Sunday, October 15, 2017

The American Health System is Shameful

Steve Grocott
Steve Grocott, Political insider /investor / businessman

Saturday, October 14, 2017

The Revised Declaration of Geneva: The Modern-Day Physician’s Pledge

A newly revised version of the Declaration of Geneva was adopted by the World Medical Association (WMA) General Assembly on October 14, 2017, in Chicago.

As the contemporary successor to the 2500-year-old Hippocratic Oath, the Declaration of Geneva, which was adopted by the World Medical Association (WMA) at its second General Assembly in 1948,1 outlines in concise terms the professional duties of physicians and affirms the ethical principles of the global medical profession. The current version of the Declaration, which had to this point been amended only minimally in the nearly 70 years since its adoption, addresses a number of key ethical parameters relating to the patient-physician relationship, medical confidentiality, respect for teachers and colleagues, and other issues. A newly revised version adopted by the WMA General Assembly on October 14, 2017, includes several important changes and additions (Supplement).
  • I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
  • THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
  • I WILL RESPECT the autonomy and dignity of my patient;
  • I WILL MAINTAIN the utmost respect for human life;
  • I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
  • I WILL RESPECT the secrets that are confided in me, even after the patient has died;
  • I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
  • I WILL FOSTER the honour and noble traditions of the medical profession;
  • I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
  • I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
  • I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
  • I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
  • I MAKE THESE PROMISES solemnly, freely, and upon my honour.
For 2500 years The Hippocratic Oath has been referenced as the 'gold standard' of medical ethics.  


I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Ethical Principles for Medical Research

The Revised Declaration of Geneva: The Modern-Day Physician’s Pledge | Law and Medicine | JAMA | The JAMA Network

Wednesday, October 11, 2017

Predict Asthma Conditions using an App

Propeller launches API that predicts local asthma conditions

“Smart inhaler” player Propeller Health is rolling out an application programming interface (API) that provides information on local asthma conditions.
The service, dubbed Air, uses machine learning to analyze millions of days of anonymized asthma-related data to forecast the potential effects of the local environment on people’s breathing, Propeller said in a statement. These data include when people have asthma symptoms and the environmental conditions at the locations and times they have symptoms.
Propeller markets a sensor that attaches to an inhaler and tracks where a patient uses his or her inhaler. The sensor then transmits this data via Bluetooth to a smartphone, where an app analyzes where, when and why a patient took his or her medication.

GlaxoSmithKline and Propeller Health are expanding their R&D partnership, inked in 2015, into a commercial one, under which both companies will be able to commercialize Propeller’s digital respiratory health management system for use with Glaxo’s Ellipta inhaler.
Propeller’s platform includes a sensor that attaches to various inhalers and tracks when patients take their medication. These data are sent via Bluetooth to a smartphone app, which uses machine learning to help patients and physicians better understand what may be causing asthma or COPD symptoms.
In December 2015, Propeller signed on to create a custom sensor for GSK’s Ellipta inhaler, to be used in clinical studies of asthma and COPD. A year later, the company notched an FDA clearance for the use of its platform with Ellipta, its eighth FDA clearance.

"We are excited to be working closely with GSK to make the sensor for the Ellipta inhaler available in our commercial programs, and for the first time, as part of commercial pilots with GSK outside the US," said Propeller CEO David Van Sickle in a statement. "Companion digital experiences simplify and personalize the management of chronic respiratory disease, and help ensure individuals and their physicians realize the benefits of inhaled medicines."

Revolutionizing the Delivery of Care for ED Patients

In the 7 years since the passage of the Affordable Care Act, the number of Emergency Department (ED) visits has steadily increased while the number of EDs has fallen —  resulting in increased pressure on hospitals. Consequently, health care systems find themselves challenged to develop innovative ways of accommodating this growing volume while still providing high-quality and efficient medical care. The surge in smartphone use, combined with the advancement of provider-focused telehealth capabilities, has created an opportunity for systems to leverage technology in service of these goals. Today, the American Telemedicine Association reports that there are currently 200 active telemedicine networks, with over half of U.S. hospitals now using some form of telemedicine.

