followed schizophrenia patients for 20 years, and those who got off antipsychotics, as a group, had much better outcomes. Over the long term, they were much more likely to be recovered, much more likely to work; they were much less likely to be experiencing psychotic symptoms; and they had better cognitive function and they were much less anxious. So how can you square that finding with research showing that when patients are withdrawn from antipsychotic medications, they relapse at a much higher rate? That is the evidence for long-term use of antipsychotics, and here is what Harrow and Jobe write: “We view the results from these discontinuation studies as involving a paradox.”
Within six to 10 months following discontinuation, they write, 25% to 55% of schizophrenia patients withdrawn from their medications relapse. But, they note, “relapse rates are considerably lower subsequently in discontinued schizophrenia patients who remain stable during these 6-10 months,” and that “patients with schizophrenia not on antipsychotics for a prolonged period do not show this tendency to relapse when they remain unmedicated.”
So the puzzle is this: Why is there such a high relapse rate in the immediate months following withdrawal, compared to the relapse rate when patients “remain unmedicated” after this initial discontinuation period?
The entire blog post is here.
Wednesday, April 3, 2013
Is It Ethical For Doctors To Prescribe Placebo?
By Alice Walton
Forbes
Originally published on March 22, 2013
A new British study out in the journal PLOS ONE is stirring up a lot of debate, as it gives some estimates on the number of doctors who are giving patients placebo to treat their various conditions. It finds that a resounding 97% of the 783 doctors surveyed admitted to giving patients some sort of placebo in their practice. But it would be misleading to say that doctors are giving patients sugar pills or saline injections at the drop of a hat – there are different kinds of placebos, and, as the survey found, doctors have different feelings about when each should be used. Not surprisingly, so does the public.
“Pure” placebos are indeed sugar pills or saline injections with no therapeutic value (aside from that stemming from the psychological effects – more on this later). This “pure” variety was used by about 12% of the general practitioners at some time in their careers. Among these doctors, there were various motivations, including the wish to generate psychological treatment effects, to calm patients, to appease patients’ wish for a treatment, and to treat “non-specific complaints.” Half the doctors only told their patients something vaguely promising, like “this therapy has helped many other patients.” About 25% told their patients that the treatment “promoted self-healing,” and less than 10% revealed that the treatment was actually placebo.
“Impure” placebos, on the other hand, are therapies for which there is no strong evidence that they work for a given problem – for instance, the use of antibiotics to treat a virus, off-label uses of medications, or probiotics for diarrhea. Impure placebos also include lab tests or physical exams that are given simply in order to reassure patients. This type of placebo was much more common, with 97% of doctors reporting their use at least once across their career, and 77% reporting “frequent” use, i.e., at least once per week.
The entire story is here.
The entire study, Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners, is here.
Forbes
Originally published on March 22, 2013
A new British study out in the journal PLOS ONE is stirring up a lot of debate, as it gives some estimates on the number of doctors who are giving patients placebo to treat their various conditions. It finds that a resounding 97% of the 783 doctors surveyed admitted to giving patients some sort of placebo in their practice. But it would be misleading to say that doctors are giving patients sugar pills or saline injections at the drop of a hat – there are different kinds of placebos, and, as the survey found, doctors have different feelings about when each should be used. Not surprisingly, so does the public.
“Pure” placebos are indeed sugar pills or saline injections with no therapeutic value (aside from that stemming from the psychological effects – more on this later). This “pure” variety was used by about 12% of the general practitioners at some time in their careers. Among these doctors, there were various motivations, including the wish to generate psychological treatment effects, to calm patients, to appease patients’ wish for a treatment, and to treat “non-specific complaints.” Half the doctors only told their patients something vaguely promising, like “this therapy has helped many other patients.” About 25% told their patients that the treatment “promoted self-healing,” and less than 10% revealed that the treatment was actually placebo.
“Impure” placebos, on the other hand, are therapies for which there is no strong evidence that they work for a given problem – for instance, the use of antibiotics to treat a virus, off-label uses of medications, or probiotics for diarrhea. Impure placebos also include lab tests or physical exams that are given simply in order to reassure patients. This type of placebo was much more common, with 97% of doctors reporting their use at least once across their career, and 77% reporting “frequent” use, i.e., at least once per week.
The entire story is here.
The entire study, Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners, is here.
Wednesday, February 13, 2013
If Medications Don’t Work, Why Do I Prescribe Them Anyway?
By Steve Balt, Psychiatrist
Thought Broadcast Blog
Originally posted January 4, 2013
I have a confession to make. I don’t think what I do each day makes any sense.
Perhaps I should explain myself. Six months ago, I started my own private psychiatry practice. I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions. I figured that an independent practice would permit me to be a more effective psychiatrist, as I wouldn’t be encumbered by the restrictions and regulations of most of today’s practice settings.
My experience has strengthened my long-held belief that people are far more complicated than diagnoses or “chemical imbalances”—something I’ve written about on this blog and with which most psychiatrists would agree. But I’ve also made an observation that seems incompatible with one of the central dogmas of psychiatry. To put it bluntly, I’m not sure that psychiatric medications work.
