American Medical Association (AMA) Seeks to Test Older Physicians: The Aging Physician–Goodbye Dr. Welby!

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The AMA is seeking to test older physicians.  This is no doubt due to the influence and lobbying of the “impaired physicians movement” and the “addiction medicine” specialists who brought us the “impaired” and “disruptive” physician constructs.    As do all groups of this ilk, they want to expand.  It is predictable and that is what we are seeing here.


Originally posted on Disrupted Physician:

The Aging Physician—Goodbye Dr. Welby!

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As a specialist in geriatric medicine I have experience in taking care of a number of  doctors who were referred to me for suspected memory problems. Still operating and teaching residents in his 70s, my first was a well-respected surgeon, a pioneer or Maverick who had made advances in his particular subspecialty.  Known for his detailed knowledge of the history of medicine and sharp clinical acumen, he had not seemed himself for a while.  His colleagues noted he appeared slower,  fatigued and forgetful at times (not remembering his keys, having trouble finding the right word).  An internist friend and co-worker who knew him for 50 years curb-sided me and asked if I would see him.  He did not have a primary care physician or even seen a doctor professionally for decades (a common phenomenon in this age cohort of doctors).

I met him the next week and he readily admitted to having difficulty concentrating and having trouble with his short term memory.  On taking his history he told me of his life and career which started as an intern in Boston in 1942 and he was on duty the night 492 people were killed in the  Cocoanut Grove fire with many of the victims transported to his hospital.  “I can see every detail as if it were yesterday–beautiful young women wearing fashionable dresses and gowns and young men in formal evening wear who looked as if they were sleeping but were dead.”

“Gastric reflux ” was the only medical problem he reported, adding it was well controlled for the better part of a decade with anti-reflux medications from the office sample closet.   I tested his memory with several cognitive scales which showed some mild deficits in short-term memory and sent him to a neuropsychologist for more comprehensive testing.  His physical examination, including a comprehensive neurological exam was normal.  I ordered the usual lab work up for dementia to look for possible metabolic causes and his B12 level returned markedly low–a result of his long-term use of proton pump inhibitors.  He was given an intramuscular injection and started on high doses of oral B12.  As one of the “reversible’ causes of dementia he was back to his usual sprightly self several months later.

Another, a 70 old psychiatrist still teaching medical students and residents had asked a third-year psychiatric resident out on a date on two separate occasions. She reported him to administration on the second request.  When I  asked him about the incident he replied he didn’t see what was wrong with what he did and it was being blown out of proportion.  “She’s in her 20’s” I said to which he replied “Well I’m only 36.” Still giving lectures to first year medical students without error or pause from knowledge he learned long ago, he could not identify a pencil or a watch when I pointed to them and asked what there were. He knew neither the month, season or year.  After an MRI and neuropsychological testing he was given a diagnosis of probable Alzheimers disease.   He had no spouse or children and his work was his life.  After that he became  profoundly depressed and six months later was dead.

Another  elderly doctor, an internist, had a fairly sudden sudden onset of memory problems and symptoms of delirium.  It turned out he was having trouble sleeping and his cardiologist prescribed him Dalmane, a benzodiazepine similar to  Valium (medications that have a whole host of adverse effects in older patients including memory problems and falls).  But valium has a half-life of hours whereas Dalmane has a half life of days.   The medication was stopped and he was back to normal after a few days.

Aging  is associated with an increased  decline  in many areas including  cognition, motor-skills, muscle strength, and vision that can individually or cumulatively create risk to the person or others in a variety of situations (driving, living situation, occupation).

With advancing age comes advancing risk and the recognition and vigilance of others is often necessary for intervention. If the risk is recognized the problem can be addressed by the appropriate healthcare providers and specialists.

Doctors are not immune from cognitive impairment or dementia and the perspicacity of others is necessary should this occur.

Recognition and awareness are important.  So too is an assessment by a qualified physician Board Certified in Neurology, Geriatrics or Geriatric Psychiatry who has education and experience in the diagnosis and treatment of memory disorders.

Slide15

Recognition, Insight and Education Essential

In 2009 Dr. Ralph Blasier, M.D, J.D., published an article in the Journal  Clinical Orthopaedics and Related Research entitled “The Problem of the Aging Surgeon: When Surgeon Age Becomes a Surgical Risk Factor” discussing the ability of older physicians to practice medicine safely and effectively.

