Doctors Who Work for Hospitals Face a New Bottom Line - NYTimes.com

or decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.

But that began to change a few years ago, when the city's largest hospital, St. Luke's Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground.

A little over half of the 1,400 doctors in southwestern Idaho are employed by St. Luke's or its smaller competitor, St. Alphonsus Regional Medical Center.

Many of the independent doctors complain that both hospitals, but especially St. Luke's, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit.

In interviews, they said their referrals from doctors now employed by St. Luke's had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.

Boise's experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe growing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.

In Boise, just a few weeks ago, even the hospitals were at war. St. Alphonsus went to court seeking an injunction to stop St. Luke's from buying another physician practice group, arguing that the hospital's dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers. The price of a colonoscopy has quadrupled in some instances, and in other cases St. Luke's charges nearly three times as much for laboratory work as nearby facilities, according to the St. Alphonsus complaint.

Federal and state officials have also joined the fray. In one of a handful of similar cases, the Federal Trade Commission and the Idaho attorney general are investigating whether St. Luke's has become too powerful in Boise, using its newfound leverage to stifle competition.

Dr. David C. Pate, chief executive of St. Luke's, denied the assertions by St. Alphonsus that the hospital's acquisitions had limited patient choice or always resulted in higher prices. In some cases, Dr. Pate said, services that had been underpriced were raised to reflect market value. St. Luke's, he argued, is simply embracing the new model of health care, which he predicted would lead over the long term to lower overall costs as fewer unnecessary tests and procedures were performed.

Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. "We're seeing a lot more consolidation than we did 10 years ago," said Jeffrey Perry, an assistant director in the F.T.C.'s Bureau of Competition. "Historically, what we've seen with the consolidation in the health care industry is that prices go up, but quality does not improve."

A Drive to Consolidate

An array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation in health care and transforming the practice of medicine in Boise and other communities large and small. In one manifestation of the trend, hospitals, private equity firms and even health insurance companies are acquiring physician practices at a rapid rate.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000, according to estimates by Accenture, a consulting firm.

Many policy experts praise the shift away from independent practices as a way of making health care less fragmented and expensive. Systems that employ doctors, modeled after well-known organizations like Kaiser Permanente, are better able to coordinate patient care and to find ways to deliver improved services at lower costs, these advocates say. Indeed, consolidation is encouraged by some aspects of the Obama administration's health care law.

"If you're going to be paid for value, for performance, you've got to perform together," said Dr. Ricardo Martinez, chief medical officer for North Highland, an Atlanta-based consultant that works with hospitals.

The recent trend is reminiscent of the consolidation that swept the industry in the 1990s in response to the creation of health maintenance organizations, or H.M.O.'s — but there is one major difference. Then, hospitals had difficulty managing the practices, contending that doctors did not work as hard when they were employees as they had as private operators. Now, hospitals are writing contracts more in their own favor.

"Hospitals are constructing compensation in ways that are based on productivity and performance," said Steve Messinger, president of ECG Management Consultants, which advises on physician acquisitions.

But the consolidation of health care may be coming at a hefty price. By one estimate, under its current reimbursement system, Medicare is paying in excess of a billion dollars a year more for the same services because hospitals, citing higher overall costs, can charge more when the doctors work for them. Laser eye surgery, for example, can cost $738 when performed by a hospital-employed doctor, compared with $389 when done by an unaffiliated doctor, according to national estimates by the independent Congressional panel that oversees Medicare. An echocardiogram can cost about twice as much in a hospital: $319, versus $143 in a doctor's office.

Conflicts over the changes are numerous. One Florida primary care physician said he could earn a $5,000 bonus for keeping patients in the hospital for less than three days, according to a lawsuit he filed this year. Hospitals, which are typically reimbursed a fixed amount of money for treating a specific illness, can make more money if patients stay for shorter periods of time.

Last month, the Justice Department reached a $9.3 million settlement with Freeman Health System, a hospital group in Joplin, Mo., which was rewarding doctors it employed partly based on how many tests they ordered. Freeman says that it alerted regulators to the potential violations and that patient care was not affected.

Recently, the Office of Inspector General at the Health and Human Services Department sent a letter to emergency physicians across the country asking for information about inappropriate admissions. Federal regulators are also examining the higher numbers of physician contracts being created, searching for violations of laws that prevent hospitals from rewarding doctors for admitting patients or for ordering lucrative tests and procedures.

Health Management Associates, a for-profit hospital chain; EmCare, a Dallas-based emergency room staffing company for hospitals; and other hospitals have disclosed that they are the subjects of federal investigations. Regulators are looking into whether the hospitals improperly pressured physicians to admit patients.

Pumping Up Admissions

According to two emergency room doctors who worked at Carlisle Regional Medical Center in Pennsylvania, the message could not have been clearer: more patients needed to be admitted.

The doctors were employed by EmCare, whose parent company was later acquired by the private equity firm Clayton, Dubilier & Rice in 2011 as part of a $3.2 billion deal. EmCare, in turn, was under contract to provide emergency room doctors for the hospital, which is owned by Health Management Associates. In interviews, doctors said that hospital administrators created targets for how many patients they should admit. More admissions translated into more dollars for the hospital.

