Showing posts with label Medicine. Show all posts
Showing posts with label Medicine. Show all posts

August 7, 2017

Should A Judge Tell You What Medication to Take with The Power to Make You?

Philip Kirby says he felt pressured into taking Vivitrol for his heroin addiction by his drug court treatment program. "Like I couldn't come into the program until I got it," he says.
Jake Harper/Side Effects Public Media
Philip Kirby says he first used heroin during a stint in a halfway house a few years ago, when he was 21 years old. He quickly formed a habit.
"You can't really dabble in it," he says.
Late last year, Kirby was driving with drugs and a syringe in his car when he got pulled over. He went to jail for a few months on a separate charge before entering a drug court program in Hamilton County, Ind., north of Indianapolis. But before Kirby started, he says the court pressured him to get a shot of a drug called Vivitrol.
Vivitrol is a monthly injection of naltrexone, which blocks opioid receptors in the brain. It's one of three medications approved by the Food and Drug Administration for treating opioid addiction. While it's effective in some people, it's not for everyone. Patients have to be ready to be opioid-free, and some patients won't do well on it. It can also have side effects, which Kirby says he experienced.
"I had sinus problems, chest problems for the whole month I was on it," Kirby says. "I couldn't shake it."

He says he also got a rash — another possible reaction to Vivitrol, according to the product's warnings. Months after he had the shot, he still had white splotches on his arms, which he attributed to the drug. But even with those symptoms, Kirby says the court urged him to stick with the medication for a couple of more months. "They were way too pushy about it," he says.
More than 130,000 Americans will go through drug courts this year, according to the National Association of Drug Court Professionals. Drug courts are designed to allow some people whose crimes stem from addiction to get treatment instead of jail time. But the treatment that is offered varies from court to court and is entirely at the judge's discretion.
Some courts offer participants a full range of evidence-based treatment, including medication-assisted treatment. Others don't allow addiction medications at all. And some permit just one: Vivitrol.
Prime targets for marketing
One reason for this preference is that Alkermes, the drug's manufacturer, is doing something nearly unheard of for a pharmaceutical company: It is marketing directly to drug court judges and other officials.
The strategy capitalizes on a market primed to prefer their product. Judges, prosecutors and other criminal justice officials can be suspicious of the other FDA-approved addiction medications, buprenorphine and methadone, because they are themselves opioids. Alkermes promotes its product as "nonaddictive."
The argument worked for Judge Lewis Gregory, who heads the city court in Greenwood, Ind. About a year and a half ago, Gregory didn't allow participants to start on addiction medications while in the program. "We were failing miserably with the heroin population," he says.

