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Last 50 Editorials

(Click on title to be directed to editorial, most recent listed first)

Honoring Our Nation's Veterans
Capture Market Share, Raise Prices
Guns and Sleep
Is It Time for a National Tort Reform?
Time for the VA to Clean Up Its Act
Eliminating Mistakes In Managing Coccidioidomycosis
A Tale of Two News Reports
The Hands of a Healer
The Fabulous Fours! Annual Report from the Editor
A Veterans Day Editorial: Change at the VA?
A Failure of Oversight at the VA
IOM Releases Report on Graduate Medical Education
Mild Obstructive Sleep Apnea: Beyond the AHI
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
VA Administrators Breathe a Sigh of Relief
VA Scandal Widens
Don’t Fire Sharon Helman-At Least Not Yet
Questioning the Inspectors
Qualitygate: The Quality Movement's First Scandal
What's Wrong with Expert Opinion?
The Tremendous Threes! Annual Report from the Editor
Obamacare and Computers-Who Is to Blame? 
HIPAA-Protecting Patient Confidentiality or Covering Something Else?
Are Medical Guidelines Better Than Flipping a Coin?
Who Will Benefit and Who Will Lose from Obamacare?
Smoking, Epidemiology and E-Cigarettes
Treatment after a COPD Exacerbation
Executive Pay and the High Cost of Healthcare
Choosing Wisely-Where Is the Choice?
The State of Pulmonary and Critical Care in the Southwest
Doxycycline and IL-8 Modulation in a Line of Human Alveolar 
Epithelium: More Evidence for the Anti-Inflammatory Function 
   of Some Antimicrobials
What to Expect from Obamacare
The Terrific Twos! Annual Report from the Editor
Maintaining Medical Competence
Interference with the Patient–Physician Relationship
Guidelines for Starting Today’s Private Practice
The Emperor Has No Clothes: The Accuracy of
   of Hospital Performance Data 
Getting the Best Care at the Lowest Price
A New Paradigm to Improve Patient Outcomes
A Little Knowledge is a Dangerous Thing
VA Administrators Gaming the System
Will Fewer Tests Improve Healthcare or Profits?
Identification of a Biomarker of Sleep Deficiency—
   Are We Tilting Windmills?
Competition or Cooperation?
Follow the Money
Happy First Birthday SWJPCC! 
The Hefty Price of Obstructive Sleep Apnea 
Mismanagement at the VA: Where’s the Problem? 
Why Is It So Difficult to Get Rid of Bad Guidelines?
Changes In Medicine: Job Security 


For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care publishes editorials related to manuscripts in the Journal as well as areas of interest to the pulmonary, critical care and sleep communities. In general, editorials are written by the editors or are invited. However, the Journal will consider editorials written by others. Before submitting, a potential author of the editorial should contact the editor.



Honoring Our Nation's Veterans

Today is Armistice Day, renamed Veterans Day in 1954, to honor our Nation's Veterans. In Washington the rhetoric from both the political right and left supports our Veterans. My cynical side reminds me that this might have something to do with Veterans voting in a higher percentage than the population as a whole, but let me give the politicians this one. Serving our Country in the military is something that deserves to be honored. I was proud to serve our Veterans over 30 years at four Department of Veterans Affairs (VA) hospitals.

However, the VA has had a very bad year. First, in Washington there were the resignations of the Secretary of Veterans Affairs, Eric Shinseki; the undersecretary for the Veterans Health Administration, Robert Petzel; and the undersecretary for the Veterans Benefits Administration, Allison Hickey. Locally, in the light of the VA wait scandal there were the firing of the Phoenix VA Medical Centers director, Sharon Helman, and her deputies along with the retirement of her boss, Susan Bowers. Furthermore, there seem to be a never-ending string of scandals ranging from the mundane of greed-driven fraud to the more exotic of accusing a VA whistleblower of engaging in sexual threesomes. Despite a healthy increase in funding, there was the threat by VA administrators of closing VA hospitals to meet a VA budget shortfall. This resulted in Congress knuckling under to allow the use of emergency funds. Veterans groups are using billboards to accuse the VA of lying (Figure 1).

