health: September 2013

Quality vs Costs of US Corporate Owned but Offshore Medical Schools

Background: Off-Shore Medical Schools for US Students Owned by US Corporations

While US health care appears to be more corporate than health care in any other developed country, one part of health care that has remained a bit less corporate is medical education. In particular, no US medical school is a for-profit venture, to my knowledge. (This just makes US medical education a bit less corporate than the rest of health care because, as we have discussed endlessly, academic medical institutions in the country have frequent institutional conflicts of interest, and their boards of trustees, administration, and faculty have frequent individual conflicts of interest.)

Nonetheless, there are many Americans attending for-profit medical schools owned and run by US based corporations. It is just that these schools are not physically located in the US. Since the number of US citizens who want to go to medical school has been greatly exceeding the capacity of US medical schools, many who want to become physicians have sought medical training in other countries. Some go to medical schools outside of the US which are primarily operated to provide doctors to the countries in which they operate. However, the limited availability of places available in such schools for foreign students, and the difficulties of training in unfamiliar medical systems and often in unfamiliar languages limit the attractiveness of this option.

Enter American entrepreneurs into the picture, who realized they could set up schools in willing locations (often in small countries in the Caribbean) meant to educate Americans in English. While there are plenty of reasons to be concerned about the role US based medical schools play in the dysfunction of US health care, there may even be more reasons to be concerned about for-profit, US owned, but off-shore medical schools that cater to US students. Yet although such schools now train a large number of students, they tend to fly under the radar.

Reasons for Concern about US Corporate Owned but Off-Shore Medical Schools

In 2010, we posted about an investigative report in the St Petersburg (FL) Times that provided reasons for concern. These included suggestions of quality problems, such as high attrition rates, high rates of failure to complete residency training and lack of quality controls over clinical education, high costs imposed on students, and the role of extremely well compensated executives with no apparent knowledge of medical education.

Now Bloomberg has published another report on for-profit, US owned Caribbean medical schools that underscores these concerns. The report focused on schools owned by the US based, publicly traded DeVry Inc. These include American University of the Caribbean School of Medicine, located in St Maarten, and Ross University School of Medicine, located in Dominica...

Quality Concerns

- Attrition

Many DeVry students quit, particularly in the first two semesters, taking their debt with them. While the average attrition rate at U.S. med schools was 3 percent for the class that began in the fall of 2008, according to the AAMC, DeVry says its rate ranges from 20 to 27 percent.

One reason for this is that for-profit schools may take students who are less academically qualified,

Many of those students, ..., failed to gain admission to U.S. schools, where the mean score on the Medical College Admission Test, or MCAT, was 31.2 out of a possible 45 last year. At DeVry’s schools, the average score was 25.

- Time to Completion of Training

Of those who remained, 66 percent of AUC students and 52 percent of students at DeVry’s other Caribbean medical school, Ross University School of Medicine, finished their program -- typically two years of sciences followed by two years of clinical rotations -- on time in the academic year ended on June 30, 2012.

- Difficulty Obtaining Residencies

The National Resident Matching Program says 94 percent of fourth-year students schooled in the U.S. landed a first-year match in 2013, while 53 percent of U.S. citizens trained internationally did.

DeVry students fare better than the average foreign-trained student. Of the 914 Ross students who applied for residency in 2013, 76 percent, or 699, earned places. Another 41 had preliminary one-year spots, which would require the students to win a second residency in order to be eligible for a medical license in 48 states.

Of the 268 AUC students who applied for residency, 212, or 79 percent, got matches, and seven more had one-year slots. The remainder of the students failed to win a residency.

- Lack of Standards

The Bloomberg article also emphasized the fact that the US owned corporate off-shore schools do not have to meet the same accreditation standards as do US based schools:

The Accreditation Commission on Colleges of Medicine, an Ireland-based body, accredits four Caribbean medical schools, including AUC, according to its website.

High Costs

While the quality of education provided by US owned corporate off-shore medical schools may be questioned, there is no doubt about their high costs.

First-year tuition on Dominica costs $56,475, based on the three terms Ross divides the year into. That compares with a median of $50,309 for tuition and fees at private U.S. medical schools in the 2012-to-2013 school year.

These costs are of particular concern because many students of off-shore schools amass impressive amounts of debt.

DeVry, which has two for-profit medical schools in the Caribbean, is accepting hundreds of students who were rejected by U.S. medical colleges. These students amass more debt than their U.S. counterparts -- a median of $253,072 in June 2012 at AUC versus $170,000 for 2012 graduates of U.S. medical schools.

And that gap is even greater because the U.S. figure, compiled by the Association of American Medical Colleges, includes student debt incurred for undergraduate or other degrees, while the DeVry number is only federal medical school loans.

These high debt loads are enabled by US government loans, even though the schools are not located or accredited in the US.

