Thursday, October 2, 2014

I'm moving off health care for this post.  Sorry to those who object, but sometimes other topics (beyond soccer!) raise issues that I like to explore with you. This one is particularly appropriate as many of us enter into a special weekend, comprising both Yom Kippur and Eid-al-Adha.  Read on if you'd like.

If you're like me, a non-Muslim living in a world in which there is a lot of news about people of that religion, it can be confusing to separate the practice of the religion from the political and nationalistic contexts in which we often view it.  Ali Asani, Professor of Indo-Muslim and Islamic Religion and Cultures, gave a short lecture this week at Harvard that I found very helpful.  It was called, The Importance of Fostering Religious Literacy: The case of Muslims in the US.”

Ali started with a provocative slide, with the simple words, "Why do they hate us?" He explained that he had often heard this sentiment from non-Muslim Americans about Muslims in the rest of the world.  He then pointed out that he had heard exactly the same question from Muslims around the world about Americans!  Clearly, there is a lack of understanding going on, and he spent most of his talk addressing the reason, which he termed religious illiteracy.

He pointed out that there is global illiteracy about religion and culture.  This results in an inability to engage with the differences between us because we have a lack of tools to understand the differences.  Mutual stereotyping exists, and then ignorance means that encounters between groups ironically leads to more polarization.

He referred to Diane Moore and her book Overcoming Religious Illiteracy and presented some of her main points as follows:

Ali listed some manifestations of religious illiteracy:

1)  Equation of religion with devotional practice, rites, rituals, and ceremonies.
2)  The essence of religion is perceived as located in sacred texts.
3)  Religious traditions are seen as timeless and unchanging and monolithic. (In contrast, there is a huge extent of diversity within Islam.)
4 ) Religions are seen as actors having agency; i.e., there is a tendency to personify religion, but it's just a construct, not a being.
5) The use of religion as the exclusive lens to explain the actions of an individual or a community.
6) An entire religious community is held responsible for the actions of an individual.

He then expanded on Moore's conclusions and pointed to the dangers of religious illiteracy as leading to stereotypes and dehumanization, accompanied by less respect for diversity.  Such illiteracy can also be exploited by ideologues to promote extremism and fundamentalism.  Finally, he noted that democracy cannot function if one is ignorant and afraid of one's neighbors.

In closing he urged the audience to help educate themselves and others to differentiate between devotional expression and the study of religion; to consider religions as internally diverse as opposed to uniform; to consider religion as evolving and and changing, as opposed to being ahistorical and static; and to see religious influences as being embedded in all dimensions of culture, as opposed to the assumption that religions function in discrete, isolated, "private" separable contexts.

In summary, there was plenty of food for thought from a thoughtful man who would like us to be able to celebrate our differences rather than be fearful of them.

L'shana tovah and Eid mubarak!
While I appreciate the efforts of Defense Secretary Chuck Hagel to improve the quality of care in the Military Health System, his order directing "all health care facilities identified as outliers in categories of access, quality and safety to provide action plans for improvement within 45 days" is ill conceived.

Sure, they'll come up with plans.  After all, they have to follow orders.  But everyone working in health care facilities understands that the work processes in place in hospitals and clinics have developed over many years. Bolting on changes will not change underlying systemic problems, and may even make them worse.

The plans that will be put forward will likely make short-term incremental improvements, but then things will fall back to old (or new) levels of dysfunction after a few months.

Mr. Hagel is absolutely correct that “Our men and women in uniform and their families deserve the finest health care in the world.”  But long-term process improvement does not come from rushing to put a plan together, especially when it comes from the top down.  The Secretary might take a hint from the nuclear Navy, where principles of front-line engagement in support of process improvement have been in place for decades.
"How could it happen?" is the question everyone's asking.

No, not the guy who walked into the White House past the Secret Service.

The nurse who asked the question.  CNN reports:

The first person to be diagnosed with Ebola on American soil went to the emergency room last week, but was released from the hospital even though he told staff he had traveled from Liberia.

Hospital officials have acknowledged that the patient's travel history wasn't "fully communicated" to doctors, but also said in a statement Wednesday that based on his symptoms, there was no reason to admit him when he first came to the emergency room last Thursday night.

A nurse asked the patient about his recent travels while he was in the emergency room, and the patient said he had been in Africa, said Dr. Mark Lester, executive vice president of Texas Health Resources. But that information was not "fully communicated" to the medical team, Lester said.

The man underwent basic blood tests, but not an Ebola screening, and was sent home with antibiotics, said Dr. Edward Goodman with Texas Health Presbyterian Hospital.

Three days later, the man returned to the facility, where it was determined that he probably had Ebola. He was then isolated.

There are probably several reasons. The simplest one, "the nurse messed," up might be correct, but it is also likely to be incomplete.  If a full-scale root cause analysis were conducted, we'd probably learn about any of the following: a lack of training of front-line clinical staff with regard to this disease, a series of protocols that are not attuned to this new and rare disease, and/or habitual poor communication between the triage staff and others.