Dr. Jean-Paul Romes, one of the physicians, recalled getting phone calls in the middle of the night questioning why he had not admitted an older patient whose hospitalization he could easily have justified. "The pressure to admit was so high," he said. Dr. Romes left the hospital last year.

After another physician, Dr. Cloyd B. Gatrell, raised concerns that the hospital had too few nurses to keep patients safe, an EmCare executive warned him to "back off," according to a lawsuit Dr. Gatrell filed last year. EmCare later fired him at Carlisle's request, according to the suit. Dr. Gatrell's wife, Kathryn, a nurse at Carlisle, had been fired earlier and also filed a lawsuit. Both Gatrells maintained they were fired for bringing up patient safety concerns, according to Dr. Gatrell's lawsuit.

Health Management, which operates 70 hospitals, said United States attorneys' offices in seven states were investigating physician referrals, including financial arrangements and the "medical necessity of emergency room tests and patient admissions."

EmCare said in an e-mailed statement that it could not comment on continuing legal matters involving it or its clients, but that its "first concern is the well-being of the patient."

Health Management is also the target of a suit filed last year in Florida state court by a former executive who says there were improper admissions. The executive, Paul Meyer, an officer in the company's compliance office, was a longtime employee of the Federal Bureau of Investigation. He said in his lawsuit that he was fired from H.M.A. in 2011 in retaliation for raising questions about what he felt were improper admissions at four of the chain's hospitals. H.M.A. said its overall admission rate from the emergency department had remained constant in recent years and that its practices were in line with those of other hospitals. It also said there was no indication that Carlisle admitted any patients unnecessarily. Admissions are "based solely on what is best for patient care," it said in an e-mailed statement.

The company said that it had addressed all of Mr. Meyer's concerns, and that he was fired for what the company said was a failure to cooperate in an internal investigation. Health Management fired the Gatrells, it said, "for performance issues," an accusation Dr. Gatrell strongly denied.

Doctors at other hospitals also say they have faced pressure to meet financial targets. Dr. Manuel Abreu said his contract with All Care Medical Consultants, a practice in Clearwater, Fla., allowed him to earn a bonus as high as $5,000 if he kept patients' hospital stays to an average of no more than three days, according to a copy of the contract included with a lawsuit he filed in Florida state court this year. The parties reached a settlement and the case was voluntarily dismissed, court records show. Calls to Dr. Abreu's lawyer and a lawyer for All Care were not returned.

Other physicians say they are pushed to ignore what is best for patients by referring them to doctors working for the same hospital. Dr. Victoria Rentel, a family practice doctor near Columbus, Ohio, recalled feeling pressured when she was employed by a local hospital to send her patients to doctors there for tests and procedures.

"I routinely got reports about the money I kept in the system," Dr. Rentel said, detailing how much revenue she was generating for the hospital through in-house referrals. "I tended to refer to specialists I knew who would deliver better care." The hospital eventually closed the clinic where she worked.

Some physicians also complain about quotas. Dr. Patricia F. White, an emergency room physician who worked at Baptist Health in Jacksonville, Fla., said that starting in 2010, her compensation was partly calculated based on the number of patients she saw an hour, according to a lawsuit she filed in August against the hospital and Emergency Resources Group, which provided emergency room staffing to Baptist.

The staffing group said it had no choice but to agree to the hospital's demands. "If we don't comply with their wishes as good partners, there is a termination notice in our contract," wrote Paul Davidson, administrator for the group, in a series of e-mails that were included with Dr. White's lawsuit.

In an e-mailed statement, Baptist Health said that patients expected timely access to quality care and that an emergency room physician's "productivity and efficiency are vital components to delivering good patient care as well as ensuring patient safety and satisfaction." A lawyer for Emergency Resources Group echoed those sentiments in an e-mailed statement, adding that efficiency was only one component of physician compensation.

Doctors at numerous hospitals said it was often difficult to criticize the policies instituted by hospitals or investor-owned physician groups because, as employees, they could easily be fired.

"We all have families, and we have mortgages," said an emergency room physician. "If you get fired, it looks bad and it's hard to get another job."

Rising Medical Costs

It was about three years ago that Dr. Julie A. Foote, who has been an endocrinologist in Boise for 18 years, began noticing the ads in the local newspaper.

Each week, another advertisement appeared, heralding the hire of a physician or a practice group by either St. Luke's or St. Alphonsus, which is part of Michigan's Trinity Health, one of the nation's largest hospital systems. "The playing field wound up being divvied up pretty aggressively," Dr. Foote said.

In the last four years, St. Luke's acquired 22 physician practices in the area.

Dr. Mark Johnson, a family practice physician who has worked in Boise for about 25 years, was part of a five-person practice that sold itself to St. Luke's. Among the factors behind the decision were the high cost of adopting an electronic health records system, and a concern that the group members would not be able to find younger doctors willing to buy them out of the practice.

"But probably the driving reason was the changing landscape of health care delivery and the uncertainty around that," Dr. Johnson said. "The thought was that we were going to be in a safer position if we were aligned and affiliated with a network."

But as St. Luke's moved forward with its plans to acquire most of the Saltzer Medical Group — a practice of about 50 doctors in Nampa, Idaho, about 20 miles west of Boise — St. Alphonsus filed an injunction to block the purchase.