And though neither AUC nor Ross, in the island nation of Dominica, is accredited by the body that approves medical programs in the U.S., students at both schools are eligible for loans issued by the U.S. Education Department.

In addition,

Students at the four schools -- the two DeVry schools, along with St. George’s University School of Medicine and, since July, Saba University School of Medicine -- are also eligible for tuition benefits from the U.S. Department of Veterans Affairs.

Leadership

The Bloomberg article briefly questioned the motivations of DeVry leadership, quoting David Bergeron, previously of the US Department of Education

If they have to make a choice between students and profit, they choose profit

They may do so because the off-shore medical schools bring in a lot of money

DeVry got 34 percent of its revenue in the year ended on June 30 from medical and health-care education, including a chain of U.S. nursing schools. The unit contributed $673 million of DeVry’s $1.96 billion in revenue, up more than sevenfold from $91 million in fiscal 2005.

'The diversification strategy is working,' Chief Executive Officer Daniel Hamburger said at an investor conference in Chicago in June. 'About a third now of our enrollment is in the growing field of health-care education.'

It seems clear that this revenue stream is greatly dependent on US government money

DeVry acquired AUC in 2011 for $235 million, attracted partly by the school’s eligibility for federal loans, says Harold Shapiro, DeVry’s chairman and a former president of Princeton University.

'Access to federal student loans is very important for a lot of DeVry programs, including that one,' says Shapiro, 78, an economist by training, who plans to retire from DeVry in November after 12 years on the board and five years as chairman. 'Obviously, it’s part of what makes it work.'

A Quick and Dirty Look at Costs vs Value

As I noted earlier, little seems to be written about the commercial nature of the US owned, but off-shore medical schools that purportedly educate a growing number of US citizens. I thought I would try to add a little to the Bloomberg article by trying to see if I could find any other obvious way to contrast the quality of the Caribbean based schools with their high costs.

As noted above, the tuition at one DeVry medical school was more than 10 percent higher than the median for US schools.

For comparison, I thought I would make some sort of quick assessment of the faculty of one DeVry school, Ross University School of Medicine. That turned out to be easier than I thought it would be.

My first stop was the web-page that conveniently lists all of the school's faculty and administration. I assumed that this would be cumbersome to use. After all, a typical US medical school has a huge faculty, divided among pre-clinical departments (anatomy, physiology, biochemistry, etc), and clinical departments (usually one for each important specialty and or sub-specialty). I thought I would start with the Ross department of internal medicine (since my background is in internal medicine). Imagine my surprise when I discovered that Ross does not have individual departments for clinical disciplines, but simply one Department of Clinical Medicine.

Imagine my further surprise when I reviewed its membership. The web-page lists all of 31 people in this department. The list, with a summary of the individuals' positions at the school, and previous training appears below in the appendix.

The qualifications of this small number of clinical faculty were mixed at best.

- Note that of the 31, 8 are not actually faculty, but staff (color coded pink)

- Of the 23 actual faculty, only 5 seem to have received their medical degree and residency training in the US (color coded blue). In addition, one received US residency training after medical school in South Africa. (This is relevant because this school caters to US students, emphatically not students from Dominica.)

- Of the remaining 18 faculty, for 10 no background information was supplied (color coded green).

While the number of clinical faculty was small, keep in mind that Ross University School of Medicine is very large:

Ross typically enrolls 900 to 950 students per academic year, who start in either January, May or September.

That’s about seven times the average of 139 for the 2013 graduating class of U.S. med schools, according to figures from the AAMC.

Yet a typical American school has orders of magnitude more faculty for almost one order of magnitude less students. For example, my own medical school, Alpert Medical School of Brown University, has 457 students in four classes, and has 180 campus-based and 652 hospital-based faculty. Its Department of Internal Medicine, just one of many clinical departments, is much larger than Ross University's single Department of Clinical Medicine.

While the argument could be made that Ross only provides the first two years of medical education at its Dominica campus, and farms out the rest to a variety of hospitals in the US, keep in mind that the second year of a typical medical school curriculum is clinical topics and taught by faculty in clinical departments, often hospital based.

So what in the world is the rationale for charging a higher tuition rate than a typical US based medical school, when the school only has to support a tiny faculty whose qualifications do not seem sufficient to demand a high price?

Summary

Based on admittedly limited information mainly from media sources, we find that US corporate owned but off-shore based medical schools make large amounts of revenue, charge their large student bodies big amounts for tuition, yet provide proportionately minuscule numbers of not clearly all well-qualified faculty, producing high attrition and residency completion rates. Yet these schools' revenue streams are derived mainly from US government loans, made even if many students will not eventually obtain medical qualification and work as physicians.

This seems like a great deal for the corporate executives and perhaps stockholders, but a poor deal for the students and the US tax-payers who support them.

