Princess Health and What They Really Think of Us, UK Version - Health Secretary Derides NHS Doctors for Not Working Enough on Weekends. Princessiccia

Princess Health and What They Really Think of Us, UK Version - Health Secretary Derides NHS Doctors for Not Working Enough on Weekends. Princessiccia

generic managers ill-informed management NHS UK

Gusty 06:42 Add Comment

A new story from the UK suggests what top leaders of health care really think about health care professionals.  I realize that I risk showing my shallow understanding of UK politics when I comment on this, but I believe that the story is straightforward enough for someone from the US to understand, and has  lessons for the US and other countries.

UK Health Secretary Says Doctors Do Not Work Enough on Weekends

The story started earlier in July, 2016, when the current UK Health Secretary within the current Conservative government told National Health System (NHS) doctors they must work seven days a week, as reported by the Guardian,

The health secretary, Jeremy Hunt, has accused the main doctors� union of walking out of NHS consultants� [equivalent to US attending physicians] contract talks aimed at preventing 'catastrophic consequences' for patients at weekends.

Hunt said he recognised the efforts of consultants, many of whom already work on Saturdays and Sundays, but that he would impose weekend-working contracts by September if an agreement could be reached.

Also, 

The proposed contract would have at its core the controversial weekend working provision, but would include the abolition of overtime payments that Hunt has described as extortionate.

 Under the current contract, last negotiated by Labour in 2003, consultants can opt out of non-emergency work outside the hours of 7am to 7pm Monday to Friday.

Mr Hunt implied that insufficient physician presence on weekends was leading to catastrophe.

Hunt will say: 'Around 6,000 people lose their lives every year because we do not have a proper seven-day service in hospitals. No one could possibly say that this was a system built around the needs of patients and yet when I pointed this out to the BMA they told me to �get real.� I simply say to the doctors� union that I can give them 6,000 reasons why they, not I, need to �get real�.'

However, UK Doctors, Including Consultants, Do a Lot of Work on Weekends

Within a few days, there was an amazing response from UK physicians showing that what the Health Secretary seemed to believe about how NHS hospitals work was, not to put too fine a point on it, wrong.

From the Guardian came a piece by an anonymous trainee physician,

Last weekend, for the first time ever, I managed to make something trend on Twitter. It wasn�t a witty comment about Andy Murray triumphing in the Davis Cup, nor was it a retweet of a picture of somebody else�s cat.

I simply told a man called Jeremy that I was at work that night.

Three days later, thousands of people were telling Jeremy that they too were at work that weekend, using the hashtag #iminworkjeremy. Day and night, Friday to Monday, a large group of people felt Jeremy simply had to know what they were up to.

Because Jeremy is fairly important in the running of the country. Well, part of the country anyway � that part where the sick can just turn up and be treated without money changing hands. The part I work in, in fact, as a junior doctor.

Jeremy is concerned about how his part of the country is being run. He is upset that the ones who keep the sick alive � the doctors � aren�t there at weekends.

It�s just a pity Jeremy is wrong.

The Jeremy in question is, of course, secretary of state for health, the Rt Hon Jeremy Hunt, who last week announced he would bring in a 24-hour health service, seven days a week. To do this, he would alter consultant contracts to stop them including an 'opt-out' from weekend working � by force, if need be. To bolster his point, he told the public that there were not many consultants in at the weekends, and also that you were more likely to die if you came to hospital at a weekend.

I am not a consultant, far from it, but I do know that if and when I become a consultant, I will work weekends and I will be in at night. I accepted this when I took the role on.

So why did I, and the rest of my campaign group, tell the nation�s health workers to tell Mr Hunt that we were indeed working over the weekend?

I think, firstly, it was in answer to the claim that consultants do not work on Saturdays and Sundays. Our campaign has demonstrated that, day and night, there are doctors of all grades at work, often working unsociable hours.

The article also pointed out that having a consultant (the equivalent in the US of attending physician) available on the weekends may not lead to true seven day service if what the consultant orders is not available on weekends.

Two days later, another junior doctor's response to Mr Hunt had gone viral, as reported by the Mirror,

In an open letter, paediatric junior doctor Benjamin Carter, said health professionals felt 'upset, demoralised and feeling entirely unappreciated' after Mr Hunt painted them as 'lazy, money-grabbing, unprofessionals' who were opposed to 24-7 healthcare.

