Clinicians, Care, and Conflicts of Interest in the Sports Medicine Environment

By Christine Baugh

A recent British Medical Journal blog post by Dr. Michael Stone sheds insight into the professional trials and tribulations of physicians working with professional soccer teams in England. As described, it is not uncommon that the team physician is recommended by a team manager and hired by the team’s executive board without thorough review. This hiring process, in turn, leads to the implicit expectation that the physician answers to the manager rather than the entire team, making the physician’s employment with the team insecure and the need for him to appease the manager a required condition of his employment. Beyond leading to an uncomfortable and potentially ineffective working environment, it is possible that this type of relationship could compromise care. These types of conflicts of interest within the sports medicine environment have been documented elsewhere.

A 2013 article in the Chronicle of Higher Education written by Brad Wolverton detailed a similar phenomenon in American collegiate sports. According to their survey of collegiate sports medicine clinicians, approximately one-third of clinicians indicated that members of the football coaching staff had influence over their employment and about half of clinicians reported having felt pressure from coaches to prematurely return athletes to play. Wolverton was able to provide striking examples of professional relationships between coaches and clinicians that led to compromised care. He also indicated that the topic was so sensitive that very few of the athletic trainers contacted were willing to talk about the issue for fear of losing their jobs.

Both the Stone and Wolverton articles highlight the complexity of sports medicine as a field and the specific conflicts that can arise when competing interests from multiple stakeholders are in play. However, critical to both authors’ conclusions, is that seemingly simple structural changes could play a major role in positively affecting health outcomes. Namely, to ensure quality of care, it is critical that the clinician’s employment is based upon the care he gives to his patients, not the team manager or team coach’s opinions of him. This is not a novel assertion. For example, the National Athletic Trainers’ Association, the National Collegiate Athletic Association (page 65), and others have put forth guidelines and recommendations indicating that having the coach serve as a primary supervisor for a clinician is inappropriate. However, it is not clear that these best practices are being implemented uniformly across sports, leagues, and teams. Given the health risks faced by athletes, and the role that sports medicine clinicians can play in mediating those risks, taking steps such as implementing an appropriate supervisory structure for sports medicine clinicians is imperative.

[This post reflects my own views only.  It does not necessarily represent the views of the Petrie-Flom Center or the Football Players Health Study at Harvard University.]

What’s to become of population health?

When the accountable care organization (ACO) model was initially conceptualized, many in the health policy world hoped it could provide a platform for real transformation of US health care.

Among the ACO model’s most promising innovations was its explicit orientation towards achieving “the Triple Aim.” First articulated by Don Berwick and the Institute for Healthcare Improvement (IHI), the Triple Aim is a strategy for optimizing the health care delivery system and achieving the best of all worlds. It outlines three goals: high quality health care, lower costs, and population health. The Center for Medicare and Medicaid Services adopted this goal and still describes a version of the Triple Aim on its webpage titled “Innovation.”

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Is “My Patient’s Agent” Always Justified?

Kelsey Berry

Is a physician always justified in acting as his or her patient’s agent?

This question is familiar to clinical and population-level bioethicists alike, though I hesitate to say that it is age-old. There are a variety of ways to approach a response to this question, as evidenced by extensive treatment of this topic in the philosophical and bioethics literature (which I will not survey here). One popular approach involves raising candidate circumstances that may justify deviations from the principal-agent relationship that obtains between physicians and patients* – for instance, ethicists might consider whether a physician is justified in deviating from acting as his or her patient’s agent under circumstances in which (a) the action that is in the best interest of the patient conflicts with the action that in the best interest of the population health, (b) the action that is in the best interests of the patient requires inefficient use of community resources on some criteria, or (c) what the patient perceives to be in his or her best interests conflicts with what the physician recommends, etc. This list is woefully inexhaustive, but it highlights a theme in this thread of argumentation. In each scenario, we’re invited to accept the initial assumption that the physician is justified, if not all of the time, at least most of the time, in acting as his or her patient’s agent. Then we are led to consider whether the candidate circumstances raised qualify as an exception to this rule.