We see another aspect of the US health care system in which money seems to trump mission, facilitated by an unseemly alliance between wealthy corporate executives and bad US government policy. We need to reexamine our fascination for "market based" approaches to health care, when almost nothing about any part of health care resembles, or could resemble a free market (see this post). We need to make health care more transparent, and shine more sunshine on the nooks and crannies, like off-shore but US corporate owned medical schools. We need to facilitate health care leadership and governance that puts patients' and the public's health first, way ahead of the personal enrichment of the participants.

Appendix

"Faculty" Listing for Ross University School of Medicine Department of Clinical Medicine

Jane Bateson - "Data Analyst & Research Associate"

Anne M Beaudoin - "Operations Specialist"

Liris Benjamin - "Associate Professor," "Doctorate in Physiology from the University of West Indies"

Lisa Buckley - "Simulaton Cordinator"

Yasmin Burnett -"Associate Professor" [no further details listed]

Diana Callender - "Professor and Chair" "graduate of the University of the West Indies where she completed her MBBS and

Residency in Clinical Hematology."

Terri Carlson- "Associate Professor," "Creighton University Medical School in Omaha, Nebraska and completed residency

training in Family Practice at University of California, San Francisco in 2001."

John Charyk - "Assistant Professor," "medical school at Georgetown University in Washington DC. In 1981 he completed his

family medicine residency program at the University of Colorado in Denver."

Phillip E. Cooles - "Professor," "BSc at King's College, London, then a medical degree at St George's Hospital medical

school, and then a residency in internal medicine in Aberdeen, completing the MRCP"

Lauri Costello - "Assistant Professor," "UC Davis for medical school then further north to Spokane Washington for her

residency at Family Medicine Spokane,"

Hedda Dyer - "Associate Professor," "University of Edinburgh Medical School with a bachelor of Medicine and Surgery (MB

CHB). She is a Member of the Royal College of Surgeons of Edinburgh, Scotland (MRCS Ed)"

Sean Fitzgerald - "Assistant Professor" [no further details]

Lyudmyla Golub - "Associate Professor," "Doctor of Medicine degree in 1983 from Vinnitsa National Medical University,

Ukraine. She completed an Internship in Surgery at Vinnitsa Teaching Hospital #3, Ukraine"

Lata Gowda - "Harvey Facilitator"

Aimee Hougaboom - "Simulation Coordinator"

David Johnson * - "IME Facilitator"

Sybille Koenig - "Coordinator, Standardized Patients Program"

Jaya Kolli - "Professor," "undergraduate degree at the Guntur Medical College, Andhra University, India. He went on to the

Government General Hospital/Guntur Medical College, Nagarjuna University, in Guntur, India and completed a residency in

Internal Medicine"

Kamalendu Malaker * - "Visiting Faculty" [no further details]

Ganendra Mallik - "Associate Professor" [no further details]

Sanghita Mallik - "Assistant Professor" [no further details]

Robert Nasiiro - "Professor" [no further details]

Worrel Sanford * - "adjunct Assistant Professor" [no further details]

Robert Sasso - "Professor" [no further details]

Harold Schiff - "Associate Professor," "board certified neurologist, trained at Boston City Hospital, Boston University and

has a fellowship in Behavioral Neurology, Higher Cognitive Function and Geriatric Neurology. He graduated from the

University of the Witwatersrand, Johannesburg South Africa"

Nancy Selfridge - "Associate Professor" "medical training and MD degree from Southern Illinois University School of

Medicine"

Rose-Claire St. Hilaire * - "IME Instructor" [no further details]

Lynn Sweeney - "Assistant Professor,"graduated from the University Of Tennessee School Of Medicine in 1987. She completed

residency in emergency medicine at the University of Arkansas for Medical Sciences"

Valarie Thomas - "Assistant Professor," "D.V.M. degree from the Universidad Agraria de La Habana in Havana Cuba"

Nash Uebelhart - "Assistant Professor," [no further details]

Miscilda Vital-Harrigan - "Assistant Professor," [no further details]

Why Trust Drug Company Executives After One Admits Commercially Sponsored Clinical Research Is All About "Competitive Advantage?"

Mickey, the semi-anonymous blogger on 1BoringOldMan, wrote a righteously angry post in support of transparent clinical research. As we have noted frequently, clinical trials done on human subjects are often manipulated to increase the likelihood of results favorable to commercial sponsors, or suppressed when even such manipulation does not produce the desired results.

Note that such suppression and manipulation degrade the scientific value of the studies, impede the evidence-based medicine process to rationally apply clinical research evidence to improve the health of patients and the public, and violate the trust of research subjects who volunteer to participate based on the assumption that clinical research is meant to improve patient care and public health, and contribute to science, not just secure commercial advantage.