St. Alphonsus argues that St. Luke's dominance is hurting its business because it has experienced steep declines in hospital admissions and referrals from physicians acquired by St. Luke's.

St. Luke's says it is positioning itself to compete better by improving its ability to coordinate patient care. It recently filed an application with Medicare officials to become a so-called accountable care organization. Hospitals designated as A.C.O.'s can usually keep a portion of any savings they generate. They cut health care costs by avoiding unneeded procedures and tests or by keeping patients out of the hospital, while still meeting quality targets.

But St. Luke's remains under investigation by state and federal authorities for possible antitrust violations. While most physician group purchases are too small to draw regulators' attention, concerns have been raised about whether consolidation is resulting in higher prices and fewer choices for patients.

In 2009, the F.T.C. forced the sale of two outpatient clinics that had been acquired by Carilion Clinic, based in Roanoke, Va., saying Carilion's fee structure would have increased patients' out-of-pocket expenses for a brain imaging test, for example, to $350 from $40.

In another case, the F.T.C. and the Nevada attorney general ordered Renown Health in Reno to release 10 cardiologists from their noncompetition agreements after the hospital system bought the two largest cardiology groups in the area, giving it 88 percent of the market.

In Boise, doctors are pressured to refer only within their own system, according to St. Alphonsus in its complaint. It reported a 90 percent drop in admissions to its hospitals by physicians employed by St. Luke's. In one community, independent doctors often send patients 40 miles away for CT scans because prices at St. Luke's are 60 percent higher, the complaint said.

Mr. Pate, the St. Luke's chief executive, disputed the notion that physicians employed by St. Luke's were prohibited from referring patients to outside doctors.

"My own wife was referred by a St. Luke's physician to a St. Al's physician for her particular condition because he felt the St. Al's physician was the best for this problem," he said. "If the wife of the C.E.O. is being referred to a physician at another hospital, that should prove that our physicians send many referrals over there."

Mr. Pate acknowledged that prices for some services had risen, but he said this was only because they had been severely underpriced. In the long run, he argued, overall costs will decline as St. Luke's is better able to coordinate care, avoiding expensive emergency room visits and redundant tests.

But some people remain skeptical that patients will be better served.

"I'm not certain what all this means is that patients are getting cost-effective care, which is how the nation is painting this evolution," Dr. Foote said. "If this is better quality for less price, I want to see the less price."

http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?pagewanted=print&_r=0

Jump Start by Robb Armstrong

Prosthetic Arms a Complex Test for Amputees - NYTimes.com

After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.

The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.

He had been blown up, and was drowning at the bottom of an irrigation ditch.

Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.

Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.

Success.

"As a baby, you can hold onto a finger," the corporal said. "I have to relearn."

It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.

Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body's most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.

To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.

"There are a lot of mental gymnastics with upper limb prostheses," said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.

The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.

Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.

For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.

But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional "sockets" into which electrodes from a prosthetic limb can connect.

More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.

In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.

But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.

Corporal Gallegos was not always that person.

His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.

Corporal Gallegos grew up in Texas, raised in poverty primarily by his divorced mother. He was smart, ambitious and a bit of a know-it-all, said his wife, Tracie, who attended high school with him. A college scholarship seemed assured.

But the idea of military service called louder. "I felt I was too immature to go to school and be some brat in college," he said. The Marine Corps seemed the perfect challenge.

He loved the corps, and the corps seemed to love him. Before deploying in 2010, he was made the leader of a three-man fire team and was sent to learn basic Pashto, the language of Afghanistan's largest ethnic group.

His unit, Lima Company of the Third Battalion, Fifth Marines out of Camp Pendleton, arrived in Helmand Province that September and immediately faced some of the toughest fighting of the war, losing 25 men in seven months, most from improvised explosive devices.

In October, Corporal Gallegos was walking second in a patrol through the Sangin district when he stepped into an irrigation canal, heard a boom and blacked out. When he awoke, he found himself anchored to the bottom by his body armor and weaponry. He tried to pull himself out with his right arm, not realizing it had been virtually severed just below the shoulder.

On an evacuation helicopter, the corporal glimpsed his intact arm wrapped in bandages, giving him hope that doctors could reattach it.

That hope was dashed at Brooke Army Medical Center, where he began the long process of recovery. His attitude, he admits now, was negative, influenced by another Marine who rarely used his prosthetic arm because it was so uncomfortable.

But then Corporal Gallegos met an Air Force amputee who was among the first at Brooke to receive targeted muscle reinnervation surgery. The airman warned him that rehabilitation would be frustrating and painful, but that the payoff would be huge.

"You wouldn't notice, unless you were looking right at him, that he was missing his arm," Corporal Gallegos said. "I was like, 'I want to be better than him.' "

First, though, he had to learn to cope with phantom-limb pain. A pulsing sensation like having a tourniquet applied to the arm, the pain was sometimes powerful enough to keep the strapping corporal in bed, leaving him unable to concentrate or converse.

"He's in constant pain," said Ms. Gallegos, who is in nursing school. "But he just won't complain, because he doesn't want people to ask, 'Are you O.K.?' That question really bugs him."

Over time, medication and surgeries dampened the pain enough that he could throw himself into practicing on a robotic arm. The device, he found, was a brain teaser, frustrating his efforts to make it obey. More than once, he threatened to throw it out the window.

