Friday, December 19, 2008

BBC NEWS | Health | People 'still willing to torture'

Decades after a notorious experiment, scientists have found test subjects are still willing to inflict pain on others - if told to by an authority figure.

US researchers repeated the famous "Milgram test", with volunteers told to deliver electrical shocks to another volunteer - played by an actor.

Even after faked screams of pain, 70% were prepared to increase the voltage, the American Psychology study found.

Both may help explain why apparently ordinary people can commit atrocities.

Yale University professor Stanley Milgram's work, published in 1963, recruited volunteers to help carry out a medical experiment, with none aware that they were actually the subject of the test.

A "scientist" instructed them to deliver a shock every time the actor answered a question wrongly.

When the pretend 150-volt shock was delivered, the actor could be heard screaming in pain, and yet, when asked to, more than eight out of ten volunteers were prepared to give further shocks, even when the "voltage" was gradually increased threefold.

Some volunteers even carried on giving 450-volt shocks even when there was no further response from the actor, suggesting he was either unconscious or dead.

Similar format

Dr Jerry Burger, of Santa Clara University, used a similar format, although he did not allow the volunteers to carry on beyond 150 volts after they had shown their willingness to do so, suggesting that the distress caused to the original volunteers had been too great.

Again, however, the vast majority of the 29 men and 41 women taking part were willing to push the button knowing it would cause pain to another human.

Even when another actor entered the room and questioned what was happening, most were still prepared to continue.

He told Reuters: "What we found is validation of the same argument - if you put people in certain situations, they will act in surprising and maybe often even disturbing ways."

He said that it was not that there was "something wrong" with the volunteers, but that when placed under pressure, people will often do "unsettling" things.

Even though it was difficult to translate laboratory work to the real world, he said, it might partly explain why, in times of conflict, people could take part in genocide.

Complex task

Dr Abigail San, a chartered clinical psychologist, has recently replicated the experiment for a soon-to-be-aired BBC documentary - all the way up to the 450-volt mark, again finding a similar outcome to Professor Milgram.

"It's not that these people are simply not good people any more - there is a massive social influence going on."

She said that the volunteers were being asked to carry out a complex task in aid of scientific research, and became entirely focused on it, with "little room" left for considering the plight of the person receiving the shock.

"They tend to identify massively with the 'experimenter', and become very engaged and distracted by the research.

"There's no opportunity for them to say 'What's my moral stand on this?'"

Do Patients Trust Doctors Too Much? -

When a doctor friend of mine recently heard a radio ad for a Web site where patients could rate their doctors, he almost drove off the road.

"I can't believe they've added doctors to the list," he said of the site, Angie's List, perhaps best known for its user-generated report cards on local contractors. "Why do patients want to assess my relationship with them in the same way they evaluate a roofing job?" he asked, shaking his head over what he interpreted to be more evidence of the disintegrating doctor-patient relationship.

I agreed with my friend and, not long after our conversation, curiosity piqued, I paid for a subscription to the site.

The pages seemed to overflow with information. There were reviews of roofers, childcare providers, dog walkers and tattoo and piercing shops. One of the newest and most popular categories was doctors, where reviewers could grade their doctors by answering the site's specific questions and elaborate with additional comments.

Doctors, like every other business, service, and facility listed, were evaluated using the same generic report card. Everyone received a grade for each of five categories — price, quality, responsiveness, punctuality, and professionalism — as well as an answer to the all-important bottom line question: Hire again?

So much for Marcus Welby, I thought, after going through a couple of the reviews.

But the more I read, the more I realized that there was a correlation between good grades and attentiveness. Reviewers gave less-than-passing, and even failing, grades to those physicians who seemed rushed, brusque or distracted; and they uniformly gave "A's" and "B's" to doctors who were warm, concerned and focused.

Even more could be gleaned from what went unsaid. Amongst the many comments I read, I found almost no mention of a doctor's actual medical skill.

That was not the case with roofers, for example, where in addition to grades, reviewers' comments offered great specifics — and even photographs — regarding the quality of the handiwork, the types of supplies used and the aesthetics of the finished product. All the detailed commentaries fleshed out each company's final grades, and it was easy to get a pretty good sense of an individual roofer's skill and craftsmanship.