His primary message is that a decline in physical and cognitive abilities is associated with the aging process and that these issues are especially pertinent to the field of medicine.

An area  little researched, Blasier gives anecdotal examples such as a surgeon in his late 80s who had to regularly depend on younger colleagues to finish his operations. He concludes that these anecdotal examples suggest many surgeons lack insight into the degradation of their own skills and suggests recognition, insight, and education can help facilitate retirement of the aging surgeon  before  a decline in competency and skill creates a problem.

The awareness, education and insight of others is necessary to identify age associated illness in doctors who can then be referred to the proper specialists for evaluation.  And although no evidence base exists, anecdotal reports such as these caused some groups to see an opportunity to increase the grand scale of the hunt.

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Aging Physicians Next Target of Physician Health Programs

As with the “impaired” and “disruptive” physician, the “physician health and wellness movement” organized as the Federation of State Physician Health Programs (FSPHP) is linking the “aging” physician with threats to patient safety and  hospital liability.  “Experts say doing nothing could result in lawsuits, higher liability insurance rates, ruined reputations for practices and all involved, and even possible losses of practices and the licenses of non-reporting physicians.”

And if you look at the articles and presentations aimed at  the administrative, regulatory, and legal arenas of medicine it appears a new moral panic is percolating in the “physician wellness” cauldron.

Labelling a group dangerous and creating fear in those responsible for that group is an effective means to sway policy and opinion.

With absolutely no evidence base these groups have acted as   “moral entrepreneurs ” and used this same methodology to successfully change policy and regulation in the medical profession and advance their goals.  The methodology is to

1. Label a group and link that group to danger

2. Offer to assist in identifying and eliminating that danger

3. Corner the market and control all aspects including assessment, testing and monitoring by swaying those in authority to make it public policy and regulation.  Screen Shot 2015-03-11 at 8.10.37 PM

The methodology is not new–witches are real, witches are dangerous and witches need to be identified and exterminated at all costs.  Convince the authorities to assist you in protecting the public from harm and advance  the greater good

In this manner the FSPHP has convinced state medical boards to adopt and enforce policies that have incrementally and systematically increased their autonomy, scope and power since they first cultivated a relationship with the Federation of State Medical Boards (FSMB).  This occurred in 1995 when they took an uninvited seat at the table of power by offering a non-disciplinary “safe harbor” as an alternative to discipline for doctors impaired by drugs or alcohol.

Since then they have increased their scope from  the “impaired” to the “disruptive” to everything else.  Arising from the “impaired physicians movement”  as “addiction specialists” these doctors whose specialty of addiction is not even recognized by the American Board of Medical Specialties have now become the “experts” in all matters related to physician health.  Jacks of all trades covering neurology, psychiatry, geriatrics, and occupational medicine.

A 2011 updated FSMB  Policy on Physician Impairment  states that Medical Boards should recognize the state Physician Heath Program (PHP) as their experts in all matters relating to licensed professionals with “potentially impairing illness,”   and these  include those potentially impairing maladies that increase as we age.

They are also using “everyone else does it why don’t we?” logical fallacy.  According to a Washington Post article “other professions are subject to age-related regulations. For example, airline pilots must undergo regular health screenings staring at age 40 and must retire at age 65. FBI agents must retire at age 57.”Screen Shot 2015-03-11 at 8.10.59 PM

Proposing drug testing in doctors a  JAMA article  uses this same logic stating when sentinel events occur in the airline, nuclear power and railway industry the get drug tested.  However all of these industries use FDA approved tests, certified labs, strict chain-of-custody and MRO review in their drug testing.  One of the authors of the JAMA paper, Dr. Greg Skipper, introduced the non-FDA approved and unvalidated Laboratory Developed Tests currently used in PHPs such as EtG.   He claims no conflicts-of-interest.   Comparing drug testing to industries that use the highest quality of testing and safeguards to protect the donor from false-positives to the junk science used in PHPs is comparing apples to oranges. Which one do you think they’s be using in the random drug testing of doctors?

Furthermore, airline pilots, railway engineers and nuclear power plant employees have a choice of assessment and treatment centers should they get a positive test.  Doctors do not.  They are mandated to “PHP-approved” facilities.  This is enforced by state medical boards as they adhere to an ASAM   Public Policy Statement  recommending only “PHP approved” treatment centers be used for assessment and treatment and a recent  audit  found the PHP in North Carolina could not provide any measurable indices  or qualitative indicators of how an assessment center is stamped “approved.” The best they could come up with is “reputation” and other ‘informal sources.  What the audit missed is all of the 19  out-of-state “PHP-approved” centers Medical Directors can be found on this list.

