CMS Paid $93.6M in Incorrect Medicare EHR Incentive Payments

""CMS and Medicare often do foolish things that cost much more than what they recover.  This year the OIG audit discovered there were overpayments of the EHR incentives for hospitals.  It represented less than  1 % of the total amount paid to hospitals.  There was no mention in EHR intelligence that overpayment was made to providers (physicians).  CMS is being 'generous by reducing the number of deviant hospital amounts from 96 million to about 1.6 million for some obscure reason of their own about the dates of incentive.  (Merry Christmas) (humbug to CMS) . They requested a 'voluntary' refund from the remaining criminal element of hospitals if they would do   'DUE DILIGENCE' by examining their cost analysis of their hospital and provide it to CMS. EHR intelligence did not report if there is a hard deadline for the report, or face further penalties such as being terminated from CMS.
I realize that is a long stretch on my part, but worse things have occurred in the past year that makes this even pale in significance.""

HEALTH TRAIN EXPRESS disavows any payment, gratuities, and responsibility for the content published herein.

The remainder of the Health Train Express is copied from EHR Intelligence and is printed below. Attribution is given to John Lynn

The incorrect Medicare EHR incentive payments represented less than 1% of total payments to acute care hospitals, but OIG still recommends the recovery of some reimbursements.

An audit of 8,297 Medicare EHR incentive payments made to acute care hospitals from Jan. 1, 2013 to Sept. 30, 2017, revealed that CMS did not always make the payments in accordance with federal requirements. (ie, 4 years)


“The incorrect net incentive payments occurred because the Medicare administrative contractors did not review the supporting documentation for all hospitals to identify errors in the hospitals' cost-report numbers used to calculate the incentive payments, and CMS did not include labor and delivery services in the incentive payment calculations, which resulted in hospitals receiving inflated incentive payments,” described Joanne M. Chiedi, the acting inspector general of the Department of Health and Human Services (HHS) in the report.

OIG recommended that CMS recovery $1.3 million of the incorrect Medicare EHR incentive payments from acute care hospitals. These payments were made during the reopening period, so CMS has the authority to recoup the incorrect reimbursements.

For the remaining incorrect Medicare EHR incentive payments which were outside of the reopening period, OIG recommended that CMS notify the acute-care hospitals associated with the incorrect payments so that those hospitals can exercise reasonable diligence to investigate and return any identified similar incorrect payments.

OIG also advised CMS to attempt recovery of the nearly $93.6 million in estimated incorrect net incentive payments made during the audit period and to ensure that all final and non-final payments made after our audit period are correct. CMS should do this by instructing Medicare Administrative Contractors to review all hospitals’ supporting documentation to identify errors in the hospitals’ cost-report numbers used to calculate the incentive payments, including supporting documentation for labor and delivery inpatient bed-days for cost reports with cost-reporting periods beginning on or after October 1, 2013.

Let's do some simple math. (for some) $ 1.6 million divided by the 4 year period amounts to around $ 400,000 per annum The cost of recovery is nowhere near 100 percent forgiveness.  It amounts to a tax increase and an increase of bureaucratic overhead for the 'offending' hospitals. If CMS and HHS really want to save money for the weary taxpayer, they could fire the employees that would ordinarily have their work time filled with this sort of nonsense. However, they are undoubtedly civil service employees who cannot be fired, except for sexual deviancy.

A better way is for CMS (which it does for most things, as does the DOD), is to contract an accounting firm or use the IRS to process the paper pile swamp.

The OIG in its infinite wisdom recommended.  "CMS should do this by instructing Medicare Administrative Contractors to review all hospitals’ supporting documentation to identify errors in the hospitals’ cost-report numbers used to calculate the incentive payments, including supporting documentation for labor and delivery inpatient bed-days for cost reports with cost-reporting periods beginning on or after October 1, 2013".






















https://tinyurl.com/rolbskj

Merry Christmas and a Happy Chanukah

Look for us after the New Year

A Doctor’s Diary: The Overnight Shift in the E.R. -

In the typical emergency room, demand far outpaces the care that workers can provide. Can the E.R. be fixed?

