Seven Words You Can Never Say at HHS

The recent announcement of the seven words you can never say at Health & Human Services (HHS) reminded me of the late George Carlin’s routine, “Seven Words You Can Never Say on Television” (1). Policy analysts at the Centers for Disease Control (CDC) in Atlanta were told of the list of forbidden words at a meeting last Thursday, December 14, with senior CDC officials who oversee the budget, according to an analyst who took part in the 90-minute briefing (2). The forbidden words are "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said. In other cases, no replacement words were immediately offered.

This is the latest attempt by government departments to distort fact. As an example, The New York Department of Education tried a similar tactic in 2012 (3). Among the words were dinosaur, birthday, and Halloween. Some of the reasons given were that dinosaurs suggest evolution which creationists might not like; Halloween was targeted because it suggests paganism; and birthday because it isn’t celebrated by Jehovah’s Witnesses; The Bush administration waged a similar war on climate change (4). That war has been extended by the Trump Administration as part of their war on any science that the Trump administration does not like (5). Science that does not fit Trump’s agenda or ideology is insulted or called “fake news”. Climate change is fact and not a hoax dreamed up the Chinese as Trump has claimed (6).

Mr. Carlin is not alive to make fun of the latest war on free speech but perhaps others will take up Carlin’s calling. Seven words they might suggest be banned include stupid, moron, fool, clown, weird, dumb and incompetent-all frequently used by President Trump on Twitter (7). The CDC is a scientific organization. Appointing unqualified politicians to head scientific organizations to carry out a political agenda is like mixing oil and water. No matter how times you say it, the water will not float on top of the oil. Science relies on a precise vocabulary and is not Republican or Democrat, conservative or liberal, or right or left. In my view, those that banned these words made an indirect attack on fact and should be “ashamed” (7).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Carlin G. 7 words you can never say on television. Available at: https://www.youtube.com/watch?v=kyBH5oNQOS0 (accessed 12/18/17).
2. Sun LH, Eilperin J. Words banned at multiple HHS agencies include ‘diversity’ and ‘vulnerable’. Washington Post. December 16, 2017. Available at: https://www.washingtonpost.com/national/health-science/words-banned-at-multiple-hhs-agencies-include-diversity-and-vulnerable/2017/12/16/9fa09250-e29d-11e7-8679-a9728984779c_story.html?utm_term=.c983e2f2af81 (accessed 12/18/17).
3. CBS News New York. War on words: NYC dept. of education wants 50 ‘forbidden’ words banned from standardized tests. March 26, 2012. Available at: http://newyork.cbslocal.com/2012/03/26/war-on-words-nyc-dept-of-education-wants-50-forbidden-words-removed-from-standardized-tests/ (accessed 12/18/17).
4. Union of Concerned Scientists. Scientific integrity in policy making. September, 2005. Available at: https://www.ucsusa.org/our-work/center-science-and-democracy/promoting-scientific-integrity/reports-scientific-integrity.html#.Wjf0TFWnGUk (accessed 12/18/17).
5. Editorial Board. President Trump’s war on science. New York Times. September 9, 2017. Available at: https://www.nytimes.com/2017/09/09/opinion/sunday/trump-epa-pruitt-science.html (12/18/17).
6. Marcin T. What has Trump said about global warming? Eight quotes on climate change as he announces Paris agreement decision. Newsweek. June 1, 2017. Available at: http://www.newsweek.com/what-has-trump-said-about-global-warming-quotes-climate-change-paris-agreement-618898 (accessed 12/18/17).
7. Lee JC, Quealy K. The 394 people, places and things Donald Trump has insulted on twitter: a complete list. New York Times. November 17, 2017. Available at: https://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html (accessed 12/18/17).

Cite as: Robbins RA. Seven words you can never say at HHS. Southwest J Pulm Crit Care. 2017;15(6):294-5. doi: https://doi.org/10.13175/swjpcc154-17 PDF 

Equitable Peer Review and the National Practitioner Data Bank

The General Accounting Office (GAO) recently reported that Department of Veterans Affairs (VA) did not report most physicians whose clinical care was found to be, or suspected of being, substandard to the National Practitioner Data Bank (NPDB) or to state licensing boards (1). The GAO examined 5 VAMCs and found required reviews of 148 providers’ clinical care after concerns were raised from October 2013 through March 2017. Of the 148, 5 were subjected to adverse privileging actions and 4 resigned or retired while under review but before adverse actions were taken. Only 1 of these 9 was reported to the NPDB and none was reported to his or her state medical board.