With doctors, however, there were no detailed descriptions of medical skill beyond the overall grade. Instead, the playing field seemed oddly level. One surgeon, it appeared, could operate much like another; pediatricians and internists could diagnose and manage with similar abilities; and obstetricians could deliver babies regardless of shape, size, or form. All doctors, whatever their grades, seemed to possess similar and interchangeable skills that they could then apply to you. You just might not like the way they treated you in the process.

I found this extraordinary degree of trust astonishing. When I look for a doctor, of course I am concerned about how that doctor relates to me as a patient. But there are a whole host of other issues I consider as well, such as the physician's training, board certification, experience, membership in a respected professional society, safety records and hospital affiliations. And I admit that I don't feel comfortable as a patient in another doctor's hands until I learn the answers to at least some of my questions.

But as it turns out, most patients don't feel the same way. And many of them are just as trusting when it comes to treatment specifics.

Earlier this year, the American College of Surgeons, the national scientific and educational organization of surgeons, conducted a nationwide survey that found that the average patient devotes an hour or less to researching his or her surgery or surgeon. While prospective patients worry about the costs or complications of an operation, they don't necessarily look for information that would address their concerns.

In fact, more than a third of patients who had an operation in the last five years never reviewed the credentials of the surgeon who operated. Patients are more likely to spend time researching a job change (on average, about 10 hours) or a new car (8 hours) than the operation they are about to submit to or the surgeon who wields the knife. And many patients are satisfied with the answers they receive from their surgeon or primary care doctor, whoever those individuals happen to be.

I was intrigued by the survey, so I called Dr. Thomas Russell, executive director of the American College of Surgeons. "There is a tendency, probably more so now than in the era of Marcus Welby, for patients not to get particularly involved and not to feel compelled to look into their surgery or surgeons," he told me.

There are consequences to that kind of blind trust. "Today, medicine and surgery are really team sports," Dr. Russell continued, "and the patient, as the ultimate decision maker, is the most important member of the team. Mistakes can happen, and patients have to be educated and must understand what is going on."

Dr. Russell has made it part of his personal mission to educate patients and recently wrote a book, "I Need an Operation...Now What? A Patient's Guide to a Safe and Successful Outcome," as a response to the survey. "Patients and their families need to be armed with the fortitude and the right questions in order to find the best doctors for their problems," he said.

In other words, a healthy doctor-patient relationship does not simply entail good bedside manners and responsible office management on the part of the doctor. It also requires that patients come to the relationship educated about their doctors, their illnesses and their treatment.

"If we are truly going to reform the health care system in the U.S.," Dr. Russell said, "everybody has to participate actively and must educate themselves. That means doctors, nurses, other health care professionals, lawyers, pharmaceutical companies, and insurance companies. But most of all, it means the patient."

Trust is important. But as Sir Francis Bacon, who was among the first to understand the importance of gathering data in science, once observed, knowledge is power.

Thursday, December 18, 2008

Psychiatrists Revise the Book of Human Troubles -

The book is at least three years away from publication, but it is already stirring bitter debates over a new set of possible psychiatric disorders.

Is compulsive shopping a mental problem? Do children who continually recoil from sights and sounds suffer from sensory problems — or just need extra attention? Should a fetish be considered a mental disorder, as many now are?

Panels of psychiatrists are hashing out just such questions, and their answers — to be published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — will have consequences for insurance reimbursement, research and individuals' psychological identity for years to come.

The process has become such a contentious social and scientific exercise that for the first time the book's publisher, the American Psychiatric Association, has required its contributors to sign a nondisclosure agreement.

The debate is particularly intense because the manual is both a medical guidebook and a cultural institution. It helps doctors make a diagnosis and provides insurance companies with diagnostic codes without which the insurers will not reimburse patients' claims for treatment.

The manual — known by its initials and edition number, DSM-V — often organizes symptoms under an evocative name. Labels like obsessive-compulsive disorder have connotations in the wider culture and for an individual's self-perception.