Also,

He said: 'Please allow me to paint a picture for you, as I am sure you are aware by now due to the #?IminworkJeremy movement, a great many doctors work weekends. I for one tend to work 1 in every 3.

'This includes juniors and consultants, my consultants in particular have a rota for who is covering the weekends day and night because we need that expertise. When on call for that weekend, my consultants do ward rounds, they see sick children, they are present for the emergencies that their wealth of experience and knowledge helps resolve.

'They do not opt out, they do not complain, and they certainly do not go straight back to the golf course. They might not always be on site for the whole 72 hour weekend, but they are never more than a phonecall away.

'I look up to my consultants as pillars of excellence and professionalism. For you to say that we as a group operate with a lack of vocation and professionalism is not only false, it is gravely insulting.'

Dr Carter posted his letter to Facebook, where it has been shared more than 5,000 times in just a few hours.

In addition,

In a moving section, he explained that much of the anger aimed among doctors is because they have to deal with life and death on a daily basis, for a relatively modest wage.

He said: 'Already our pay is comparable to a high street manager [equivalent to a manager of a shop on Main St in the US], and that it pails in comparison to a city [equivalent in the US to Wall Street] worker and that neither of those professions require their workers to deal with life and death daily, to endure aggression from those we are trying to help and to be reduced to tears that result from exhaustion and the sheer emotional burden of our daily work.

'I invite you to come to my place of work and be there holding a dying child's hand and then tell me afterwards that I don't have a sense of vocation.'

A day later, a UK consultant calculated just how "extortionate" his overtime payments were, per the Independent,

A consultant angered by Health Secretary Jeremy Hunt's claims that a 'Monday to Friday' culture exists within the NHS has published an honest account of exactly how much he earns on call and at weekends.

Karan Kapoor posted the no holds barred letter to his Facebook page, describing what he takes home as a newly-appointed NHS ENT (Ear, Nose and Throat) consultant when working outside his usual hours.

His on-call supplement per month, he reveals, pays just �313.54 [currently = $532.49] - the equivalent of �2.61 [currently = $4.05] per hour and significantly less than the minimum wage. 

He concluded,

'I am genuinely offended that you have openly questioned my professionalism and vocation or that of my colleagues,' Mr Kapoor writes.

'I am no different to the thousands of Consultants, Junior Doctors, Nurses, Physios, Pharmacists, Secretaries, Speech Therapists, etc.

'We don't go on strike, we don't hold the country to ransom, we don't compromise patient care because we were meant to go home 2 hours ago, instead we go above and beyond, understanding the true meaning of professionalism and being exemplar to any health service in the world.

'Without this silent and diligent commitment, the NHS would have crumbled many years ago.'

The story also noted the groundswell of anger inspired by Mr Hunt's implication that today's NHS doctors do not work on weekends,

Last week a petition to call a debate on a vote of no confidence in the Health Secretary hit 100,000 - the required number of signatures to be considered for debate in Parliament - in less than 24 hours.

The petition, which was started by Dr Ash Sadighi, argues that Mr Hunt has 'alienated the entire workforce of the NHS' with his plans 'to impose a harsh contract and conditions on first consultants and soon the rest of the NHS staff.'

Finally, the Independent documented another online outburst generated by a consultant surgeon posting a picture of "himself moping a hospital floor" on Facebook.

What Generic Managers Really Think of Health Professionals

We have frequently discussed how US health care has been taken over by generic managers.  In 1988, Alain Enthoven advocated in Theory and Practice of Managed Competition in Health Care Finance, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the "physicians' guild" and replace leadership by clinicians with leadership by managers (see 2006 post here). Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post here). As we noted here, the growth continued, so there are now 10 managers for every US physician.

The managers who first took over health care may have had some health care background.  Now it seems that health care managers are decreasingly likely to have any health care background, and increasingly likely to be from the world of finance.  Meanwhile, for a long time, business schools seem to have been teaching managers that they have a God given right to manage every organization and every aspect of society, regardless how little they know about what the particular context, business, calling, etc involves.  Presumably this is based on a faith or ideology that modern management tools are universally applicable and nigh onto supernatural in their powers.  Of course, there is not much evidence to support this, especially in health care.