In response to GAO's report and in testimony to the Subcommittee on Oversight and Investigations, VA officials said the agency was taking three steps to improve reporting of providers who don't meet required standards:

1. Reporting more clinical occupations to the NPDB;
2. Improving the timeliness of reporting;
3. Enhancing oversight to ensure that no settlement agreements waive the VA's ability to report to NPDB and state licensing boards (2).

What is lacking in the report is determination if substandard actually occurred and how it was determined. The VA has 3 ways of identifying substandard care (1).

1. Tort claims (the VA equivalent of a medical malpractice lawsuit);
2. Complaints or incident reports;
3. Peer review.

Each has major problems of accuracy and fairness at the VA.

The majority of US physicians have been sued (3). The minority of suits are associated with malpractice and malpractice has no apparent association with the outcome of the litigation (4). Over 90% of medical malpractice cases are settled out of court (5). A common misconception is that settling a case before trial means a large financial settlement. However, 90% of the 90% or 82% of all claims, close with no payment (5). However, the VA uses US District Attorney to defend malpractice claims (6). In many instances, the US District Attorney’s office settles the case without determining if there is malpractice. The VA then submits the offending physician(s) name to the NPDB or state boards whether malpractice has been shown or not.

Complaints or incident reports are common in many hospitals, and many, if not most, have little merit (7). However, the weight given to a complaint should be viewed differently depending on the source. When colleagues raise concern about a physician’s care this is more credible than a patient complaining about not receiving their narcotics to a patient advocate. In the GAO report it is unclear if this was a source the of possible substandard care.

Lastly, there is peer review. There are several problems with this process in the VA. The VA selects the “peers”. In many instances the reviewers are un- or under-qualified to review the case (6). Furthermore, the selected reviewers may be conflicted clouding a balanced and fair determination if the physician’s care met the standard of care. There are multiple instances of this at the VA, of which a couple have been cited in the SWJPCC (6).

No surprisingly, a bureaucracy in the federal government has suggested a bureaucratic solution to a nonexistent problem. The goal should not be for more bureaucratic reporting, but a system for determining if a physician’s care has met the standard of care. The VA has shown it is incapable of making this determination fairly and accurately. What is needed is an outside review separated from VA influence and politics. If malpractice is still questioned after an initial VA review, the medical schools or private practioners could provide a source of physician peer review. The case could be presented to a panel of non-VA physician peers chosen in an equitable ratio by the VA and the accused practitioner. In the absence of a more equitable review process, the VA will only succeed in driving away the quality practitioners the veterans need.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. General Accounting Office. VA health care: improved policies and oversight needed for reviewing and reporting providers for quality and safety concerns. Report to the chairman, committee on veterans’ affairs, House of Representatives. GAO-18-63 (Washington, D.C.: November, 2017). Available at: http://www.gao.gov/assets/690/688378.pdf (accessed 12/6/17).
2. Terry K. VA medical centers fail to report substandard doctors, GAO says. Medscape. December 5, 2017. Available at: https://www.medscape.com/viewarticle/889600?nlid=119420_4502&src=wnl_dne_171206_mscpedit&uac=9273DT&impID=1501593&faf=1 (accessed 12/6/17).
3. Matray M. Medscape malpractice report 2017 finds the majority of physicians sued. Medical Liability Monitor. November 15, 2017. Available at: http://medicalliabilitymonitor.com/news/2017/11/medscape-malpractice-report-2017-finds-the-majority-of-physicians-sued/ (accessed 12/6/17).
4. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec 26;335(26):1963-7. [CrossRef] [PubMed]
5. Chesanow N. Malpractice: when to settle a suit and when to fight. Medscape. September 25, 2013. Available at: https://www.medscape.com/viewarticle/811323_3 (accessed 12/6/17).
6. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013 Dec 1;2(3):e27. [CrossRef] [PubMed]
7. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight bureaucracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.