Judge Lewis Gregory, head of the city court in Greenwood, Ind., began allowing drug court participants to begin taking Vivitrol after meeting with an Alkermes sales representative.
Jake Harper/Side Effects Public Media
At the time, Gregory was only familiar with buprenorphine and methadone. Both are opioid medications that can prevent withdrawals, reduce cravings and ultimately help people maintain a stable recovery. When they are properly prescribed and administered, patients don't get a euphoric feeling or a "high."
Buprenorphine and methadone have been the standard of care for opioid addiction for years, but because they're opioids, it is possible to misuse them. They're also sold illegally on the street.
"I was certainly not going to do a medication-assisted treatment program with drugs which people use to get high," Gregory says, adding that he would not order someone to stop buprenorphine treatment if it were legally prescribed by a physician, a situation he rarely sees.
Then he received some Vivitrol literature in the mail and a phone call from an Alkermes sales representative. "So we ended up meeting in the early part of 2016, and she began educating me a bit," he says.
Six months later, his court began a Vivitrol program, permitting some participants to use the drug. A sales representative sometimes sits in on the court's treatment team meetings, Gregory says.
Many treatment specialists say allowing judges and other criminal justice officials with no medical training to exert influence over medical decisions is problematic. The power makes them prime targets for Vivitrol marketing, they say.
"You would think it would be more appropriate to go after physicians," says Basia Andraka-Christou, who researches drug courts at the Fairbanks School of Public Health at Indiana University.
"What this is implying is that the judges in these cases are actually making a lot of the medical decisions, and that should be very concerning to everyone," she says.
Adriane Fugh-Berman, who researches pharmaceutical marketing at Georgetown University, says she has not heard of another drug company going after judges. She says it's not just unique — it's inappropriate and could ultimately be damaging to patients. "They're not health care providers. They don't know data. They don't know research," she says. 
A company strategy
The drug court Kirby went through doesn't allow medications other than Vivitrol for treating addiction. In fact, NPR and Side Effects Public Media have identified at least eight courts out of the several dozen in Indiana that say they only allow Vivitrol treatment.
NPR and Side Effects Public Media have learned that Alkermes sales reps have also marketed the drug to court officials in Missouri and Ohio. A report from ProPublica found that extensive marketing is leading judges to favor Vivitrol around the country.
The company is open about this part of its sales strategy. At an investor event last year, policy director Jeff Harris said drug courts are a huge market for Vivitrol.
"We're making progress but still just barely scratching the surface on the need that exists across the country," Harris said in a presentation. "There are over 3,000 counties in the United States, and there are over 3,000 drug courts." A shot of Vivitrol costs about $1,000, making it pricier than the other addiction treatments. In many cases, the drug is paid for through Medicaid or other public funds. And marketing to criminal justice settings seems to have paid off for the company, whose earnings have grown significantly since its introduction. Vivitrol sales reached $209 million in 2016 — up from just $30 million in 2011. Sales have continued to climb this year.
Alkermes goes beyond marketing to judges. It also lobbies state and national policymakers to write laws that favor Vivitrol — and in some cases, hamper access to other addiction medications. The company has said it supports the use of all medications for addiction, but in practice, it doesn't.
The company supported one law in Indiana that encourages the use of Vivitrol in drug courts. Signed in 2015, the bill allows judges to require medication as a condition of participating in a drug court, and the language specifically highlights Vivitrol treatment.
Alkermes declined repeated interview requests. In a written statement, the company defended the practice of marketing in criminal justice settings by noting that judges don't actually prescribe their product.
No one-size-fits-all solution
Drug court judges interviewed for this story say they don't mandate Vivitrol treatment, and that people can say no.
"We encourage it, but we never force anybody," says Judge Gail Bardach of the Hamilton County, Ind., drug court, where Philip Kirby was a participant.