Figure 1. Billboard across from the VA October 12, 2015.

I could go on and on. However, the real question is not so much of what dirty deeds are being done, but how the VA administrators get away with it.

There has been both a lack of oversight and lack of accountability. Robert McDonald, who replaced Shinseki, has promised to punish the evil doers but has replaced action with the mantra "all is well" and has done nothing. In several instances wrong-doing has apparently been rewarded, such as Bowers replacement having lied to Congress (1). If the VA cannot police itself-and it apparently cannot-there are a multitude of regulatory agencies that have shirked their oversight responsibilities. I thought it was time to mention a few.

First, there are both the Veterans Integrated Service Networks, the regional VA offices, and VA Central Office itself in Washington. Both these organizations have been caught in the scandals and have done nothing. Second, there is Congress. The House Veterans Affairs Committee has seemed to make a sincere effort to identify some of the problems but Secretary McDonald and his cadre of 11,000 in Central Office has repeatedly stone-walled any investigation and Congress has done nothing. Third, there is the White House. The Obama Administration has seemed more interested in declaring the problem fixed than actually fixing the problem and has done nothing.

Those are the obvious but there are some less obvious regulatory failures. First, there are the multiple hospital inspectors. Within the VA is the Office of Inspector General (IG) who is charged with investigating wrong-doing within the VA. Locally they had been called to Phoenix multiple times including for the wait time scandal but have done nothing. The poor performance resulted in the resignation of the acting VA IG, Richard Griffin, under pressure. Second, there is the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). The Phoenix VA Medical Center managed to go from a "top performer" in 2011 to noncompliant "with U.S. standards for safety, patient care and management" in 2014. Only the naive would believe that a hospital can transition that much in 3 years. There is also the Arizona Board of Medical Examiners and Nursing. Both doctors and nurses were involved in the cover-up of the wait scandal but these boards have done nothing. The VA is the largest system for training future physicians and nurses, and it seems that the future doctors and nurses might not be learning the highest professional and ethical standards. Nonetheless, the Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing have done nothing.

However, my personal disgust is highest for the Department of Justice (DOJ). It is known that seventy percent of the hospitals were fudging their wait data. The administrators, not the doctors or nurses, received bonuses for short wait times. None of the administrators have gone to jail or even been charged with fraud. None have even had to repay their bonuses. The DOJ has done nothing. If 70% of the doctors were caught faking data to received bonuses, I have every confidence that the legal eagles at DOJ would gleefully put each and every one on trial.

So what can be done? There appears to be no oversight. This was clearly illustrated in the report from the recent Human Resources (HR) team from Central Office sent to Phoenix to help with what can be kindly described as a dysfunctional department. They were essentially shown the door by the acting director, Glen Grippen, saying that he "calls the shots" (2).

The solution is that Mr. Grippen and others of his ilk should no longer call the shots. They have shown a consistent arrogance and disregard for our Nation's Veterans and those that serve them. He and others need oversight, not by a far-off committee in Washington as President Obama has proposed which will likely fare no better than Congress. Oversight could be best provided by local physicians and nurses who have interest in Veteran care but are not employed by the VA. This used to occur in many VA hospitals and was called the Dean's Committee. The dean of the local medical school along with the chairman of the departments of medicine, surgery, pathology, radiology, and others formed a committee that oversaw care at the VA. The committee had interests in the patient care of Veterans but also in the physicians who were faculty at the local medical school and the medical students, residents and fellows who were under their supervision. This committee was a victim of Ken Kizer's "prescription for change" in the 1990s. Now, this old system might be an antidote for Kizer's prescription which has seemed to turn poison.