By Gina Siddiqui

Illustrations by Golden Cosmos

Well, maybe.  Back in the day (1965) when I rotated through the emergency room (called emergency department) the same question arose. Since that time many solutions have been attempted, with varying success.

 

My choices as a doctor in the emergency room are up or out. Up, for the very sick. I stabilize things that are broken, infected or infarcted, until those patients can be whisked upstairs for their definitive surgeries or stents in the hospital. Out, for everyone else. I stitch up the simple cuts, reassure those with benign viruses, prescribe Tylenol and send home.

Up or out is what the E.R. was designed for. Up or out is what it’s good at. Emergency rooms are meant to have open capacity in case of a major emergency, be it a train crash, a natural disaster or a school shooting, and we are constantly clearing any beds we can in pursuit of this goal.

The problem is, traffic through the emergency room has been growing at twice the rate projected by United States population growth and has been for almost 20 straight years, despite the passage of the Affordable Care Act, and through both economic booms and recessions. Americans visit the E.R. more than 140 million times a year — 43 visits for every 100 Americans — which is more than they visit every other type of doctor’s office in the hospital combined.

The demand is such that new E.R.s are already too small by the time they are built. Emergency rooms respond like overbooked restaurants during a chaotic dinner rush, with doctors pressed to turn stretchers the way waiters hurriedly turn tables. The frantic pace leaves little time for deliberating over the diagnosis or for counseling patients. Up, out.

The underlying problem is a shortage of physicians.  Patients after discharge from a hospital may not be able to see a followup physician for two or three weeks, allowing a relapse into what originally brought them to an emergency department.

Private exams on stretchers in hallways, patients languishing without attention for hours, nurses stretched to the breaking point; all of it has become business as usual. I think about this on nights like tonight, when I start my shift inheriting 16 patients in the waiting room. I think about what I will learn that these people need, and about what I will fail to provide.

Should the emergency room treat only emergencies? More than 80 percent of our patients arrive without sirens blazing, by walking in or after parking their cars with the valet out front. A rash that won’t stop itching, a lower back that won’t stop aching, a child who won’t stop vomiting. If their problems aren’t in our manual of emergency conditions, we say they are misusing the E.R. and try to dispense of them as quickly as we can. But here they are, having waited six hours to see me, asking for help. What to do for them?

I click a few perfunctory buttons in their charts. I say there’s nothing life-threatening going on as I hand them boilerplate discharge paperwork to sign. Someone calls me to see my next patient. I send them back to their families, jobs and responsibilities equipped with little more than these unceremonious goodbyes.

Almost one in 10 — 8.2 percent — of these discharged E.R. patients return to an E.R. within three days. What I leave unaddressed — persistent pain, nagging uncertainty about a diagnosis, a social dilemma — tends to stay that way, begetting yet another visit. An E.R.’s success is measured by how fast it sees these patients, not by whether it breaks these cycles.

Although the E.R. was built to quickly get the sick “up” into the hospital, it has exposed, better than anywhere else, what patients lack while “out” in their otherwise private lives. Patients like Cynthia and Jean-Luc will survive devastating diseases under our care “up” in the hospital, but we send them “out” unable to sustain their precarious conditions without us. Patients like Mariah make their needs clear in the E.R., but we are too busy to meet them, and by the time they come back it’s often too late.

 

Such matters now fall into the category Social Determinants of Health. This category may be the overriding cause of their disease(s). Homelessness, poverty, lack of social services, acute climactic events

These factors often contribute to 8.2% of the return visits to the emergency department of most hospitals.
Financial limitations, lack of social workers limit the services in the emergency department. Insurers, medicare will not reimburse for these services in the emergency department

From 2012 to 2014 the federal government, recognizing that neither up nor out was solving the problem for a growing group of patients, financed an experiment at the University of Colorado. The typical E.R. has surgeons on-call to treat patients with broken bones; following that model, the E.R. in Colorado set up a team on-call for patients with broken homes.