But facing potential jail time and court officials who really believe in Vivitrol, participants say getting the shot doesn't always feel like a choice.
"They made it seem like they were forcing it upon me, like I couldn't come into the program until I got it," Kirby says.
For some patients, Vivitrol does help. Jeremy Templin went through the Hamilton County drug court program a few years ago after he was arrested for theft. He said the decision to go on Vivitrol seemed like it was made without him, but he credits his recovery, in large part, to the drug.
"I don't know what it would have been like without it, but I know that I did have it, and here I am today," he says. "I'm still alive."
But Vivitrol is far from a one-size-fits-all solution. It's not ideal for patients who are dealing with chronic pain on top of their addiction, or for pregnant women. It's expensive. Furthermore, relapse rates for all kinds of opioid addiction treatment are high, and after a period of not using, tolerance for opioids is low. Treatment with Vivitrol, which contains no opioid ingredients, could make someone more likely to overdose if they relapse, addiction specialists warn.
Dan Mistak, an attorney with Community Oriented Correctional Health Services, says courts should allow all medication options and let doctors make treatment decisions — including whether someone should use medication in their recovery.
"We rely on outside experts all the time in the judicial system. We don't ask a judge to come in and be an expert in arson," for example, he says. "This is a responsibility that a judge doesn't want."
The federal government and the National Association of Drug Court Professionalsagree that courts should allow all three FDA-approved opioid addiction medication options.
"Especially with this exploding opioid use epidemic, we have to make available, as much as we can, whatever interventions are out there that are likely to be effective," says Terrence Walton, chief operating officer for the NADCP, which lists Alkermes as one of its biggest donors.
For some judges, limited access to buprenorphine and methadone shapes their decisions about what to allow in drug court programs. The medications are heavily regulated, and many communities lack providers who can prescribe and dispense the drugs. Judge Bardach says she would consider allowing participants to use methadone if there were a provider closer to the court.
A need for regulation?
Currently, there is no regulatory agency that can ensure that judges follow best practices.
"There are not that many ways to leverage accountability over these courts," says Christine Mehta, a researcher at Physicians for Human Rights. Mehta recently authored a report on drug courts, focusing on three states. "Really the key is attaching restrictions and requirements to funding," she says.
The federal government has put some requirements in place for courts receiving grants from the Bureau of Justice Assistance. They have to show that they "will not deny any eligible client access to the program because of their use of FDA-approved medications for the treatment of substance use disorders." But only about 200 of the more than 3,000 drug courts nationwide operate with help from a BJA grant.
The Substance Abuse and Mental Health Services Administration has similar grant-making guidelines in place, but it currently funds only 172 courts.
Mehta says states and counties need to implement similar requirements and work to educate drug court officials about all addiction medication options. She argues that until drug courts allow all of the medications, they're not fulfilling their promise.
"If drug courts say that they provide access to treatment instead of prison, they are inherently violating that by saying, 'Well, we only provide Vivitrol,' " she says.
Mehta says Alkermes' marketing would be less effective if judges were compelled to follow best practices.
Georgetown researcher Fugh-Berman thinks that pharmaceutical companies like Alkermes should be barred from marketing to court officials and lawmakers.
"It would be great if the [FDA] went after this," she says. "I think it does fall under their jurisdiction, but I wouldn't rely on that being enough." She says Congress could pass a law preventing such marketing, as well.
Philip Kirby says his probation officer finally relented when he lifted his shirt and showed that his rash was covering his whole body.
That rash has since cleared up, but it has left a pattern of white spots on his arms.
"I don't know if they'll go away," he says. "I hope they go away eventually."
He says he wishes he'd never taken Vivitrol in the first place.