To motivate himself in those moments, he thought about his Marine Corps friends. Eventually he had a skin-tone silicone sleeve for his prosthetic arm engraved with the names of all 10 Marines from Lima Company who died in Sangin. Now, when he needs a lift, he looks at the arm — in the very place he once wore his wife's hair tie — and recites their names like a personal prayer.

As he began wearing mechanical arms longer each day, his prosthetist, Ryan Blanck, decided that he might be ready for targeted reinnervation surgery. The procedure works off the natural ability of muscles to amplify nerve signals. By rerouting nerves into healthy muscle and reshaping the tissue to bring it closer to sensors in the prosthesis, the procedure strengthens the brain's signals, and hence its ability to control the machine.

Wearing the same type of prosthetic arm he had used before, Corporal Gallegos noticed the difference almost immediately. No longer did he have to think so hard about contracting various muscles: when he wanted the arm to move, it did, faster and more fluidly.

That did not mean, however, that it behaved as he wanted. He still has problems with "cross talk," where certain nerves dominate over others. If a wrist nerve dominates, for instance, a patient may have to think about bending the wrist to make the hand close. But with repeated use, the nerves sort themselves out and the need for trickery fades, Dr. Kuiken said.

For all his gains with the prosthesis, Corporal Gallegos has not overcome the embarrassment he feels when wearing his robotic arm in public. Once the hand fell off in a crowded restaurant, eliciting gasps from a nearby child. In darkened movie theaters, the Terminator-like sounds his arm makes draw startled whispers. And to this day, he will not wear short-sleeve shirts to restaurants.

"Even if it is 75 degrees out, I'll wear a jacket just to avoid getting stared at," he said.

For a year after nearly drowning in Afghanistan, Corporal Gallegos could not go near water, any water, even the River Walk, a restaurant-lined path along the San Antonio River. But a therapist pushed him to overcome his anxiety, first by swimming, then kayaking, then surfing.

Ben Kvanli, a former Olympian who runs a kayaking program for disabled troops, said Corporal Gallegos was an ambivalent paddler at first. But his technique was good, partly because the prosthesis forced him to use his core muscles more. And he was fast.

Fast enough, indeed, that Mr. Kvanli is encouraging him to try out for the national Paralympic team next year.

"Independence is a big part of this," Mr. Kvanli said. "He is proving something."

Fiercely self-reliant from childhood, Corporal Gallegos has struggled with losing independence after losing his arm. Suddenly, he had to ask for help with buttons, zippers and shoelaces. And he loathes asking for help.

There are holes in his living room wall that testify to his failed attempts to hang things using his prosthetic arm. And he still cringes at the memory of barking orders at his wife while she assembled a living-room furniture set that he could not assemble himself. "Stuff is a lot more complicated," he said. "I'm still figuring out what my norm's going to be, just on a day-to-day basis."

For that reason, he no longer makes big plans for the future, as he once did. Keep it simple, he tells himself: Get out of the Marine Corps. Go to college. Learn how to tie his shoelaces with a robotic hand.

And maybe, just maybe, become a Paralympian.

So there he was one recent afternoon, kayaking down the sun-dappled San Marcos River, using the wrong prosthesis because he had broken his kayaking limb while surfing. Normally he is at the front of the pack, but today his arm kept slipping off and he seemed in pain as he struggled just to keep up.

Yet he said nothing that could be heard as a complaint. And at the end of the six-hour trip, he went over the 14-foot Graduation Falls, the first time he had done so in a boat. After dropping vertically into the frothing water, his kayak momentarily disappeared beneath the surface before popping out like a cork.

Eyes smiling below the brim of his helmet, Corporal Gallegos paddled to shore, hefted his boat onto his good shoulder and started the trudge upstream.

He did not ask for help.

http://www.nytimes.com/2012/11/27/us/prosthetic-arms-a-complex-test-for-amputees.html?src=me&ref=general

Health, Medical, and Science Updates - Stone Hearth News

Health, Medical, and Science Updates, a newsfeed of sorts, concierged by Stone Hearth News, selectively tracks and reproduces fresh and reliable news and information about health, medicine, science, and the social sciences. 

http://www.stonehearthnewsletters.com/

End of the Line in the ICU - The Brooklyn Rail

Last year I graduated from nursing school and began working in a specialized intensive care unit in a large academic hospital. During an orientation class a nurse who has worked on the unit for six years gave a presentation on the various kinds of strokes. Noting the difference between supratentorial and infratentorial strokes—the former being more survivable and the latter having a more severe effect on the body's basic functions such as breathing—she said that if she were going to have a stroke, she knew which type she would prefer: "I would want to have an infratentorial stroke. Because I don't even want to make it to the hospital."

She wasn't kidding, and after a couple months of work, I understood why. I also understood the nurses who voice their advocacy of natural death—and their fear of ending up like some of our patients—in regular discussions of plans for DNRtattoos. For example: "I am going to tattoo DO NOT RESUSCITATE across my chest. No, across my face, because they won't take my gown off. I am going to tattoo DO NOT INTUBATE above my lip." 