"This is not cardiology or nephrology, where the basic diseases are well known," said Edward Shorter, a leading historian of psychiatry whose latest book, "Before Prozac," is critical of the manual. "In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors" — political, social and financial.

"What you have in the end," Mr. Shorter said, "is this process of sorting the deck of symptoms into syndromes, and the outcome all depends on how the cards fall."

Psychiatrists involved in preparing the new manual contend that it is too early to say for sure which cards will be added and which dropped.

The current edition of the manual, which was published in 2000, describes 283 disorders — about triple the number in the first edition, published in 1952.

The scientists updating the manual have been meeting in small groups focusing on categories like mood disorders and substance abuse — poring over the latest scientific studies to clarify what qualifies as a disorder and what might distinguish one disorder from another. They have much more work to do, members say, before providing recommendations to a 28-member panel that will gather in closed meetings to make the final editorial changes.

Experts say that some of the most crucial debates are likely to include gender identity, diagnoses of illness involving children, and addictions like shopping and eating.

"Many of these are going to involve huge fights, I expect," said Dr. Michael First, a professor of psychiatry at Columbia who edited the fourth edition of the manual but is not involved in the fifth.

One example, Dr. First said, is binge eating, now in the manual's appendix as a tentative category.

"A lot of people want that included in the manual," Dr. First said, "and there's some research out there, some evidence that drugs are helpful. But binge eating is also a normal behavior, and you run the risk of labeling up to 30 percent of people with a disorder they don't really have."

The debate over gender identity, characterized in the manual as "strong and persistent cross-gender identification," is already burning hot among transgender people. Soon after the psychiatric association named the group of researchers working on sexual and gender identity, advocates circulated online petitions objecting to two members whose work they considered demeaning.

Transgender people are themselves divided about their place in the manual. Some transgender men and women want nothing to do with psychiatry and demand that the diagnosis be dropped. Others prefer that it remain, in some form, because a doctor's written diagnosis is needed to obtain insurance coverage for treatment or surgery.

"The language needs to be reformed, at a minimum," said Mara Keisling, executive director of the National Center for Transgender Equity. "Right now, the manual implies that you cannot be a happy transgender person, that you have to be a social wreck."

Dr. Jack Drescher, a New York psychoanalyst and member of the sexual disorders work group, said that, in some ways, the gender identity debate echoed efforts to remove homosexuality from the manual in the 1970s.

After protests by gay activists provoked a scientific review, the "homosexuality" diagnosis was dropped in 1973. It was replaced by "sexual orientation disturbance" and then "ego-dystonic homosexuality" before being dropped in 1987.

"You had, in my opinion, what was a social issue, not a medical one; and, in some sense, psychiatry evolved through interaction with the wider culture," Dr. Drescher said.

The American Psychiatric Association says the contributors' nondisclosure agreement is meant to allow the revisions to begin without distraction and to prevent authors from making deals to write casebooks or engage in other projects based on the deliberations without working through the association.

In a phone interview, Dr. Darrel A. Regier, the psychiatric association's research director, who with Dr. David Kupfer of the University of Pittsburgh is co-chairman of the task force, said that experts working on the manual had presented much of their work in scientific conferences.

"But you need to synthesize what you're doing and make it coherent before having that discussion," Dr. Regier said. "Nobody wants to put a rough draft or raw data up on the Web."

Some critics, however, say the secrecy is inappropriate.

"When I first heard about this agreement, I just went bonkers," said Dr. Robert Spitzer, a psychiatry professor at Columbia and the architect of the third edition of the manual. "Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything."

Scientists who accepted the invitation to work on the new manual — a prestigious assignment — agreed to limit their income from drug makers and other sources to $10,000 a year for the duration of the job. "That's more conservative" than the rules at many agencies and universities, Dr. Regier said.

This being the diagnostic manual, where virtually every sentence is likely to be scrutinized, critics have said that the policy is not strict enough. They have long suspected that pharmaceutical money subtly influences authors' decisions.

Industry influence was questioned after a surge in diagnoses of bipolar disorder in young children. Once thought to affect only adults and adolescents, the disorder in children was recently promoted by psychiatrists on drug makers' payrolls.