Disadvantaged patients who kept returning to the E.R. were matched to social workers, health coaches and doctors who visited them where they lived and kept in touch for several months. By staying involved after the E.R. visits and not letting details fall through the cracks, the team reduced these patients’ need to revisit the hospital by 30 percent compared with the need of those in a control group.

The E.R. at Yale, where I work, addressed a different group in need. Elderly patients who came to the E.R. after a fall were offered a follow-up at home. There, they were screened for risk factors that might lead to another fall, such as loose rugs, medications that increased their risk of balance problems, or lack of necessary equipment or support at home. Over the next month, those who received such visits called 911 about half as often as similar patients who did not participate in the program.

Programs like these are not considered the E.R.’s core business, so they often rely on grants — and they end if funding dries up. Of the slim resources that E.R.s do set aside to address patients’ barriers outside the hospital, most are put toward hiring social workers and care managers. But these employees, stymied by mountains of paperwork and unrealistic patient loads, never get outside the hospital to see their patients, either.

The programs at Colorado and Yale succeeded by framing the E.R.’s resources differently. They recognized that the E.R. staff could identify problems that were destined to arise after discharge — and empowered those employees to help. Both programs orchestrated follow-ups outside the E.R; those teams worked on the day-to-day problems at home that go unaddressed in hospitals and clinics and can cause catastrophes







A Doctor’s Diary: The Overnight Shift in the E.R. - The New York Times:

Original Publication of what would become Health Train Express Inland Empire Regional Health Information Organization: Two Important Legislative Actions (Federal)

Another time, another era. We here at Health Train have our own Wayback machine. I find it hard to believe it has over13 years since my idea to start a blog occurred.  

Two Important Legislative Actions (Federal)

House Subcommittee Passes Amended Health IT Bill

June 09, 2006


The House Energy and Commerce Subcommittee on Health on Thursday approved by voice vote a bill (HR 4157) that would promote the use of health care IT, CQ Today reports (Schuler, CQ Today, 6/8).

The legislation, sponsored by Reps. Nancy Johnson (R-Conn.) and Nathan Deal (R-Ga.), would codify the Office of the National Coordinator for Health IT within HHS and would establish a committee to make recommendations on national standards for medical data storage and develop a permanent structure to govern national interoperability standards. The bill also would clarify that current medical privacy laws apply to data stored or transmitted electronically (iHealthBeat, 6/8).

Prior to approval, the subcommittee approved a substitute amendment sponsored by Deal that removed two provisions from the legislation. The provisions would have increased the number of diagnosis and procedure codes from 24,000 to more than 200,000 and would have allowed federal medical privacy laws to pre-empt state laws (CQ Today, 6/8).

The subcommittee also approved an amendment sponsored by Rep. Diana DeGette (D-Colo.) that would require a study on the effect of the bill on the health care system (Povich, CongressDaily, 6/9).

The full committee plans to mark up the legislation on June 13, Deal said (CQ Today, 6/8).







 If you click on the hyperlink it will bring you to the beginning of my enlightenment.





Inland Empire Regional Health Information Organization: Two Important Legislative Actions (Federal)

Measles on the Rise

  

The Global Measles Epidemic Isn’t (Just) About Measles

Strong health systems, along with immunization efforts, are key to fighting disease around the world.

By Andrew SchroederAPRIL 20, 2019 6:00 AM

Measles, once a common and deadly childhood illness which had been declared “eliminated” from many parts of the world including the United States, Canada and Europe nearly two decades ago, is back on the global health agenda.   Measles cases globally rose nearly 300 percent in the first quarter of 2019 as compared with the first quarter of 2018, according to surveillance data covering 190 countries released last week from the World Health Organization.