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And what will happen with the “aging physician” is the same.  Doctors will be forced into “assessments” at “PHP-approved” facilities where they will be misdiagnosed, over-diagnosed and forced into monitoring contracts under threat of loss of licensure. Goodbye Dr. Welby!

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The Aging Physician—Goodbye Dr. Welby!

IMG_8901The methodology is not new–witches are real, witches are dangerous and witches need to be identified and exterminated at all costs. Convince the authorities to assist you in protecting the public from harm and advance the greater good

In this manner the Federation of State Physician Health Programs (FSPHP)  has convinced the Federation of State Medical Boards state medical boards (FSMB)  to adopt and enforce policies that have incrementally and systematically increased their own  autonomy, scope and power.   This began in 1995 when the FSPHP first cultivated a relationship with the FSMB and subsequently took an uninvited seat at the table of power by offering a non-disciplinary “safe harbor” as an alternative to discipline for doctors impaired by drugs or alcohol.IMG_8900

Since then they have increased their scope from the “impaired” to the “disruptive” to everything else. Arising from the “impaired physicians movement” as “addiction specialists” these doctors whose specialty of addiction is not even recognized by the American Board of Medical Specialties have now become the “experts” in all matters related to physician health. Jacks of all trades covering neurology, psychiatry, geriatrics, and occupational medicine.

A 2011 updated FSMB Policy on Physician Impairment states that Medical Boards should recognize the state Physician Heath Program (PHP) as their experts in all matters relating to licensed professionals with “potentially impairing illness,” and these include those potentially impairing maladies that increase as we age.  This has gone too far.  Isn’t it time we take back the profession of medicine from illegitimate and irrational authority?Slide15

Disrupted Physician

IMG_8902

As a specialist in geriatric medicine I have experience in taking care of a number of  doctors who were referred to me for suspected memory problems. Still operating and teaching residents in his 70s, my first was a well-respected surgeon, a pioneer or Maverick who had made advances in his particular subspecialty.  Known for his detailed knowledge of the history of medicine and sharp clinical acumen, he had not seemed himself for a while.  His colleagues noted he appeared slower,  fatigued and forgetful at times (not remembering his keys, having trouble finding the right word).  An internist friend and co-worker who knew him for 50 years curb-sided me and asked if I would see him.  He did not have a primary care physician or even seen a doctor professionally for decades (a common phenomenon in this age cohort of doctors).

I met him the next week and he readily admitted to having difficulty concentrating and having trouble with his short term…

View original post 1,533 more words

The Aging Physician—Goodbye Dr. Welby!

IMG_8902

As a specialist in geriatric medicine I have experience in taking care of a number of  doctors who were referred to me for suspected memory problems. Still operating and teaching residents in his 70s, my first was a well-respected surgeon, a pioneer or Maverick who had made advances in his particular subspecialty.  Known for his detailed knowledge of the history of medicine and sharp clinical acumen, he had not seemed himself for a while.  His colleagues noted he appeared slower,  fatigued and forgetful at times (not remembering his keys, having trouble finding the right word).  An internist friend and co-worker who knew him for 50 years curb-sided me and asked if I would see him.  He did not have a primary care physician or even seen a doctor professionally for decades (a common phenomenon in this age cohort of doctors).

I met him the next week and he readily admitted to having difficulty concentrating and having trouble with his short term memory.  On taking his history he told me of his life and career which started as an intern in Boston in 1942 and he was on duty the night 492 people were killed in the  Cocoanut Grove fire with many of the victims transported to his hospital.  “I can see every detail as if it were yesterday–beautiful young women wearing fashionable dresses and gowns and young men in formal evening wear who looked as if they were sleeping but were dead.”

“Gastric reflux ” was the only medical problem he reported, adding it was well controlled for the better part of a decade with anti-reflux medications from the office sample closet.   I tested his memory with several cognitive scales which showed some mild deficits in short-term memory and sent him to a neuropsychologist for more comprehensive testing.  His physical examination, including a comprehensive neurological exam was normal.  I ordered the usual lab work up for dementia to look for possible metabolic causes and his B12 level returned markedly low–a result of his long-term use of proton pump inhibitors.  He was given an intramuscular injection and started on high doses of oral B12.  As one of the “reversible’ causes of dementia he was back to his usual sprightly self several months later.