The team working on childhood disorders is expected to debate the merits of adding pediatric bipolar as a distinct diagnosis, experts say. It is also expected to discuss whether Asperger's syndrome, a developmental disorder, should be merged with high-functioning autism. The two are virtually identical, but bear different social connotations.

The same team is likely to make a recommendation on so-called sensory processing disorder, a vague label for a poorly understood but disabling childhood behavior. Parent groups and some researchers want recognition in the manual in order to help raise money for research and obtain insurance coverage of expensive treatments.

"I know that some are pushing very hard to get that in," Dr. First said, "and they believe they have been warmly received. But you just never know for sure, of course, until the thing is published."

In all, it is a combination of suspense, mystery and prepublication controversy that many publishers would die for. The psychiatric association knows it has a corner on the market and a blockbuster series. The last two editions sold more than 830,000 copies each.

Wednesday, December 17, 2008

Wait-Listed to Death -

The United States recently passed a tragic milestone. For the first time, there are more than 100,000 Americans waiting for an organ transplant. If recent history is any guide, more than 6,000 of them will die waiting this year.

The outrage is that the federal government makes it extremely difficult to find a donor. A law to prevent the buying and selling of organs has had the unintended consequence of discouraging almost all incentives to donate, including state tax deductions. Arlen Specter (R., Pa.) is trying to convince his

Senate colleagues to pass a life-saving rewrite.

It wasn't supposed to be this way when Congress passed the National Organ Transplant Act of 1984, sponsored by then-Senator Al Gore. As federal laws go, this one isn't our favorite, creating as it did a national bureaucracy to allocate donated livers, kidneys, hearts and other organs. But Senator Gore correctly stated at the time that if voluntary efforts failed to provide enough organs to save patients, then incentives should be created to encourage donation.

The problem occurred when Congress added a provision subjecting donors and patients to criminal penalties of up to five years in prison and a $50,000 fine if "valuable consideration" was provided to a donor. Members wanted to prevent for-profit businesses from paying poor people in the Third World to give up their livers for rich American patients. But since "valuable consideration" carries the threat of jail time, it has encouraged everyone involved to make an overly broad interpretation.

After Pennsylvania passed a pilot program in 1994 to pay burial expenses for organ donors, state employees refused to implement the law for fear of federal prosecution. The impact of the federal statute is as appalling as it is ironic. Kidney transplant recipient Sally Satel has noted that burial and cremation expenses can be provided when a body is donated to science -- as long as it isn't used to save the life of a current patient.

While the chilling effect of the federal ban has remained since 1994, the national transplant waiting list has more than quadrupled. This may be why organizations like the National Kidney Foundation, which has previously opposed all incentives to encourage the gift of life, are now reconsidering. NKF tells us that board members will review its position at a meeting next month.

Only half of families now choose to donate the organs of a deceased loved one, adding up to about 8,000 deceased donors each year. While about 6,000 living donors choose each year to help friends and family, fewer than 100 Good Samaritans show up each year at transplant centers to make living donations to strangers. Despite the growing transplant waiting list, the total number of organ donors decreased slightly in 2007.

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All Those Little Words Can Mean A Lot To A Patient - Dr . Yoel Abells, National Post

The power of language is profound. The words we say and the way we say them can have a significant impact upon the person to whom these are directed. A minor alteration in the way something is phrased can mean the difference between offering hope or despair, between providing one with a sense of success or failure. Nowhere is this more apparent than in physician-patient interactions.

I can recall a number of years ago having a patient who was in labour. She was fully dilated and had been pushing for quite some time. It had become apparent that she would not deliver vaginally and would require a Caesarean section. I was mortified when I heard the resident explain to her that the reason for the operation was that she was unable to bring the baby down the birth canal. Not surprisingly, upon hearing this, the patient was distraught. She felt that the necessity for surgery was her fault. Greater sensitivity in wording would have prevented her from feeling this way. What should have been said was that the baby would not move down, thereby reassuring the mother that her effort was not the problem.