Let's hope the country learns from this experience.  That's a most important task for the CDC to focus on right now.

Think how powerful a teaching tool this would be: If the nurse and MDs at Texas Health produced a 7-minute YouTube video of what went wrong and how they've changed their protocols.  That would go, er, viral within hours.
Continuing our series on the CMS Open Payments database, I offer this chart prepared by Walid Gellad, and posted on Twitter at @walidgellad, summarizing the payments made from Intuitive Surgical to doctors and hospitals for five months in 2103.  Gellad describes himself as "Primary care physician. Health services research. Co-direct Pitt Center for Pharmaceutical Policy & Prescribing. Opinions my own."  Here's his bio.

Striking to me, as I noted below, is the number of payments and amount (over $2 million) made for "education," i.e., paying doctors to attend training sessions on the use of the daVinci robotic surgery equipment.

Wednesday, October 1, 2014

In my post below, I offer some information about payments made nationally by Intuitive Surgery to hospitals and doctors to support the extended use of the daVinci surgical robot.  Here, I take a look at some local examples.  As I searched through the Massachusetts listings, two names popped out as repeated recipients of cash or in-kind payments and services in amounts exceeding $2500:

Jeffrey Spillane,  Southeastern Surgical Associates, in Hyannis, who operates at Cape Cod Hospital; and James Hermenegildo, Truesdale Surgical Associates, in Fall River, who operates at Charleton Memorial and St. Anne's Hospital.

Dr. Spillane is credited as "the first thoracic surgeon to bring Robotic Assisted Thoracic surgery to Cape Cod." His practice website lists the following promotional article in the local newspaper: "A da Vinci for the modern age," Cape Cod Times.  Further, his page at SSA leads patients to this Southeastern Robotic Surgery Web Site and also to watch this Intuitive Surgical-produced video.

For the five months of 2013 data so far reported by CMS, Dr. Spillane is listed as receiving five payments of $3000 or $3500 from Intuitive for "education" along with payments $150 or $300 for food and beverage on the same dates.

Dr. Hermenegildo is credited by Southcoast Health System with introducing robotic single site surgery for gall bladder removal to the geographical area south of Boston.  (I have written about doubts that are raised by Intuitive's hope to expand the daVinci's reach into cholecystectomies.)

This surgeon's reported payments for the five months include three of $2500 each for education, six payments of $500 each for education, and two payments of $150 for food and beverage.

I don't know much about the Intuitive Surgical training program, but I am surmising that personal attendance at educational events provides doctors with the $2500-$3500 fee (along with meals), and perhaps the online modules offer a $500 fee.  Whatever those details, I don't see why it is appropriate for doctors to be paid for education programs by equipment manufacturers.

But, at this point, the issue is not about my opinion.  Neither does this post have anything to do with the technical competence of these doctors, which I assume is at the highest levels.  Instead, the CMS report raises a different type of issue, one at the heart of the doctor-patient relationship. Trust.

In sum, the most important questions can only be answered by patients being served by these two doctors and the thousands of others listed in the Open Payments database:  "Have you been informed that the manufacturer of equipment that is used in one of three possible approaches to your surgery has made payments to your doctor? Do you have any concerns as to whether your doctor's clinical approach to your care might be influenced by the (now reported) financial relationship with this manufacturer?"
It's been a long time since I wrote about the extremely close relationship between the University of Illinois Chicago, its surgical faculty, and Intuitive Surgical, the manufacturer of the daVinci robot.  I am drawn to do so again by the publication yesterday by CMS of the Open Payments database, showing payments from manufacturers to doctors and hospitals.  The presentation demonstrates the remarkable number of payments ISRG has made throughout the country in support of its robotic surgery devices. UIC is just one of many beneficiaries.

As noted by Charles Ornstein at Pro Publica, though, this database is by no means complete. He points out:

* The data doesn’t cover all payments.
The Physician Payment Sunshine Act, part of the 2010 Affordable Care Act, called for the first public release of this data 18 months ago. But because of delays writing detailed rules implementing the law, the first release of data will happen today and it will only cover payments for a few months, from August to December 2013.

* By design, some data on research payments won't be included.
The Sunshine Act allows drug and device companies to delay the publication of data related to research of new products or, in some cases, new uses for existing products. The payments won't be made public until the product is approved by the Food and Drug Administration, or four calendar years after the payment was made, whichever comes first. It is unclear how much money is involved, but, again, just because a doctor doesn't show up as receiving a research payment doesn't mean he or she hasn't received one.

* Because of errors, additional data isn't being released.
CMS has acknowledged that one third of the payment records submitted by companies for last year had data problems that could lead to cases of mistaken identity. The names associated with those payments won't be released today. Federal officials are asking companies to recheck the data, which should be released publicly next year.

With these limitations is mind, I went to the database and filtered the entries by name of company--Intuitive Surgical--and there are thousands of entries.  I then ranked them in descending order.  Most recipients were hospitals, but some were individuals.