A European initiative to combat suppression of clinical research has been opposed by a lawsuit from US pharmaceutical manufacturers AbbeVie, spun off from Abbott Laboratories, and Intermune. The European Medicines Agency had been willing to to make public unpublished patient level data from commercially sponsored clinical trials. The lawsuit has shut down the process, and is meant to shut it down permanently, claiming that the clinical data, obtained from volunteer research subjects, includes "trade secrets."

As summarized by Mickey, their motivation seems to be to conceal how pharmaceutical manufacturers and other commercial sponsors of human research use this research for promotional, rather than scientific purposes.

An AbbeVie lawyer asserted that some adverse effects data should be kept confidential, and that "internal tactical decisions on how we are going to run a study, engage with regulators, and confront and solve problems and challenges we have uncovered during clinical trials" should also be kept secret because revealing them could "give other companies a tremendous competitive advantage," never mind whether keeping secrets could undermine science, decrease the study's usefulness to aid clinical and policy decision making, and break the implicit contract between researchers and study subjects.

It is becoming more obvious that many drug company executives, and other leaders of large health organizations, may care more about "competitive advantage" than patients, science or the public good, as Mickey points out. So much for that advertising puffery about drug development to improve patient health. Thus it may be ridiculous to think that these executives they will negotiate to improve transparency of clinical research in good faith when doing so could decrease such advantage, again no matter what the effect on patients, public health, or science.

On this case there is an opportunity to speak out, Dr David Healy has a petition up on Change.org to oppose the AbbeVie and Intermune lawsuit which might get some notice if there are enough signatures.

A New And Quite Perverse Hospital Ploy to Defend Medical Malpractice - Blame the Dead Patient? Two Examples

I did not think hospitals would ever get to the level of perversity, in defense of EHRs and EHR-related malpractice, seen herein.

Just a few days ago I came across the following article on a web search.

It is an astonishing story of a 49 year old man who died in part because an ED physician in a Suffern, NY hospital did not know how to use the EHR that had life saving diagnostic information within, and the hospital attempted to BLAME THE PATIENT for not "explaining his medical history thoroughly enough" to the ED doctor.

You read that correctly.

Ironically and sickeningly, yesterday my dead mother and I just had something similar done to us by a suburban Philadelphia hospital, Abington Memorial, as below:

Family Awarded $3.4 Million After ER Misses Aneurysm

http://blogs.lawyers.com/2012/02/family-awarded-3-4-million-after-er-misses-aneurysm/
Posted February 17, 2012 in Medical Malpractice by writer Aaron Kase

It’s gospel in health care– if you have chest pains, get to the emergency room, especially if you have a history of heart problems. But an inexperienced ER doctor in New York thought his patient’s complaints weren’t serious, and sent him home with muscle relaxers. The result was deadly.

A Rockland County jury Wednesday awarded $3.4 million to the family of Michael McKenzie, who was discharged from the Good Samaritan Hospital in Suffern in 2007 after complaining of chest pains and other symptoms consistent with a serious heart problem. The hospital determined that McKenzie, 49, was not having a heart attack, then ER doctor Michael Kane diagnosed him with a muscle strain and sent him home with muscle relaxers.

Two days later, McKenzie was found dead in his house by his 10-year-old son, killed by an aortic aneurysm.

The hospital should have found the aneurysm, argued Anthony DiPietro, the attorney for McKenzie’s family.”They just blew it,” says DiPietro, who headquarters his practice in New York City. “He had textbook signs of an aortic dissection [bleeding into the wall of the main artery that carries blood from the heart]: Chest pain, back pain, shortness of breath, sudden onset, woke him up from sleep, and he wasn’t doing any activities when it happened.”

Compounding the hospital’s error, McKenzie had a history of heart problems that should have pointed them toward the correct diagnosis. In 2003, he had been diagnosed with a dilated aortic root, or enlarged artery, with is a huge red flag for a future rupture. Good Samaritan knew about the dilated root because they had noted it in his chart during a heart procedure McKenzie had undergone the year before his death.

But the doctor, who had been at the hospital less than a month and was working unsupervised, never knew about McKenzie’s history. Why not? Because he didn’t know how to use the hospital’s electronic medical records system.

That's beyond pathetic, but it gets worse. Far worse:

“He admitted it as part of his deposition,” DiPietro says. “They equivocated. First they said the system wasn’t working [an apparent attempted mistruth - ed.], but then he said he really didn’t know how to use it yet.” According to a local news report, the doctor was certified in obstetrics and gynecology at the time, and didn’t receive his certificate in emergency medicine until the following year.

The hospital argued that the aneurysm wasn’t present when McKenzie visited their ER–despite the fact that his certificate of death stated it had been present for days. The hospital also claimed that McKenzie was responsible for his own death because he didn’t explain his medical history thoroughly enough– the same history that was documented in the hospital’s own records.

Let me repeat that for emphasis:

The - hospital - also - claimed - that - McKenzie - was - responsible - for - his - own - death - because - he - didn’t - explain - his - medical - history - thoroughly - enough– the - same - history - that - was- documented - in - the - hospital’s - own - records.

