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Editorials

Last 50 Editorials

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

Equitable Peer Review and the National Practitioner Data Bank
Fake News in Healthcare
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership
Disclosures for All
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy
Breaking the Guidelines for Better Care
Worst Places to Practice Medicine
Pain Scales and the Opioid Crisis
In Defense of Eminence-Based Medicine
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now
Mitigating the “Life-Sucking” Power of the Electronic Health Record
Has the VA Become a White Elephant?
The Most Influential People in Healthcare
Remembering the 100,000 Lives Campaign
The Evil That Men Do-An Open Letter to President Obama
Using the EMR for Better Patient Care
State of the VA
Kaiser Plans to Open "New" Medical School
CMS Penalizes 758 Hospitals For Safety Incidents
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
   Reflections
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

 

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.

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Friday
Dec082017

Equitable Peer Review and the National Practitioner Data Bank

The General Accounting Office (GAO) recently reported that Department of Veterans Affairs (VA) did not report most physicians whose clinical care was found to be, or suspected of being, substandard to the National Practitioner Data Bank (NPDB) or to state licensing boards (1). The GAO examined 5 VAMCs and found required reviews of 148 providers’ clinical care after concerns were raised from October 2013 through March 2017. Of the 148, 5 were subjected to adverse privileging actions and 4 resigned or retired while under review but before adverse actions were taken. Only 1 of these 9 was reported to the NPDB and none was reported to his or her state medical board.

In response to GAO's report and in testimony to the Subcommittee on Oversight and Investigations, VA officials said the agency was taking three steps to improve reporting of providers who don't meet required standards:

  1. Reporting more clinical occupations to the NPDB;
  2. Improving the timeliness of reporting;
  3. Enhancing oversight to ensure that no settlement agreements waive the VA's ability to report to NPDB and state licensing boards (2).

What is lacking in the report is determination of substandard actually occurred and how it was determined. The VA has 3 ways of identifying substandard care (1).

  1. Tort claims (the VA equivalent of a medical malpractice lawsuit);
  2. Complaints or incident reports;
  3. Peer review.

Each has major problems of accuracy and fairness at the VA.

The majority of US physicians have been sued (3). The minority of suits are associated with malpractice and malpractice has no apparent association with the outcome of the litigation (4). Over 90% of medical malpractice cases are settled out of court (5). A common misconception is that settling a case before trial means a large financial settlement. However, 90% of the 90% or 82% of all claims, close with no payment (5). However, the VA uses US District Attorney to defend malpractice claims (6). In many instances, the US District Attorney’s office settles the case without determining if there is malpractice. The VA then submits the offending physician(s) name to the NPDB or state boards whether malpractice has been shown or not.

Complaints or incident reports are common in many hospitals, and many, if not most, have little merit (7). However, the weight given to a complaint should be viewed differently depending on the source. When colleagues raise concern about a physician’s care this is more credible than a patient complaining about not receiving their narcotics to a patient advocate. In the GAO report it is unclear if this was a source the of possible substandard care.

Lastly, there is peer review. There are several problems with this process in the VA. The VA selects the “peers”. In many instances the reviewers are un- or under-qualified to review the case (6). Furthermore, the selected reviewers may be conflicted clouding a balanced and fair determination if the physician’s care met the standard of care. There are multiple instances of this at the VA, of which a couple have been cited in the SWJPCC (6).

No surprisingly, a bureaucracy in the federal government has suggested a bureaucratic solution to a nonexistent problem. The goal should not be for more bureaucratic reporting, but a system for determining if a physician’s care has met the standard of care. The VA has shown it is incapable of making this determination fairly and accurately. What is needed is an outside review separated from VA influence and politics. If malpractice is still questioned after an initial VA review, the medical schools or private practioners could provide a source of physician peer review. The case could be presented to a panel of non-VA physician peers chosen in an equitable ratio by the VA and the accused practitioner. In the absence of a more equitable review process, the VA will only succeed in driving away the quality practitioners the veterans need.