Over 112,000 cases were reported to start this year, as opposed to just over 28,000 from the beginning of 2018. That year likewise saw a significant gain as compared to 2017. Although still not close to the shocking levels of the mid-20th century, when tens of millions of children were infected and millions died, the trend for new measles infections seems to be inexorably and frustratingly on the rise.

This trend places children under the age of 10, particularly in poor and conflict-affected parts of the world, at increasing levels of entirely avoidable risk.

This global map diagrams the areas of the world where there are ongoing problems with measles

MEASLES, CONFLICT AND HEALTH SYSTEMS

In addition to the effect of vaccine hesitancy, we need look no further than the WHO’s own country-level data on the locations and growth trends of measles cases.

Almost all the enormous jump in measles cases from 2017 until the beginning of this year is attributable to a handful of places. This year, almost two-thirds of the entire reported global measles caseload is attributable to just two countries: Ukraine and Madagascar.  These two countries are highly instructive as to the true reasons why we should pay attention to measles as something like a “canary in the coalmine” for the underlying weaknesses of public health systems.

Let’s start with Ukraine, which may appear, at first glance, to be the most puzzling.

Why should a middle-income country on the edge of Europe, with a historically reliable, near-universal public health system, suddenly become a kind of poster child for the rampant spread of infectious childhood illnesses for which immunization exists? The answer is pretty simple: conflict.

Prior to 2014, Ukraine maintained a measles vaccination rate of 95 percent, generally considered the gold standard level for herd immunity. Then, conflict broke out between Ukraine and Russia. As a result, the Ukrainian Ministry of Health budget was frozen and measles vaccination procurement largely ceased until late 2015. By 2016, Ukraine’s vaccination rate had plunged to just 41 percent, one of the lowest rates on the planet.

In subsequent years, the vaccination rate in Ukraine crept back up close to its pre-conflict levels, with about 91 percent coverage achieved last year. But the damage had been done. A multi-year cohort of Ukrainian children had lost their immunity to the disease. Combined with widespread disruption of the primary health care system, and the physical effects of conflict on large numbers of communities, measles took root again quickly and began to spread.

Some of the migration of measles from the Ukraine epidemic has apparently gone international, with cases in New York, Israel and elsewhere traced directly to index cases of travelers from Ukraine.

Elsewhere, in places from Yemen to Nigeria, one can also detect the sharply negative impact of conflict on basic health system capacities and measles infection rates. The lessons of the Ukrainian measles epidemic, as is also the case with these other countries, are not only that it doesn’t take much to fundamentally disrupt a well-functioning health system and produce an otherwise preventable outbreak. Disruptions to health systems in one country, given high levels of global mobility through air travel, can quickly be felt in many places throughout the world.

THE GLOBAL MEASLES RESURGENCE

One of the most common explanations in the media for the measles resurgence has to do with a set of beliefs promoting reluctance to follow through with childhood vaccinations. The WHO earlier this year labeled this emerging reluctance one of the world’s “top ten” threats to global health.

The spread of misinformation about childhood vaccination is leading to a wave of what the World Health Organization calls “vaccine hesitancy.” Over time, declining tendencies to follow through on evidence-based public health recommendations may threaten long-established successful practices, which have improved the health of children since the mid-20th century.

In parts of California, New York, and Washington State, for instance, there is evidence that relatively small outbreaks have been correlated with reduced vaccination rates due to anti-vaccine misinformation combined with the novel introduction of the virus, often through travelers.

Globally, however, how can the disease’s resurgence be explained? Without question, the world needs to remain vigilant to any possibility that the consensus around childhood vaccination may be undermined over time by rising “vaccine hesitancy.” However, large numbers of people around the world are still not able to access the vaccinations they both want and need.  

Measles, respiratory illness with a characteristic rash, is extremely contagious. Although most people who contract the disease will recover, a small fraction of young children goes on to develop more severe complications, including pneumonia and encephalitis, a swelling of the brain that can cause permanent brain damage or even death. 