Many doctors and hospital received payments for "education"  or "services other than consulting, including serving as faculty or speaker at venues other than a continuing education program."  One of the top recipients in these categories is the University of California, with a total exceeding $600,000.  There were some large items, $175,000 and $100,000; but most of the 79 entries were in the range of $3000 to $6000 payments.

No doubt it is coincidental that the surgery department at UC Davis presents this website parroting unsupported assertions about robotic surgery's benefits to patients.

Another is Houston's Methodist Hospital, which received over $200,000 in the "education" category.

Again from their website, we see the misleading comparison of robotic surgery to open surgery, but no mention of the relative value of manual laparoscopic surgery.

In all, there are almost 17,000 payments from ISRG from this five-month period.  Some are pennies for reimbursements, but almost 1600 are in the range of $2000 to $10,000.  Where are the recipients?  Baltimore, Philadelphia, Tampa, Atlanta, Phoenix, Miami, New York, Loveland, Reno, Newark, Kissimmee, Lansing, Austin, Orlando, Basking Ridge, Greenville, Owensboro, Detroit, Brooklyn, Ypsilanti, Kirland, Menomee Falls, Mt. Clemens, Hialeah, Bemidji, Tulsa, Blue Ash, Sarasota, Patchogue, Jackson, Plains, Cincinnati, Columbus, Jonesboro, Oklahoma City, Novi, Minneapolis, Shelby Township, Pittsburgh, Eau Claire, Green Bay, Denver, Appleton, Jupiter, Kansas City, Las Vegas, Gainesville, Wausau, Rochester, North Little Rock, Milwaukee, and dozens more.

In the old days of politics, we would have called this "walking around money," sprinkling beneficence to engender widespread support and loyalty.

Let's get back to Illinois.  Right near the top of the CMS list was the UIC's Pier Giulianotti.  According to CMS, he received two payments of $50,000 each in cash or cash equivalents as "grants" for the Clinical Robotic Surgery Association.  What's that?  According to its website, it is a "new society devoted to the minimally invasive robotic surgery." It is registered as a not-for-profit corporation.

I couldn't find any mention of Intuitive Surgical financial support on the website, even in Dr. Giulianotti's welcoming letter, but I did find a number of testimonials for the organization from UIC faculty members.  You might remember some of these people from the full page New York Times Magazine advertisement in which the University allowed its name and reputation to be used in support of Intuitive Surgical.

Here's one person from the ad:

Robotic surgery is a constantly evolving field, CRSA website is an invaluable tool to stay up to date.  The platform is easily navigable and is very practical. Information shared on the website includes basic procedures and more complex ones making the site of unique interest for beginners and for expert robotic surgeons. The possibility to assist to entire procedures during the live events is a formidable educational  opportunity to learn from the masters without the need to travel. It's amazing to see how such a large group of surgeons from all over the world is open to share their experiences and work as a group to improve the quality of care and the quality of Surgery.
Francesco Bianco, MD, Assistant professor of Surgery
Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago.

Here's another:

The CRSA represents a common ground where pioneers of robotic surgery coming from various subspecialties work side by side with young, ambitious and promising robotic surgeons. This synergism has created a dynamic and exciting surgical community where masters of robotic surgery share on a daily basis their terrific experience in the operative theater with innovative ideas brought in by young, brilliant individuals that have the potential to be the next generation of robotic surgery innovators.

The website of the association is clearly in line with these traits as it offers a tremendous amount (835 and the number increases each month) of advanced robotic surgery videos presented in a modern looking and easy to navigate internet frame.

CRSA represents for me the ideal place to cultivate and share my passion for robotic surgery and innovation and to provide my contribution for the advancement of the field and therefore I strongly and unconditionally support this association.
Antonio Gangemi, MD, FACS, Assistant Professor of Surgery
Division of General, Minimally Invasive and Robotic Surgery University of Illinois at Chicago, IL, USA.

And another:

Having the opportunity to share the experience from international surgeons has an incredible value for our clinical and research practices. The CRSA website allows surgeons to be connected and integrated allowing to share experiences in difficlut cases.

CRSA has more than 800 videos about diverse robotic procedures, I dont know of any other portal so complete and diverse. Direct communication with other robotic surgeons dealing with similar problems is a powerful advantage of the portal as well.

For any robotic surgeon , experienced or begginer CRSA portal gives extensive material , comments and opinions that improve their clinical experience. CRSA website is also an important communication channel to be informed about upcoming meetings, trainig courses and news of the robotic world. I highly recommend the CRSA website to any surgeon around the world who wants to start a robotic practice.
Enrique Elli, MD, Assistant Professor of Surgery, Associate Director of Bariatric Surgery
Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago.

Tuesday, September 30, 2014

First it was prostate removals, then it was hysterectomies, then it was gall bladder removals, and now (tah dah!), Intutive Surgical offers robotic hernia surgery.  Again, another procedure that is already offered at low cost and with excellent results.

Please watch over the coming days as people start to correlate the names of surgeons who have endorsed these "advances" with payments from this company.
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