At around that time, the importance of language in the patient-doctor relationship was highlighted by Dr. Robert Buckman in his seminal work How to Break Bad News: A Guide for Health Care Professionals. Published in 1992, the book's goal was to provide health care providers

It was clear that little or no time was being spent teaching medical students how to communicate (physicians in particular) practical guidelines for imparting information to patients, especially when the news was bad. It was clear that little or no time was being spent teaching medical students how to communicate, and there were no textbooks available to provide direction. This book was intended to fill the gap. In many ways it did. Moreover, medical schools started to place greater focus on helping students learn the nuances of communication. As a result, further positive changes have occurred.

Unfortunately, over the past few years, I have begun to see a return to old, bad habits. Perhaps because of heavier workloads, or due to the science of medicine having become so overwhelmingly complex, cavalier use of language has reappeared. This must not be allowed to happen because--much as was the case with my patient in labour -- patient care suffers. Dr. Jerome Groopman addresses this issue in his most recent book How Doctors Think: "Most of what doctors do is talk and the communication piece is not separable from doing quality medicine. You need information to get at the diagnosis and the best way to get information is by establishing rapport with the patient. Competency is not separable from communication skills. It's not a trade-off."

The art of medicine is no less important than the science. It is rooted in clear and compassionate interactions between physicians and their patients. Today's doctors need to be reminded of this. Moreover, our institutions of medical training must reinvest time into teaching tomorrow's physicians how to effectively connect with patients using the sublime power of words.

Tuesday, December 16, 2008

Are Nut Bans Promoting Hysteria? - Well Blog -

Every parent of a school-age child has heard the warnings about nut allergies. Some schools ban nuts entirely, while others set aside special nut-free tables. Parents are often quizzed about the ingredients and preparation methods for birthday treats they send to school. One parent told me she was asked whether a clean knife used to cut brownies had ever been used to spread peanut butter.

While nut allergies are clearly a risk to some children, often the response to this health concern represents “a gross overreaction to the magnitude of the threat,” argues Dr. Nicholas A. Christakis, an internal medicine doctor and professor at Harvard Medical School, in a recent column in the British medical journal BMJ.

In the column, Dr. Christakis points out that about 3.3 million Americans are allergic to nuts, and even more — 6.9 million — are allergic to seafood. But of 30 million hospitalizations each year, just 2,000 are due to food allergies, and about 150 people die annually from serious allergic food reactions. That’s the same number of people killed by bee stings and lightning strikes combined. About 10,000 children are hospitalized annually with traumatic brain injuries from sports, 2,000 children drown each year, and about 1,300 die in gun accidents, he writes.

Dr. Christakis notes that while it’s reasonable for schools and parents to take basic precautions, there is no scientific evidence that nut bans are particularly effective at protecting children. But more important, he argues, is that limiting widespread exposure to nuts can make things worse. The “policy of avoidance” means that fewer children are being exposed to nuts, likely increasing their risk for developing an allergy. A 2008 study in The Journal of Allergy and Clinical Immunology of 10,000 British children found that early exposure to peanuts lowers risk of allergy, rather than increasing it.

Dr. Christakis is best known for his work on social networks and the effect they can have on health issues like obesity, smoking and even happiness. He also argues that extensive efforts to protect children from nuts has created a culture of anxiety that spreads.

“We try to relieve anxiety about nut allergy by signs saying, ‘this is a nut free zone,’ which suggests that nuts are a clear and present danger,” Dr. Christakis said. “But in doing so, we increase the anxiety.”

To read more about Dr. Christakis’s research, go to his Web site, where you will also find a link to the full BMJ article, “This Allergies Hysteria Is Just Nuts.”

What an End-of-Life Adviser Could Have Told Me - The New Old Age Blog -

If only I’d had the 800 number for Compassion & Choices in the last difficult months of my mother’s life. She was paralyzed, incontinent and unable to speak. I watched the light leave her eyes and her body crumple like a rag doll’s, and I knew that one day soon she would say, “Enough.”

During this period, my mother and I talked and talked and talked about her end-of-life choices, as we had for many years. A decade earlier the conversation had seemed totally academic, even a bit weird. But now we were both grateful that this was familiar territory. At regular family meetings at the nursing home where she lived, the social workers, nurses and doctors joined what had been our private dialog. Our willingness to look my mother’s certain death squarely in the eye, they said, was both unusual in families and beneficial to her quality of life.