The often-unarticulated premise, that the physician is typically justified in acting as his or her patient’s agent, is not without philosophical support from several prominent theories. We also have pragmatic reasons to begin with this premise, for there are few specific actors (to whom we can easily point) that compete with the patient for a principal-agent relationship of the type that obtains between a physician and his or her patient. Of course, other patients under care are obvious contenders, as are other potential patients. Though adjudicating between a physician’s obligations to both existing and potential patients raises interesting issues, the conflicts these principal-agent relationships give rise to still trade on the basic assumption that the physician has reason to maintain the basic fiduciary relationship in most circumstances. Continue reading

Immediate Job Opening: Clinical Ethicist at Boston Children’s Hospital

Clinical Ethicist

Boston Children’s Hospital

Boston, MA

The Office of Ethics at Boston Children’s Hospital has an immediate opening for a clinical ethicist. 

Applications are being accepted online, at www.childrenshospital.jobs.   To locate the position on the website, enter “32902BR” in the box labeled “AutoReqID.”

Boston Children’s Hospital is a 395-licensed-bed children’s hospital in the Longwood Medical and Academic Area of Boston, Massachusetts. At 300 Longwood Avenue, Children’s is adjacent to its teaching affiliate, Harvard Medical School.

Job description: Clinical Ethicist 32902BR

The Clinical Ethicist provides formal and informal ethics consultations.  Organizes and participates in clinical ethics rounds, and collaborates with clinical teams, patients and families, to address ethical issues in pediatric health care and research. Develops ethics resources and education and serves as a facilitator for change directed toward strengthening the Hospital staff’s sense of moral responsibility and moral community.

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Serious Risks from New Prescription Drugs

by Donald W. Light

Based on http://www.ethics.harvard.edu/lab/blog/436-new-prescription-drugs-a-major-health-risk

Few people know that new prescription drugs have a 1 in 5 chance of causing serious reactions after they have been approved. That is why expert physicians recommend not taking new drugs for at least five years unless patients have first tried better-established options and need to. Faster reviews advocated by the industry-funded public regulators increase the risk of serious harm to 1 in 3. Yet most drugs they approve are found to have few offsetting clinical advantages over existing ones.

Systematic reviews of hospital charts by expert teams have found that even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients given drugs have serious adverse reactions for a total of 2.74 million. Further, the expert teams attributed as many deaths to the drugs as people who die from stroke. A policy review done at the Edmond J. Safra Center for Ethics at Harvard University concluded that prescription drugs are tied with stroke as the 4th leading cause of death in the United States. The European Commission estimates that adverse reactions from prescription drugs cause 200,000 deaths; so together, about 328,000 patients in the US and Europe die from prescription drugs each year. The FDA does not acknowledge these facts and instead gathers a small fraction of the cases.

Perhaps this is “the price of progress”? For example, about 170 million Americans take prescription drugs, and many benefit from them. For some, drugs keep them alive. If we suppose they all benefit, then 2.7 million people have a severe reactions, it’s only about 1.5 percent – the price of progress?

However, independent reviews over the past 35 years have found that only 11-15 percent of newly approved drugs have significant clinical advantages over existing, better-known drugs. While these contribute to the large medicine chest of effective drugs developed over the decades, the 85-89 percent with little or no clinical advantage flood the market. Of the additional $70 billion spent on drugs since 2000 in the U.S. (and another $70 billion abroad), about four-fifths has been spent on purchasing these minor new variations rather than on the really innovative drugs.

In a recent decade, independent reviewers concluded that only 8 percent of 946 new products were clinically superior, down from 11-15 percent in previous decades. (See Figure) Only 2 were breakthroughs and another 13 represented a real therapeutic advance.

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MS Admitting Privilege Law Struck Down by 5th Circuit

Ed Note: Guest post by Jonathan F. Will

On July 29, 2014 a panel of the 5th Circuit struck down a Mississippi statute that would have effectively closed the only remaining abortion clinic in the state. Just four months ago a different panel of the 5th Circuit upheld a nearly identical statute enacted in Texas. Both statutes require physicians performing abortions to have admitting privileges in local hospitals.

The differing results are unremarkable because both the purpose and effects prongs of Casey’s undue burden analysis are necessarily fact driven. But there are some open questions worth highlighting from the decisions. The Mississippi law raises a matter of first impression. Namely, of what relevance is it, if any, that Mississippi women would have to cross state lines to obtain an abortion if the law was upheld? After all, even if the last abortion clinic closed, Mississippi women would have a shorter distance to travel to obtain such services than some Texas women now have because of the other 5th Circuit decision.