Another, a 70 old psychiatrist still teaching medical students and residents had asked a third-year psychiatric resident out on a date on two separate occasions. She reported him to administration on the second request.  When I  asked him about the incident he replied he didn’t see what was wrong with what he did and it was being blown out of proportion.  “She’s in her 20’s” I said to which he replied “Well I’m only 36.” Still giving lectures to first year medical students without error or pause from knowledge he learned long ago, he could not identify a pencil or a watch when I pointed to them and asked what there were. He knew neither the month, season or year.  After an MRI and neuropsychological testing he was given a diagnosis of probable Alzheimers disease.   He had no spouse or children and his work was his life.  After that he became  profoundly depressed and six months later was dead.

Another  elderly doctor, an internist, had a fairly sudden sudden onset of memory problems and symptoms of delirium.  It turned out he was having trouble sleeping and his cardiologist prescribed him Dalmane, a benzodiazepine similar to  Valium (medications that have a whole host of adverse effects in older patients including memory problems and falls).  But valium has a half-life of hours whereas Dalmane has a half life of days.   The medication was stopped and he was back to normal after a few days.

Aging  is associated with an increased  decline  in many areas including  cognition, motor-skills, muscle strength, and vision that can individually or cumulatively create risk to the person or others in a variety of situations (driving, living situation, occupation).

With advancing age comes advancing risk and the recognition and vigilance of others is often necessary for intervention. If the risk is recognized the problem can be addressed by the appropriate healthcare providers and specialists.

Doctors are not immune from cognitive impairment or dementia and the perspicacity of others is necessary should this occur.

Recognition and awareness are important.  So too is an assessment by a qualified physician Board Certified in Neurology, Geriatrics or Geriatric Psychiatry who has education and experience in the diagnosis and treatment of memory disorders.

Slide15

Recognition, Insight and Education Essential

In 2009 Dr. Ralph Blasier, M.D, J.D., published an article in the Journal  Clinical Orthopaedics and Related Research entitled “The Problem of the Aging Surgeon: When Surgeon Age Becomes a Surgical Risk Factor” discussing the ability of older physicians to practice medicine safely and effectively.

His primary message is that a decline in physical and cognitive abilities is associated with the aging process and that these issues are especially pertinent to the field of medicine.

An area  little researched, Blasier gives anecdotal examples such as a surgeon in his late 80s who had to regularly depend on younger colleagues to finish his operations. He concludes that these anecdotal examples suggest many surgeons lack insight into the degradation of their own skills and suggests recognition, insight, and education can help facilitate retirement of the aging surgeon  before  a decline in competency and skill creates a problem.

The awareness, education and insight of others is necessary to identify age associated illness in doctors who can then be referred to the proper specialists for evaluation.  And although no evidence base exists, anecdotal reports such as these caused some groups to see an opportunity to increase the grand scale of the hunt.

IMG_8901

Aging Physicians Next Target of Physician Health Programs

As with the “impaired” and “disruptive” physician, the “physician health and wellness movement” organized as the Federation of State Physician Health Programs (FSPHP) is linking the “aging” physician with threats to patient safety and  hospital liability.  “Experts say doing nothing could result in lawsuits, higher liability insurance rates, ruined reputations for practices and all involved, and even possible losses of practices and the licenses of non-reporting physicians.”

And if you look at the articles and presentations aimed at  the administrative, regulatory, and legal arenas of medicine it appears a new moral panic is percolating in the “physician wellness” cauldron.

Labelling a group dangerous and creating fear in those responsible for that group is an effective means to sway policy and opinion.

With absolutely no evidence base these groups have acted as   “moral entrepreneurs ” and used this same methodology to successfully change policy and regulation in the medical profession and advance their goals.  The methodology is to

1. Label a group and link that group to danger

2. Offer to assist in identifying and eliminating that danger

3. Corner the market and control all aspects including assessment, testing and monitoring by swaying those in authority to make it public policy and regulation.  Screen Shot 2015-03-11 at 8.10.37 PM

The methodology is not new–witches are real, witches are dangerous and witches need to be identified and exterminated at all costs.  Convince the authorities to assist you in protecting the public from harm and advance  the greater good

In this manner the FSPHP has convinced state medical boards to adopt and enforce policies that have incrementally and systematically increased their autonomy, scope and power since they first cultivated a relationship with the Federation of State Medical Boards (FSMB).  This occurred in 1995 when they took an uninvited seat at the table of power by offering a non-disciplinary “safe harbor” as an alternative to discipline for doctors impaired by drugs or alcohol.