Another nurse says that instead of DNR, she's going to be DNA, Do Not Admit. We know that such plainly stated wishes would never be honored. Medical personnel are bound by legal documents and orders, and the DNR tattoo is mostly a very dark joke. But the oldest nurse on my unit has instructed her children never to call 911 for her, and readily discusses her suicide pact with her husband. You will not find a group less in favor of automatically aggressive, invasive medical care than intensive care nurses, because we see the pointless suffering it often causes in patients and families. Intensive care is at best a temporary detour during which a patient's instability is monitored, analyzed, and corrected, but it is at worst a high tech torture chamber, a taste of hell during a person's last days on earth. 

I cared for a woman in her 90s whose family had considered making her a DNR,but decided against it. After a relatively minor stroke that left her awake but not lucid, Helen* went into kidney failure and started on continuous hemodialysis. Because she kept pulling out her IV lines and the feeding tube we had dropped into her nose and down to her stomach, we put boxing glove-like pillow mitts on her hands. When I approached with her medicine, Helen batted at me with her boxing gloves, saying, "NO. STOP." She frowned, shook her head and then her fist at me. Her wishes were pretty clear, but technically she was "confused," because when asked her name, the date, and her location, she failed to answer. During the next shift, Helen's heart stopped beating. But despite talking with the doctors about her advanced age and the poor state of her health, her family had nonetheless decided that we should "do everything we can" for her, and so Helen died in a frenzy of nurses pumping her with vasopressors and doing chest compressions, probably cracking several ribs. 

That was a situation in which a patient's family made a decision that probably caused Helen to suffer and did not help her. But there are circumstances where it is the healthcare team that chooses to push on with intensive interventions. And there are circumstances where bureaucracy, miscommunication, and the relatively low priority, among very busy physicians, of making decisions about how far to pursue medical care cause patients to linger in the ICU weeks past the point when any medical professional thought meaningful recovery was possible. 

Consider another example, of a patient with advanced cancer, in this case an elderly woman with a well-informed husband who knew his wife was dying and that she didn't want to end her life with an extended ICU stay. After her last tumor resection this woman developed an infection, and during a meeting with her husband the attending physician explained that the main problem we were immediately dealing with was the infection, which was bad and could well be something she would not recover from. The patient's husband explained that he knew that his wife didn't want to be there and that her underlying diagnosis plainly meant that her life was going to end, that they both understood this and didn't want to painfully draw things out. Then he asked if he had any decisions to make—in effect being as blunt as he could without simply insisting that they withdraw care then and there. 

The doctor said no. She said that the patient needed to complete the course of antibiotics to see if the infection could be cured, after which they could approach the question of whether to continue with intensive medical care. I imagine the doctor saw some distinction between letting the patient die of her primary, terminal diagnosis and letting her die of a complication. So the husband's efforts to stick up for his wife went unheard, and she stayed in the ICU, comatose, for about two more weeks—quite the opposite of her stated wish—before everyone agreed to let her go. 

On the other side of the spectrum are the poor forgotten patients, the ones who linger because nobody will speak up for them and the medical team is not legally allowed to decide to do anything short of maintaining life, day after day. One man with a severe stroke languished over a month while his family members dodged the responsibility of visiting, witnessing his condition, and making a decision about his care. Every morning the health care team rounded on him and we discussed the various states of decay of his body—he had severe diarrhea, frank blood in his urine, and ventilator associated pneumonia—and then moved on to discuss the efforts being made to contact his family and impress upon them the need for action. The ICU had nothing to offer him, and someone needed to choose: he would either have a tracheostomy and permanent surgically placed feeding tube in order to be moved to a ventilator dependent nursing home, or have his care withdrawn. 

Similarly, we had a homeless woman with a severe brain injury. CT scans of her brain showed an undifferentiated mass of swollen tissue—this is very bad. We were draining cerebrospinal fluid out of her head because the swelling had obstructed the flow of this fluid, causing hydrocephalus and increased pressure within her brain. Her pupils did not react to light, and she had no corneal reflexes—that is, when you touched her eyeball, she didn't flinch. What kept her from being brain dead was the fact that her ventilator was set to "pressure support," meaning that she initiated breaths, and she still had a cough reflex. 

The first day I took care of her, when she'd already been there over a week, I was told that there was a plan to seek a court-appointed guardian to make her health-care decisions. Any friend or relative could have become her decision maker, but this woman was alone. A few days later—why did it take that long?—the social worker presented the patient in court and a lawyer became her official guardian. This lawyer was unwilling to withdraw care. Further, he was unwilling to make the patient a NO CODE. If her vital signs became unstable and she started to die, we would have to use vasopressors, chest compressions, and defibrillation to keep her heart beating and keep her alive. 

After this, she remained in the ICU for over a week, and the medical team began itching for ways to get her off of the unit, because she began to be seen as a living corpse taking up a critical care bed and its associated resources—things that could save a different very ill person. Eventually, their only objective was to wean her off of the ventilator and move her out of the ICU, so that her continued care would be someone else's issue to deal with. 

These four patients had different injuries and different circumstances. What was common to them was that they all suffered the bodily harm and indignity of being physically invaded in every sense, robbed of their integrity entirely, and pinched and poked continuously during the last days and weeks of their lives. Since nobody at the time thought they were going to get better, the people doing this to them—myself and other nurses—had an overarching question: Why? 