THE PERIL OF UNDER-FUNDING HEALTH CARE

The ongoing situation in Madagascar, which Direct Relief continues to respond to with local partners including the Ministry of Health, is quite different from that in Ukraine. Madagascar is one of the least developed countries, with a Human Development Index (HDI) that ranks 161st out of 189 measured countries. Its public health budget has been constantly under pressure for many years simply due to the tradeoffs required to manage multiple emerging health threats to rapidly changing communities. As a result, the measles vaccination rate in Madagascar has fallen to one of the world’s lowest at 58 percent.

Vaccination is not the only element of the health system that leads to an increased likelihood of measles contagion.  Poor nutrition leads to weakened immune systems for children and diminished capacity to resist infection. This is one of the key reasons why Direct Relief has been assisting with distributing of high-dose vitamin A to strengthen immune systems for vaccinated and unvaccinated children alike.

Weak primary care systems also present challenges to ensuring that all children are regularly seen by a physician and that suspect cases of measles are quickly identified and treated. Combined with low vaccination rates and persistent under-nutrition, weak primary care and disease surveillance can allow cases to multiply well before there is a chance to identify and intervene.

THE KINDLING THAT SPARKS AN OUTBREAK

Measles is well suited to epidemics given these system weaknesses. The reproduction rate for measles, the number epidemiologists use to measure the likelihood that one infected person infects others in the absence of counter-measures, is very high.

A systematic review in The Lancet from 2017 confirmed an average reproduction rate of 18, with considerable observed variance depending on contextual factors including poverty and the strength of health systems. That means a single measles infection may commonly produce at least 18 new infections in the absence of counter-measures. Likewise, measles is infectious for 7 days prior to the individual becoming symptomatic, which means that infections can easily spread undetected. That astonishing rate of transmission, including challenges with early detection, is what constantly threatens to transform measles outbreaks into exponentially growing epidemics.

In addition to defending the core public health value and practice of mass vaccination, we still have a long way to go to achieve a genuine universality of vaccine access, not to mention the related health systems interventions that maximize the chances of children to resist infectious diseases. That lack of equitable access threatens the most vulnerable in those countries most of all. But it threatens communities far outside their borders to given the fluency of global trade and travel.

Weak primary health systems, whether born of conflict, poverty or, as is often the case, a combination of both, remains among the greatest threats to human health everywhere.

Appeals court strikes down ACA's individual mandate

Just about the time the House of Representatives voted to forward their  "Impeachment resolution to the U.S. Senate, a ghost of another haunting has risen from the dead.

The Individual Mandate of the ACA assures that no one can be denied health insurance based upon previous medical conditions.

A federal appeals court on Wednesday ruled that the Affordable Care Act's individual mandate is unconstitutional, but ordered a lower court to take a fresh look at how much of the rest of the law should fall along with it.

What's next: This decision will likely keep the ACA's protections for pre-existing conditions in legal limbo well past the 2020 election.

The intrigue: Republican attorneys general have argued that congressional Republicans’ 2017 tax law, which nullified the ACA's individual mandate, made that policy unconstitutional.

• A panel of the 5th Circuit Court of Appeals said Wednesday that it agrees.
• Republicans, and the Trump administration, have said the courts should strike down the entire law along with the mandate.
• The 5th Circuit wrestled during oral arguments over how much of the law to strike down, ultimately deciding to kick that question back to the lower court for a new hearing. That lower court previously said the entire law would have to go.

Yes, but: The individual mandate is now essentially toothless, and it turned out not to be particularly effective when it was in effect.

• So, if the court is inclined to strike down the mandate alone, letting the rest of the law stand, that would be a much safer proposition than it appeared to be in 2012.

Go deeper: Government funding bill deal will repeal key ACA taxes

Why it matters: The decision is a colossal win for the health care industry.

• If this wasn't good enough news for the industry, the deal won't address surprise medical bills — and it avoids prescription drug prices except for the CREATES Act, which helps generics get to market faster.
• The taxes have been repeatedly delayed. And while the industry has pushed for their repeal for years, it hasn't yet been successful.