Since then they have increased their scope from  the “impaired” to the “disruptive” to everything else.  Arising from the “impaired physicians movement”  as “addiction specialists” these doctors whose specialty of addiction is not even recognized by the American Board of Medical Specialties have now become the “experts” in all matters related to physician health.  Jacks of all trades covering neurology, psychiatry, geriatrics, and occupational medicine.

A 2011 updated FSMB  Policy on Physician Impairment  states that Medical Boards should recognize the state Physician Heath Program (PHP) as their experts in all matters relating to licensed professionals with “potentially impairing illness,”   and these  include those potentially impairing maladies that increase as we age.

They are also using “everyone else does it why don’t we?” logical fallacy.  According to a Washington Post article “other professions are subject to age-related regulations. For example, airline pilots must undergo regular health screenings staring at age 40 and must retire at age 65. FBI agents must retire at age 57.”Screen Shot 2015-03-11 at 8.10.59 PM

Proposing drug testing in doctors a  JAMA article  uses this same logic stating when sentinel events occur in the airline, nuclear power and railway industry the get drug tested.  However all of these industries use FDA approved tests, certified labs, strict chain-of-custody and MRO review in their drug testing.  One of the authors of the JAMA paper, Dr. Greg Skipper, introduced the non-FDA approved and unvalidated Laboratory Developed Tests currently used in PHPs such as EtG.   He claims no conflicts-of-interest.   Comparing drug testing to industries that use the highest quality of testing and safeguards to protect the donor from false-positives to the junk science used in PHPs is comparing apples to oranges. Which one do you think they’s be using in the random drug testing of doctors?

Furthermore, airline pilots, railway engineers and nuclear power plant employees have a choice of assessment and treatment centers should they get a positive test.  Doctors do not.  They are mandated to “PHP-approved” facilities.  This is enforced by state medical boards as they adhere to an ASAM   Public Policy Statement  recommending only “PHP approved” treatment centers be used for assessment and treatment and a recent  audit  found the PHP in North Carolina could not provide any measurable indices  or qualitative indicators of how an assessment center is stamped “approved.” The best they could come up with is “reputation” and other ‘informal sources.  What the audit missed is all of the 19  out-of-state “PHP-approved” centers Medical Directors can be found on this list.

Screen Shot 2015-03-11 at 8.13.13 PM

And what will happen with the “aging physician” is the same.  Doctors will be forced into “assessments” at “PHP-approved” facilities where they will be misdiagnosed, over-diagnosed and forced into monitoring contracts under threat of loss of licensure. Goodbye Dr. Welby!

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Policy and Regulatory Decision Making in the Medical Profession: A Framework to Identify the influence of Special Interest Groups and “Bent” Science

content-1 In  Bending Science: How Special Interests Corrupt Public Health Research 1  Thomas McGarity and Wendy Wagner describe how special interest groups scheme to advance their own economic or ideological goals by using distorted or “bent” science to influence legal, regulatory and public health policy.

The authors describe a “separatist view” of science and policy that assumes scientific research is sufficiently reliable for public policy deliberations and legal proceedings when it reaches them.  This is illustrated as a pipeline in which it is presumed  the scientific community has properly vetted the information flow through rigorous peer-review and professional oversight.  The final product that exits the pipeline is understood to be unbiased and produced in accordance with the professional norms and procedures of science.   The reliability, integrity and validity of the final product is indubitably accepted.Screen Shot 2015-02-05 at 10.49.27 AMThe separatist  view does not consider the possibility that the scientific work exiting the pipeline could be intentionally shaped and contaminated by biasing influences as it flows through the pipeline.  When this occurs the final product exiting the pipeline is distorted or “bent” and bent science can result in bad decision making and bad policy.

Bent science starts with a pre-determined outcome and works backward from a desired result. It is not true science. Those orchestrating the deception (“benders”) use a variety of tactics and strategies to shape, package and spin science to support their own hidden agenda and suppress opposing science.

Benders attempt to hide, dismiss and debunk contrarian research and unsupportive science.  Benders will attack and harass the science and scientists that pose a threat to their interests. Using carefully crafted studies designed to confirm a desired outcome, the pre-determined conclusions are subsequently promoted and publicized to the relevant stakeholders who are often unable ( or sometimes unwilling) to discern real science from junk-science.