I have every reason to believe the idea that "professional" managers and business people should be in charge of all parts of society and all economic sectors has spread well outside the US.  UK Health Secretary Jeremy Hunt seems to be an example.  His background, according to the Gov.UK website, is that "Before his election as an MP, Jeremy ran his own educational publishing business, Hotcourses."  A Financial Times article noted that in 2014, he still had a major financial interest in the company,

Jeremy Hunt, the health secretary, has suffered a setback in his attempt to sell his education listings business after private equity group Inflexion pulled out of a proposed �35m deal.

Hotcourses, which claims to be the world�s largest database of educational courses, was set up by Mr Hunt and his business partner, Mike Elms, in 1996, before he entered parliament.

The article noted further, ironically in regard to the Mr Hunt's recent controversy,

The deal was an awkward reminder for the coalition of the large personal wealth of many cabinet ministers at a time when Labour has criticised the government for being 'out of touch' with ordinary voters.

As far as I could tell, before his political  career, Mr Hunt was a businessman with no experience or expertise in health care or biomedical science. And as of May, 2015, according to the the ThisIsMoney.uk website, Actually, he still seemed to be a businessman.  Mr Hunt still owned nearly half of the company, and was still receiving large dividend payments from it.

Nonetheless, Mr Hunt is now in charge of the whole of the British NHS.  However, his recent public pronouncement that NHS doctors do not work on weekends, and that is why the health service does not provide adequate services on weekends, reveals that he seems not to be very familiar with the organization he is supposed to be leading.  Again, we have seen many examples of leaders of big US health care organizations who seem ill-informed about their organizations, and sometimes hostile to their organization's health care mission.

However, we have not often heard a generic manager simultaneously publicly express so much hostility to health professionals  and so little knowledge about what those professionals actually do.  I suspect that is merely because many US managers are reined in better by their public relations departments and legal counsel. 

We are well into our global experiment involving handing control of virtually everything to managers, administrators, executives, and business people.  I submit it is not going well, and maybe leading us to some ultimate ruination.

As we have said again, again, again... It is way past time for health care professionals to take back health care from generic managers.  True health care reform would restore leadership by people who understand the health care context, uphold health professionals' values, are willing to be held accountable, and put patients' and the public's health ahead of self-interest. 

In the UK, doctors finally seem to be rising in protest against a particularly ill-informed businessman who is currently their boss.  It is past due for US doctors to hold to account similarly ill-informed, and sometimes also mission-hostile generic managers to whom they report.

Princess Health and Hacking an ICD - A Dual Medical Informatics/Ham Radio Perspective. Princessiccia

Princess Health and Hacking an ICD - A Dual Medical Informatics/Ham Radio Perspective. Princessiccia

hacking ICD ill-informed management Medtronic

Gusty 14:28 Add Comment

Roy Poses wrote at "Hacking an ICD" that:

An ICD is a device whose correct operation is critical for the health and safety of patients in whom it is implanted. One would think that the managers responsible for the design of such devices would have pushed to make sure that the operation of such devices could not be hacked or accidentally altered in ways that could put patients' health and lives at risk.

Indeed.

It is probably not well known that in addition to being a Medical Informaticist, I am also a ham radio enthusiast, licensed at the Extra class. I know more about electronics than most physicians - and most IT people in hospitals to boot, although that often didn't matter in the dysfunctional world of hospitals and health IT.

As a medical informaticist and ham radio operator, I am concerned by the possibility of long(er) range hacking of implantable medical devices than that accomplished by researchers recently.

Apparently ICD's use a frequency of about 175 kHz for data communications. 175 kHz is in a band known as longwave. For comparison and orientation, the bottom of the familiar medium wave band -- a.k.a. ordinary AM radio-- is 520 kHz.

(An aside for those interested: shortwave starts at about 1,800 kHz or 1.8 MHz and extends to about 30,000 kHz or 30 MHz, and is called "shortwave" for historical reasons; the actual wavelengths are appx. 160 meters to 10 meters. These wavelengths were considered "short", comparatively speaking, in the early days of radio. The shortwaves have the property, under proper conditions, of being refracted back to earth by the earth's ionosphere and can be reflected by the earth itself. This allows the waves to do "multiple hops" and propagate over great distances far in excess of line-of-sight, even around the world. Hence the ability of ham radio enthusiasts to talk to people all over the world on the shortwave bands allocated to them.)