Cite as: Robbins RA. Equitable peer review and the national practitioner data bank. Southwest J Pulm Crit Care. 2017;15(6):271-3. doi: https://doi.org/10.13175/swjpcc152-17 PDF

Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to Require Sleep Apnea Testing in Commercial Transportation Operators

In another move favoring business interests and against the common good, the Trump administration’s Department of Transportation announced recently that they are rescinding plans to require testing for obstructive sleep apnea (OSA) in train and commercial motor vehicle operators (1). As exemplified by its withdrawal from the Paris climate accords, this decision is another example of how the current administration disregards scientific findings and present-day events in establishing policy that will be detrimental to Americans.

Let us step back for a moment and briefly review the evidence that the Trump administration has ignored.

• It is well established that obstructive sleep apnea (OSA) can result in daytime sleepiness (2) and that sleepiness is detrimental to safe operation of a train or motor vehicle.
• Many studies have established that persons with OSA have an increased risk of motor vehicle crashes (3).
• Studies in commercial truck drivers have observed that this population has a high prevalence of OSA (4).
• It is estimated that OSA costs the American economy $150 billion annually (5).
• There now are relatively easy and inexpensive protocols to screen high risk individuals for OSA (4).
• Obstructive sleep apnea is a treatable condition, and treatment mitigates OSA impairment in sleepiness and reduces crash risk (6,7). In contrast, non-compliance with treatment is associated with a five-fold increase in crash risk (6).
• The costs of diagnosis and treatment are much lower than the costs that ensue when OSA persists untreated (5). For example, significant healthcare savings result from successful treatment of truck drivers (8).
• Failure to recognize and treat OSA has resulted in several high-profile transportation accidents. The following are some recent incidents:
  • September 2016: A commuter rail train slammed into the station at Hoboken, NJ killing a female bystander and leaving a child without a mother. The engineer had undiagnosed severe OSA (9).
  • December 2013: A Metro North commuter rail engineer fell asleep and his train sped around a curve resulting in a crash that killed 4 and injured 70 (10). The National Transportation Safety Board determined that undiagnosed severe OSA was the probable cause of the accident. The lack of a policy which required sleep disorder screening was further determined to be a contributing factor (11).
  • September 2013: A Greyhound bus overturned on Interstate 70 because the driver fell asleep resulting in multiple injuries. The driver was later found to have untreated OSA (12).
  • June 2009: A tractor-trailer traveling at a high speed did not see stopped cars ahead on Interstate 44 resulting in a crash that killed 10 and injured 6. It was later determined that the truck driver had mild OSA contributing to fatigue (13).

Despite the weight of the aforementioned evidence, the current administration has chosen to ignore it in favor of letting private industry regulate itself implying the current regulations are sufficient. As illustrated by the incidents cited above, recent events have proven them wrong. As Sir Winston Churchill once said “Those who fail to learn from history are doomed to repeat it”. Continuing with the current policy will inevitably result in further preventable disasters and more loss of life.

What can be done? At the federal level, one should consider advocating to your own congressional representatives for reconsideration of this poorly considered policy. On a personal level, federal policy is ultimately guided by the “ballot box”, which is something to consider for the next election. Finally, be aware that the next time you are driving down the interstate, the truck or bus driver approaching you from behind may have untreated OSA!

Stuart F. Quan, M.D.^1,2, Laura K. Barger, Ph.D.¹, Matthew D. Weaver, Ph.D.¹, and Charles A. Czeisler, Ph.D., M.D.¹