The VA is pushing to hire more personnel to deal with wait times and lack of patient care. However, it is unclear how many of the new hires are doctors and nurses contributing to patient care and how many are administrators and bureaucrats.  My experiences and conversations with my colleagues convinces me that not all hospitals are as badly managed as those in the Southwest. Those considering a career at the VA need to carefully investigate each hospital to see if it is the type of place that the leadership will provide the resources to care for the Veterans, which is after all, the definition of leadership.

Richard A. Robbins, MD

Editor, SWJPCC


  1. Wagner D. Department of Veterans Affairs names new regional health director. Arizona Republic. October 15, 2015. Available at:
  2. Wagner D. VA team blasts Phoenix personnel office. Arizona Republic. November 2, 2015. Available at:

Cite as: Robbins RA. Honoring our Nation's Veterans. Southwest J Pulm Crit Care. 2015;11(5):228-30. doi: PDF


Capture Market Share, Raise Prices

Two principles in medical economics central to the Affordable Care Act (ACA) were dealt blows by recently published studies. The first principle is the belief that economies of scale will result in lower prices. The theory is that larger insurers will have lower prices because they are more administratively efficient. The second principle is that provider-owned health plans, usually hospitals, will reduce premiums. The theory is that  by controlling doctors over charging health plans in a fee-for-service model will lower prices.

The first study published in Technology Science found that the largest insurer in each of the states served by raised their prices in 2015 by an average of over 10 per cent compared to smaller competitors in the same market (1). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

The second study published by HealthPocket compared the lowest monthly premiums for provider-owned to nonprovider-owned plans within twelve counties across the US (2). The counties analyzed were spread across the eastern, central, and western regions of the U.S. Premiums were based on a 40-year-old, non-smoker profile. Insurance offered by health-care providers such as hospitals, was on average 12% more expensive compared to  traditional insurers. The data were also analyzed by the type of plan under the ACA: bronze, silver and gold. There were too few platinum plans to perform an analysis. Table 1 shows the local results in the three western states analyzed.

Table 1. Monthly premiums for Provider and Non-Provider Health Plans Under the ACA (2).

Silver plans account for two-thirds of plan selections on the ACA marketplaces during the 2015 annual enrollment period (3). Only the premiums for the bronze and silver provider-owned health plans in Arizona cheaper. Both in New Mexico and Utah all the provider-owned health plans and the more frequently selected silver plan in Arizona were all more expensive.

The premises of economies of scale and elimination of the fee-for-service reimbursement are both central to the ACA. Both appear to be myths. The results of these studies illustrate the sobering reality that the best intentions in reforming American healthcare do not necessarily produce the intent imagined. Despite the theoretical promise of reducing expenses by eliminating waste, both studies show an increase in healthcare costs, opposite the direction that traditional economics predict. Both larger companies and provider-owned health plans have a profit motive with numerous conflicts which likely accounts for these increases in premiums. Rather than allowing mergers and focusing on controlling physician behavior as strategies in reducing costs, it is time to focus on the insurers. Their strategy appears to be "capture market share, raise prices" and therefore their profits. This later premise agrees more with the data. Most of us who work in healthcare know this, it is time for those in Washington to pay attention to what is going on rather than their prejudices and political beliefs. 

Richard A. Robbins, MD*


Southwest Journal of Pulmonary and Critical Care


  1. Wang E, Gee G. Larger Issuers, Larger Premium Increases: Health insurance issuer competition post-ACA. Technology Science. 2015081104. August 11, 2015. Available at: (accessed 8/31/15).
  2. Colemen K, Gleeson J. Cheapest healthcare provider-owned insurance plans still 12% more expensive than cheapest insurance plans not owned by providers. HealthPocket. August 20, 2015. Available at: (accessed 8/31/15).
  3. Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report. ASPE Issue Brief. (March 10, 2015).