Despite my mother’s helplessness and misery those last months, she wasn’t dying of anything. She had a garden-variety set of ailments for an 87-year-old woman: high blood pressure, diabetes, arthritis, an inner-ear disturbance. A series of imperceptible strokes, known as T.I.A.’s, had left her body useless. But they didn’t necessarily portend a deadly event. She’d dodged the bullets of cancer, serious heart or pulmonary disease, and dementia. It is not uncommon, having lived past 85, to keep on living for a very long time — “healthy” in the narrow sense of the word, but increasingly incapacitated. That, alas, was my mother’s fate.

She often longed for the oblivion of Alzheimer’s disease. But her sharp mind — she never skipped a beat — entitled her to organize her own death, within legal limits, which she did by deciding to stop food and hydration. We had discussed and researched this option, and we had read enough to be reasonably confident this manner of dying was not a frightful ordeal but rather a gentle death. We trusted that an enlightened nursing home like the one she was in wouldn’t force her to eat and drink. They had readily accepted earlier decisions to forgo diagnostic tests or hospitalizations, and later antibiotics for pneumonia.

Our study of what is known as V.S.E.D., or “voluntarily stopping eating and drinking,” was impressive for amateurs, if I do say so myself. My mother had a pretty good death, on her own terms, and we had the nursing home’s full support. I’m proud and grateful to have been able to advocate for her and to have been by her side. That said, there were several rough patches. And after recently meeting Judy Schwarz, the patient support coordinator for Compassion & Choices in New York, I now can see we’d have had an easier time of it had she been along for the ride.

What follows are a few of the bumps in the road that I bet would have been smoothed with her expert guidance.

A Crisis of Confidence for Finance Workers -

Meltdown. Collapse. Depression. Panic. The words would seem to apply equally to the global financial crisis and the effect of that crisis on the human psyche.

Of course, it is too soon to gauge the true psychiatric consequences of the economic debacle; it will be some time before epidemiologists can tell us for certain whether depression and suicide are on the rise. But there’s no question that the crisis is leaving its mark on individuals, especially men.

One patient, a hedge fund analyst, came to me recently in a state of great anxiety. “It’s bad, but it might get a lot worse,” I recall him saying. The anxiety was expected and appropriate: he had lost a great deal of his (and others’) assets, and like the rest of us he had no idea where the bottom was. I would have been worried if he hadn’t been anxious.

Over the course of several weeks, with the help of some anti-anxiety medication, his panic subsided as he realized that he would most likely survive economically.

But then something else emerged. He came in one day looking subdued and plopped down in the chair. “I’m over the anxiety, but now I feel like a loser.” This from a supremely self-confident guy who was viewed by his colleagues as an unstoppable optimist.

He was not clinically depressed: his sleep, appetite, sex drive and ability to enjoy himself outside of work were unchanged. This was different.

The problem was that his sense of success and accomplishment was intimately tied to his financial status; he did not know how to feel competent or good about himself without this external measure of his value.

He wasn’t the only one. Over the last few months, I have seen a group of patients, all men, who experienced a near collapse in their self-esteem, though none of them were clinically depressed.

Another patient summed it up: “I used to be a master-of-the-universe kind of guy, but this cut me down to size.”

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Monday, December 15, 2008 Experts back brain boosters for all

Your son is in his final year of high school and says some of the other students are taking Ritalin to help them concentrate while they study and write exams.

The drug may help him get into the university of his choice or win a scholarship. He wants to try it. What do you say?

Surveys suggest that in the United States, an increasing number of healthy university students are using so-called cognitive-enhancing drugs such as Ritalin and modafinil to improve their academic performance. One found that on some campuses, as many as one in four students used these kinds of drugs to get better marks, and that over all 7 per cent had done so.

The trend is likely to spread, experts say. In this week's edition of the journal Nature, a group of scientists and ethicists say it's time we all started thinking about the benefits of healthy individuals taking drugs to boost their brain power.

Many people consider the non-medical use of these kinds of drugs to be cheating, in the same way that athletes who take performance-enhancing drugs are breaking the rules.