All of us love the opportunity to help save a life. That happens in intensive care, and it is exciting and miraculous. But in the instances I've described, and many, many others, nobody involved is under the delusion that a life is being saved. This is where we become cynical, and where many nurses choose not to reflect on the painful purgatories trapping our patients. Rather, they express their opinions succinctly in wry conversations about DNR tattoos, and they master—or bluff—an exquisite segregation of the mental and physical work of caring for these patients from their own emotional energy. They do this in order to be able to continue working. They get over the absurdity of certain circumstances, and they manage not to care. 

I've not accomplished this. The absurdity weighs me down, and so I want to describe it to you. Medical science can do incredible things. But you would not believe the type of life these life-sustaining treatments often allow. 

People who are at the end of their life and are being kept alive artificially have a way of shutting down. Fighting this process is not a peaceful act. Most of the patients I've described were on ventilators, with plastic tubes pushed into their mouths and down their tracheas in order to provide respiratory support. The tubes are taped to their faces, and patients who can move at all are usually both tied down by their arms and sedated when on a ventilator, because it is so physically uncomfortable that patients will use their last ounce of strength to pull the tube out of their mouth. These patients were already comatose due to their injuries, but other critically ill patients who were previously awake and responsive become unable to speak while on a ventilator. Once intubated, patients are unable to clear their respiratory secretions—phlegm—and so we stick smaller rubber tubes connected to suction into the breathing tube, down their trachea and towards the entrance to the lungs themselves, in order to vacuum the secretions out of their lungs. You can imagine that this too is uncomfortable. 

Patients obviously can't eat, so they will have had a feeding tube pushed up their nose or through their mouth and their esophagus, down into their stomach. This often takes a few tries, requiring us to pull up the bloody tube, re-lube it, and push it back in at a different angle. If a patient is ill long enough, these instruments will be replaced with a tracheostomy in the neck rather than a tube down the mouth and a feeding tube going directly into the stomach rather than down through the nose. These are for patients who aren't expected to be able to eat or breathe independently in the long term. 

These patients often develop diarrhea, sometimes simply because of the liquid food they receive—cans of smelly, nutritionally balanced tan colored slush—and sometimes because they've acquired a very hardy and aggressive bacteria, C. difficile, that is widespread in hospitals and causes profuse, foul stool. If they have diarrhea several times a day and their skin is exposed to it, the skin begins to break down, and so we place a rectal tube in their bottom, held in place beyond the rectum with a small water filled balloon. The diarrhea drains into a clear bag that hangs on the side of the bed. Sometimes when a patient is very sick, as in the case of the man whose family avoided him for over a month after his stroke landed him on my unit, they lose their rectal tone and the tube falls out. This is how I found myself up to my elbows in diarrhea with another nurse, struggling to clean the crevasses of his body and tape an ostomy bag around his bottom, the last hope to contain the flow of stool so that the patient wouldn't sit in a continuous puddle of it while permission for his death was pending. 

Breathing tubes, feeding tubes, and rectal tubes are only part of it. The patients of course have urinary catheters and IVs, often larger IVs that are placed centrally—threaded straight toward the heart to allow us to push drugs in concentrations that would damage smaller veins. Healthier hospitalized patients complain sometimes about their IVs and frequently about their urinary catheters—a rubber tube up your urethra isn't pleasant. If the patients I'm describing could talk, though, I think the urinary catheter would be the least of their complaints. 

In addition to the invasion of tubes, ICU patients live in a world of bright lights and loud alarms, continuous stimulation. People pry open their eyes and shine flashlights into them, then pry open their mouths. 

We treat most patients with small shots of heparin in their subcutaneous flesh, in order to prevent blood clots. This makes them bruise easily, and patients who've been with us for a while are often peppered with tiny bruises from the shots. Then there are the bigger bruises caused by painful stimulus given by doctors and nurses who are monitoring the arousability of the patient, the depth of their coma. If he doesn't wake up when you shout, or when you shake him, what about when you pinch and twist his trapezius muscle, or grind your knuckles against his sternum for a while?

It's been said that dying is easy, and it's living that's painful. Not so in the world of intensive care. Patients who have a hope of recovering from their injury, genuinely surviving it, may be fighting to live. For them the torturous days as an ICU patient are required in order to surmount their injury. And there are always cases where nobody knows what the outcome may be, where the right thing to do is maintain physical function and give the body time to heal. Many patients will survive with deficits, will not return to their former selves but will be able to leave the hospital, go to rehab, begin the hard work of adjusting to another kind of life. But time and again we care for patients who are fighting to die, and having a very hard time of it, because in the ICU there are only two ways to die: with permission, too often not granted or granted too late, or in the last-ditch fury of a full code blue. 

We are not helping these people by providing intensive care. Instead, we are turning their bodies into grotesque containers, and reducing their lives to a set of numbers monitoring input and output, lab values, and vital signs, which we tweak to keep within normal ranges by adjusting our treatments, during the weeks and days immediately preceding their death. This is the opposite of what should be prioritized when a person is known to be nearing the end of their life without the hope of getting well. 

I want this to change. People who choose to do the work of caring for the gravely ill must concentrate on monitoring and responding to changes in their vital signs, administering their medications, examining all of their physical systems, coordinating their various tests and procedures, bathing them and cleaning up their bodily messes, dressing their wounds, keeping them comfortable, and communicating with their families. I don't think that we should also have to deal with feeling that our work is morally questionable and at times, reprehensible.