A hospital dares blame a likely frightened-out-of-his-wits patient presenting to their ED with chest pain, back pain, shortness of breath, of sudden onset that woke him up from sleep, for his own death?

That, readers, is the most perverse hospital behavior I have ever encountered since entering medicine in 1977 (actually 1972-3 in summer NSF programs at Hahnemann Hospital in Philadelphia).

Not to mention, of course, that said patient cannot defend himself, because he's dead and buried...

In fact, in a highly unusual move, the judge in the case allowed doctors to recount conversations they had with McKenzie to the jury, statements usually prohibited under New York’s “Dead Man’s Statute” designed to keep hearsay out of the courtroom.

It's a very special hearsay indeed when the hear-sayers know the patient is in his grave and cannot respond.

The tilted playing field notwithstanding, the jury nevertheless found the hospital negligent and awarded $3.4 million to McKenzie’s widow, two adult daughters and now 14-year-old son. The money couldn’t come soon enough– the widow, now sole provider for her son, recently lost her job and their home went into foreclosure. “Hopefully this will allow them to keep the house,” DiPietro says.

The ironically-named hospital planned an appeal:

A Good Samaritan spokesperson said the hospital plans to appeal.

I will attempt to find if the dockets are publicly accessible.

So, to recap, an ED doc didn't know how to use an EHR that contained lifesaving diagnostic information misses an aneurysm, the patient dies, and the defense attempts to blame the patient for his own death for (allegedly) not telling the doctor thoroughly enough about his own medical condition, i.e., the frightened, in-severe-pain patient didn't know medicine but should have - doesn't everyone?

-------------------

I could almost not believe this story, thinking maybe it was exaggerated - until just a few days later I EXPERIENCED THE SAME ISSUE MYSELF, PERSONALLY.

As substitute plaintiff in the death of my mother in 2011 due to a 2010 medication reconciliation failure at Abington Memorial Hospital, as mentioned on this blog and in the press (e.g., Bloomberg News, http://www.bloomberg.com/news/2013-06-25/digital-health-records-risks-emerge-as-deaths-blamed-on-systems.html and Kaiser Health News, http://www.kaiserhealthnews.org/stories/2013/february/18/scot-silverstein-health-information-technology.aspx), the hospital responded (finally) to the points raised in the Complaint filed in October 2011, after exhausting many procedural delay tactics.

The are attempting to blame my mother, who I took to the ED while she was in process of nearly having a stroke, and me as well for her injuries.

From their Sept. 9, 2013 filing:

... 41. The injuries allegedly sustained by [substitute] Plaintiffs decedent [my dead mother - ed.] were caused in whole or in part or the same may have been contributed to by the actions of the Plaintiffs decedent [my dead mother - ed.], and accordingly, any claim for damages is barred or the damages recoverable herein must be reduced in accordance with the provisions of the Pennsylvania Comparative Negligence Act, as may be applied to facts disclosed in discovery.

They're apparently claiming (quite falsely, as I was there) that my mother, brought to the ED by me with a headache and suffering cerebral ischemia, never advised the doctors and nurses about her heart medication Sotalol (which was in their ED and floor EHR's from prior visits - just as in the aneurysm case above) that they summarily terminated, leading to disaster, so that her injuries and death are her own fault.

Of course, my mother is dead, so only I can speak for her.

My mother would personally respond to Abington Memorial Hospital's charges blaming her for her injuries under their care and subsequent death, but she is not available to do so, at least in this world. Rest in Peace, Mom, I have your six.

They also attempt to blame me for my mother's harm and death, a layperson (I have not practiced medicine in over 21 years):

54. Upon information and belief, Scot Silverstein’s actions and/or omissions may have been the cause or one of the causes of the harm suffered by the Decedent and/or her Estate.

55. Upon information and belief Scot Silverstein may be contributorily or comparatively negligent for any harm to the decedent and/or her Estate.

They also falsely claim I never informed medical staff about my mother's heart medication, nothwithstanding their own medication reconciliation (verification) policy calls for a best-effort complete re-verification of medications from all available sources at every transition of care, such as when she went from ED to ICU, and then ICU to floor, when I was not present. Such resources would include, among others: 1) me, via telephone (not used); 2) the patient (apparently this resource was not used); 3) past EHR visit med lists showing the heart medication (also, apparently not used).

As the Abington Hospital filing was signed and verified by their VP "Patient Advocate" / Director of Risk Management Regina Sturgis, considering these cases, I must ask the question if the practice of "blaming the harmed or dead patient" for their harm is a risk management strategy taught in the seminars these folks attend.

Blaming dead patients or their families for harm from medical misadventures is absolutely horrifying. It shows disrespect for the dead and is depraved, especially coming from a hospital, I think any prospective patient would agree.