This story is part of a reporting collaboration with NPR, Side Effects Public MediaKaiser Health News and WFYI. Esther Honig of WOSU in Columbus, Ohio; Bram Sable-Smith of KBIA in Columbia, Mo.; and NPR's Shaheen Ainpour contributed reporting.

July 25, 2015

Med Student Takes selfie as he Performs cesarean exposing patient genitals

In Lima Peru, Doctors perform cesarean exposing the patient genitals and face.
 This case is in addition to the medial student story.
Doctors performing a caesarean. Photo via Flickr
This article originally appeared on VICE UK.
 "Lady I can deliver your baby but first let me take a selfie," wrote smooth-talking Venezuelan student obstetrician Daniel Sanchez on his Instagram page last week. In the accompanying picture he smirks at the camera while a woman, naked from the waist down, gives birth behind him. Another obstetrician’s fingers are still in, or around, her vagina as she begins crowning.
 Med Student Daniel Sanchez
 Sanchez (who has since set his Instagram account to private) went on to boast that his team can "bring kids into the world and reconstruct pussies," claiming their skills are such that women (and implicitly their partners) can look forward to being "brand new, like a car with zero kilometers on the clock." How splendid, say the image's 31 likers. Unfortunately for Sanchez, more than 4,000 people who signed a petition calling for disciplinary action to be taken against him think it's less acceptable.
In an email exchange with the petition's creator (Jesusa Ricoy of the Roses Revolution, a global movement against obstetric violence) Sanchez has apologized for any offense while denying taking the picture himself. He carefully mansplains to us all that the woman in question is respected because "you cannot see her genitals or her face" and assures that she gave consent. He's also keen to make it known that he is one of the most empathetic students on the team and that women often request that he specifically perform their vaginal examinations, saying, "doctor hagame el tacto usted que es mas delicado" ("doctor you touch me because you are more gentle").
Even if Sanchez did gain the unidentified woman's consent before displaying an intensely private and vulnerable moment to the world, his priorities were skewed. She was busy pushing a small human out of her body. Having done that a couple of times myself I'm confident that posing for a photo wasn't at the top of her to-do list.
But that's only part of the problem. Most shocking to me is the power dynamic in the photo. The woman is surrounded. She's on her back, at a moment of birth where she can't move even if she wanted to. The doctors are standing, uniformed against her nudity. They have faces, feelings, and agency. She has been reduced to a torso. A reproductive channel to be rooted around in without regard.
Jesusa Ricoy started the online protest against the image to "tackle the culture in which this kind of thing is permitted and accepted." Her movement was founded in response to a series of cartoons in the Spanish Society of Obstetricians and Gynaecologists journal that shamed, mocked, and sexualized women. With oversized breasts matching their inane questions, reduced to splayed legs and genitals in stirrups or running with a vaginal prolapse dragging on the ground to the delight of chasing dogs; it was clear how these doctors viewed the women they were supposed to care for. Despite protests, the Society has never apologized for the cartoons.
Sanchez's photo isn't a lone example. This image of an apparently unconscious, naked woman after a caesarean section was again posted online by doctors. Over this weekend Ricoy found another medic instagramming dubious birth images. Nurse Francisco Salgado has now deleted his photo showing the post-birth stitching of a woman's perineum. A tastefully blurred and bloodied vagina and thighs is the background of an in-focus head attending to her. Salgado has added a caption that reads; "someone will be in my eternal debt #thankfulhusbandsstich." The “husband stitch" refers to the practice of painfully suturing a woman's vaginal opening to be smaller and tighter than before birth.
Of course the images in and of themselves aren't the real problem. They are simply hieroglyphics for much of what's wrong with the way women are treated in childbirth and, more broadly, throughout their reproductive lives. Away from the filtered reality of Instagram, the power is still usually in the wrong place.
Venezuela was the first country to legally recognize the term " obstetric violence." The law forbids abusive practices and anything that brings with it "loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women." The legal definition has provided hope around the world, but the reality in many Venezuelan hospitals is still grim.
In Brazil last year Adelir Carmen Lemos de Góes was taken from her home by police and forced against her will to have a cesarean section because doctors didn't agree with her birth choices. Routinely, according to the recent Birth in Brazil study, vaginal birth is a lonely world of pain. Women are denied the opportunity to have a companion, access pain relief, or the freedom to move around in labor. The caesarean section rate is out of step with women's preferred choice of labor with a recent study showing that while 73 percent of women want a vaginal birth, 50-80 percent of them end up with cesarean sections.
This isn't a problem unique to South America. It's so endemic that the World Health Organization has launched a campaign explaining that "across the world many women experience disrespectful, abusive, or neglectful treatment during childbirth in facilities. These practices can violate women’s rights, deter women from seeking and using maternal health care services and can have implications for their health and well-being." While those in the developing world are often hit hardest by abusive practices and a culture that dehumanizes childbearing women, it would be naive to think this doesn't impact women closer to home as well. Activists Cristen Pascucci and Lindsay Atkins's newly launched "Exposing the Silence" photo project documents women in the US who have experienced obstetric violence. There are equally shocking forced cesarean cases in the US and a rising culture of punitive measures against pregnant women who seek to restrict their reproductive freedoms more broadly.
The UK does better, but women still report intimate, surgical procedures being performed without their consent. A lack of dignity and compassion is cited time and again in investigations into failing maternity units and tragic, avoidable deaths. Women say that they are made to feel like vessels, not human beings, in birth.
Humanity is the key to breaking down acceptance of practices that not only humiliate, imprison, endanger, and abuse women, but eat away at their basic rights. In South America the extent of the problem has provoked a revolutionary solution. Thehumanizing birth movement (resulting in government-sponsored programs like the Stork Network in Brazil) pushes for safe and quality care with a woman-centered, respectful approach at all times. Putting basic human dignity back in to childbirth and reversing the power balance is an approach now being watched and emulated around the world.
Forced cesareans, obstetric violence, and dehumanized care can seem a world away from an arrogant junior doctor with a selfie-stick. But women are shamed and dehumanized in the birth room every day. Their heads may as well be cropped out, as in Sanchez's photo, as they lie stranded, just identity-less vaginas awaiting rescue or pillage; the balance of power tipped entirely in the wrong direction. It's women, not doctors, who "bring kids into the world." Let's start with getting that on the first page of the obstetric text book.