When I was 13 years old I built a one-transistor transmitter on a cigar box from a plan by Heathkit that transmitted low power morse code at a frequency of about 550 kHz. It ran off a few AA batteries and used a short wire as an antenna. It was easily receivable on a radio across the house.

The first cordless phones ca. early 1980s, wireless baby monitors, and other devices operated at about 1,700 kHz, just above the AM radio band. They were very low power devices with short antennas relative to wavelength (~175 meters) but were usable at dozens of feet from their base units.

Using an antenna, say, the size of a CB whip (properly loaded electrically to resonate at 175 kHz, not very efficient but usable), or even better, a directional loop antenna, plus a transmitter of 5 or 10 or, perhaps, 100 watts of power (not very hard to build), and using a sensitive receiver designed for those frequencies (my $150 retail Grundig Yacht Boy is an example, http://www.eham.net/reviews/detail/816) with modifications and a suitable low-noise receiving antenna, would potentially extend the range of communications with RF-controlled implantable devices.

Not to miles with any type of portable equipment, I should add, due to efficiency issues with very short antennas (relative to wavelength) and the low power of the ICD's transmitter, but tens of feet might be possible. Throw in digital signal processing on the hacker's receiver, which is available via common, cheap, off-the-shelf DSP chips and algorithms, and even more range would be likely. You would be surprised at what a DSP-equipped and/or computer-enhanced receiver can pull out of the "ether" even under extremely poor signal conditions.

One wonders if any ICD's transmitter and receiver are encrypted in any way - apparently the devices tested were not. My car FOB is, although even those can be hacked (e.g., "Prius Security System Cracked", http://www.treehugger.com/files/2007/08/a_talk_given_at.php):

A talk given at the computer security conference, CRYPTO 2007, explained how the key-fob system installed on the Toyota Prius has been cracked. The KeeLoq auto anti-theft cipher is used in common devices made by Microchip Technology Inc, which are also used by Chrysler, Daewoo, Fiat, General Motors, Honda, Volvo, Volkswagen, and Jaguar. The attack requires that the thief gets within range of your RFID keyfob, in order to break the encryption. This could mean stealing your keys, or just sitting next to you in a cafe with a laptop. The cipher used in these devices is 64 bit, which has always been theoretically possible to break, but has now been shown to be breakable in about an hour. This is important, because the shorter the amount of time required with the key, the more likely this attack is to become used outside of a research lab.

May I add that while encryption is not foolproof, lack of encryption seems the work of fools.

On a somewhat unrelated note, you can buy a wrist watch that picks up time-setting signals from an atomic clock via station WWVB, Fort Collins, Colorado (http://en.wikipedia.org/wiki/WWVB) at long wave frequency 60 Khz for $30. I have one and in Philadelphia, it works well.

Some hams bounce signals off the moon for earth-moon-earth communications. They use high power, high gain antennas, and very low noise receivers. It works quite well.

Never underestimate what can be done at RF.

On one (predictable) industry response:

Medtronic's Rob Clark said the company's devices had carried such telemetry for 30 years with no reported problems. 'This is a very low-risk event for patients that have these devices,' Clark said in a telephone interview."

It would have been just a bit harder to hack a computerized device 30 or 20 or even 10 years ago. When kids can buy a laptop with computing power exceeding that of the Cray supercomputer for $500 and crack into, say, the Pentagon's systems, we are indeed living in different times.

Dr. Poses also wrote that:

The most charitable explanation for why they [the manufacturers] did not think to [engineer ICD's to be exceptionally hacker-proof] is that they really did not understand the clinical context in which this device would be used.

I think a better explanation is that the manufacturers' management has little imagination and underestimate the capabilities of people much smarter and more creative than themselves (e.g., tech-savvy kids). It would not surprise me to find engineering memos warning management that more safeguards needed to be incorporated, only to be asked "What's the ROI?"

The bottom line is: manufacturers might need to work a little harder when they deploy wireless devices, as hacking of gadgets and computerized equipment such as cell phones seems to be an increasingly common pastime for today's youth. (It's too bad ham radio is itself losing numbers as the previous generation ages and dies out.) The internet itself is used to spread techniques and malicious code among hackers.

One can imagine the consequences of a malicious RF device hacker or smart-but-delinquent kid in, say, a crowded shopping mall.