Richard A. Robbins, MD

Editor, SWJPCC

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. General Accounting Office. VA health care: improved policies and oversight needed for reviewing and reporting providers for quality and safety concerns. Report to the chairman, committee on veterans’ affairs, House of Representatives. GAO-18-63 (Washington, D.C.: November, 2017). Available at: http://www.gao.gov/assets/690/688378.pdf (accessed 12/6/17).
  2. Terry K. VA medical centers fail to report substandard doctors, GAO says. Medscape. December 5, 2017. Available at: https://www.medscape.com/viewarticle/889600?nlid=119420_4502&src=wnl_dne_171206_mscpedit&uac=9273DT&impID=1501593&faf=1 (accessed 12/6/17).
  3. Matray M. Medscape malpractice report 2017 finds the majority of physicians sued. Medical Liability Monitor. November 15, 2017. Available at: http://medicalliabilitymonitor.com/news/2017/11/medscape-malpractice-report-2017-finds-the-majority-of-physicians-sued/ (accessed 12/6/17).
  4. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec 26;335(26):1963-7. [CrossRef] [PubMed]
  5. Chesanow N. Malpractice: when to settle a suit and when to fight. Medscape. September 25, 2013. Available at: https://www.medscape.com/viewarticle/811323_3 (accessed 12/6/17).
  6. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013 Dec 1;2(3):e27. [CrossRef] [PubMed]
  7. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight bureaucracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.

Cite as: Robbins RA. Equitable peer review and the national practitioner data bank. Southwest J Pulm Crit Care. 2017;15(6):271-3. doi: https://doi.org/10.13175/swjpcc152-17 PDF

Friday
Oct272017

Fake News in Healthcare

An article in the National Review by Pascal-Emmanuel Gobry points out that there is considerable waste in healthcare spending (1). He blames much of this on two entitlements-Medicare and employer-sponsored health insurance. He also lays much of the blame on doctors. “Doctors are the biggest villains in American health care. ... As with public-school teachers, we should be able to recognize that a profession as a whole can be pathological even as many individual members are perfectly good actors, and even if many of them are heroes. And just like public-school teachers, the medical profession as a whole puts its own interests ahead of those of the citizens it claims to be dedicated to serve.”

Who is Pascal-Emmanuel Gobry and how could he say something so nasty about teachers and my profession? A quick internet search revealed that Mr. Gobry is a fellow at the Ethics & Public Policy Center, a conservative Washington, D.C.-based think tank and advocacy group (2). According to his biography, Gobry writes about religion, culture, politics, economics, business, and technology, but not health care. He is a columnist at The Week, a contributor at Forbes, a blogger at the Patheos Catholic and his writing has appeared in the Wall Street Journal, The Atlantic, and The Daily Beast amongst others. He holds a Master of Science in management from HEC Paris (Hautes études commerciales de Paris, a quite prestigious business school) and lives in Paris.

To make his point on waste, Mr. Gobry comments on Atul Gawande’s 2007 New Yorker “exposé on the Herculean efforts by a handful of scientists to get intensive-care physicians to implement a basic hygiene measures checklist so as to stop hospital-borne diseases” (3). He goes on to quote the Centers for Disease Control that hospital-borne diseases kill about 100,000 people per year, that the checklist was of no cost to the doctors, and its scientific rationale was unquestionable. “Doctors still resisted it with all their might because they found it mildly inconvenient; perhaps they found it even less acceptable that anybody might tell them how to do their jobs”. I showed this article to one of my former pulmonary/critical care fellows who has been in practice about 10 years. He commented, “Another guy who doesn’t practice medicine or know what he’s talking about.”

Gobry is referring to the Institute of Healthcare Improvement (IHI) central line associated blood stream infection (CLABSI) guidelines. These include hand washing, sterile gloves, sterile gown, wearing of a cap, full body drape, chlorhexidine, and not using femoral sites for insertion. In our intensive care units only chlorhexidine usage was associated with a decline in CLABSI (4). Every ICU I have practiced in has emphasized handwashing and demanded use of sterile gloves, gowns and drapes. The remaining guidelines are not supported by good evidence.

Gobry also claims that a computer is better at diagnosis than most physicians. He claims that the evidence is “pretty robust at this point, and the profession resists it tooth and nail. In a few years, we’ll be able to know how many unnecessary deaths this led to, but the number will have lots of zeroes”. However, in the only direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms (84.3% vs. 51.2%) (5).

Journalists like Gobry are writing melodramatic articles about medicine and often getting it wrong. In this case he sensationalized Gawande’s article and misquoted the evidence for both the IHI guidelines and computer diagnosis.

There’s a TV commercial about an actor playing a doctor. Gobry is a business journalist attempting to play a doctor at the National Review. My former fellow is right. Gobry is a guy who does not know what he is talking about. Unfortunately, his writings can affect public policy and influence politicians who know even less. As President Trump said, “Nobody knew that health care could be so complicated” (6).