June 24, 2015

Doctor Looses License for Sexually Gruesome Experiments on His Trainees

Image result for john hagmann md
 RICHMOND — John Hagmann, a 59-year-old doctor accused of sexually assaulting and performing gruesome experiments on his trainees, had his medical license revoked Friday at a misconduct hearing of the Virginia Board of Medicine. 
“Let it be noted that it was unanimous,” misconduct panel chairman Kevin O’Connor said. “I’d like to thank the courageous medical students who came forward in this case.”
Hagmann never showed up to the hearing, which came as no surprise to the Board. “I was informed twice last week by his counsel that Dr. Hagmann intended not to attend,” Virginia Senior Assistant Attorney General Frank Pedrotty said at the beginning of the day’s proceedings.
This was confirmed by Hagmann’s attorney, Ramon Rodriguez, who said that Hagmann is out of the country and requested more time to prepare for the hearing.
“All Dr. Hagmann sought was a fair hearing of the facts where he could be present to answer the Board’s questions, provide witnesses and defend himself,” Rodriguez told BuzzFeed News by email. Rodriguez also said that Hagmann “intends to appeal what appears to be a clear violation of his constitutional right to due process.”
Hagmann’s license was suspended in March, two years after an anonymous student first reported his abusive behavior to the Uniformed Services University, the military school where Hagmann often conducted trainings.
Witnesses testified to a panel of nine doctors that Hagmann gave students dangerous drugs while they were inebriated, and performed unnecessary penile nerve blocks and rectal exams on them. Hagmann also allegedly asked students to perform rectal exams on himself, among other procedures that raised alarm on the panel. 
“Everything was just so abhorrent and abnormal,” said John Prescott of the Association of American Medical Colleges, who testified at the hearing as an expert on medical training. “In a combat situation, there’s no need for a penile block, ever.”
The hearing followed a report from the Virginia Board of Medicine, which was released in March and discovered by PETA in May. The report details how Hagmann had abused his power since at least 2012.
“The evidence was so overwhelming and bizarre that it was almost shocking to the conscience of a prosecutor who has been doing this for 26 years,” Pedrotty said in his final argument. “He represented a real and present danger to the health of his patients.”
It’s unclear whether Hagmann will face criminal charges, Pedrotty told BuzzFeed News. He added that it’s “unlikely” because in a criminal case Hagmann’s students would be regarded as volunteers.
Hagmann allegedly left the metal tip of a lidocaine infusion device in Patient C’s chest, then had to remove it mechanically from his breast bone without sufficient anesthesia to forestall “extraordinary” pain. According to Patient C, Hagmann disparaged the suturing skills of Special Forces medics and walked away saying he was disgusted by a bad sewing job.

“When we look at all of these things, we see a lot of problems all across the board,” said panel chairman O’Connor after Patient C’s testimony. “The themes we keep coming back to are coercion, isolation and predation,” he said later in the hearing.
“I am shocked as we all are,” said panel member Maxine Lee, in response to testimony from another medical student, “Patient A,” who said that Hagmann had repeatedly catheterized him.
Patient A also testified that Hagmann had performed a long rectal exam on him, and then said he realized he had “violated” the student and offered to let the student similarly examine him, in return.

An Army Captain who testified as “Individual E” by phone, said that during one of Hagmann’s courses, the handle of a medical device broke off while it was attached to her shin bone and had to be removed with pliers, under a procedure conducted with only a local anesthetic. “I started crying,” she said. “It was very painful.”
In July 2013, at a DMI training in a warehouse in Partlow, Virginia, Hagmann drank beer with a man, “Patient B.” This man then performed a penile and rectal examination on Hagmann, who videotaped it.

Patient B testified that he also allowed Hagmann to examine, manipulate, and photograph his penis. Hagmann was apparently interested in Patient B’s penis because he wanted to know “the effect his uncircumcised penis had on masturbation and sexual intercourse,” according to the Board’s earlier report. Hagmann also took photos of the student’s foreskin in “various stages of manipulation,” saying the pictures were a “training tool.”