This is the context in which NewYork-Presbyterian (NYP) and Weill Cornell Medicine jointly launched their cutting-edge Emergency Department Telehealth Express Care Service (ECS). This innovative program has enabled us to provide a much better experience for low-acuity patients presenting to the EDs at NewYork-Presbyterian/Weill Cornell Medical Center and NewYork-Presbyterian/Lower Manhattan Hospital. Building upon this success, NYP has recently expanded ECS to the Columbia-affiliated NewYork-Presbyterian/Columbia University Medical Center and NewYork-Presbyterian/Allen Hospital campuses, and similar expansions at the NYP regional hospitals are expected in the coming months.

NYP OnDemand ED Express Care Service
This was the context in which we conceived and launched the ED Telehealth Express Care Service for low-acuity patients presenting to the ED. To operationalize this program, we first identified the conditions that would be amenable to treatment via telehealth, including minor rashes, sprains and contusions, upper respiratory infections, wound checks, suture removals, and tetanus immunizations. Next, we developed our workflow: after an initial RN triage and medical screening exam by a physician assistant or nurse practitioner, qualifying ED patients are offered a real-time video visit with one of our board-certified Emergency Medicine faculty physicians.

This ECS consultation is conducted in a private patient room with comfortable lounge chairs and a monitor, and the patient is connected to a physician located in a separate room. Patients are interviewed by the physicians remotely while they are in the private room and then directly discharged from the room. Discharge paperwork is printed directly in the room and prescriptions are called in electronically to the patient’s pharmacy. Importantly, the remote physician covers both Express Care sites, offering us economies of scale by having a single “server” for multiple queues.

This has been a pilot program at NYP and is undergoing evaluation for effectiveness, cost and reimbursement issues.  At this time the visit is billed as an ED event, which reimburses greater than a telemedicine or office visit.

This usage of telehealth is a unique application of telemedicine.  A single telehealth physician could evaluate patients from many different EDs.

Tuesday, October 10, 2017

The Future of the Neurologic Examination | Medical Education and Training | JAMA Neurology | The JAMA Network

Has the development of high tech obsoleted the neurologic physical examination?  

Michael J. Aminoff, MD, DSc, FRCP1
JAMA Neurol. Published online October 2, 2017. doi:10.1001/jamaneurol.2017.2500

The development of precision medicine, gene therapies, advanced imaging techniques, novel monitoring systems, ingestible or injectable sensors, and remote medical care (telemedicine) is leading to remarkable changes in health care. But the increasing ability to deliver care remotely will also reduce physical interactions between physicians and patients, with implications that have barely been explored.

There is no doubt that the art of the neurologic examination is already being lost, as some of these advances come to supplant rather than complement the clinical examination. Indeed, the modern trainee neurologist can perhaps be pardoned for wondering about the place of the clinical examination when, for example, magnetic resonance imaging or computed tomography can detect, localize, and provide prognostic information about a central lesion in just a few minutes and genetic studies can diagnose certain disorders regardless of the clinical findings. The neurologic examination requires time, patience, effort, and expertise and may have to be performed in difficult or unpleasant circumstances, whereas an imaging or laboratory study simply requires completion of a request form and the responsibility is passed to a colleague. Why, then, examine the patient?

This gradual technical change will cause a paradigm shift for authorization of high cost imaging studies which have for to with required an A-OK from insurance companies. It makes sense when it comes to accuracy and the speed of correct diagnosis.
Implantable Vagus Nerve Stimulation for Epilepsy
This is also true of other organ systems, where imaging and/or genetic testing are used.

The Future of the Neurologic Examination | Medical Education and Training | JAMA Neurology | The JAMA Network

Public Health Issue: Epidemics, blame the Smartphone

I resisted buying a smartphone until about two years ago.  All my sons have had them for 10 years or more.  No they did not have them when they were three or four.  My eldest son bought an iPhone when he was 18.  ( I couldn't afford one, with 3 in college.