Finally, ham radio experimenters worldwide are not unfamiliar with longwave experimentation. Note in particular the bolded statement below:

With no Amateur Radio low-frequency [longwave -ed.] allocation in North America, stations operating under FCC Part 5 Experimental licenses in the US or under special experimental authorizations in Canada nonetheless continue to research the nether regions of the radio spectrum. By and large, LF experimentation is occurring in the vicinity of 136 kHz--typically 135.7 to 137.8 kHz--where amateur allocations already exist elsewhere in the world. The FCC rejected the ARRL's 1998 petition for LF allocations at 135.7 to 137.8 kHz and 160 to 190 kHz, however, after electric utilities objected that ham radio transmissions might interfere with power line carrier (PLC) signals used to control the power grid.

"Most of the new LF activity of Part 5 licensees has been in the shared 137 kHz amateur allocation available in some parts of the world," says low-frequency experimenter Laurence Howell, KL1X/5. "Although not in the Amateur Radio Service, these Part 5 experimental stations continue to add to our knowledge on propagation and engineering."

The holder of Part 5 Experimental license WD2XDW, Howell who's also GM4DMA, previously operated LF from Alaska. He's since relocated to Oklahoma, and has now resumed his LF work on 137.7752 and 137.7756 kHz. Already he's reporting some spectacular success, despite antenna limitations. On October 28, New Zealand LFer Mike McAlevey, ZL4OL, copied WD2XDW's 137 kHz carrier "bursts" over a path of more than 13,000 km (8000 miles).

The take-away message is that:

• In biomedicine, the most meticulous resilience engineering is never a bad idea.

When drug and device manufacturers understand this fully, perhaps we will no longer have incidents of bad health informatics that can kill.

-- SS

Princess Health and Hacking an ICD. Princessiccia

Princess Health and Hacking an ICD. Princessiccia

ICD ill-informed management medical devices Medtronic

Gusty 07:35 Add Comment

Implantable cardiac defibrillators (ICDs) are battery-powered, computerized electronic devices implanted in the body. They are designed to detect dangerous heart rhythms and administer a shock to the heart to stop these them. We have discussed these devices before, including a story about how one manufacturer suppressed data that suggested some of their ICDs were less reliable than heretofore thought.

It appears that a new, and potentially worrisome adverse effect of these devices has just been discovered.

An article to be published in the IEEE Symposium on Security and Privacy [Halperin D, Heydt-Benjamin TS, Ransford B et al. Pacemakers and implantable cardiac defibrillators: software radio attacks and zero-power defenses. IEEE Symposium Security Privacy 2008; in press. Link here.] demonstrated the vulnerability of an implantable cardiac defibrillator to computer hacking.

Let me set the stage. ICDs, and other implantable devices may need to be tested, and sometimes their functional parameters need to be adjusted. Obviously, it would be cumbersome and hazardous to remove such a device after it was implanted to check and adjust it. So the devices incorporate methods to check and adjust them remotely. It appears most do so using "wireless" means. Wireless, of course, is the traditional UK term for radio.

Halperin et al found that they could communicate with a representative ICD, the Medtronic Maximo DR VVE-DDDR model via radio. Note that the ICD they tested was not implanted in a patient, but sitting on a bench, and that their radio equipment used to "hack" it was in close proximity to it.

Once they figured out how to communicate, the found that they could:
- Discover patient data such as name, date of birth, medical ID number, and medical history
- Monitor electrophysiological telemetry data
- Turn off specific ICD functions
- Induce the ICD to deliver a shock, potentially one that could cause a severe rhythmn disturbance
- Increase the power consumption of the ICD so that its battery would fail prematurely.

Further, they found that they could overcome a design feature of the ICD meant to prevent anyone from communicating with it from more than a very short distance. The ICD is not supposed to respond to radio signals unless it is first exposed to a strong local magnetic field which triggers a magnetic switch in the device. But the investigators found, "in order to rule out the possibility that proximity of the magnet ... is necessary for the ICD to accept programming commands, we tested each ... attack with and without a magnet near the ICD. In all cases, both scenarios were successful."

Thus, this article suggested this ICD could be hacked, and that hacking it could pose significant risks to patients who had the ICD implanted.