*The views expressed are those of the author and do not necessarily represent those of the Southwest Journal of Pulmonary and Critical Care, the American Thoracic Society or the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. Capture market share, raise prices. Southwest J Pulm Crit Care. 2015;11(2):88-9. doi: PDF


Guns and Sleep

Gun deaths are a problem in America. Irrespective of one’s position on gun control, the statistics do not lie. According to the Centers for Disease Control and Prevention (CDC), there were 11,208 deaths caused by firearms in 2013 (1). The recent high profile cases in Cincinnati, OH, Lafayette, LA and Memphis, TN further highlight the issue. Obviously, each case of death by a firearm had its own set of underlying factors that contributed to the final fatal outcome, but one wonders whether sleep deprivation can be implicated in some of them.

Sleep duration in adults over the past approximately 30 years has been declining in the United States (2). A variety of reasons can be cited as underlying causes such as greater use of artificial lighting, an expanding 24 hour non-stop society, promotion of a work ethic that values “burning the midnight oil”, and use of electronic devices before bedtime (especially those that emit blue wavelength light). In addition, both legal and illegal drugs have important impacts on sleep quality and quantity. For example, amphetamines can cause insomnia and by extension a reduction in sleep time (3), and perhaps more importantly, caffeine will have the same effect if used to excess (4). The most recent recommendation from the American Academy of Sleep Medicine is for adults to sleep at least 7 hours per night (5). However, recent CDC data indicate that 29.2% of adults sleep less than 6 hours per night and are thus chronically sleep deprived (2).

Symptoms of sleep deprivation include longer reaction times, lapses in attention or concentration, poor short term memory, errors of omission and sleepiness. However, sleep deprivation also leads to confusion, stress, irritability and impulsivity. Importantly, decision making and the ability to formulate reasonable moral judgments are impaired. All of these negative impacts of sleep deprivation can lead to high-risk behavior. Thus, can it be posited that in some cases, sleep deprivation, perhaps fueled by the legal or illegal use of stimulant compounds, leads to impaired judgment and increased impulsivity, poor decisions and fatal shootings?

Several years ago, I was asked to be a defense expert in a case where a jilted wife fatally shot her husband’s lover. After learning about her husband’s affair, the wife had become distraught and unable to sleep for ~2 days. She then sought out the victim and shot her. Her sleep deprivation was used as a mitigating factor to reduce the charge from 1st to 2nd degree homicide. Although not a shooting, more recently, a Florida man was acquitted of the murder by suffocation of his father because he was sleep deprived after consuming a large amount of Red Bull (80 mg caffeine per 8.46 fluid ounces). Cases such as these have led to speculation that sleep deprivation may be an effective defense where the fatal act could plausibly be explained by a change in mood or cognitive impairment.

The potential impact of sleep deprivation is likely not limited to citizens accused of fatal shooting, but law enforcement officers as well. Police officers frequently work overnight or rotating shifts, and many accept overtime duty as well. A recent survey of 4957 police officers found that >40% screened positive for at least one sleep disorder with 28.5% being excessively sleepy, suggesting an element of sleep deprivation (5). Most troubling was that those who were identified as having a sleep disorder had a 51% greater likelihood of making an error or safety violation and a 63% greater chance of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects. Could some of the recently publicized adverse interactions between police officers and citizens be partially explained by lack of sleep?

Although a possible causal link between gun violence and sleep deprivation is speculative, there is no doubt that insufficient sleep is becoming endemic in our society and has significant personal and public health consequences. There should be a concerted effort on the part of public health officials, public and private institutions and individuals to reverse this trend by publicizing the adverse impact of insufficient sleep, undertaking policy measures to promote adequate sleep and set themselves as examples of healthy sleepers.