That same month, at DMI’s 20-acre facility in Pink Hill, North Carolina, Hagmann allegedly forced students to take between five and eight shots of liquor in 20 to 30 minutes, then injected a few of them with the dissociative drug ketamine. He then encouraged drunk students to perform nerve blocks on the penises of classmates who had been given ketamine, according to the report.

At the hearing, Pedrotty said that repeated attempts were made to get Hagmann’s response to these complaints. Hagmann has not returned phone or email requests from BuzzFeed News.
Army Colonel Neil Page, who investigated the charges for USU in 2014, said that Hagmann hadn’t denied that any of the procedures occurred, but characterized them as standard combat medicine education.
Medical students prepare to testify before the Virginia Board of Medicine. Jay Paul / Reuters / Via
John Hagmann receiving “Outstanding Uniformed Educator Award” at USU in 1989. 
Reuters / Uniformed Services University of the Health Sciences Handout

Hagmann’s company, Deployment Medicine International (DMI), has taken $10.5 million in taxpayer dollars to run classes on combat medicine for members of the military.

“Everything we do is oriented towards saving lives in a theatre of war,” reads a DMI brochure. “DMI is the most experienced and professional corporation in this genre of medicine.” 
This blog post from 2012 shows photographs of Hagmann carrying out medical procedures on students in the U.K., sometimes without gloves.
DMI has been awarded almost $700,000 in Department of Defense contracts since the Navy claims it first learned about Hagmann’s gross ethical misconduct in July 2013, including a $343,800 contract from the Navy a week after a student came forward with allegations of abuse. Hagmann was suspended from receiving defense contracts last week. 
On Wednesday, Reuters reported that several high-ranking military officials have known about Hagmann’s disturbing teaching methods since at least 2005. In email exchanges with Reuters, Hagmann wrote: “In 25 years no one has ever been harmed. What military training — or even most sports — can report that?”
U.S. Army Colonel Neil Page, who led a USU investigation into Hagmann in 2014, testified that Hagmann had retired from the university in 2000 under a dark cloud after getting unprofessional conduct job ratings. 
A one-time pioneer in combat resuscitation medicine, Hagmann returned to teaching at USU in 2012 on the strength of his reputation and the turnover of leadership at the school, Page said, producing “amnesia” about his questionable activities.
On July 24, 2013, a USU student reported troubling behavior from Hagmann, at which point the university suspended its relationship with the company, according to USU spokesperson Sharon Holland. 
The school notified the Naval Criminal Investigative Service five days later, she added, then contacted the Defense Criminal Investigative Service within 48 hours. A Defense Criminal Investigative Service representative declined to confirm or deny the existence of an investigation to BuzzFeed News. 
The university conducted a “comprehensive internal investigation,” Holland told BuzzFeed News by email. That was completed in December 2013. But the report wasn’t sent to the Virginia Board of Medicine until February 25, 2014. It then took more than a year for the Virginia Board of Medicine to temporarily revoke Hagmann’s license.

The original tip to Reuters came from animal rights group PETA. 

Military medic trainings sometimes use pigs and other live animals to teach trainees how to treat injuries such as bullet or stab wounds in the field.

PETA had been tracking DMI since 2013, when a student of one of the live animal training classes sent the organization a video of the treatment of animals. 
In the video, a student asks an instructor with his face blurred whether the pigs could be replaced by a mannequin. The instructor, presumably an employee of DMI, responds “Hajjis could do it, that would be even better. But it’s not politically correct, and we can’t do that.” Hajji is an honorific given to Muslims who have made the pilgrimage to Mecca. Some members of the military have adopted the word as a derogatory term for people from the Middle East. 
Now that the investigation has been made public, PETA is suspicious of the way the Navy seems to have punted responsibility to the Virginia Board of Medicine. 
“It seems odd to me that an institution that prides itself on self-policing like the Department of Defense — if they did have information about the abuse of soldiers, why did they turn it over to a third party?” Justin Goodman, PETA’s director of laboratory investigations, told BuzzFeed News.