¹Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

Harvard Medical School, Boston, MA USA

²Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Federal Register. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. Last updated: 2017. Available at: https://federalregister.gov/d/2017-16451 (Accessed: August 10, 2017)
2. Committee on Sleep Medicine and Research Board on Health Sciences Policy. Sleep disorders and Sleep Deprivation--An Unmet Public Health Problem. Washington, D.C.: National Academies Press, 2006; 404.
3. Tregear S, Reston J, Schoelles K, Phillips B.Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009 Dec 15;5(6):573-81. [PubMed]
4. Kales SN, Straubel MG.Obstructive sleep apnea in North American commercial drivers. Ind Health. 2014;52(1):13-24. [CrossRef] [PubMed]
5. Anonymous. Hidden health crisis costing America billions. Underdiagnosing and undertreating obstructive sleep apnea draining healthcare system. Last updated: 2016. Available at: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx (Accessed: August 15, 2017)
6. Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with employer-mandated sleep apnea treatment and increased risk of serious truck crashes. Sleep. 2016 May 1;39(5):967-75. [CrossRef] [PubMed]
7. Tregear S, Reston J, Schoelles K, Phillips B.Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1373-80. [CrossRef] [PubMed]
8. Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med. 2010 May;52(5):473-7. [CrossRef] [PubMed]
9. Anonymous Hoboken train crash investigation hampered by heavy damage. CBS News. 2016; Available at: http://www.cbsnews.com/news/hoboken-train-crash-investigation-hampered-heavy-damage/ (Accessed: August 15, 2017)
10. Anonymous. December 2013 Spuyten Duyvil derailment. Last updated: 2017. Available at: https://en.wikipedia.org/wiki/December_2013_Spuyten_Duyvil_derailment (Accessed: August 10 , 2017)
11. National Transportation Safety Board. ​Metro-North Railroad Derailment. Last updated: 2014. Available at: https://www.ntsb.gov/investigations/AccidentReports/Pages/RAB1412.aspx (Accessed: August 15, 2017)
12. Lee D.  Sleep Test Leads to $6M Greyhound Settlement. Last updated: 2016. Available at: http://oldarchives.courthousenews.com/2016/03/09/sleep-test-leads-to-6m-greyhound-settlement.htm (Accessed: March 9, 2017)
13. National Transportation Safety Board. Highway Accident Report: Truck‐Tractor Semitrailer Rear‐End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma June 26, 2009. Last updated: 2010. Available at: https://www.ntsb.gov/investigations/AccidentReports/Reports/HAR1002.pdf (Accessed: August 10, 2017)

Cite as: Quan SF, Barger LK, Weaver MD, Czeisler CA. Saving lives or saving dollars: The Trump administration rescinds plans to require sleep apnea testing in commercial transportation operators. Southwest J Pulm Crit Care. 2017;15:84-6. doi: https://doi.org/10.13175/swjpcc102-17 PDF 

Disclosures 

Editor's note: In 2016 Dr. Quan authored an editorial titled "Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now" in SWJPCC. The editorial encouraged screeening of transportation workers for sleep apnea.

IOM Releases Report on Graduate Medical Education

On July 29 the Institute of Medicine (IOM) released a report on graduate medical education (GME) (1). This is the residency training that doctors complete after finishing medical school. This training is funded by about $15 billion annually from the Federal government with most of the monies coming from the Center for Medicare and Medicaid Services (CMS). The report calls for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid. Instead payments would be made to community clinics phased in over about 10 years. To administer the program, the report recommends the formation of two committees: 1. A GME Policy Council in the Office of the Secretary of the U.S. Department of Health; and 2. A GME Center within the Centers for Medicare & Medicaid Services to manage the operational aspects of GME CMS funding. The later committee would administer two funds: 1. A GME Operational Fund to distribute ongoing support for residency training positions that are currently approved and funded; and 2. A GME Transformation Fund to finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.

If adopted, the plan would end decades of attempts by CMS to coerce medical school graduates into primary care, especially in rural, underserved areas. By controlling funding for GME training, CMS would be able to dictate how physician training. Negative reaction was expected and swift from the American Hospital Association, the American Medical Association and the American Council on Graduate Medical Education, whose members would lose CMS money (2-4). Also expected, the proposal was supported by the American Academy of Family Physicians whose members who would gain under the proposal (5).

The IOM committee has a point. Despite a growing public investment in GME, there are persistent problems with uneven geographic distribution of physicians, too many specialists, not enough primary care providers, and a lack of cultural diversity in the physician workforce. Furthermore, according to the report "a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice.”

