Protecting the Public’s Health-Except in Tennessee

State regulatory boards that regulate professionals such as doctors, nurses, psychologists, etc. are often appointed by politicians and headed by lawyers. Under this category has been most Medical Boards and their parent organization the Federation of State Medical Boards. Although they claim to be protecting the public, they seem more concerned with identifying “disruptive” physicians and blacklisting them through the National Practitioner Data Bank (1). However, in July the Federation issued a warning to physicians against propagating COVID-19 vaccine misinformation and disinformation citing a "dramatic increase" by physicians (2). The statement gave some hope that the Federation was striving to maintain some degree of professional standards by saying that spreading disinformation to the public was dangerous because physicians enjoy a high degree of public credibility.

The Tennessee Board of Medical Examiners followed the Federation’s lead by issuing a verbatim restatement warning that physicians who spread false information about COVID-19 vaccinations risk suspension or revocation of their medical license. Under repeated threats by Rep. John Ragan, R-Oak Ridge, co-chair of the State of Tennessee’s Joint Government Operations Committee, the warning was removed on December 7. 

Figure 1. Representative John Ragan.

Rep. Ragan insisted board members do not have the authority to create a new disciplinary offense without the approval of the lawmakers on his committee. He threatened to dissolve the board and appoint all new members if it did not immediately take it down and the Tennessee board succumbed to Rep. Ragan.

Across the country, state medical licensing boards are struggling to balance the politics and public interest with how to respond to scientifically baseless public statements about COVID-19 by some physicians. The Federation says the statements are increasing public confusion, political conflict, preventable illnesses and deaths (3). There have been only a small number of disciplinary actions by medical boards against physicians for spreading false COVID-19 information. Critics say the boards have been weak in responding to these dangerous violations of medical standards. For example, Dr. Lee Merritt, an orthopedic surgeon, from my home state of Nebraska has appeared on talk shows and in lecture halls to spread false information about COVID-19 (4).

Figure 2. Dr. Lee Merritt

Among her claims: that the SARS-CoV2 virus is a genetically engineered bioweapon (the U.S. intelligence community says it is not) and that vaccination dramatically increases the risk of death from COVID (data show the opposite). The entire pandemic, she says in public lectures, is a vast global conspiracy to exert social control. Yet, in October, she was able to renew her medical license in the state of Nebraska. Documents obtained through a public records request by NPR showed it took just a few clicks: 12 yes-or-no questions answered online allowed her to extend her license for another year.

Physician ethics have also been under assault in medical schools. Several medical schools recently founded by healthcare organizations seem overly concerned that their graduates might object to some COVID-19 statements on a scientific basis (5). Through these new medical schools, business interests hope to indoctrinate medical graduates on how to serve the public any way a healthcare administrator tells them. Even a healthcare organization as lofty as the American College of Physicians now has their ethics statement written by a lawyer (6).

These, as well as other examples, demonstrate that as we lose control of the ethics of our profession, we lose control of our profession. Assuming the physicians reading this editorial are against the dissemination of false information, what can we do? One example, came from Houston, Texas where Dr. Mary Bowden, who posted "harmful" and "dangerous misinformation" about Covid-19 and its treatments on social media, had her medical staff privileges suspended. She subsequently resigned from Houston Methodist (7).

We as physicians should work through our medical staffs over these issues. Hopefully, we will not try to repress legitimate concerns from physicians expressing objections to hospital or medical staff policies through appropriate channels. However, if the medical staff chooses to proceed over those objections, each physician can use their conscience to refuse to work with physicians disseminating misinformation. We are one medical family and what hurts one of us, hurts us all.  