In striking down the Mississippi law, the 5th Circuit cited an Equal Protection case from the 1930s involving racial discrimination, and suggested (at least in part) that Mississippi cannot “lean on its sovereign neighbors to provide protection of its citizens’ federal constitutional rights.” The idea being that if a state cannot rely on a sister state to provide education for minorities, a state likewise should not be permitted to rely on a sister state to provide abortion services. Regardless of my feelings about the outcome of the case, I have to agree with the dissenting opinion of Judge Garza that this analogy doesn’t work very well.

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Just “Fix-It”

Guest post by Gretchen Schwarze (Vascular Surgeon)

Cross-posted from GeriPal

She seemed awfully angry and at the very least dubious that I couldn’t do more for her father. After 7 hours of surgery trying to salvage her father’s leg, I tried patiently to explain that this new (third) bypass we had just successfully completed was unlikely to provide her dad with a long-term solution. Ultimately, he would lose the leg, if we were lucky he’d have it for another year or two. Accounting for the “unlucky” side of the coin was even more depressing; immediate wound or graft infection, a postoperative heart attack from the liter of blood I had just lost or early graft failure which few surgeons would attempt to reverse given the tenuous nature of the graft to begin with. I didn’t have the heart to mention these things too, she was already upset.

It’s conversations like these that make me feel like there is something intrinsically wrong with the way we conceptualize modern medicine, and by “we” I mean both doctors and patients. I worry that a much deeper issue – a larger social construct – plays a role in decision-making and influences treatment choices because it obscures the limits and boundaries of what health care can provide.

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New Medical Tourism Website with Info for Patients

My good friends and co-authors at Simon Fraser University have a nice new website aimed at Canadians (though useful for people from all countries) considering using medical tourism about what to think about, questions to ask, steps to take, etc (Full Disclosure: I participated in a feedback session on the website). Here is a story about the website in the National Post, and here is the website itself.

Religious Freedom and Access to Health Care

SCOTUSfrontCheck out the “hot off the press” New England Journal of Medicine Perspectives piece “When Religious Freedom Clashes with Access to Care” by Petrie-Flom Faculty Director I. Glenn Cohen, Executive Director Holly Fernandez Lynch, and NEJM Executive Editor (and PFC Faculty Affiliate), Gregory Curfman.  We review the legal background for SCOTUS’ Hobby Lobby decision, summarize the majority and dissenting opinions, and clarify some key implications of the case, including further problematization of the employer-based health insurance system, reduced likelihood of future attempts to offer religious exemptions to health care mandates, and expanded religious challenges in the health care space.  We close by noting that although the public’s ire and praise has been directed at the Justices, they were applying Congress’ statute – and Congress could (but is very unlikely to) amend the Religious Freedom Restoration Act to be less stringent, or otherwise intervene to ensure that women have affordable access to contraceptive services regardless of their employer’s beliefs.

Take a look and let us know what you think!

Medical Students and Professionalism

In one of the more interesting cases I’ve read about recently, a judge in the Northern District of Ohio granted an injunction against Case Western Reserve University, forbidding Case from expelling a medical student (a former classmate of mine) for his failures in professionalism.  As a brief summary of the case, a medical student just weeks from graduating from Case was convicted of driving while impaired.  He reported the conviction to the residency program he had matched at, and the program then notified Case before the student reported it to the school himself.  Case took the position that failing to alert the medical school of the arrest merited expulsion and withholding the medical degree that the student was to receive with distinction the very next month. Although reporting such arrests was not a requirement of graduation, the school believed that he should have reported the arrest and prosecution, particularly in light of the fact that the student had a history of other infractions throughout his time as a medical student. Continue reading

“Isn’t Incarceration Better than Death?”

Katherine L. Record, JD, MPH, MA

Shortly after criticizing Massachusetts for incarcerating innocent individuals with substance use disorder (SUD) when drug rehab facilities are full, I received an email from a woman who lost her son to a heroin overdose just four months ago.

“Is preventing an overdose by detaining the SUD sufferer not a better alternative than leaving them to languish?” she asked.

She had found her 24 year-old son cold and blue, just hours after kissing him goodnight. He had been evicted from his sober living home for testing positive for drugs, but his mother did not know he had relapsed when he arrived at her front door. He was, in hindsight, a clear danger to himself – so why did his step-down house let him wander away? Why didn’t anyone call the authorities? Is jail not better than death?