Between the lines: Voters are decidedly not asking Washington to lift industry taxes while avoiding dealing with two of the most popular health care issues, but if that's how this plays out, it's a great indicator that the industry's lobbying strength is as good as ever.

• It's also a good sign that cost control — the intention of the Cadillac tax, a 40% excise tax on the most generous employer plans — is still not very popular with lawmakers, even as health care costs continue to rise.
• The tax was expected to raise $200 billion over 10 years.

The other side: The industry says that the ACA taxes end up getting passed along to patients.

Go deeper:

• The Affordable Care Act's free health plans
• SCOTUS seems to side with insurers in ACA risk corridor case
• The return of the ACA wars

REFERENCE:

Some Essentials about Medicare Enrollment Period

Medicare Enrollment Period It is that time of the year. In mid-October until early December 7th is the enrollment period for Medicare and Advantage Programs. It is a weird set of dates, and each year it is extended, for one reason or another.  This year it is because there was a last-minute rush. I am not certain what that means? Was the Health care.gov web site overloaded, hacked or some other governments misdirect?  Now you have another chance to enroll.....until mid-January You can assign an authorized representative to accomplish these tasks 1.Create a Medicare.gov access 2.Select your plan(s) 3. Register a favorite physician, hospital, durable medical goods and more. Would you like for a family member or caregiver to be able to call Medicare on your behalf? Medicare can't give your personal health information to anyone unless we have permission in writing first. There are 2 ways to give permission:   (1) Print and fill out form CMS-10106: "Authorization to Disclose Personal Health Information" and then mail it to us. OR   (2) Submit the form online with a Medicare account.  Don't have a Medicare account yet? Signing up is easy and gives you electronic access to your health information. Once you've signed up, fill out and submit the form online by following these steps: Click on your name in the top right corner of the page. Click "My account." Select "Manage my representatives." Click “Medicare Authorization to Disclose Personal Health Information form."  Enter the requested information and click the "Continue" button. If all else fails go to the following url (it goes in the box at the top of your browser screen) .  http:/medicare.gov Get Started Sincerely, The Medicare Team Note: People living in New York have additional steps they must take. View the "Authorization to Disclose Personal Health Information form" to learn more.

You can update your preferences or use ou

'Residents From Hell': Indignities and Outcomes in Medical Training

We have all heard the stories of physician burnout and suicide. Medical training is arduous, difficult and long. Even with supportive mentors and teachers, it will take a toll on trainees.

This is a story of one such event.

The story is told,

"Don, my resident, grabbed me by the collar and pushed me against the wall of the empty hospital corridor.

"What the hell were you thinking, Pies?" he growled, his breath hot against my face. "Did you not consider that Mr A could be septic?"

"I'm sorry, Don!" I said miserably, my heart knocking against my rib cage.

"Don't apologize to me! Apologize to Mr A! He could have died if I hadn't found your screw-up!"

"I know, I know, Don. It's just that—I assumed the systolic reading…"

"Damn it! How many times have I told you? Assumption is the mother of screw-up!"

Don used a coarser term than "screw-up." He never minced words or missed an opportunity to let me know what a pitiful excuse for a medical intern I was. He was one member of the duo I used to call "The Residents From Hell." Together, Don and Phil (not their real names) helped make my medical internship one of the most painful experiences of my entire life. Yet, despite the numerous psychic traumas they inflicted on me, these two skilled physicians also helped me become a better doctor.

I had entered my internship with a pretty high opinion of my medical knowledge. Having majored in biology at Cornell University and has earned "honors" in my internal medicine course, I had some basis for my delusion of grandeur. But I soon discovered, among many similar revelations, that knowing the physiology of sepsis is not the same as detecting it in an older patient. Mr.  A proved the point.

A thin, frail gentleman in his 70s, Mr. A had been admitted to the medical unit with some vague symptoms the staff described, lazily, as "the dwindles"—a 10-lb weight loss over the past month, poor appetite, and a general sense of malaise. At the time of admission, no one had considered sepsis in the differential diagnosis. Mr A did not show any of the classic signs of sepsis, such as fever and chills, low body temperature, decreased urination, rapid breathing, or a low systolic blood pressure.