Richard A. Robbins, MD                                  

Editor, SWJPCC

References

1. Robbins RA. The disruptive administrator: tread with care. Southwest J Pulm Crit Care. 2016:13(2):71-9. doi: http://dx.doi.org/10.13175/swjpcc049-16.
2. Federation of State Medical Boards. FSMB: Spreading Covid-19 Vaccine Misinformation May Put Medical License at Risk. Available at: https://www.fsmb.org/advocacy/news-releases/fsmb-spreading-covid-19-vaccine-misinformation-may-put-medical-license-at-risk/ (accessed 12/13/21).
3. Sawyer N, E Bloomgarden E, Cooper M, Nichols T, Hickie C. Opinion: State medical boards should punish doctors who spread false information about covid and vaccines. The Washington Post. September 21, 2021. Available at: https://www.washingtonpost.com/opinions/2021/09/21/state-medical-boards-should-punish-doctors-who-spread-false-information-about-covid-vaccines/ (accessed 12/13/21).
4. Brumfiel G. A doctor spread COVID misinformation and renewed her license with a mouse click. Heard on All Things Considered. November 4, 2021. Available at: https://www.npr.org/sections/health-shots/2021/11/04/1051873608/a-doctor-spread-covid-misinformation-and-renewed-her-license-with-a-mouse-click (accessed 12/13/21).
5. Shireman R. For-Profit Medical Schools, Once Banished, Are Sneaking Back. The Century Foundation. March 20, 2020. Available at: https://tcf.org/content/commentary/for-profit-medical-schools-once-banished-are-sneaking-back-onto-public-university-campuses/ (accessed 12/13/21).
6. Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: Seventh Edition. Ann Intern Med. 2019 Jan 15;170(2_Suppl):S1-S32. [CrossRef] [PubMed]
7. Watts A, Elassar A. Texas doctor suspended for spreading 'misinformation' about Covid-19 submits resignation letter. November 16, 2021. Available at: https://www.cnn.com/2021/11/13/us/houston-doctor-suspended-covid-19/index.html (accessed 12/13/21).

Cite as: Robbins RA. Protecting the Public’s Health-Except in Tennessee. Southwest J Pulm Crit Care. 2021;23(6):162-4. doi: https://doi.org/10.13175/swjpcc067-21 PDF 

Linking Performance Incentives to Ethical Practice

Health spending is a huge part of the United States economy as it is a large business. We all have seen increasing inclusion of corporate practices in health care. One such inclusion is the incentive programs which have at their core the goal of production of the desired behavioral outcomes directly related either to performance output or extraordinary achievement. However, management influence on the organization’s ethical environment and culture can inadvertently encourage or endorse unethical behavior despite the best intentions. One way would be failing to link performance incentives to ethical practice. When leaders create strong incentives to accomplish a goal without creating equally strong incentives to adhere to ethical practice in achieving the desired goal, they effectively set the stage for ethical malpractice. Incentivizing ethical practice is equally important as incentivizing other behaviors (1). In the health care industry, unlike in the sales industry, professionalism and patient care are not like sale numbers and the costs of not providing excellent care can be serious. When emphasis is more about good performance numbers than accurate performance numbers, hospital accreditation reviews may result in, issuance of orders that are impossible to fulfill, or finding scapegoats to blame in a crisis. This can have powerful effects in shaping the organization’s environment and how staff members perceive the organization, their place in it, and the behaviors that are valued. Ironically, it isn’t unusual for leaders to assume all is fine from an ethical perspective when in fact it may not be. Research has shown that the higher in the organizational level the healthier the perceptions of organizational ethics is perceived (2).

It takes a great deal more than high ideals and good intentions to have ethical authority. It requires commitment and a proactive effort to achieve high standards. If executives are to meet the challenge of fostering an ethical environment and culture, it’s essential that they cultivate the required specific knowledge, skills, and habits. More and more, the public expects its leaders to hold themselves and their employees accountable and high on that expectation is ethical practice.

A focused example is the current opioid crises. In 2004 Centers for Medicare & Medicaid Services added pain scale as the 5^th vital sign. Subsequently, both the Department of Veterans Affairs and The Joint Commission mandated a pain scale as the 5^th vital sign (3-8). These pain scales ask patients to rate their pain on a scale of 1-10. The Joint Commission mandated that "Pain is to be assessed in all patients” and would give hospitals "Requirements for Improvement" if they failed to meet this standard (8). The Joint Commission also published a book in 2000 for purchase as part of required continuing education seminar (8). The book, sponsored by the opiate manufacturer Purdue Pharma (maker of oxycodone), cited studies that claimed, "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addictive side effects "inaccurate and exaggerated." The health organizations used patient satisfaction scores for Performance Incentives and some patients who were addicted or on their way to becoming addicted would complain to administrators when they did not get drugs they were seeking.