-- SS

N.S.A. Able to Foil Basic Safeguards of Privacy on Web, Including Medical Records - Yet Another Reason To Be Concerned About What You Tell Your Physician

There's already a major issue with privacy and protection of medical records in electronic form. See the multiple blog posts at this query link: http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy

Now this from the New York Times:

N.S.A. Able to Foil Basic Safeguards of Privacy on Web
By NICOLE PERLROTH, JEFF LARSON and SCOTT SHANE
September 5, 2013

The National Security Agency is winning its long-running secret war on encryption, using supercomputers, technical trickery, court orders and behind-the-scenes persuasion to undermine the major tools protecting the privacy of everyday communications in the Internet age, according to newly disclosed documents.

The agency has circumvented or cracked much of the encryption, or digital scrambling, that guards global commerce and banking systems, protects sensitive data like trade secrets and medical records, and automatically secures the e-mails, Web searches, Internet chats and phone calls of Americans and others around the world, the documents show.

But don't worry, your electronic medical records are secure, and will NEVER be used for political purposes by your adversaries...

Beginning in 2000, as encryption tools were gradually blanketing the Web, the N.S.A. invested billions of dollars in a clandestine campaign to preserve its ability to eavesdrop. Having lost a public battle in the 1990s to insert its own “back door” in all encryption, it set out to accomplish the same goal by stealth.

The agency, according to the documents and interviews with industry officials, deployed custom-built, superfast computers to break codes, and began collaborating with technology companies in the United States and abroad to build entry points into their products. The documents do not identify which companies have participated.

At least we may have gotten faster PC's as a side result of the research that supported these efforts.

... the agency used its influence as the world’s most experienced code maker to covertly introduce weaknesses into the encryption standards followed by hardware and software developers around the world.

Some of the agency’s most intensive efforts have focused on the encryption in universal use in the United States, including Secure Sockets Layer, or SSL; virtual private networks, or VPNs; and the protection used on fourth-generation, or 4G, smartphones. Many Americans, often without realizing it, rely on such protection every time they send an e-mail, buy something online, consult with colleagues via their company’s computer network, or use a phone or a tablet on a 4G network.

Might as well just send them a copy of all your communications to spare them the effort...

... Ladar Levison, the founder of Lavabit, wrote a public letter to his disappointed customers, offering an ominous warning. “Without Congressional action or a strong judicial precedent,” he wrote, “I would strongly recommend against anyone trusting their private data to a company with physical ties to the United States.”

Hey, how about let's ALL have our medical records stored by health IT companies providing ASP (Application service provider, http://en.wikipedia.org/wiki/Application_service_provider) offsite EHR hosting services to hospitals and clinics...

From the site "techdirt.com":

Allegedly the NSA and GCHQ (UK Government Communications Headquarters) have basically gotten backdoors into various key security offerings used online, in part by controlling the standards efforts, and in part by sometimes covertly introducing security vulnerabilities into various products. They haven't "cracked" encryption standards, but rather just found a different way in. The full report is worth reading ... (http://www.techdirt.com/articles/20130905/12295324417/nsa-gchq-covertly-took-over-security-standards-recruited-telco-employees-to-insert-backdoors.shtml).

Half facetiously: unless you're a real nobody, if you, say, contracted V.D. from that sexy prostitute at that Vegas Convention, you perhaps better not tell your doctor about it.

Maybe this is what it will take to get the government to start taking electronic medical record privacy, confidentiality and security more seriously.

Our legislators, like everyone else, have a stake in the game.

-- SS

Market Fundamentalism and the Denial of Conflicts of Interest, and of Worse Offenses

While we often point out the pervasiveness of conflicts of interest in medicine and health care, and the likely ill effects of this state of affairs, it seems that the powers that be in health care tend to airily dismiss conflicts of interest as at most a minor problem that needs management (e.g., look here.)

How Market Fundamentalist Ideology Nullifies the Concept of Conflicts of Interest

On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody discussed how application of the reigning orthodoxy in economics, sometimes called neoliberalism, market fundamentalism, or economism, can be used to dismiss the concept of conflicts of interest.

Basically, supporters of market fundamentalism et al seem to assume that all markets are idealized free markets, and that free markets are like a super computer combining all human thought to provide wisdom in the form of price information. Furthermore, since the market is based on supposedly rational choices made by free individuals, one cannot go back to question such choices.

So when, for example, an academic physician makes the "free choice" to accept thousands of dollars from a drug company as a "market consultant," and then also gives talks about clinical topics that happen to favor that drug company's products, such choices cannot be questioned. Therefore, the notion that these choices constitute a conflict of interest, and that the choice to accept the drug company money in particular might increase the likelihood of abuse of the physician's entrusted responsibility to make the best decisions for individual patients, and to teach other physicians honestly and without bias, essentially makes no sense within this framework.