Some people doubted that such hacking could actually take place in real-life, as opposed to laboratory settings. For example, per the AP story, FDA spokesperson Pepper Long "acknowledged a hacker could use specialized software and a small antenna to intercept transmissions from a defibrillator. But she said the chance of that happening � or of a defibrillator being maliciously reprogrammed using a technique similar to the one a doctor would use to program it � was 'remote.'" Furthermore, per the Reuters story, "Medtronic's Rob Clark said the company's devices had carried such telemetry for 30 years with no reported problems. 'This is a very low-risk event for patients that have these devices,' Clark said in a telephone interview."

In my humble opinion, however, the problems that Halperin et al found with the Medtronic ICD have real importance. Let me first note that both the FDA and Medtronic representatives treated the issue epidemiologically. They based their pronouncements on the assumption that an adverse event that has not happened in the past due to a device in wide use is not likely to happen in the future. That does not make sense if the potential adverse event would involve conscious, malicious human action. Just because hackers have not yet attacked an ICD does not mean they will not do so in the future, especially after the possibility of doing so has gotten wide publicity.

Another way some have minimized the practical importance of their findings is that the experiment by Halperin et al was carried out on an ICD on a bench, using equipment that was in close proximity. Some may thus feel that the possibility of hacking carried out from longer range is low. I strongly believe that is not a good assumption. Many features of the ICD and its radio communication system suggest that hacking could be carried out from considerably longer range. There are hints in the Halperin et al article that could suggest to anyone moderately knowledgeable about radio how this could be done. I do not want to discuss these in any more detail, because I do not want to facilitate such long-ranging hacking. But I believe it is a real danger.

But why is this relevant to Health Care Renewal? It seems glaringly obvious that the risk of hacking could have been substantially reduced had the ICD been designed so it would not respond to any radio communication that did not have an appropriate authorization code, and/or if communication with it were encrypted. In fact, Halperin et al suggested some relatively simple measures that could be used to increase the security of these devices. Yet the Medtronic ICD, and presumably other ICDs and implantable devices, were not designed with such elementary security precautions in mind. As security expert Bruce Schneier wrote (reported in Information Week),

Of course, we all know how this happened. It's a story we've seen a zillion times before: The designers didn't think about security, so the design wasn't secure.

But an ICD is a device whose correct operation is critical for the health and safety of patients in whom it is implanted. One would think that the managers responsible for the design of such devices would have pushed to make sure that the operation of such devices could not be hacked or accidentally altered in ways that could put patients' health and lives at risk. The most charitable explanation for why they did not think to do so is that they really did not understand the clinical context in which this device would be used.

This is yet another reminder that those who run health care organizations often fail to think about patients' welfare first instead of other considerations. We need to change the culture of health care organizations to put patients first. Until we do so, we are going to get hacked.

Princess Health and A Scathing Commentary on California's New Institute for Regenerative Medicine. Princessiccia

Princess Health and A Scathing Commentary on California's New Institute for Regenerative Medicine. Princessiccia

California Institute for Regenerative Medicine ill-informed management

Gusty 11:40 Add Comment

The Los Angeles Times included a scathing commentary on California's new stem cell research agency. Author Michael Hitzik charged that "the California Institute for Regenerative Medicine has behaved not like the state agency it is, but with the arrogance of a private corporation that happens to be playing with the taxpayers' cash." Hitzik charged that the agency has not yet developed ethical rules or financial disclosure requirements, but it has hired a private lobbying firm, "perhaps the only state agency that pays an outside lobbyist to battle the Legistlature." In addition, Hitzik alleged that the chairman of the agency, "Bay Area real estate developer Robert Klein II.... often seems to assume that anyone who criticizes himself of his agency must be fanatically hostile to embryonic stem cell research, or worse." Furthermore, in challenging lawsuits filed against the agency, Klein claimed that "over half of all California families ... have a member who might benefit from stem cell research." Since no one yet knows what the practical outcomes of stem cell research will be, this claim about how many people will benefit from it is obviously unsubstantiated, and thus is not the sort of claim that should be made by the head of a biomedical research organization. Finally, Hitzik claimed that the Institute "seems determined to start issuing grants within the next few months, possibly before it has in place an operational budget, a full sheaf of ethical standards and conflict-of-interest rules, or, indeed, bond money."
This appears not to be an auspicious start for the leadership of this Institute.