Stuart F. Quan, MD

Gerald E. McGinnis Professor of Sleep Medicine

Harvard Medical School

Brigham and Women's Hospital

Boston, MA


  1. Centers for Disease Control. Fast stats. Available at: (accessed 8/6/15). 
  2. Ford ES, Cunningham TJ, Croft JB. Trends in self-reported sleep duration among US adults from 1985 to 2012. Sleep. 2015;38(5):829-32. [CrossRef] [PubMed]
  3. Coghill DR, Caballero B, Sorooshian S, Civil R. A systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014;28(6):497-511. [CrossRef] [PubMed]
  4. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013 Nov 15;9(11):1195-200. [CrossRef] [PubMed]
  5. Watson NF, Badr MS, Belenky G, et al. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(6):591-2. [CrossRef] [PubMed]
  6. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA. Harvard work hours, health and safety group. JAMA. 2011;306(23):2567-78. [CrossRef] [PubMed]

Reference as: Quan SF. Guns and sleep. Southwest J Pulm Crit Care. 2015;11(2):68-9. doi: PDF


Is It Time for a National Tort Reform?

With the Supreme Court upholding the nationwide implementation of the ACA, the topic of tort reform adoption on a national scale has been in the limelight again.

Since the 1970s, the issue of national tort reform has had several reincarnations in the country’s different legislative bodies (1). The duration of the debates and discussions are largely dependent on the interest and influence of the two major stakeholders - the insurance companies and the physicians.

Currently, 38 states have implemented various versions of tort reform, mostly centered on the caps on noneconomic damages (2).

Groups advocating for national tort reform argue that having no limits on medical malpractice financial awards, has fueled the practice of ‘defensive medicine’. This leads to costly but ineffective medical interventions and higher insurance premiums. Both consequences are cited as major contributors to the country’s spiraling healthcare expenditure (1,2). Proponents also contend that the absence of tort reform negatively affects the size and composition of the physician workforce (3). Statistics show that states with damage caps have 12% more physicians per capita than those without (4).

On the other hand, those against national tort reform claim that caps on medical malpractice lawsuits would lead to more medical errors and negligent physician practices. They also cited the lack of supporting evidence of tort reform’s favorable effect on the reduction of healthcare spending (1).

Most studies on tort reform are related to healthcare spending and based on state-level enforcement. The data show that healthcare costs are only modestly affected by increases in malpractice premiums and litigation costs (3,5). The CBO estimated that if a national tort reform package was enacted, healthcare spending would be reduced by 0.5% (5). Baiker and Chandra (3), showed that state implementation of tort reform did not lead to physician shortages except for a minor reduction in some rural areas. The CBO (2009) reported that state tort reforms did not result in adverse patient health outcomes (2,5).

It is evident from these findings that there needs to be a comprehensive tort reform that does not solely focus on the cost and risk of malpractice litigation. Tort reform should be approached from a different perspective where the emphasis is on interventions that improve physicians’ efficiency, promote patient safety and reduce costs. Once studies consistently show the benefits of a multidimensional tort reform package adhering to nationally-accepted standards, then its nationwide implementation may be closer to becoming a reality.

Cielo Marie Maca, MD

Pulmonary, Critical Care and Sleep Medicine

Covering VA Medical Centers in VHA 23, VHA 16, VHA 18


  1. Scott B. Who benefits from tort reform?. Medical Economics. Aug. 9, 2013. Available at: (Accessed July 9, 2015).
  2. Congressional Budget Office. A CBO Paper: The effects of Tort reform: Evidence from the States. June 2004. Available at: (Accessed July 9, 2015).
  3. Baicker K, Chandra A. The effect of malpractice liability on the delivery of health care. Forum for Health Economics & Policy (Abstract) 2005;8(1). DOI: 10.2202/1558-9544.1010 (Accessed July 10, 2015).
  4. New Physician. Which States Have Tort Reform? (accessed July 10, 2015).
  5. Congressional Budget Office. Letter of the CBO to US Senator Orrin G. Hatch. Oct. 9, 2009. (Accessed July 10, 2015).

Reference as: Maca CM. Is it time for a national tort reform? Southwest J Pulm Crit Care. 2015;11(1):45-6. doi: PDF


Time for the VA to Clean Up Its Act

One year after a Veterans Affairs (VA) scandal was ignited here in Phoenix, the number of veterans on wait lists is 50 percent higher than at the same time last year, according to VA data (1). The VA is also facing a nearly $3 billion budget shortfall. VA Secretary Bob McDonald has asked for “flexibility” to reallocate billions of dollars in clinical funds to cover the shortfall.