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I. Glenn Cohen Discusses Ethics of Medical Personnel Involvement in Executions

cohen_talking_peoplePetrie-Flom Faculty Director I. Glenn Cohen appeared on The Rachel Maddow Show last night to discuss his recent opinion piece in JAMA, coauthored with Robert D. Truog and Mark A. Rockoff (both of Harvard Medical School), on “Physicians, Medical Ethics, and Execution by Lethal Injection.” In the piece, Cohen et al. argue that medical specialty boards should withdraw board certification from members who participate in executions.

From the interview:

…we think it [execution] is totally incompatible with the role of the doctor. A doctor is about healing. A doctor is about soothing pain. A doctor is not meant to be conscripted by the state to make what is the involuntary killing of another person look as though it’s a medical procedure, like getting your teeth pulled or putting your dog to sleep. It’s kabuki theater, Rachel, and we think doctors should stand up. Whatever your position is on capital punishment, it’s wrong to make this procedure look like medicine. That’s not what it is. [...]

Watch the full interview.

Direct-to-Patient Laboratory Test Reporting

MJYPetrie-Flom Student Fellow Michael Young has coauthored a new piece with Ethan Scheinberg (Harvard Law School) and Harold Bursztajn (Harvard Medical School) now available through JAMA, “Direct-to-Patient Laboratory Test Reporting: Balancing Access With Effective Clinical Communication” The article discusses ethical and clinical implications of a 2014 HHS ruling allowing patients direct access to completed medical laboratory reports.

From the article:

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High Noon for Population-Wide Mammography Screening?

By Prof. Dr. med. Dr. phil. Nikola Biller-Andorno

Director, Institute of Biomedical Ethics, University of Zurich, Switzerland

Safra Network Fellow, Harvard University (13-14)

Visiting Professor, Div. Medical Ethics, Harvard Medical School (12-14)

It is amazing how much heat a report can draw that simply states what has been all over town for some time now: We do not know if mammography screening does more good than harm, we do not even know for sure if it does any good at all.

The Swiss Medical Board, an independent health technology assessment initiative that was started in 2008, stated that based on the empirical data availability the introduction of mammography screening all over Switzerland could not be recommended.

As could be expected the report drew fire. Curiously, one of the chief complaints was that it was “unethical” to upset women who might no longer know if screening was good for them or not.

This sounds just a little bit paternalistic – particularly given that we know that most women seriously overestimate the benefits of screening when making their decision, a point that my colleague Peter Juni and myself illustrate in a Perspective piece published on May 22, 2014 in the New England Journal of Medicine.

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Doctors, Lethal Injection, and Firing Squads

Yesterday JAMA published a new perspective I co-wrote with Bob Truog and Mark Rockoff  “Physicians, Medical Ethics, and Execution by Lethal Injection“. In that article we make the case that the recommendations coming out of the Oklahoma botched lethal injection executions to require physician involvement would force physicians into an untenable medical ethical position. We also argue that it supports a kind of kabuki theater of medicalization, where execution becomes normalized.

Now comes a news report of a Utah lawmaker pushing to give those set to be executed the option of firing squad which he views as more humane than lethal injection. Many people will no doubt recoil at this notion. But here is my intentionally provocative question (and this is on my behalf not my co-authors): If you are in favor of capital punishment, wouldn’t a single close range shot to the head as a form of execution be, in some ways, more defensible than lethal injection? If you recoil at the notion of this being a way of doing execution, have you perhaps fallen for the kabuki theater of medicalization? Why not choose a method of execution that is more honest about the gravity (and perhaps the horror) of what we are doing rather than present something as somewhere on a continuum with sedation?

Art Caplan on handshakes in medical settings

Art Caplan has a new opinion piece up at NBC News on the suggestion, in a recent JAMA article, that handshakes should be banned in healthcare settings. From the article:

Now, the handshake ban might make sense if it were not for the fact that the constant touching of microbe-laden things by providers and patients is likely to go on and, handshake or not, they are still likely to fist bump, shoulder pat, rub noses or whatever else they think shows love, care and concern for one another.

Health care has gotten very sterile and impersonal as more technology appears, less time is set aside for talking and more health providers find themselves chained to their computers or handheld medical devices. While not every culture values a handshake, many do, and putting the kibosh on grip and grinning just adds to the perception that caring and curing are heading down different highways.

Read the full article.