No one excuses the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, intrusion by unqualified bureaucrats, administrators and politician’s incentivizing more pain medications and punishing appropriate care likely contributed to the current crisis. In November 2017 four cities in West Virginia teamed up to file suit against The Joint Commission over the organization’s handling of pain management standards (9). In healthcare, physicians must advocate for their patients, build trust, insist on high standards of care, and participate creatively in improving the health care system in a fiscally responsible way (10). We should hold firm to pressures from manufacturers, administrators, and medical boards s to do what is in the best interests of our patients. Preserving the standards of professionalism in medicine while maintaining the highest levels of ethical standards has the best chance of healing this opiate epidemic. Let's maintain the trust and professionalism of our discipline during this crisis. 

F. Brian Boudi, MD

Associate Editor, SWJPCC

References

1. Wynia MK. Performance measures for ethics quality. Eff Clin Pract. 1999;2(6):294-9. [PubMed]
2. Treviño LK. Ethical culture: What do we know? Fellows Meeting, July 2003, Ethical Research Center. Available at: www.ethics.org/download.asp?fl=/downloads/Ethical_Culture_Summary.pdf; last accessed December 18, 2006.
3. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995 Apr;82(4):1071-81. [CrossRef] [PubMed]
4. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005 Jul 25;165(14):1574-80. [CrossRef] [PubMed]
5. National Pain Management Coordinating Committee. Pain as the 5Th vital sign toolkit. Department of Veterans Affairs. October 2000. Available at: https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf (accessed 2/22/17).
6. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117 [CrossRef] [PubMed]
7. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540. [CrossRef] [PubMed]
8. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 2/22/18).
9. Sullivan W, Plaster L. Four West Virginia cities sue The Joint Commission. Emergency Physician Monthly. December 5, 2017. Available at: http://epmonthly.com/article/four-west-virginia-cities-sue-joint-commission/ (accessed 2/22/18).   
10. The unspoken challenges to the profession of medicine. Boudi FB, Chan CS. Southwest J Pulm Crit Care. 2017;14(6):222-4. [CrossRef]

Cite as: Boudi FB. Linking performance incentives to ethical practice. Southwest J Pulm Crit Care. 2018;16(2):96-8. doi: https://doi.org/10.13175/swjpcc036-18 PDF 

Brenda Fitzgerald, Conflict of Interest and Physician Leadership

Barely noticed in the news last week was Brenda Fitzgerald’s resignation as director of the Centers for Disease Control (CDC) after only 6 months on the job (1). Her resignation came one day after Politico reported that she bought shares in a tobacco company one month after assuming the CDC directorship (2). The stock was one of about a dozen new investments that also included Merck and Bayer (3). Fitzgerald had come under criticism by Senator Patty Murray for slow walking divestment from older holdings that government officials said posed potential conflicts of interest (1). While serving as director of the Georgia Department of Health, Fitzgerald owned stock in five other tobacco companies: Reynolds American, British American Tobacco, Imperial Brands, Philip Morris International, and Altria Group (4).

“It gives you a window, I think, into her value system,” said Kathleen Clark, a professor of law focusing on government ethics at Washington University in St. Louis (2). “It doesn’t make her a criminal, but it does raise the question of what are her commitments? What are her values, and are they consistent with this government agency that is dedicated to the public health? Frankly, she loses some credibility.” Purchasing tobacco stocks by any physician is disturbing, even more so when done by the director of the agency that spearheads the US government’s efforts to reduce smoking.

The influence of money on healthcare legislation has become increasingly concerning. Merck, whose stock Fitzgerald purchased on August 9, has been working on developing an Ebola vaccine and also makes HIV medications (2,3). Bayer, whose stock she purchased on August 10, has in the past partnered with the CDC Foundation to prevent the spread of the Zika virus (2,3). Fitzgerald’s purchases of tobacco stocks represent just one more instance of a potentially inappropriate relationship between politicians and business. Previous research published in the Southwest Journal of Pulmonary and Critical Care (SWJPCC) demonstrated a correlation between tobacco company political action committee contributions and support of pro-tobacco legislation (5).