However, with that last finding, I made a potentially lethal assumption. I had checked Mr A's blood pressure while he was sitting on his bed, but I failed to check for an orthostatic drop in blood pressure. I assumed that a reading of about 105/70 mm Hg (as I recall) was an accurate reflection of the patient's hemodynamic state. But when Don checked Mr A's blood pressure when he was standing, the reading was an ominous 85/55 mm Hg—a huge drop, potentially signifying sepsis.

Emergency physician Justin Morgenstern, MD, has described the wide range of cognitive errors that lead doctors to make serious mistakes. Among them is ascertainment bias: we "see what we expect to see." For example, a disheveled, homeless man staggering into the emergency room, slurring his speech, is assumed to be "drunk" when he is actually hypoglycemic. When Mr A was admitted to our unit, I expected to see someone who was either depressed (I was, after all, heading into a career in psychiatry) or showing signs of a covert malignant tumor. I was not expecting to see someone in the early stages of sepsis. Morgenstern also describes "value bias," sometimes known as "effective error" and defined as "the tendency to convince yourself that what you want to be true is true, instead of less appealing alternatives."

Clinical depression was a diagnosis I probably "wanted to be true" because I was familiar with it and knew how to treat it. Sepsis, not so much. Whether we see what we expect to see or convince ourselves that what we want to be true is true, we are making unwarranted assumptions. And as Don was trying to teach me, assumptions can come with consequences.

I'd be lying if I said that I appreciated Don and Phil's tutelage at the time they were tormenting me. Far from it. Although they taught me to question my assumptions and avoid premature diagnostic closure, they also taught me, firsthand, the pain of humiliation and indignity. I still remember, on another occasion, standing outside my newly admitted patient's room, alongside my medical student, and Phil saying with icy composure, "Pies, don't kill this patient!" Maybe he thought he was being funny. Or maybe he was trying to goad me into being the kind of meticulous clinician we all want to be. But Phil's words left me feeling like an insect crushed beneath his heel. I recall that brain-searing insult with a wince, even now—over 40 years later.

That font of Jewish ethics, the Talmud, likens humiliating another human being to "spilling blood"—perhaps reflecting the fact that our faces tend to blanch when we experience public humiliation. And yet, as Friedrich Nietzsche once said, "Anything that doesn't kill me strengthens me." Although nothing can justify the deliberate humiliation of another human being, Phil and Don's "instruction" taught me to overcome my wounded feelings and get the job done. And their deplorable indignities taught me to aim higher in my own treatment of patients, colleagues, and students.

Yes, I learned from Don that "assumption is the mother of screw-up." That lesson has served me well, particularly when considering the differential diagnosis of a medically complicated patient. What looks at first like schizophrenia may ultimately turn out to be tertiary syphilis—the "Great Masquerader." What seems to be understandable grief or depression can turn out to be the early signs of pancreatic cancer.

However, the most valuable lesson I took from "The Residents From Hell" is to treat all persons—especially those with little power—with courtesy and dignity. To be sure: Diagnostic acumen is the foundation of good medical care. Don and Phil possessed that trait in abundance. Yet atop that foundation stands the House of Medicine—its essential constituents being respect, compassion, and kindness.

This story illuminates a not so uncommon scenario in medical education. Fortunately, it seems to be diminishing. The mantra of "I went through it, so you can too." This extends to hazing, bullying, night call, extensive on-call hours and 24 hour days. Ten years ago or so a standard was implemented to strictly decrease work hours and to restrict certain behaviors by senior physicians towards house staff residents). However, there remain pockets of misbehavior. The behavior also extends to junior attending staff in some universities and hospital organizations.