Before you jump to the conclusion that I’m just another disgruntled, anti-medication psychiatrist who thinks we’ve all been bought and misled by the pharmaceutical industry, please wait. The issue here is, to me, a deeper one than saying that we drug people who request a pill for every ill. In fact, it might even be a stretch to say that medications never work. I’ve seen antidepressants, antipsychotics, mood stabilizers, and even interventions like ECT give results that are actually quite miraculous.
But here’s my concern: For the vast majority of my patients, when a medication “works,” there are numerous other potential explanations, and a simple discussion may reveal multiple other hypotheses for the clinical response. And when you consider the fact that no two people “benefit” in quite the same way from the same drug, it becomes even harder to say what’s really going on. There’s nothing scientific about this process whatsoever.
And then, of course, there are the patients who just don’t respond at all. This happens so frequently I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me. But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use proper doses, and I wait long enough to see a response. My training is up-to-date; I’ve even been invited to lecture at national conferences about psychiatric meds. I can’t be that bad at psychiatry, can I?
The entire blog post is here.
Thought Broadcast Blog
Originally posted January 4, 2013
I have a confession to make. I don’t think what I do each day makes any sense.
Perhaps I should explain myself. Six months ago, I started my own private psychiatry practice. I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions. I figured that an independent practice would permit me to be a more effective psychiatrist, as I wouldn’t be encumbered by the restrictions and regulations of most of today’s practice settings.
My experience has strengthened my long-held belief that people are far more complicated than diagnoses or “chemical imbalances”—something I’ve written about on this blog and with which most psychiatrists would agree. But I’ve also made an observation that seems incompatible with one of the central dogmas of psychiatry. To put it bluntly, I’m not sure that psychiatric medications work.
Before you jump to the conclusion that I’m just another disgruntled, anti-medication psychiatrist who thinks we’ve all been bought and misled by the pharmaceutical industry, please wait. The issue here is, to me, a deeper one than saying that we drug people who request a pill for every ill. In fact, it might even be a stretch to say that medications never work. I’ve seen antidepressants, antipsychotics, mood stabilizers, and even interventions like ECT give results that are actually quite miraculous.
But here’s my concern: For the vast majority of my patients, when a medication “works,” there are numerous other potential explanations, and a simple discussion may reveal multiple other hypotheses for the clinical response. And when you consider the fact that no two people “benefit” in quite the same way from the same drug, it becomes even harder to say what’s really going on. There’s nothing scientific about this process whatsoever.
And then, of course, there are the patients who just don’t respond at all. This happens so frequently I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me. But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use proper doses, and I wait long enough to see a response. My training is up-to-date; I’ve even been invited to lecture at national conferences about psychiatric meds. I can’t be that bad at psychiatry, can I?
The entire blog post is here.
Sunday, December 4, 2011
Statement of the American Psychological Association on the DSM-5 Development Process
There are a variety of posts on this blog highlighting concerns about DSM-5. APA published this press release on December 2, 2011.
Press Release
WASHINGTON—Diagnostic classification systems of disorders and diseases are an integral part of health care delivery. Any such system, including the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association and the pending revision of the International Classification of Diseases (ICD-11) of the World Health Organization, must be based on the best available science and serve the public interest.
The American Psychological Association has members with significant expertise in the scientific areas relevant to the DSM, and we have urged them to take part in the DSM revision efforts. We are encouraged that many psychologists are making meaningful contributions to the process as individuals, as members of the DSM-5 Task Force and work groups, and through the divisions of the American Psychological Association. This involvement includes offering comments on draft provisions and participating in field trials.
We applaud the Society for Humanistic Psychology (Division 32 of our association) for its leadership role in generating dialogue and information-sharing within the broader mental health community concerning the revisions process. The Society also has prepared, disseminated, and garnered wide support for an "open letter" to the DSM-5 Task Force and the American Psychiatric Association, which expresses specific concerns related to the DSM-5 development process.
We share their belief that the purpose of any diagnostic classification system should be to improve treatment outcomes. Thus it is essential to consider the impact of any new diagnostic system or category on vulnerable individuals, groups and populations, particularly children, older adults, and ethnic minorities. By appropriately identifying individuals in need of treatment, it is possible to both safeguard the welfare of individuals and to direct treatment resources where they are most needed. Concerns also have been raised that over-identification or misidentification of individuals as being in need of treatment could lead to the use of unnecessary and potentially harmful interventions.
The American Psychological Association recognizes that there is a diversity of opinion concerning the ongoing DSM-5 development process. Our association has not adopted an official position on the proposed revision; rather, we have called upon the DSM-5 Task Force to adhere to an open, transparent process based on the best available science and in the best interest of the public. In this regard, we appreciate the Task Force's expressed commitment to seriously consider the issues and concerns raised by experts in the mental health field in their deliberations.
We call upon our members (either as individuals or groups) to continue to add their perspectives to enhance the validity and clinical utility of the DSM-5. The American Psychological Association will continue to monitor the revision process and be a strong voice for its transparency.
The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists. APA's membership includes more than 154,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.
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