I am a doctor playing a journalist at the Southwest Journal of Pulmonary and Critical Care. Our articles may not be as sensational as Gobry’s, but we stick to what we know-pulmonary, critical care and sleep medicine. I think we usually get it right. President Trump has railed against “fake news”, most recently on Lou Dobbs Tonight (7). Journalists like Gobry contribute to fake news by being deliberately obtuse, appealing to emotions, name-calling, and omitting or distorting facts. As physicians, we have been denigrated by journalists like Gobry and others who make outrageous claims for their own purposes. It is the responsibility of physicians to challenge those like Gobry who get it wrong.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Gobry P-E. The most wasteful health spending is also the most popular. National Review. October 25, 2017. Available at: http://www.nationalreview.com/article/453088/health-care-spending-wasteful-popular (accessed 10/25/17).
  2. Ethics & Public Policy Center. Pascal-Emmanuel Gobry. https://eppc.org/author/pascal-emmanuel-gobry/ (accessed 10/25/17).
  3. Gawande A. The Checklist. The New Yorker. December 10, 2007. Available at: https://www.newyorker.com/magazine/2007/12/10/the-checklist (accessed 10/25/17).
  4. Hurley J, Garciaorr R, Luedy H, et al. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73. Available at: http://www.swjpcc.com/critical-care/2012/5/10/correlation-of-compliance-with-central-line-associated-blood.html
  5. Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016 Dec 1;176(12):1860-1861. [CrossRef] [PubMed]
  6. Howell T Jr. Trump: 'Nobody Knew That Health Care Could Be So Complicated'. Fox News. February 27, 2017. Available at: http://nation.foxnews.com/2017/02/27/trump-nobody-knew-health-care-could-be-so-complicated (accessed 10/25/17).
  7. Trump DJ. Lou Dobbs Tonight. October 25, 2017. Available at: http://video.foxbusiness.com/v/5624925494001/?#sp=show-clips (accessed 10/26/17).

Cite as: Robbins RA. Fake news in healthcare. Southwest J Pulm Crit Care. 2017;15(4):171-3. doi: https://doi.org/10.13175/swjpcc132-17 PDF 

Friday
Oct062017

Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad Leadership

Obsequious is defined as “obedient or attentive to an excessive or servile degree”. Obsequious comes from the Latin root sequi, meaning "to follow”. An Obsequious PhysIcian Executive (OPIE) is more likely to be servile to the hospital administration than a leader of the medical staff. This is not surprising since they are chosen for a “leadership” position not by the physicians they purportedly lead, but by the hospital administration they serve. OPIEs become the administration’s representative to the physicians and not the physicians’ or patients’ representative to the administration. Their job often becomes keeping the medical staff “in-line” rather that putting the success of the medical center first.

My own views have developed over 40 years of observing OPIE behavior in a multitude of medical centers. Although there are many exceptions, OPIEs often share certain characteristics:

  1. Academic failure. OPIEs are usually academic failures. They are the antithesis of the triple threat who excels as a physician, teacher and researcher. In contrast, they excel at nothing and often are obstructionistic of others’ attempts to accomplishment anything meaningful.
  2. Advanced degrees not pertaining to medicine. Frustrated by their lack of success, they seek advancement by alternative routes such as nontraditional career paths or obtaining degrees outside of medicine, e.g., a master’s degree in business administration (MBA). Though they will argue that they are just serving a need or advancing their education, more likely they are seeking the easiest path for advancement, especially if their past accomplishments are best described as “modest”. Beware the unaccomplished physician with a MBA.
  3. Blame others for failure. Not all ideas, even from good people, are successful. Some are bad ideas destined to failure. When an OPIE’s idea fails, they blame others. Worse yet, they lie about a staff in order to place themselves in a good light. This appears to be one of the root causes of the waiting time scandal at the VA. In contrast, a leader accepts responsibility for failure and proposes a new and hopefully better plan.
  4. Bullying. OPIEs often fail to see two sides to any argument and are usually impatient and short-tempered with any who disagree. Rather that attempting to build a consensus, they attempt to bully those who show any resistance.
  5. Retaliation. If bullying fails, OPIEs seek retaliation. This can be through various means-often denial of resources. For example, one chief of staff sat for over a year on a request for a Glidescope (a fiberoptic instrument used for intubation) in the intensive care unit and then was faultfinding when a critical care fellow did not use a Glidescope during an unsuccessful intubation intubation. OPIEs might limit clinic space or personnel but then disparage the physicians when patients are not seen quickly enough to meet an administrative guideline. Lastly, if all else fails they may retaliate by invoking quality assurance. Quality is often ill-defined and it is all too easy in this day of “patient protection” to slander a good physician.