Misinformation, propaganda, and deception are disseminated in a variety of venues. Public relations firms are used to manipulate public perception and freelance writers are hired  brandish favorable consensus statements.  Authoritative reviews and critiques are ghostwritten under the names of  “outside experts” who profit both monetarily and by adding a high-profile publication to their resume.

Opinion is paraded as fact and with a dearth of professional oversight the charade usually goes unnoticed and unopposed.

Data-dredging, cherry picking, confirmatory bias, confirmatory distortion, fabrication, falsification, exaggeration, and a whole host of deceptive tactics are used to work backward from an already determined result.

Any information that contradicts the answer is manipulated, undermined, suppressed or downplayed; even if it is the result of real science and evidence-based research; even if it is the truth.  Professional procedure, protocol and ethics are off the table.  It is an underhanded free-for-all. Bare knuckle boxing. Trash your opponents work and label it junk-science. Undermine the integrity of your opponents.  Use ad hominem attacks to question the opponents motives. Claim the scientists are hacks on the take.  Start rumors about them. Screen Shot 2015-02-05 at 10.50.32 AM Loudly claim you are the one who is evidence based. Proclaim professionalism and authority.  Quibble. Move the goalpost.   Nit-pick and split hairs.  Proclaim over and over and over again you are the one who is evidence based.

And the problem is it usually works.  It is an unfair playing field.  When no meaningful barriers are in place to detect cheating and identify cheaters they usually win.

Bending science can have serious and sometimes horrific consequences and multiple examples including the Tobacco and pharmaceutical industry are given in the book.

Calling for immediate action  to reduce the role that bent science plays in regulatory and judicial decision making, the authors emphasize the assistance of the scientific community is necessary in designing and implementing reform.

“Shedding even a little light on how advocates bend policy -relevant science could go a long way toward remedying these problems.  Indeed, precisely because the advocates have overtaken the law in this area, heightened attention to the social costs of bending science could itself precipitate significant change.”

But there are difficulties in challenging bent science including a general lack of recognition of the problem. With an absence of counter-studies to oppose deliberately manufactured ends-oriented research this would be expected.

Bent science involves the deliberate manufacturing of a pool of  information designed to promote a specific agenda.  A level playing field would require a pool of opposing research specifically addressing that agenda.  In reality this requires both the incentive and the power to do so–an unlikely scenario short of an equally well funded competitor or sufficient public concern about the problem.

In fact counter-forces are often nonexistent. Investigatory techniques developed and promoted by the FBI crime lab (such as firearms identification and intoxication testing) is one example described in the book.  These techniques evolved with little meaningful oversight from the larger scientific community and could be badly bent but there is no meaningful pool of information to disprove them.  The authors aptly state that   “defendants in most criminal cases lack resources to mount effective challenges, much less undertake their own counter-research.”

And part of the “art” of bending involves swaying public opinion and the mainstream media is typically aligned with the benders so opposing viewpoints seldom make the headlines.

Additionally, there is no meaningful oversight or avenue to pursue accountability. No systems exist to prevent, catch and publicly expose bent-science or those who bend science.

The influence of special interest groups on the practice of medicine is unknown.  No one has examined the role of bent science in the rules, regulations, policies and decisions made by those who are in charge of the standards of medical practice and professional behavior of doctors but as a regulated profession governed by the  decisions and policies of regulators it is certainly possible.

Regulation of the Medical Profession

Alexis de Toqueville once observed that a key feature of American government was the decentralized character of administration. “Written laws exist in America,” he wrote, “and one sees the daily execution of them; but although everything moves regularly, the mover can nowhere be discovered. The hand which directs the social machine is invisible.”2

Administrative law is the body of law that allows for the creation of public regulatory agencies and contains all of the statutes, judicial decisions and regulations that govern them. Administrative agencies implement their powers in the form of rules, regulations, orders and decisions.   State medical boards are the regulatory agencies responsible for the licensure and discipline of physicians. They grant the right to practice medicine in the form of a medical license and each state has Medical Practice Act that governs and defines the practice of medicine. The medical board is empowered to take action against a doctor for substandard care, unprofessional behavior and other violations as defined by the state Medical Practice Act.

Administrative Code governs the licensure and disciplinary process and the State Administrative Procedure Act governs the legal process (due process, discovery, etc.). Regulatory changes are enacted through procedural, interpretive and legislative rules.