Dr Brody further enlarged on the internal contradictions within the ideology of neliberalism/ market fundamentalism/ economism, in another post on his Economism Scam blog.

Of course, the ideology seems to ignore the possibilities that 1) people's choice may not be free, may not be rational, and may not be based on coldly rational cognition and the best possible knowledge; and 2) one person's economic choice may limit another person's choices, or directly harm another person.

By Extension, Fraud and Corruption Denialism

Furthermore, not only does neoliberalism et al seem to deny the existence of meaningful conflicts of interest, it also could be used to deny the meaningful existence of deceptive marketing, of market domination through oligopoly or monopoly, and then of outright fraud, bribery, and extortion.

See for example how former US Federal Reserve chairman Alan Greenspan seemed to deny the existence of fraud, which he asserted would always be nullified by the ideal market. As we posted here, according to an article in Stanford Magazine, Greenspan told Ms Brooksley Born, the federal regulatory agency head who tried to develop some effective regulation of financial derivatives,

'Well, you probably will always believe there should be laws against fraud, and I don’t think there is any need for a law against fraud,' she recalls. Greenspan, Born says, believed the market would take care of itself.

By further extension, market fundamentalism could be used to deny the evils of chattel slavery.

The Conflicted as Defenders of Conflicts of Interest

Finally, notice that neoliberalism/ market fundamentalism/ economism ideology seems to have conveniently been adopted by pundits, both in economics and in medicine and health policy who may be personally profiting from conflicts of interest on one hand, and whose conflicts seem to arise from payments from large corporations whose management seem to be personally profiting even more so.

For example, we have discussed examples of how defenders of existing financial relationships - which in my humble opinion are actually conflicts of interest - employ logical fallacies to make their points. Some of these defenders seem to have obvious conflicts of their own (for example, this post included examples of physicians rationalizing their financial ties to drug companies, and this post included fallacies employed by a current medical school leader, but former extremely well paid biotechnology company executive.). On the other hand, I have yet to find a logical, reality-based defense of these conflicts of interest made by anyone who demonstrably does not have such conflicts of their own.

Summary

Human beings have been wrestling with corruption since the dawn of history. There are ancient arguments against bribery in the Bible (e.g., in the Old Testament, in Exodus and Deuteronomy), and fraud (e.g., in Leviticus, the Proverbs, and the Gospel of Mark). One can argue that a fundamental purpose of civilization is to reduce self-serving misbehavior such as bribery, fraud, and extortion, and other varieties of corruption. The notion that free markets make the concepts of fraud, and of conflicts of interest (that are risk factors for corruption - look here) meaningless is nothing more than school playground sophistry.

To truly reform health care, we need to return it from its current Wild West mentality to a state more resembling civilization. We need to reject silly notions that free markets erase the concepts of conflict of interest, or of fraud, or of other aspects of corruption.

Study Explains Errors Caused by EHR Default Values - With Only Four Reports of "Temporary" (By the Grace of God) Patient Harm

From Health Data Management and the Pennsylvania Patient Safety Authority:

Study Explains Errors Caused by EHR Default Value
Joseph Goedert
Sept. 5, 2013

A new study analyzes errors related to “default values” which are standardized medication order sets in electronic health records and computerized physician order entry systems.

The Pennsylvania Patient Safety Authority, an independent state agency, conducted the study. “Default values are often used to add standardization and efficiency to hospital information systems,” says Erin Sparnon, an analyst with the authority and study author. “For example, a healthy patient using a pain medication after surgery would receive a certain medication, dose and delivery of the medication already preset by the health care facility within the EHR system for that type of surgery.”

These presets are the default value, but safety issues can arise if the defaults are not appropriately used. Sparnon studied 324 verified safety reports, noting that 314, or 97 percent, resulted in no harm. Six others were reported as unsafe conditions that caused no harm and four reports caused temporary harm involving some level of intervention.

One might ask: how many unreported or yet-to-be-reported EHR/CPOE cases involved, or will involve, permanent harm?

Sept. 9, 2012 Addendum: We learn this from Healthcare IT News (http://www.healthcareitnews.com/news/ehr-adverse-events-data-cause-alarm): "Sparnon said two of the reports involved temporary harm that required initial or prolonged hospitalization." I note that hospitalization, especially prolonged hospitalization, exposes the patient to still more risk.

Regarding the "temporary harms", one which includes "default times" as opposed to doses:

The four cases requiring intervention involved accepting a default dose of a muscle relaxant that was higher than the intended dose, giving an extra dose of morphine [keep playing with 'extra doses' of drugs like morphine enough, and you're going to kill someone - ed.] because of an accepted default administration time that was too soon after the last dose, having a patient’s temperature spike after a default stop time automatically cancelled an antibiotic [do this enough, and you're going to get sepsis and septic shock to deal with - ed.] and rising sodium levels in a patient because confused wording made nurses believe that respiratory therapy was administering an ordered antidiuretic. [Apparently the 'default'- ed.]