My first was a prepaid LG which was a month to month...These phones are all cheaply made, with poor screens, inadequate memory and other issues I do not fathom. I found one for $125 with a monthly fee of $45.00 The idea of having a contract appealed less to me than paying  $125 dollars or more for a 'bundled cable/internet/phone service.  

By now my brother had an iPhone, Macbook and iMac.  My son had traded up twice with his iPhone and also a Macbook. Two of my sons are computer scientists . I cautioned them about the technical of DUI (of smartphones).I doubt they listen to me.  It is equivalent to having 2 or 3 alcoholic drinks or having an open bottle in the car.

Suggestions for safer us of your smartphone

The smartphone has insidiously crept into our lives, much like antibiotic resistant bacteria. It can be found in our toilet areas, and other private spaces. No longer do hormonally gifted girls and boys flirt with a wink, they can do it electronically or even more boldly with suggestive photos. How does one use "protection" in such a situation?

Like any opiod it soothes and eases pain and eventually is an addiction. The temptation was too great   I caved, at first trying an was not so great !. I opted for the latest greatest most expensive Galaxy S8+.   Then I perseverated over cases and protectors.!  Another story and not worth explaining here to my entrapped audience.

Along with my own opinions I found several articles written about the subject. Andrew Doan, M.D., PhD in neuroscience and fellow ophthalmologist has done research into video game and internet addiction, discussing the role of endorphin release in users of videogames and the like.

Associated literature (from PubMed)

Tendon rupture associated with excessive smartphone gaming.



Excessive use of smartphones has been associated with injuries.


A 29-year-old, right hand-dominant man presented with chronic left thumb pain and loss of active motion from playing a Match-3 puzzle video game on his smartphone all day for 6 to 8 weeks. On physical examination, the left extensor pollicis longus tendon was not palpable, and no tendon motion was noted with wrist tenodesis. The thumb metacarpophalangeal range of motion was 10° to 80°, and thumb interphalangeal range of motion was 30° to 70°. The clinical diagnosis was rupture of the left extensor pollicis longus tendon. The patient subsequently underwent an extensor indicis proprius (1 of 2 tendons that extend the index finger) to extensor pollicis longus tendon transfer. During surgery, rupture of the extensor pollicis longus tendon was seen between the metacarpophalangeal and wrist joints.


The potential for video games to reduce pain perception raises clinical and social considerations about excessive use, abuse, and addiction. Future research should consider whether pain reduction is a reason some individuals play video games excessively, manifest addiction, or sustain injuries associated with video gaming.

Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports.


Traditional factors that once explained men's sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brain's motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography's unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use. In the interim, a simple diagnostic protocol for assessing patients with porn-induced sexual dysfunction is put forth.

Excessive Video Game Use, Sleep Deprivation, and Poor Work Performance Among U.S. Marines Treated in a Military Mental Health Clinic: A Case Series.


Excessive use of video games may be associated with sleep deprivation, resulting in poor job performance and atypical mood disorders. Three active duty service members in the U.S. Marine Corps were offered mental health evaluation for sleep disturbance and symptoms of blunted affect, low mood, poor concentration, inability to focus, irritability, and drowsiness. All three patients reported insomnia as their primary complaint. When asked about online video games and sleep hygiene practices, all three patients reported playing video games from 30 hours to more than 60 hours per week in addition to maintaining a 40-hour or more workweek. Our patients endorsed sacrificing sleep to maintain their video gaming schedules without insight into the subsequent sleep deprivation. During the initial interviews, they exhibited blunted affects and depressed moods, but appeared to be activated with enthusiasm and joy when discussing their video gaming with the clinical provider. Our article illustrates the importance of asking about online video gaming in patients presenting with sleep disturbances, poor work performance, and depressive symptoms. Because excessive video gaming is becoming more prevalent worldwide, military mental health providers should ask about video gaming when patients report problems with sleep.
The evidence is strong that persistent use of many types of electronic devices may be addictive and contributory to multiple disorders, even extending to traumatic injury.