Both medical practice acts and administrative procedure acts are subject to change.  Changes in medical practice acts can redefine what is acceptable practice and what constitutes professional behavior. This can increase the power and control these agencies have over doctors both professionally and socially.

Changes in Administrative practice acts can decrease what rights a doctor has if this power and control is abused.  Changes in the wording of administrative code and administrative practice acts can have profound implications in these rights including due-process, timeliness of being heard, rights to appeal decisions and time-constraints for judicial review.

And when these changes occur they do so silently.  The hand that directs the machine is indeed invisible.  The consequences, however, are not.  These changes not only impact those touched by the hand but can have a systemic impact on the entire profession.

State medical practice acts as well as administrative practice acts and code are susceptible to change and therefore susceptible to the influence of special interest groups benefitting from such change.  Regulation of the medical profession is thus susceptible to bent science.

Bent Science and the Medical Profession

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The impact of bent science on the regulation of the medical profession has not been studied. As a profession governed by regulatory agencies medicine is certainly not immune to the influence of special interest groups who could in turn influence public policy and regulatory decisions, rules and regulations to benefit their own interests.

Making sound decisions about regulation calls for an understanding of the problem it is intended to solve. This demands methodologically sound science and evidence-based facts arrived at through rigorous peer review and professional oversight. The science on which policy decisions are made must be reliable and unbiased. Legitimate policy must be based on recognized and legitimate institutions and experts.

If the information regulatory agencies rely on to discipline doctors and protect the public is unreliable then serious consequences can occur.

It would be beneficial to look for changes in public policy, guidelines, rules and regulations involving the medical profession and examine the reasons behind them. When did the problem present? Who presented it? Was it based on methodologically sound and accurate data?  What organizations do the problem presenters represent?  What organizations or individuals aligned or associated with the presenters might benefit?  What are the consequences?  Who is harmed?

Howard Becker describes the role of “moral entrepreneurs,” who crusade for making and enforcing rules that benefit their own interests by bringing them to the attention of the public and those in positions of power and authority under the guise of righting a society evil.8   

The mechanics and mentality is similar to the science benders and, as discussed below,  they use some of the same techniques.

Moral entrepreneurs take the lead in labeling a particular behavior deviant and spreading this label throughout society.  They associate the behavior of some group with a society evil, affix an easily recognizable label to it and then express the conviction that the evil must be combated.  Labeled as being outside the central core values of consensual society, the deviants in the designated group are perceived as posing a threat to both the values of society and society itself.

Activities can rise to the level of ‘social problems” when harm or danger is attributed to those activities and governmental powers are called upon to put an end to those harms. Bent science requires convincing others of a viewpoint and the likelihood of this occurring increases when the activity that is identified as a problem resonates with underlying societal concerns and anxieties.  The problem is then endorsed by experts who give legitimacy to such claims.3,4 This legitimacy results attracts media attention which further enforces support from both the public and policy makers.5,6  

As a result any bent science directed at regulatory and public policy decision making should be clearly visible.

The sociologist Stanley Cohen used the term ”moral panic” to characterize the amplification of deviance by the media, the public, and agents of social control.7 According to cultural theorist Stuart Hall, the media obtain their information from the primary definers of social reality in authoritative positions and amplify the perceived threat to the existing social order. The authorities then act to eliminate the threat.9 The dominant ideas or ideologies are reproduced by relying on the opinions of the defining authority and then spread through the media.

An internet search of what labels have been affixed to doctors in association with a threat to society there are three.  A google search of “impaired physician” yields 20, 600 results; “disruptive physician” yields 17, 400 results; and “aging physician” yields 27, 800 results. A large number of these articles, opinion pieces and reviews associate impaired, disruptive and aging physicians with patient death and other adverse events, medical error, and malpractice.   The labels affixed to these physicians have been characterized as a major threat to public health and the rhetorical tools used in many of these articles seems aimed at increasing public anxiety.

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A PubMed search yields 154 results for the “impaired physician”; 47 results for the “disruptive physician”; and 19 results for the “aging physician.”  Many of these are opinion pieces written by the same group of physicians and aimed at hospital administrators, regulators and those involved in the legal or business aspects of medicine.

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There is, in fact, no evidence based research that associates the impaired, disruptive or aging physician with any adverse events. The “impaired,” “disruptive” and “aging” physician labels  as evinced by a quick google search seem escalated far beyond the level warranted by the existing evidence.