Since the scandal broke last year, VA providers have increased their workloads, adding 2.7 million more appointments than the previous year. However, the VA has played "games" with patient eligibility for years. When money was plentiful VA administrators would open the doors to patients since the following years' budgets were based on the number of patients seen. However, when money was tight, the doors would be slammed shut leaving many patients in the lurch scrambling to obtain health care elsewhere. Now it appears that patients might be returning to the VA.

“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.” Now the VA is asking Congress' permission to use clinical funds to pay for the budgetary shortfall.

The VA has threatened furloughs and hiring freezes to reduce spending. This seems to be quite sensible. However, in the past, the VA has cut clinical positions which undoubtedly contributed to longer wait times. For example, when I was chief of pulmonary at the Phoenix VA, one of my physicians retired, giving 6 month notice. However, we were not allowed to replace the physician because of a "hiring freeze". This apparently only applied to clinicians since a new associate director was hired.

As we predicted over a year ago, the VA would continue to be troubled due to lack of reform and oversight (2).  The present VA secretary, Robert McDonald, is still relatively new on the job and inexperienced in both healthcare and government service. His inaction suggests that he may be confused, or worse, listening to long-entrenched central office bureaucrats. Below are some suggestions which could result in substantial savings and would have little impact on patient care.

Furlough the staffs of the Veterans Integrated Service Networks (VISNs), the 21 VA regional offices which are scheduled to be downsized. The VISNs provide no healthcare and the savings in salaries from the nearly 5000 employees would be substantial (2). Similarly, VA central office which grew from 800 employees to 11,000 in less than 15 years could probably do with a few less administrators (3).

Local VA bureaucracies reflect the growth of central office and VISN bureaucracies. It is unclear what many of the hospital associate and assistant directors do other than sit in meetings. Most hospitals could do without them for a while. Similarly, compliance officers and patient "advocates" really serve no purpose. Despite multiple patient complaints about wait times, the lack of action that led to the VA scandal demonstrates that they are not effective. There are also some physicians and nurses who do not see patients. For example, most VA Chiefs of Staff do not see patients. Nursing administration is bloated with "clip board" nurses who do little than attend meetings and create an ever increasing, and seemingly never ending, stream of paperwork for nurses who are already overworked. Surely, we could do without some of these people. 

It seems unlikely that VA officials will implement any meaningful cost savings. Instead they will try to preserve the status quo by petitioning Congress to allow them to shift clinical funds depriving veterans of healthcare. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card”. This program allows certain veterans to obtain taxpayer-funded care from private doctors. VA administrators have blamed the budget shortfall on this program along with a new treatment for hepatitis C (1). The VA has been accused of dragging its feet on the Choice program and once again appears to be trying to sabotage the program and keep the funds. Gibson said in the interview that in future years more money will also be needed. He said he intended to tell lawmakers, “Veterans are going to respond with increased demand, so get your checkbooks out.”

VA administrators appear more concerned with keeping money inside their dysfunctional agency than caring for vets. Based on past history, Congress will probably let the VA shift the money and none of the recommendations above will happen. If furloughs occur, they will be lower level employees and result in little financial saving. Of course, administrative bonuses will be hefty this year because in their eyes, the administrators have successfully averted a financial crisis. Unless there are some fundamental changes made at the VA, the trend of the last 20 years of bloating the bureaucracy at the expense of healthcare will continue.

Richard A. Robbins, MD

Editor, SWJPCC


  1. Oppel, RA Jr. Wait lists grow as many more veterans seek care and funding falls far short. New York Times, June 20, 2015. Available at: (accessed 6/24/15).
  2. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef]
  3. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med 2014;371:295-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Time for the VA to clean up its act. Southwest J Pulm Crit Care. 2015;10(6):350-1. doi: PDF