Monday, October 9, 2017

Doctors Feel Excluded from Health Care Value Efforts

This is not a new problem.  It has been going on for more than a decade.  Physicians have been excluded from reform and even feel as if we are the "guinea pigs" for administrators to experiment upon.

U.S. hospitals and health care groups have experimented over the past decade with new management structures and alternative payment models to provide quality health care at lower cost. But physicians have been slow to embrace these for a host of reasons. Chief among them, our research shows, is that they feel excluded from the process.
The only practical way to make value-based care a reality is for health care organizations to bring physicians back into the decision-making process. After years of experimentation, doctors want evidence that new models for health care management, reimbursement, and policy will actually improve clinical outcomes for their patients. Without it, they see little reason to alter the status quo. That’s a fundamental and overlooked obstacle to progress. And it explains why management-led organizations that have not embraced physician input have run into resistance.
The Harvard Business Review 
  • by Tim van Biesen
  • Josh Weisbrod

  • With our colleagues at Bain & Company, we recently surveyed 980 U.S. physicians in eight specialties, 100 health system finance officers, as well as 100 health system procurement officers — the people in charge of buying supplies for hospitals. What we found was startling: Physicians clearly understand the challenge posed by rising costs for clinical care and prescription drugs, but many don’t feel they are in a position to help rein in costs. They do not feel sufficiently engaged in making important decisions about cost control, performance improvement, and adoption of new reimbursement models. Indeed, many feel overruled, with mandate after mandate from hospitals and management-led health organizations being done to them, not with them.

    Steeped in a field that requires lifelong learning, many physicians are natural innovators and quick to test new systems and tools. But they staunchly resist new approaches that could put patient care at risk. That helps explain why management-led organizations that have not fully embraced physician input, for example, have run into resistance or have failed to make a greater impact. The US healthcare model remains firmly centered on physicians.
    In fact, more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. 

    Comparing our 2015 and 2017 survey findings, one notable slowdown has been in the adoption of value-based payment models. Many physicians anticipated a broad rollout of value-based care two years ago and a corresponding decline in practices using the traditional fee-for-service model. But few have been persuaded to switch, noting a lack of evidence that outcomes are the same or better using value-based care. More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.

    Despite the reluctance to drop fee-for-service payment systems, many organizations continue to experiment with value-based care as part of a mix of payment models, recognizing the continual pull in the industry toward the value-based approach. Providers that want to move toward value-based payment models can generate greater support by working closely with their physicians to shape these models and addressing their concerns about outcomes, simplicity and fairness to all stakeholders.

    All of these issues impact greatly acquisition of medical devices, pharmacy benefits

    Providers will have greater success at implementing change if they improve stakeholder alignment on cost-saving initiatives. Physicians need a clinical rationale for changing the way they deliver care—financial logic alone will not change long-established behaviors.

    • The adoption of new healthcare structures, value-based models and tools to curb spiraling costs and improve care has slowed and in some cases plateaued following five years of rapid experimentation and change.
    • Simply put, the system is struggling to adapt to the already set of reforms.

    This chart demonstrates the disparity amongst providers as to preferred method(s) of reimbursement.

    Value based payment is an undefined term, and many experts are struggling to define an algorithm measuring APMs and their benefits.

    Physicians recognize that fee for service is more expensive than other models......but are concerned that the more advanced value-based models negatively affect the quality of care.

    For more details: The Changing Landscape

    Doctors Feel Excluded from Health Care Value Efforts

    Positive Hospital Marketing Campaigns Have A Painful Downside : Shots - Health News : NPR

    In today's health world, marketing has become a major influence. It must be since corporations always analyze their ROI based upon the uptick in their business.