 A detainee in 2003 at the Abu Ghraib prison in Baghdad, Iraq. Associated Press / Via

Others have also called for an end to the use of animals in these trainings, including Hank Johnson, a Georgia Representative on the House Armed Services Committee. 
Johnson first learned of Hagmann’s exploits when a Reuters journalist contacted him for comment in the article that brought the story to the public eye, on June 8th. 
After reviewing the case and discovering DMI had its eligibility for federal contracts renewed in May 2015, Johnson sent a letter to Secretary of Defense Ashton Carter asking for a detailed investigation into the allegations. 
In addition to the animal issue, Johnson worries about using contractors for such important and sensitive courses. “We definitely need to always ask the question, why are we contracting out that training capacity?” Johnson told BuzzFeed News.
Military contractors may lack appropriate ethical oversight.

When it comes to contractors, “you’re not being directly monitored, and to the extent there is monitoring it’s probably paperwork compliance,” Jonathan Moreno, a bioethicist at University of Pennsylvania who specializes in national security, told BuzzFeed News.
That said, even if there had been more oversight, Moreno said, “the rules are not designed for people who are nuts.”
USU had not submitted Hagmann’s course for ethical review before hiring his company. “Prior to the disclosure of the inappropriate procedures used, the DMI training courses were well regarded around the world for many years,” Holland, the USU spokesperson, told BuzzFeed News by email.
This is one of several recent cases of military contractors grossly violating ethical standards due to lack of oversight.
In 2007, employees of Blackwater Security Consultants murdered 17 Iraqi civilians and injured 20 others in what is now known as the Nisour Square Massacre; four of the employees were later convicted of murder or manslaughter.
Likewise, the torture at Abu Ghraib prison was carried out by both service members and employees of CACI International and Titan Corporation. Though some soldiers faced consequences, including jail time and dishonorable discharge, no contractors were punished, and U.S. courts decided that the corporations had immunity from litigation.
Cases like these are making lawmakers take a close look at the use of contractors, which the military often uses as a way to reduce costs. According to a government report, more than 50% of the military is made up of private contractors.

August 19, 2014

Keeping sane as Medicine is gone Crazy


Medicine is moving at Mach speed, and physicians are in the middle of its path. Regulation. Consolidation. New technologies. With so many forces bearing down on doctors, how do you stay sane?
We asked physician experts and consultants to talk about the leading causes of dissatisfaction and burnout among physicians, and to give practical advice on handling them.

Doctors Face Challenges From All Sides

There are plenty of overarching macroeconomic forces unsettling doctors: a sluggish economy, uncertainty about the impact of the Affordable Care Act, and the rise of narrow provider networks, just to name a few. But these big-picture stressors often take a backseat to the everyday headaches that fill a physician's long days.
Four out of 10 respondents to Medscape's 2013 Physician Lifestyle Report say they're burned out, and it isn't the distant, foreboding pressures that are primarily to blame. Instead, doctors cited a couple of everyday, pervasive reasons: "too many bureaucratic tasks" and "too many hours of work."
Not surprisingly, these common complaints share some underlying causes.


Office visits squeezed into packed schedules are a constant strain on physicians, says Christine Sinsky, MD, an internist in Dubuque, Iowa. Clinical care has become much more complicated. Patients are older, sicker, and often more overweight, and physicians are expected to monitor and document far more information than in the past.
"We have to do all this frantic multitasking, which leads to paying less attention, which leads to stress, which leads to burnout," she says.


Monitoring and documenting care has become more complex as a result of increased regulation, PQRS (the Centers for Medicare & Medicaid Services' Physician Quality Reporting System), meaningful use, medical home criteria, and other requirements.
"It's not just about doing the right thing for your patients," Dr. Sinsky says. "It's about proving to someone else that you've done the right thing, and sometimes the proving takes longer than the doing."
Clinical documentation is only the beginning. Physicians currently spend almost one quarter of their time (22%) attending to nonclinical paperwork, according to a 2012 survey conducted by the Physicians Foundation.[1] With implementation of ICD-10 to take place in October, that percentage will likely increase.
“We spend too much time away from our patients dealing with checkbox-type medicine, and that really interferes with patient care," says Joseph Valenti, MD, a Denton, Texas-based ob/gyn and Physicians Foundation board member.