Need to relax? How meditation can help you stay calm

By ElanaMiller, M.D., Resident Psychiatrist, UCLA Follow @ElanaMD

Arshya Vahabzadeh, M.D., Resident Psychiatrist, Harvard University/Mass.General/McLean

Follow @VahabzadehMD

For many of us, daily
life doesn't lend itself well to relaxation and reflection. We find ourselves
running around from task to task. We wake up hurriedly, rush to work, get
bombarded with calls and emails throughout the day, speed through meals, try to
fit in a workout, and schedule time with friends / spouses / kids. . . which leaves us with little to zero time for ourselves. It's a tough way to live, day in and day out.
Meditation is one tool we can use to find some calm.

Put simply, meditation
is the practice of focused, mindful attention. One starts focusing on the
breath, following the breath in and out. Inevitably, we get distracted, and our
mind wanders: Did I feed the dog? That was so annoying what Bill did at
work today. Oh, I'm getting distracted, I'm so bad at meditating!

This is okay - and even expected. When the mind wanders we simply bring the focus back to the breath. When a very strong emotion of physical sensation calls our attention
away, we can make that sensation the new object of meditation, watching as it
gets stronger or weaker. When the sensation isn't so strong anymore, we return
to the breath. Training the mind is like training a puppy - when it runs
away, we bring it back, over and over.

So how does this simple
practice help cultivate relaxation in daily life?

1. Meditation helps you stay in the present

So much of our time is
spent in the past and the future that we rarely are present in the moment. We
spend so much time remembering, regretting, planning, and worrying that we miss
the moments of joy and spontaneity that are right in front of us.

Meditation helps train
the mind to focus on the present moment. Instead of regretting things we can't
change, or worrying about bad things that haven't even happened yet, we can
learn to accept and appreciate our current circumstances.

2. Meditation teaches you how to redirect your mind

Sometimes we get caught
up thinking (obsessing!) about a big problem, and we have the idea that if we just think
hard enough we can solve it - but that's rarely the case. The best insights
usually come in those "in between" moments - in the shower, when
you're driving, when you're enjoying a cup of tea.

But even if we're aware
that worrying and ruminating won't solve our problems, we don't know how to
shut our minds off. Meditation can teach you this skill! Like any skill, it
requires practice. But with dedicated practice, even five or ten minutes a day,
we can learn how to let go of worries and redirect our mind to the present
moment.

3. Meditation teaches you to be more aware of your thoughts and
emotions

Too often we have a
thought and react to it without considering why. We get angry at someone and
start yelling. We hear a critical remark and get defensive. Instead of taking
our thoughts and assumptions as facts and immediately reacting (possibly saying
or doing something we'd regret), we can pause and consider what's really going
on.

Maybe we feel angry but
are really hurt. Maybe we feel defensive because part of what the other person
said is true. Meditation teaches us to be more aware of our deepest
thoughts and emotions, so that we can choose to react to conflict in a wise
way.

4. Meditation helps you tolerate difficult emotions

Some people have a
misunderstanding that meditation somehow helps you get rid of all negative
emotions - after all, isn't that what enlightenment is?

The truth is, though,
that painful emotions like sadness, anger, and shame are part of being human. We
make things worse when we fight against these emotions or blame ourselves for
having them.

Instead of getting
caught up in the narratives of our emotions, we can learn to experience them
just as they are. Anger can feel like a tightness and burning of the chest.
Shame can be a flushed feeling of the face and churning feeling in the stomach. Meditation teaches us to experience these emotions without getting caught
up in the story.

Does Meditation really
work? What are the basic elements?

According to a
government survey, almost 1 in 10 adults use meditation each year to help them
cope with conditions such as anxiety, depression, pain, stress, insomnia, and
symptoms associated with chronic illness. It is believed that meditation can
improve the ability to focus attention and improve how we handle our emotions.
These improvements may have broader benefits for our daily lives including
personal relationships.

Researchers have linked
meditation to some beneficial changes in the human body. Some experts have
suggested that meditation may dampen down our body’s sympathetic nervous
system, the system responsible for our “fight or flight” response. There is
also continuing interest on how meditation can alter different parts of the
brain, although the answer remains unclear and research is ongoing.

The National Center for Complementary and Alternative Medicine, a federally funded research organization, suggests that there are several elements that are important when you are trying any type of meditation. These elements include finding a quiet location, a comfortable posture, being able to focus your attention, and having an open attitude to the experience.

Interested in learning
more about how meditation can help you lead a happier and more relaxed life?

Check out zenpsychiatry.com where Elana Miller, M.D., blogs about
integrative strategies to be happy, live well, and fulfill your greatest
potential. To get tips and helpful advice sent straight to your inbox, sign up
for her free newsletter.