    Regulatory agencies seem to ignore blatant ethical violations and false advertising billboards, and 'branding' of their slogans. A large very successful health system whose brand is "THRIVE" will be instantly recognized without seeing it's name.

    Physicians would be sanctioned by medical boards for this tactic, although some larger medical groups slip through the watching eyes of regulatory agencies.

    Is the problem with the hospitals or regulatory agencies such as the JCAH Joint Commission for Accreditation of Hospitals.

    Hospitals aren't held to standards at all. So a hospital can go out and say, 'This is where miracles happen. And here's Joe. Joe was about to die. And now Joe is going to live forever.'

    "So a hospital can go out and say, 'This is where miracles happen. And here's Joe. Joe was about to die. And now Joe is going to live forever.' "
    Lori Wallace is not going to live forever. Before cancer, she says, she would have been attracted to the messages of hope. But now, she says, she needs realism — acceptance of both the world's beauty and its harshness. She wrote an essay about that for the women in her breast cancer support group.
    The essay is titled "F*** Silver Linings and Pink Ribbons." Wallace reads me the whole piece from start to finish. We are sitting at her kitchen table. Her son is nearby with his pet snake.
    Toward the middle of the essay, Wallace writes, "My ovaries are gone, and without them my skin is aging at hyperspeed. I have hot flashes and cold flashes. My bones ache. My libido is shot and my vagina is a desert." The essay is open, funny and unflinching, just like Wallace.
    She reads me the final paragraph: "I will try to be thankful for every laugh, hug and kiss, and other things, too. That is, if my chemo-brain allows me to remember."
    "That's what I wrote," Wallace says. "That's what I wrote. Brutal honesty."

    Positive Hospital Marketing Campaigns Have A Painful Downside : Shots - Health News : NPR

    Friday, October 6, 2017

    CMS Proposal for New Medicare Payment System Could Lead to Large Payment Variability for Specialists | Avalere Health

    Upcoming Medicare payment changes could affect your care.

    Through a series of complex new regulations physician specialists face severe reduction in reimbursments. The group includes ophthalmologists, rheumatologists and oncologists.

    New analysis from Avalere finds that payments to certain physician specialists could increase or decrease by as much as 16% for their 2018 performance under the Merit-based Incentive Payment System (MIPS).

    The adjustments could take effect if the Centers for Medicare & Medicaid Services (CMS) finalizes a proposal to change how payments to clinicians are calculated under MIPS. For most types of physicians, these payment adjustments would only range between +/- 5%, as provided for under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
    The changes will be transparent for most patients.  The specialties most impacted are those which use designer antiinflammatory and/or those which decrease blood vessel growth to malignant tumors and age related macular degeneration (VEGF).  These drugs are covered under Part B of Medicare.

    The drugs are a new class of therapeutics, and are expensive, also requiring continuing usage by patients. They are often used as a mainline or last resort treatment.

    Avalere’s research finds certain types of specialists, including rheumatologists, oncologists, and ophthalmologists bill for more Part B drugs than their counterparts in primary-care focused specialties. As a result, Part B drugs represent a larger percentage of total billed Medicare allowed charges for these specialists. Under the CMS proposal, Avalere found that some specialists could see payment adjustments as high as +/-16% for MIPS performance year 2018 (see Figure 1).  

    Under the CMS proposal, the magnitude of risk for certain types of specialists would continue to increase as the MIPS program reaches full implementation. In performance year 2020, the payment adjustments could reach as high as +/- 29% for rheumatologists and oncologists (see Figure 2).

    If finalized, this policy would mark a significant shift in CMS’ approach to payment adjustments. Payment adjustments for the legacy programs that MIPS sought to replace, like the Physician Quality Reporting System and Meaningful Use, have applied only to Medicare physician fee schedule services and not to Part B drugs.
    “Many specialists may not have an alternative to the MIPS track due to limited opportunities for specialists to join an Advanced Alternative Payment Model,” said Richard Kane, senior director at Avalere.