Fitzgerald’s ethics issues are apart from a broader assessment of her leadership at the CDC. She had no research experience while leading an organization where research is one of its primary functions. She had previously promoted anti-aging medications to her patients despite no evidence of their efficacy (6).  She made few public statements during her time at the CDC and waited 133 days before holding her first staff meeting. She was scheduled several times to testify before Congress but sent deputies instead.

Fitzgerald seems to represent a high-profile version of the obsequious physician executive (OPIE), i.e., a physician obedient or attentive to an excessive or servile degree (7). Like the OPIE at the local hospital, Fitzgerald may have been appointed not for skill as a leader but her compliance as a subordinate to her supervisors. It raises the question of who would want to be director of the CDC when the current administration has been openly hostile, targeting the agency for deep budget cuts.

Hopefully, the next director of the CDC will be less conflicted. Previously, the SWJPCC has published tobacco company PAC contributions to candidates for political office (5). At the request of the Arizona Thoracic Society we intend to do the same prior to the November 2018 elections (8). In the interim, you can check tobacco company PAC contributions to federal candidates on the Campaign for Tobacco Free Kids website or for contributions at the state level at followthemoney.org (9,10).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Sun LJ. CDC director resigns because of conflicts over financial interests. Washington Post. January 31, 2018. Available at: https://www.washingtonpost.com/news/to-your-health/wp/2018/01/31/cdc-director-resigns-because-of-conflicts-over-financial-interests/?utm_term=.05ee75769108 (accessed 2/3/18).
2. Karlin-Smith S, Ehley B. Trump's top health official traded tobacco stock while leading anti-smoking efforts. Politico. January 30, 2018. Available at: https://www.politico.com/story/2018/01/30/cdc-director-tobacco-stocks-after-appointment-316245 (accessed 2/3/18).
3. Fitzgerald B. Periodic Transaction Report | U.S. Office of Government Ethics; 5 C.F.R. part 2634 Executive Branch Personnel Public Financial Disclosure Report: Periodic Transaction Report (OGE Form 278-T). Revised 12/21/17. Available at: https://www.politico.com/f/?id=00000161-4804-d9fe-a9fd-5af5834d0000 (accessed 2/3/18).
4. Fitzgerald B. Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e). Revised 10/12/17. Available at:  https://www.politico.com/f/?id=00000161-4867-da2c-a963-cf770b6b0000 (accessed 2/3/18).
5. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
6. Levitz E. Trump’s CDC pick peddled ‘anti-aging’ medicine to her gynecologic patients. New York Magazine. July 10, 2017. Available at: http://nymag.com/daily/intelligencer/2017/07/trumps-cdc-pick-peddled-anti-aging-medicine-to-patients.html (accessed 2/3/18).
7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]
8. Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. [CrossRef]
9. Campaign for Tobacco Free Kids. Tobacco PAC contributions to federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions (accessed 2/3/18).
10. The National Institute on Money in State Politics. Money in state politics. Available at: https://www.followthemoney.org/tools/election-overview/?s=AZ&y=2016 (accessed 2/3/18).

Cite as: Robbins RA. Brenda Fitzgerald, conflict of interest and physician leadership. Southwest J Pulm Crit Care. 2018;16(2):83-5. doi: https://doi.org/10.13175/swjpcc029-18 PDF 

Choosing Wisely-Where Is the Choice?

A little over a year ago an editorial was posted in the Southwest Journal about the Choosing Wisely campaign from the American Board of Internal Medicine and Consumer Reports (1). You may remember that Choosing Wisely announced a list of procedures or treatments that patients should question (2). In the editorial we wondered why pulmonary organizations such as the American Thoracic Society (ATS) and the American College of Chest Physicians authored none of the recommendations and offered 10 suggestions. We also openly questioned if the recommendations were intended to improve patient care or reduce costs, and thus improve the profits of third party carriers.