Americans have a lot of work to do in developing a more sensible, fairer, and less wasteful healthcare system. That work needs to include taking a hard look at the conditions of patients whose lives may end in intensive care, both at the level of the entire health care system and at the level of the individual—our wishes for ourselves and our family members whose health is failing or has already failed. Our goal is to help these people, and assuming that prolonging their lives for the longest time possible is the only way to do this is a foolish and harmful mistake.

http://www.brooklynrail.org/2012/11/express/end-of-the-line-in-the-icu

The Health Care Blog

We run guest posts by influential bloggers across healthcare every day, featuring pieces by observers at the center of the stories transforming the field.

You can think of us as a little bit like the Huffington Post with a focus on medicine, science and the business of medicine. Since passage of the Obama administration's health reform law, we've paid close attention to the Affordable Care Act, tracking the implications of the landmark legislation for the industry and consumers, as well as the looming legal battle over the law's future in Washington.

We also pay pointed attention to the healthcare startup scene and the new technologies that are changing healthcare. Since the national drive for health information technology less than a decade, we've tracked trends and ideas on the technology side of healthcare.

Is the cloud really going to change everything? Is there going to be a Facebook for healthcare? (Hint. You probably already know the answer.) Will doctors ever embraceelectronic medical records? What's the next big thing that hospitals and health systems are turning to in data and analytics?

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Medical apps could hurt, not help - Sioux City Journal

When the iTunes Store began offering apps that used cellphone light to cure acne, federal investigators knew that hucksters had found a new spot in cyberspace.

"We realized this could be a medium for mischief," said James Prunty, a Federal Trade Commission attorney who helped prosecute the government's only cases against health app developers last year, shutting down two acne apps.

Since then, the Food and Drug Administration has been mired in a debate over how to oversee these new high-tech products and government officials have not pursued any other app developers for making medically dubious claims. Now, both the iTunes Store and Google Play Store for Android users are riddled with health apps that experts say do not work and in some case could even endanger people.

These apps offer quick fixes for everything from flabby abs to alcoholism, promising relief from pain, stress, stuttering and even ringing in the ears. Many of these apps do not follow established medical guidelines. Few have been tested through the sort of clinical research that is standard for less new-fangled treatments sold by other means, a probe by The New England Center for Investigative Reporting (NECIR) has found.

While some apps are free, thousands must be purchased, ranging from 69 cents to $999. Nearly 247 million mobile phone users worldwide are expected to download health apps in 2012, according to Research2Guidance, a global market research firm.

In an examination of 1,500 health apps that cost money and have been available since June 2011, the center found that more than one out of five claims to treat or cure medical problems -- exactly the sorts of apps that FDA-proposed guidelines suggest need regulation. Of the 331 therapeutic apps, 142 -- or 43 percent -- relied on cellphone sound for treatments. Another dozen used the light of the cellphone, and two others used phone vibrations. Scientists say none of these methods could possibly work for the conditions in question.

"Virtually any app that claims it will cure someone of a disease, condition or mental health condition is bogus," says John Grohol, an online health technology expert, pointing out that the vast majority of available apps have not been scientifically tested. "Developers are just preying on people's vulnerabilities."

Satish Misra, a physician and managing editor of the app review website iMedicalApps, adds: "They take some therapeutic method that is real -- and in some cases experimental -- and create a grossly simplified version of that therapy using the iPhone. Who knows? Maybe it works." But until testing shows otherwise, "my feeling would be that it doesn't."

There are many outstanding health apps, particularly those intended for doctors and hospitals, that are helping to revolutionize medical care, according to physicians and others. Among the most well-regarded apps for consumers: Lose It for weight loss, Azumio to measure heart rates and iTriage to check symptoms and locate the closest hospitals with the shortest emergency-room wait times.

But consumers have almost no way of distinguishing great high-tech tools from what Prunty called the "snake oil." Without government oversight or independent testing of apps, people mainly rely on developers' advertisements and anonymous online reviews, many of which are positive but some, such as this one, are not: "Shame on Apple for even allowing this piece of crap on here. ... It preys on people with health issues."

When contacted, Apple declined to discuss anything about its apps. The company has issued lengthy guidelines for app developers, which say it will reject apps that crash, have bugs or do not perform as advertised.

A Google spokeswoman also declined to discuss its apps or its rules for developers. Google's content guidelines also ban sexually explicit material, gratuitous violence or anything that may damage users' devices.

The FDA is drafting regulations that outline what types of health apps will need government approval before they can be marketed in the United States. But the regulations have been bogged down by debates, hearings and legislative back and forth over whether government oversight would stifle innovation.

"Applying a complex regulatory framework could inhibit future growth and innovation in this promising market," six Republican members of Congress wrote last spring to the heads of the FDA and the Federal Communications Commission, reflecting some of the concern.

A few private groups are working to assess the quality of various apps. iMedicalApps gets health care professionals to review software applications that mainly interest physicians. Happtique, a subsidiary of the Greater New York Hospital Association, is about to launch the nation's first app certification service, which will evaluate apps for safety and effectiveness. It will award some apps the high-tech equivalent of the Good Housekeeping Seal of Approval. "We truly believe people need a trusted source," said Ben Chodor, Happtique's CEO.