However, can a committee formed by CMS be expected to improve the health of America? Based on the composition of the committee and their past performance we think not. First, the committee was co-chaired by Don Berwick who was head of the Institute for Healthcare Improvement (IHI), CMS Administrator and presently a candidate for Massachusetts governor (6). During Berwick's tenure, the IHI proposed a number of non- or weakly evidence-based metrics. Many of these have been found to make no impact on patient-centered outcomes such as mortality, length of stay, readmission rates, morbidity, etc. (7). An example was the 18 month 100,000 Lives Campaign which according to Berwick prevented 122,300 avoidable deaths. However, the methodology, incomplete data and sloppy estimation of the number of deaths makes Berwick's claim dubious. Furthermore, when the campaign was expanded to the 5,000,000 Lives Campaign the "results" could not be reproduced. Also during Berwick's tenure, IHI prematurely championed tight control of blood sugar in the ICU, an intervention which resulted in a 14% increase in ICU mortality when properly studied (8). Undaunted, Berwick put many of these same meaningless metrics in place when he became administrator of CMS. One of these metrics, readmission rates, has been associated with a higher mortality (9). Now Berwick is running for Massachusetts governor. One wonders how politics might have affected the report.

Other members of the committee include the committee co-chair, Gail Wilensky, who was administrator of HCFA (the precursor of CMS), nurses, physician assistants, economists, a representative from industry and a number of academics. Missing were members of the large community of practicing physicians. It seems the IOM committee was assembled to produce a political rather than an evidence-based answer of how to solve patient care disparities. To paraphrase a well-known quote, the first casualty of politics is usually the truth. It seems likely that the proposed GME Center within CMS would have a similar composition to Berwick's present IOM committee and would likely offer political rhetoric rather than meaningful reform to GME. Similarly to those championed by Berwick at IHI and later CMS, we suspect that a series of meaningless metrics would be required that would do nothing other than add a paper burden to a medical system already drowning in paperwork. By removing local control, CMS will likely ignore local strengths. For example, the University of Colorado has an extremely strong pulmonary and critical care division. Although America needs this physician expertise, especially critical care, it seems likely that CMS might move these residency slots to family practice or general medicine. We believe that local control with appropriate incentives, is more likely to solve these problems than a centralized bureaucracy in Washington.

Lastly, a word about the report's claim graduates lack the skills to perform basic procedures. Our observations are similar and we are inclined to accept the claim. However, we point out that it was decisions of committees such as those proposed that required attending physicians to perform procedures in order to be reimbursed and that residents have fewer opportunities to perform procedures due to work hour restrictions. The committee's implication that somehow physician trainers are to blame seems quite disingenuous. Not identified in the report but crucial to physician development is developing skills to critically evaluate medical literature, rather than blindly follow the guidelines proposed by CMS, IHI or others of a similar ilk. 

The proposals in the IOM report are a bad idea from a committee whose head has been rife with bad ideas. The committee's report is not the "New Flexner Report" but will be the coffin nail in the death of quality, caring physicians if adopted.

Richard A. Robbins, MD

Clement U. Singarajah, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

References

1. Institute of Medicine. Graduate medical education that meets the nation's health needs. July 29, 2014. Available at: http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx (accessed 8/5/14).
2. American Hospital Association. IOM panel recommends new financing system for physician training. July 29, 2014. Available at: http://www.ahanews.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_072914_IOM&domain=AHANEWS (accessed 8/5/14).
3. Hoven AD. AMA urges continued support for adequate graduate medical education funding to meet future physician workforce needs. July 29, 2014. Available at: http://www.ama-assn.org/ama/pub/news/news/2014/2014-07-29-support-graduate-medical-education-funding.page (accessed 8/5/14).
4. Kirch DG. IOM’s vision of GME will not meet real-world patient needs. July 29, 2014. Available at: https://www.aamc.org/newsroom/newsreleases/381882/07292014.html (accessed 8/5/14).
5. Blackwelder R. Recommended GME overhaul will support a physician workforce to meet nation’s evolving health needs. July 29, 2014. Available at: http://www.aafp.org/media-center/releases-statements/all/2014/gme-physician-workforce.html (accessed 8/5/14).
6. About Don. Available at: http://www.berwickforgovernor.com/about-don (accessed 8/5/14).
7. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
8. NICE-SUGAR Study Investigators. Intensive versus conventional insulin therapy in critically ill patients. N Engl J Med 2009;360:1283-97. [CrossRef] [PubMed]

Reference as: Robbins RA, Singarajah CU. IOM releases report on graduate medical education. Southwest J Pulm Crit Care. 2014;9(2):123-5. doi: http://dx.doi.org/10.13175/swjpcc107-14 PDF