More Factors Straining Physicians' Sanity

EHR Woes

Although electronic record-keeping has been a boon to efficiency in many fields, it has significantly increased physicians' workloads. In addition to the headaches associated with mastering new systems, doctors spend a lot more time on data entry and a lot less time looking their patients in the eye than they used to.


Whether they've gone to work as employees of larger groups or are struggling to remain autonomous, physicians are feeling the effects of market consolidation. Many employed doctors bemoan the loss of clinical autonomy and struggle to adapt to new corporate cultures. Meanwhile, their colleagues in independent practices must constantly struggle with making ends meet given their limited resources and competition from larger provider groups, which have the clout to negotiate better contracts with insurers.
Twenty percent of the 2000-plus physicians surveyed by Physicians Wellness Services (PWS) and Cejka Search as part of their 2012 Physician Stress and Burnout Survey were not employees -- a number that closely aligns with the 14.2% of respondents who cited "financial issues such as the cost of running a practice, debt, etc." as a major cause of stress.[2]

Staying Calm, and Keeping Your Spirits Positive

Daunting as these challenges may be, experts say physicians can chip away at them if they're willing to reconsider their practices and adjust to shifting demands. Here are some steps you can take now to help you stay in control.

Build a Team

Dr. Sinsky, one of six researchers who studied nearly two dozen high-functioning primary care practices for an article published in the May/June 2013 issue of Annals of Family Medicine [3] says teamwork lies at the heart of addressing many of these frustrations.
"We can't deliver the outcomes we want for the future with the practice model and the staffing model of the past," she says.
For instance, a physician who works with a part-time medical assistant or a different medical assistant every day can't optimally delegate responsibilities because the gap in their training and licensing authority is too great, which forces the doctor to deal with a lot of administrative work, Dr. Sinsky says. Working with a team of nurses or physician assistants enables physicians to build a more flexible staffing model, she explains, because doctors can delegate more and team members can share tasks depending on what's needed.
Here's an example of smart streamlining of tasks: "During flu season, you don't want a physician spending a lot of time putting orders in for over a thousand patients," Dr. Sinsky says. "That's a lot of clerical work. Instead they can have a standing order saying, 'Anyone who agrees to a flu shot can have one.'"
In the interest of saving time -- including your time -- it makes sense to draft written protocols for your staff, recommends Melissa Stratman, CEO of Coleman Associates, a Boulder, Colorado-based consulting firm that helps physicians redesign work processes. "Implement a couple of protocols a week. It will make employees' jobs more interesting and satisfying, and enable you to delegate. Discuss the protocols at staff meetings, and ask employees for their comments and suggestions," she says.
  Having a cross-functional team means a team member can handle patient documentation for the physician, Dr. Sinsky says. Although some practices may opt to hire designated medical scribes, Dr. Sinsky says it's advantageous to train team members to do the work, so that a practice has the flexibility to use them in other capacities when needs arise.

Reengineer Tasks

Ordering routine tests before an office visit saves the practice time and promotes better communication with patients, Dr. Sinsky says. With results already in hand, you can discuss the numbers with your patients and use the exchange as an opportunity to motivate them, set goals, and develop an action plan. Ordering tests in advance likewise eliminates the need to call patients with their results after the visit. Similarly, by providing multimonth prescriptions for patients with stable conditions, practices can avoid repeating the same work multiple times throughout the year.
Simply taking the time to educate your medical assistants about what you need and why you need it can save lots of time and free up staff to handle more clerical functions, says Stratman.
Shelly Reese/ Freelance writer, Cincinnati, Ohio
 adamfoxie blog advise: 
To the Doctor:
Ronald Groat, MD, a Minneapolis psychiatrist and consulting physician for PWS, reminds physicians to practice what they preach: Eat right, exercise, and spend time with your family and friends. "You have to remember your priorities," he says. "You can't forget -- and neglect -- the people and activities that are important to you and give your life meaning. If you can't find that balance in your existing situation, then you should consider how you can make changes. It may be worth your while to reduce your income if it translates to a better quality of life.
To the Patient:
If your Doctor or new young Doctor shows signs of unhealthy habits like, smoking, obese or bad hygiene you need to take a second look.  

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