New op-ed on doctors and the death penalty, coauthored by I. Glenn Cohen

Petrie-Flom Faculty Director I. Glenn Cohen has coauthored a new opinion piece now available through JAMA, “Physicians, Medical Ethics, and Execution by Lethal Injection.” From the article:

In the wake of the recent botched execution by lethal injection in Oklahoma, however, a group of eminent legal professionals known as the Death Penalty Committee of The Constitution Project has published a sweeping set of 39 recommendations that not only tinker with, but hope to fix, the multitude of problems that affect this method of capital punishment.

Many of the recommendations this committee makes with regard to legal and administrative reforms appear worthwhile and reasonable. Their final recommendation, however, concerns the role of the medical profession in performing lethal injection. It states: “Jurisdictions should ensure that qualified medical personnel are present at executions and responsible for all medically-related elements of executions.”

In particular, the recommendation specifies that “Execution team members…are licensed, practicing doctors, nurses or emergency medical technicians who are responsible for performing functions in their day-to-day practice that are similar to those they will perform at the execution.” Regardless of this committee’s recommendations, physician participation in capital punishment is an ethical dilemma that the profession of medicine must address.

Read the full article.

Preventing Post-hospital Syndrome

By Michael Young

Recent Center for Medicare & Medicaid regulations incentivizing reductions in 30-day hospital readmission rates have prompted a flurry of research into how clinicians and administrators can optimize patient health following hospital discharge.  Preventable hospital readmissions in the U.S. are estimated to account for up to $15 billion in annual healthcare spending.  In considering this problem, many analysts and innovators have focused on deficiencies in transitional care as a root cause of many preventable readmissions.  While efforts to improve transitional care carry considerable promise, they tend to leave relatively underexplored a determinant of readmissions of equal if not paramount importance: the inpatient experience itself.

Writing in this week’s JAMA, Allan Detsky and Harlan Krumholz propose seven key interventions that can enhance patients’ hospital experiences and in so doing may portend improvements in patient health following discharge.

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#BELHP2014 Panel 5, Behavioral Economics and the Doctor-Patient Relationship

[Ed. Note: On Friday, May 2 and Saturday, May 3, 2014, the Petrie-Flom Center hosted its 2014 annual conference: "Behavioral Economics, Law, and Health Policy."  This is an installment in our series of live blog posts from the event; video will be available later in the summer on our website.]

This session was kicked off by Jennifer Zamzow, Post-Doctoral Fellow, Center for Ethics and Policy, Carnegie Mellon University, with a talk called “Affective Forecasting in Medical Decision-Making: What Do Physicians Owe Their Patients?”  Jennifer began with an example of a recently paralyzed patient requesting termination of life-sustaining care on the grounds that his injury feels like a fate worse than death.  On the one hand, we feel compelled to respect the decisions of competent patients, but on the other hand, given what we know about errors in affective forecasting, we anticipate that the patient would be able to eventually adapt to his new circumstances and lead a happy, full life.  The question, then, is whether physicians have any obligation to help their patients make more accurate affective forecasts.

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A More Transparent System for Clinical Trials Data in Europe – Mind the Gaps!

Following the approval of the European Parliament (EP) earlier last month, the Council of the European Union (the Council) adopted on 14 April 2014 a “Regulation on clinical trials on medicinal products for human use” repealing Directive 2001/20/EC.  As described in a press-release, the new law:

“aims to remedy the shortcomings of the existing Clinical Trials Directive by setting up a uniform framework for the authorization of clinical trials by all the member states concerned with a given single assessment outcome. Simplified reporting procedures, and the possibility for the Commission to do checks, are among the law’s key innovations.”

Moreover, and very importantly, the Regulation seeks to improve transparency by requiring pharmaceutical companies and academic researchers to publish the results of all their European clinical trials in a publicly-accessible EU database. In contrast to earlier stipulations which only obliged sponsor to publish the end-results of their clinical trials, the new law requires full clinical study reports to be published after a decision on – or withdrawal of – marketing authorization applications. Sponsors who do not comply with these requirements will face fines.

These groundbreaking changes will enter into force 20 days after publication in the Official Journal of the EU. However, it will first apply six months after a new EU portal for the submission of data on clinical trials and the above mentioned EU database have become fully functional. Since this is expected to take at least two years, the Regulation will apply in 2016 at the earliest (with an opt-out choice available until 2018).

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