Princess Health and A Scathing Commentary on California's New Institute for Regenerative Medicine.Princessiccia

Princess Health and A Scathing Commentary on California's New Institute for Regenerative Medicine.Princessiccia

California Institute for Regenerative Medicine ill-informed management

Gusty 11:40 Add Comment

The Los Angeles Times included a scathing commentary on California's new stem cell research agency. Author Michael Hitzik charged that "the California Institute for Regenerative Medicine has behaved not like the state agency it is, but with the arrogance of a private corporation that happens to be playing with the taxpayers' cash." Hitzik charged that the agency has not yet developed ethical rules or financial disclosure requirements, but it has hired a private lobbying firm, "perhaps the only state agency that pays an outside lobbyist to battle the Legistlature." In addition, Hitzik alleged that the chairman of the agency, "Bay Area real estate developer Robert Klein II.... often seems to assume that anyone who criticizes himself of his agency must be fanatically hostile to embryonic stem cell research, or worse." Furthermore, in challenging lawsuits filed against the agency, Klein claimed that "over half of all California families ... have a member who might benefit from stem cell research." Since no one yet knows what the practical outcomes of stem cell research will be, this claim about how many people will benefit from it is obviously unsubstantiated, and thus is not the sort of claim that should be made by the head of a biomedical research organization. Finally, Hitzik claimed that the Institute "seems determined to start issuing grants within the next few months, possibly before it has in place an operational budget, a full sheaf of ethical standards and conflict-of-interest rules, or, indeed, bond money."
This appears not to be an auspicious start for the leadership of this Institute.

Princess Health and "The Catastrophic Collapse in Morale Among Doctors". Princessiccia

Princess Health and "The Catastrophic Collapse in Morale Among Doctors". Princessiccia

generic managers ill-informed management

Gusty 14:25 Add Comment

In the April 30 Lancet, a scathing editorial about the untoward influence of managers and politicians on British health care.
(Not available without a subscription, the citation is: Anonymous. The unspoken issue that haunts the UK general election. Lancet 2005; 365: 1515.)

Here are some key quotes:

• "But sadly, Labour, Conservative, and Liberal Democrat politicians have failed to address the single most important factor hindering the improvement of health services - the catastrohic collapse in morale among doctors. Doctors at all levels within the NHS are utterly demoralised."
• "They are cynical about a new cadre of managers who have little clinical understanding but create a massively overmanaged health service. And they feel let down by their own leaders, who have consistently failed to articulate a positive and assertive vision about the contribution modern medicine makes to society."
• "What UK medicine needs is a new and stronger political voice, one that is more concerned with augmenting professional standards than with protecting professional status."

Sounds familiar here in the US. As an American physician, I feel my British colleagues pain. Maybe we can get together across the Atlantic and figure out how to fight overmanagement and foster our professional values.

Princess Health and "The Catastrophic Collapse in Morale Among Doctors".Princessiccia

Princess Health and "The Catastrophic Collapse in Morale Among Doctors".Princessiccia

generic managers ill-informed management

Gusty 14:25 Add Comment

In the April 30 Lancet, a scathing editorial about the untoward influence of managers and politicians on British health care.
(Not available without a subscription, the citation is: Anonymous. The unspoken issue that haunts the UK general election. Lancet 2005; 365: 1515.)

Here are some key quotes:

• "But sadly, Labour, Conservative, and Liberal Democrat politicians have failed to address the single most important factor hindering the improvement of health services - the catastrohic collapse in morale among doctors. Doctors at all levels within the NHS are utterly demoralised."
• "They are cynical about a new cadre of managers who have little clinical understanding but create a massively overmanaged health service. And they feel let down by their own leaders, who have consistently failed to articulate a positive and assertive vision about the contribution modern medicine makes to society."
• "What UK medicine needs is a new and stronger political voice, one that is more concerned with augmenting professional standards than with protecting professional status."

Sounds familiar here in the US. As an American physician, I feel my British colleagues pain. Maybe we can get together across the Atlantic and figure out how to fight overmanagement and foster our professional values.