We can now report that recommendations were announced at the recent ATS meeting in Philadelphia. Seven recommendations were made for critical care and seven for pulmonary disease. Five from the critical care list and five from the pulmonary list will eventually be chosen for inclusion in Choosing Wisely. The recommendations are listed below:

Critical Care

1. Thou shalt not order diagnostic tests at regular intervals (e.g., daily) but instead order tests based on needs.
2. Thou shalt not use parenteral nutrition in the first 7 days of an ICU admission in patients adequately nourished.
3. Thou shalt not transfuse red blood cells in hemodynamically stable patients with a hemoglobin > 7 gm/dL.
4. Thou shalt not sedate mechanically ventilated patients without an indication.
5. Thou shalt not continue life support for at patients at high risk for death.
6. Thou shalt not initiate or continue antimicrobials without an indication.
7. Thou shalt not place or maintain an arterial or central venous catheter without an indication.

Pulmonary

1. Thou shall not perform thoracic CT scans for follow up of pulmonary nodules more frequently than the guidelines (Fleishner Society) suggest.
2. Thou shalt not discontinue oxygen from recently discharged patient prescribed oxygen without checking for hypoxemia.
3. Thou shalt not routinely administer intravenous corticosteroids for exacerbations of asthma or chronic obstructive pulmonary disease when the patient is able to take oral steroids.
4. Thou shalt not do thoracic CT scan screening for patients at low risk for lung cancer.
5. Thou shalt not do chest x-rays on asymptomatic patients routinely.
6. Thou shalt not offer vasoactive agents for groups 2 (left heart disease) and 3 (hypoxia) pulmonary artery hypertension (PAH).
7. Thou shalt not perform thoracic CT angiography for pulmonary embolism on patients with low probability and a negative d-dimer.

In the question and answer session after the recommendations were presented, a member of the audience noted that most of the recommendations were negative, directing physicians what not to do. We confess that we added the “Thou shalt not …” to emphasize this point but cannot overlook the fact that these recommendations look suspiciously like commandments. The negativity implicit in the ATS recommendations is consistent with the recommendations by other subspecialties listed on the Choosing Wisely website (2).  While the recommendations are reputedly about reducing the use of unnecessary or potentially dangerous testing, both worthy goals, the tone suggests there will be consequences for failure to comply.

What we find offensive is the Choosing Wisely and ultimately the ABIM foundation assertion that this is an initiative “focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary” (2). Where is the encouragement and where is the choice in a series of DO NOT commandments?  It seems an even-handed approach of an objective statement would be much more appropriate and yet carry the same information, e.g. Chest CT scans are rarely required for screening patients at low risk for lung cancer rather than “Do not do thoracic CT scan screening for patients at low risk for lung cancer”.  It seems that rather than encouraging conversation the Choosing Wisely statement puts doctor and patient in an adversarial relationship especially if the doctor feels something is needed which is expressly stated with a “Do not”.

Rather than a laundry list of no-no’s a guiding principle might be better. The American College of Physicians (ACP) has offered, “The physician should always act in the best interests of the patient” (3). Despite objections to the profession of the author of the ACP statement, a lawyer, the overall sentiment is a good one (4). It removes the adversarial relationship the Choosing Wisely campaign encourages and places physicians where they belong-on the side of the patient.

In our view the present Choosing Wisely campaign has fundamental flaws-not because it is medically wrong but because it attempts to replace choice and good judgment with a rigid set of rules that undoubtedly will have many exceptions. Based on what we have seen so far, we suspect that Choosing Wisely is much more about saving money than improving patient care. We also predict it will be used by the unknowing or unscrupulous to further interfere with the doctor-patient relationship.  When the recommendations of an authoritarian body take the form of commandments and preempt clinical decision making, then it seems the wise choice of a wary clinician is to tacitly comply - in other words there is no choice.

Richard A. Robbins, M.D.*

Allen R. Thomas, M.D.*

References

1. Robbins RA, Thomas AR. Will fewer tests improve healthcare or profits? Southwest J Pulm Crit Care 2012;4:111-3.
2. http://www.choosingwisely.org/ (accessed 6/3/13).
3. Snyder L.  American College of Physicians Ethics Manual.  Sixth Edition.  Ann Intern Med. 2012:156;1:suppl 73-101.
4. Raschke RA. February 2012 critical care journal club. Southwest J Pulm Crit Care 2012;4:51-2.

*The opinions expressed in this editorial are the opinions of the authors and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA, Thomas AR. Choosing wisely-where is the choice? Southwest J Pulm Crit Care. 2013;6(6):272-4. PDF