So too, are other instances of meaningless rituals in medical care

Advances in Treatments

Advances in Treatments: As reported by the Cleveland Clinic


Led by Michael Roizen, M.D., Emeritus Chief Wellness Officer at Cleveland Clinic, a panel of physicians and scientists have selected, in order of anticipated importance, the top new innovations healthcare providers can expect to see by 2020.

1. Dual-Acting Osteoporosis Drug
Osteoporosis is a condition where bones become brittle and increase the risk of breaking often without symptoms until the first fracture. But recent Food and Drug Administration approval of a new dual-acting drug called Romosozumab could offer more control in preventing more fractures.

2. Minimally Invasive Mitral Valve Surgery
The Mitral valve allows blood flow from the heart's left atrium to the left ventricle. However, for some patients older than 75 years the value may be defective and result in regurgitation. Expanded approval of a minimally invasive valve repair device for patients who don't experience improved symptoms could be a new treatment option.

3. Inaugural Treatment of Transthyretin Amyloid (ATTR-CM)

Cleveland Clinic physicians view ATTR-CM as a disheartening progressive, underdiagnosed and potentially fatal disease. Amyloid protein fibrils deposit in, and stiffen the walls of the heart's left ventricle. But there is a new agent to prevent misfolding of the deposited protein that shows a significant reduced risk of death. Three fast-track FDA approvals in three years now have led to the first-ever medication for this condition.

4. Therapy for Peanut Allergies.
There may be new hope for children with severe peanut allergy, a condition that not only is potentially fatal but also can cause much anxiety for both children and parents alike.

This week, 2 new studies discuss research findings on the use of oral immunotherapy in children with peanut allergies, which affects up to 1.4% of children in high-income countries. Oral immunotherapy involves having individuals with an allergy to a substance ingest a tiny amount of that substance under close clinical monitoring, and gradually increasing this exposure over an extended period of time. The goal is to eventually reach a point where the body can tolerate a reasonable amount of the substance without a severe allergic reaction, at which point the individual is deemed “desensitized.”

Peanut Allergy

Closed-Loop Spinal Cord Stimulation

This treatment uses an implantable device that sends an electrical stimulus to the spinal cord for the relief of chronic pain. Unfortunately, unsatisfactory outcomes from subtherapeutic or over-stimulation events are common. Closed-loop stimulation can enable improved communication between the device and the spinal cord, giving optimum stimulation and pain relief.

6. Biologics in Orthopaedic Repair

When patients have orthopedic surgery, their bodies can take a considerable amount of time to recover, sometimes for years. Use of biologics that include cells, blood components, growth factors and additional natural substances can harness the body's own power and promote healing, and these substances are finding their way into orthopedic care to expedite improved outcomes.

7. Antibiotic Envelope for Cardiac Implantable Infection Prevention

Each year about 1.5 million patients get an implantable cardiac electronic device. Yet, infection remains a real danger. Available now are antibiotic envelopes to encase the cardiac devices and prevent infection.

8. Bempedoic Acid for Cholesterol Lowering in Statin Intolerant Patients
While typically managed by statins, some patients experience unacceptable muscle pain with statins. The use of Bempedoic acid can provide an alternative approach to lowering LDL-cholesterol and avoid side effects.

9. PARP Inhibitors for Maintenance Therapy in Ovarian Cancer



PARP, or poly-ADP ribose polymerase inhibitors, block repair of damaged DNA in tumor cells which increases cell death, especially in tumors with deficient repair mechanisms. One of the most important advances in ovarian cancer, PARP inhibitors have improved progression-free survival and are now being approved for first-line maintenance therapy in advanced-stage disease.

10. Drugs for Heart Failure with Preserved Ejection Fraction

This is a condition in which the ventricular heart muscles contract normally, but do not relax as they should. With preserved ejection fraction, the heart does not properly fill with blood, leaving less blood being pumped out into the body. Current recommendations merely cover symptom relief. Now, SGLT2 inhibitors, a class of medications in the treatment of type 2 diabetes, are being looked at as a new treatment option.

Source:  Health Data Management