Princess Health and A Growing Proliferation of Managers. Princessiccia

Princess Health and A Growing Proliferation of Managers. Princessiccia

generic managers ill-informed management managers' coup d'etat

Gusty 13:16 Add Comment

A while back, we had a dialog with EconBlog about the myth of US health care waste. One issue I had discussed was adminstrative overhead. (See my first previous post here, and follow-up here., and on cost of high-technology, here.)
I argued that my experience as a physician (and discussion with other physicians) suggests that there is a huge administrative and bureaucratic load on physicians, and that this contributes directly and indirectly to health care costs. The best I could do at the time was to cite a study that showed that physicians in practice spend an inordinate amount (a little less than US $25K a year per physician) on "unnecessarily complex or redundant administrative tasks."
I just found some fascinating data along these lines, available from the Center for Medicare and Medicaid Services (CMS) in a series of charts (here, chart 1.13.)
See in particular Table 1.13, Health Care Employment by Occupation.
It shows that from 1983 to 2000, the numbers of health care managers grew at a rate that far outstripped any other kind of health occupation. Taking the numbers off the PowerPoint presentation,

• The number of managers grew from 91,ooo in 1983 to 174,000 in 1990, to 752,000 in 2000.
• That could be compared with the numbers of physicians in those years (519,000 to 577,000 to 719,000), and the number of registered nurses (1,372,000 to 1,667,000 to 2,111,000)

So the growth rates from 1983 to 2000 were 1.39x (39%) for physicians, 1.54x (54%) for nurses, and a whopping 8.26x (726%) for managers.
Another way to look at it is, in 1983 there was 1 manager for every 5.7 physicians and every 15.1 nurses. In 2000, there was 1 manager for every 0.96 physicians and every 2.9 nurses. Again, by 2000, the number of health care managers exceeded the number of physicians. There were more managers than any other species of health care worker other than nurses.
If health care could function in 1983 with one manager for nearly every 6 doctors, why in the world did we need one manager per doctor in 2000?
I would love hear if anyone can come up with a justification for this massive increase in numbers, or show how this proliferation has lead to any improvement in health care.
On the other hand, ecological correlations are not a good way to prove causation, of course, but I would argue that this data suggests that attributing the simultaneous rise in health care costs, decrease in access, stagnation in quality, and dissatisfaction of health professionals like physicians and nurses to the incredible proliferation of managers (and attendant bureaucracy) is not far-fetched.

Princess Health and A Growing Proliferation of Managers.Princessiccia

Princess Health and A Growing Proliferation of Managers.Princessiccia

generic managers ill-informed management managers' coup d'etat

Gusty 13:16 Add Comment

A while back, we had a dialog with EconBlog about the myth of US health care waste. One issue I had discussed was adminstrative overhead. (See my first previous post here, and follow-up here., and on cost of high-technology, here.)
I argued that my experience as a physician (and discussion with other physicians) suggests that there is a huge administrative and bureaucratic load on physicians, and that this contributes directly and indirectly to health care costs. The best I could do at the time was to cite a study that showed that physicians in practice spend an inordinate amount (a little less than US $25K a year per physician) on "unnecessarily complex or redundant administrative tasks."
I just found some fascinating data along these lines, available from the Center for Medicare and Medicaid Services (CMS) in a series of charts (here, chart 1.13.)
See in particular Table 1.13, Health Care Employment by Occupation.
It shows that from 1983 to 2000, the numbers of health care managers grew at a rate that far outstripped any other kind of health occupation. Taking the numbers off the PowerPoint presentation,

• The number of managers grew from 91,ooo in 1983 to 174,000 in 1990, to 752,000 in 2000.
• That could be compared with the numbers of physicians in those years (519,000 to 577,000 to 719,000), and the number of registered nurses (1,372,000 to 1,667,000 to 2,111,000)

So the growth rates from 1983 to 2000 were 1.39x (39%) for physicians, 1.54x (54%) for nurses, and a whopping 8.26x (726%) for managers.
Another way to look at it is, in 1983 there was 1 manager for every 5.7 physicians and every 15.1 nurses. In 2000, there was 1 manager for every 0.96 physicians and every 2.9 nurses. Again, by 2000, the number of health care managers exceeded the number of physicians. There were more managers than any other species of health care worker other than nurses.
If health care could function in 1983 with one manager for nearly every 6 doctors, why in the world did we need one manager per doctor in 2000?
I would love hear if anyone can come up with a justification for this massive increase in numbers, or show how this proliferation has lead to any improvement in health care.
On the other hand, ecological correlations are not a good way to prove causation, of course, but I would argue that this data suggests that attributing the simultaneous rise in health care costs, decrease in access, stagnation in quality, and dissatisfaction of health professionals like physicians and nurses to the incredible proliferation of managers (and attendant bureaucracy) is not far-fetched.