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The “impaired” and “disruptive” labels have taken on the status of moral panic and the “aging” label, which is being associated with cognitive impairment, seems to be heading in that direction. The number of articles being published and lectures being given on the dangers of cognitively impaired doctors is increasing.  It has not yet reached the level of public awareness the impaired and disruptive have.

To acknowledge that the current level of concern about these labels is exaggerated is not to suggest they do not exist. They do.  But the disparity between the evidence-base, or lack thereof, and the level of concern warrants further investigation.

To be clear,  doctors who are impaired by drug and alcohol abuse need to be removed from practice to protect the public and receive treatment;  doctors who are abusive to others or engage in behavior that threatens patient care need to be held accountable for their actions; and doctors who are cognitively impaired due to dementia need to be removed from practice and evaluated by the proper specialists.  If a diagnosis of dementia is confirmed then they need to be removed from practice.

What is the motivation behind the “impaired,” “disruptive” and “aging” physician labels and the multiple articles linking these labels to patient harm and medical error?  There is no data driven evidence so where does it come from?   Could moral entrepreneurs be behind it?  If so then there should be evidence  of bent science and to examine this we must look for evidence that these labels have been used to influence regulatory decisions, rules, regulations and policy.

And with the recently archived Journal of Medical Regulation this task can be easily accomplished.

The Journal of Medical Regulation as Timeline and Framework for Policy Evaluation

The Federation of State Medical Boards (FSMB) is a national not-for profit organization that gives guidance to state medical boards through public policy development and recommendations on issues pertinent to medical regulation. Shortly after its founding in 1912, the Federation of State Medical Boards began publishing a quarterly journal addressing issues relating to medical licensing and regulation of doctors. First published in 1913 as the Quarterly of the Federation of State Boards of the United States, the publication has undergone several name changes and publication schedules. From1921 to 1999 it was published monthly as the Federation Bulletin. In 1999 it was changed to the quarterly Journal of Medical Licensure and Discipline and in 2010 was revised to the Journal of Medical Regulation The Journal of Medical Regulation is in the process of archiving all issues dating back to 1913.

Presently every paper dating back to 1967 is available online and the archival organization and availability of full articles published sequentially over the past half-century is historically invaluable.   As the official journal of the national organization involved in the medical licensing and regulation of doctors, this archival organization allows for an unskewed and impartial examination in both historical and cultural context. We can identify when particular issues and problems were presented, who presented them and how.

The Journal of Medical Regulation archives provides a structured context to examine these issues in their historical and cultural context.  This facilitates a retrospective analysis.  As a timeline it allows identification of when the issues were presented.  It also allows us to look at the events preceding the problem, who benefited from them, and the consequences. Could these factors be involved in influencing the regulation of medicine and shaping the medical profession? Could bent science have been involved in regulatory and administrative changes that have significantly impacted the rights and well-being of doctors and how the profession of medicine is defined?  Could some of the current problems such as the marked increase in physician suicide, sham-peer review, and physician burnout be the result of bent science?  If bent science is contributing to bad policy and bad decision making then it need to be exposed and addressed.  Bent science is bad medicine and if it exists then we need to urgently shine a light on it.

  1. McGarity TO, Wagner WE. Bending Science: How Special Interests Corrupt Public Health Research. Cambridge, MA: Harvard University Press; 2008.
  2. de Toqueville A. Democracy in America. New York: Penguin Books; 1984.
  3. Blumer H. Social Problems as Collective Behavior. Social Problems. 1971;18:298-306.
  4. Stone DA. Causal Stories and the formation of policy agendas. Political Science Quarterly. 1989;104:280-300.
  5. Best J. Threatened Children, Rhetoric and Concern about Child Victims. Chicago University of Chicago Press; 1990.
  1. Gerbner G, Gross L. The scarey World of TV’s heavy viewer. Psychology Today. 1976;9(89):41-45.
  2. Cohen S. Folk Devils and Moral Panics: The Creation of the Mods and Rockers (New Edition). Oxford, U.K.: Martin Robertson; 1980.
  3. Becker H. Outsiders: Studies in the Sociology of Deviance. New York: Free Press; 1963.
  4. Hall SC, Critcher C, Jefferson T, Clark J, Roberts B. Policing the Crisis: Mugging, the State, and Law and Order. London: Macmillan; 1978.

 

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