Misra, an internal medicine resident at Johns Hopkins Hospital, says he's most concerned about apps that claim to test or treat consumers for serious diseases. These apps can sometimes give inaccurate information or can lull people into ignoring symptoms that might need medical attention.

Cardiac Stress Test, for instance, says on Google Play (where it sells for $3.07) that it can determine "if you are ready for sports or if your heart is not in a healthy condition." A person takes his heart rate after performing 30 squats in less than 60 seconds and enters the number into the app's calculator, which then reports whether the user's heart is in shape for exercise.

"It's hard not to imagine how this app could give folks a false sense of security," Misra says, noting that assessing someone's cardiac status is not just a matter of looking at heart rate.

Simon Bertrand, who developed the app for his own use, said it is designed to help healthy people monitor their heart, similar to apps that monitor weight or body mass. "If you are in poor health condition ... go to see a doctor," he said in an email.

Later, in an interview by phone from France, Bertrand said his app was being offered for sale on Google Play within minutes of submitting it to the company. "It's just a test. It's not an application that claims to cure."

Apps that rely on cellphone light, meanwhile, cannot possibly have any therapeutic value, experts say. While light treatments can be used to relieve some medical problems, cellphone light is in the wrong spectrum and far too weak to make any impact at all, said the FTC's Prunty.

"Using the light of the cellphone is automatically suspect," Prunty said, which is why the agency decided last year to file complaints against two developers who claimed cellphone light could cure acne.

The FTC argued in its complaints that the developers' claims were "false or misleading." AcneApp, which sold for $1.99 on iTunes, claimed that blue light fought bacteria and red light helped heal skin. "Rest the iPhone against your skin's acne-prone areas for two minutes daily to improve skin health without prescription drugs," it said. The app was downloaded 11,600 times, according to the FTC complaint.

A similar app for Android phones, Acne Pwner, was downloaded 3,300 times, the FTC said.

AcneApp cited a study in the British Journal of Dermatology, which suggested that light therapy was almost twice as effective as over-the-the counter blemish treatments. But the FTC said in its complaint that the study "does not prove that blue and red light therapy" effectively treats acne.

The two companies settled the complaints, without admitting any violation of the law, by paying fines of $14,294 in AcneApp's case, and $1,700 in Acne Pwner's case.

Gregory Pearson, the Houston dermatologist who helped create AcneApp, "was not making any claims of efficacy," said his attorney, Sesha Kalapatapu.

Cellphone lights are being marketing to treat other conditions too including seasonal affective disorder (SAD), a type of depression that occurs during the winter because of lack of sunlight. But SAD experts say even the most powerful cellphone lights are far too weak to treat depression.

There's also little proof that apps relying on cellphone sounds can be effective, yet there are many such apps.

AG Method, which sells for $9.99 on the iTunes Store, says that users can get relief for everything from insomnia to toothaches by listening to something that sounds like running water for 20 minutes. "Put the sound-source on the maximum pain," it says. All the while, "HEALING IN PROGRESS" flashes in big red letters on the iPhone screen.

"There is no plausible, physiological way in which something like this would help," Misra said.

But that may not stop people from buying it. "People in pain are very gullible. They would pay their last dollar for relief," said Penney Cowan, executive director of the American Chronic Pain Association.

Tiziana Formica, a spokesman for AG Method, said in and email: "AG Method is the result of 25 years of research and includes several technologies and methodologies developed and widely tested."

Even health apps that seem more conventional often have fundamental flaws. Many don't conform to clinical practice guidelines.

An app to help people with tinnitus, or ringing in the ears, was sold in both the iTunes and Google Play stores until early August and contained multiple medical misconceptions.

"Ringing Relief Pro," which sold for $2.99, advertised itself as "an easy and inexpensive way to cure your tinnitus. ... Simply play the low frequency hum that sounds best to you for 90 seconds and your ears should ring no more!" It claimed that tinnitus occurs "when tiny hairs in your inner ear get stuck in the bent position and send false signals to the brain."

In fact, tinnitus is not caused by stuck ear hairs and can be a sign of many underlying medical conditions, including hearing loss, high blood pressure, allergies and anxiety, says Rhonda Ruby, an audiologist who has treated patients for 35 years at the West Newton Hearing Center in Massachusetts.

"There is no cure for tinnitus," she says. "When you download these sorts of apps without consulting a medical professional, it's like putting a Band-Aid on something and not figuring out what is causing the problem."

Ed Williams, the app's developer, withdrew the app from the market after being contacted by the New England Center for Investigative Reporting. A 28-year-old computer scientist, he said he developed the app after reading a newspaper article about researchers who discovered that a low-pitched sound could provide tinnitus relief.

"I am not a medical expert, and I wouldn't want anyone using my app in lieu of medical treatment, but it does seem to work for some people," he said. Once he was told about the proposed FDA regulations, though, Williams said he wanted to submit the app for government approval.

His tinnitus app may not have done very well, but Williams also developed Fake-A-Call, which allows people to set up fake phone calls when they are in meetings or awkward social situations. He said it has been downloaded millions of time and earns him thousands of dollars every month.

http://siouxcityjournal.com/medical-apps-could-hurt-not-help/article_3bb53399-b67b-5bbd-bb18-2dd32029ad18.html