But in their commentary in Nature, Stanford University's Henry Greely and his colleagues argue that taking Ritalin before an exam is no different from eating well or getting enough sleep.

The seven authors, from the United States and Britain, include ethics experts and the editor-in-chief of Nature as well as scientists. They developed their case at a seminar funded by Nature and the Rockefeller University in New York. Two authors said they consult for pharmaceutical companies. The others reported no such financial ties.

"Recent research has identified beneficial neural changes engendered by exercise, nutrition and sleep. In short, cognitive-enhancing drugs seem morally equivalent to other, more familiar enhancements," they argue in the commentary.

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Sunday, December 14, 2008

The Evidence Gap - Weak Patchwork of Oversight Keeps Bad Hospitals Running -

Syracuse - In March 2004, Sharon Yacketta walked into University Hospital here for an operation to help control her incontinence.

But her doctor, Robert S. Lai, botched the procedure, causing urine to leak into her abdomen. A month later, Dr. Lai and a second surgeon perforated her colon during a follow-up operation at University. Four years and 20 operations later, Ms. Yacketta has lost most of her colon and is still incontinent.

“They messed my life up,” Ms. Yacketta said of her surgeons. “I hope those doctors rot.”

Dr. Lai, who has left University and now practices outside Chicago, acknowledged that he and his surgical team had accidentally injured Ms. Yacketta but said he had not been negligent.

Mistakes happen even at good hospitals, of course. But evidence shows that University, which is owned by the State University of New York system, is not a good hospital. In fact, in late 2006 a state commission recommended that it be scaled back and merged with another hospital.

The state’s inability to follow through on that plan for University provides a stark example of how hard it can be — not just in New York, but around the nation — to close or shrink hospitals, even when there is evidence they are providing costly and below-average care.

Certainly the evidence against University Hospital was strong. In 2006, patients at University were three times as likely to develop infections stemming from hospitals as were patients at the average New York hospital. HealthGrades, a company that rates hospitals using data from Medicare, ranks University among the least safe hospitals in the United States — although the hospital’s executives strongly dispute that assertion. University, meanwhile, is expensive to run.

Yet, today, University remains under state ownership. And far from shrinking, University is expanding.

Unlike some other nations, including France, the United States has no federal agency charged with hospital oversight. Instead, it relies on a patchwork of state health departments and a nonprofit group called the Joint Commission that sets basic quality standards for the nation. Hospitals are rarely closed or hit with significant financial penalties for hurting patients.

One of the reasons is that even troubled hospitals are major employers, and communities generally rally behind them when they face the threat of cuts, as Syracuse did for University.

“We haven’t been forthright about the dirty little secret, the huge variation of quality and safety in the system,” said Arthur Aaron Levin, director of the Center for Medical Consumers, a nonprofit patient advocacy group. Nearly a decade after the Institute of Medicine report, preventable errors remain shockingly common, said Mr. Levin, who was a member of the commission that wrote the report.

“It’s nine years later, and we can’t even tell you if it’s better,” Mr. Levin said. “How is that permissible?”

Any effort to maintain national standards is left largely to Medicare and the Joint Commission, a nonprofit group based in Oakbrook Terrace, Ill., which along with state health departments certifies that hospitals are operating safely.

But the commission lacks the heft and enforcement powers of a federal regulator. With fewer than 1,000 employees, it accredits and sets patient safety goals for 17,000 hospitals, nursing homes and assisted-living providers nationally. A typical survey lasts less than a week and involves fewer than a half-dozen examiners, said Dr. Mark R. Chassin, the president of the Joint Commission.

Hospitals account for the largest single slice of the nation’s medical spending, 31 percent, or about $650 billion in 2007, according to Medicare. Despite that enormous bill, hospital care is uneven, and often deadly. In 1999, a report from the Institute of Medicine found that hospital errors caused as many as 98,000 deaths a year in the United States.

Medicare is pressing for quality improvements, using as leverage the $155 billion it spends on hospital care annually. But Herb Kuhn, deputy administrator of the Centers for Medicare and Medicaid Services, said hospitals would not make patient safety their top priority until Medicare changed its reimbursement system.

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