One of the latest buzzwords in healthcare is dyad leadership, a term that refers to physician/administrator teams that jointly lead healthcare organizations (1). A recent editorial touted the success of the partnership between Will Mayo MD and Harry Harwick at the Mayo Clinic in Rochester (2). My own positive example comes from Mike Sorrell MD, Charlie Andrews MD, and Bob Baker at the University of Nebraska Medical Center in Omaha. However, simply putting a physician and administrator together in leadership positions does not guarantee organizational success. In fact, if not done correctly, it leads to confusion, resentment, lack of consistent direction and divided organizational factions.

Based on their Mayo Clinic experience, Smoldt and Cortese list five key success factors they believe bring success to a dyad leadership (2):

  1. Common core values. Perhaps the most important factor in a successful dyad is that members of the physician/administrator team have the same core values and goals. Furthermore, these need to be consistent with the staffs' values and goals. Smoldt and Cortese (2) point out that at Mayo Clinic the core value of “the needs of the patient come first” is deeply imbedded. The staff of an organization will primarily deduce leadership core values from their daily actions. Administrative bonuses or increased reimbursement are not necessarily common core values, and if emphasized over patient care, the dyad is doomed to failure.
  2. Willingness to work together toward a common mission and vision. In a medical center, if the administrative leadership and staff can work together toward a vision, it is more likely to be achieved. If leadership becomes too territorial or engages in OPIE behavior, the ideal of leveraging each other’s strengths will be lost. If the staff perceives that the dyad is emphasizing their personal goals and finances over institutional success, the staff will be unwilling to work with or support the dyad.
  3. Clear and transparent communication with each other and the organization. To gain the most from dyad leadership, each member of the team should leverage and build on the strengths of the other. The more time the individuals spend together as a leadership team and with staff at a medical center, the more frequent and open the communication will be. If over time, communication declines, it is probably a sign that the dyad is not working and is often followed by the OPIE behaviors of bullying, lying and retaliation.
  4. Mutual respect. A team works best if its members operate in an atmosphere of mutual respect. If the dyad team does not share or show mutual respect for each other, mutual respect will likely also be lost among the healthcare delivery team. It is especially important for the dyad to remember that respect must be earned, and a big part of earning respect is to show respect for the views and positions of the staff.
  5. Complementary competencies. No one organizational leader is good at everything that needs to be done in a medical center. Employing a dyad leadership approach can expand the level of competence in the top leadership. For example, in a physician/administer leadership team, it is not unusual for the administrator to have better financial skills than the physician. It goes without saying that physicians and nurses have better medical skills in their own scope of practice than an administrative/physician dyad.

Integrated delivery of care is an absolute for a successful medical center. OPIE behavior dooms the medical center. Establishing a physician/administrator dyad leadership team with the right administrator and physician can be a good step towards success.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Zismer DK, Brueggemann J. Examining the "dyad" as a management model in integrated health systems. Physician Exec. 2010 Jan-Feb;36(1):14-9. [PubMed]
  2. Smoldt RK, Cortese DA. 5 success factors for physician-administrator partnerships. MGMA Connection Plus. September 24, 2015. Available at: http://www.mgma.com/practice-resources/mgma-connection-plus/online-only/2015/september/5-success-factors-for-physician-administrator-partnerships (accessed 10/4/17).

Cite as: Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. doi: https://doi.org/10.13175/swjpcc121-17 PDF

Saturday
Aug192017

Disclosures for All

The August 15 edition of the Annals of Internal Medicine published an article “Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination - Randomized Controlled Trial" (1). The study examined open book vs. closed book testing for the American Board of Internal Medicine (ABIM) examination and found no or minimal changes in the outcomes between the two testing conditions.

All in all, this is not very exciting. However, what is interesting is a blog on the article written by Westby G. Fisher, MD in his Dr. Wes blog (2). He examined the disclosures from the Annals editors of the article who claimed no financial relationships or interests to disclose. However, Fisher points out that on its last available Form 990, the publishers of the Annals of Internal Medicine, the American College of Physicians (ACP), earned over $24.6 million in a single year selling their Medical Knowledge Self-Assessment Program to US physicians to study for their board certification and recertification examinations (3). Furthermore, Fisher notes that an accompanying editorial written by ACP's former senior executive vice president, Steven E. Weinberger, MD, a pulmonologist and an employee of the ACP, also did not disclose any meaningful conflicts. However, with compensation of nearly $800,000 in 2014, Weinberger’s compensation was over 3 times the average compensation of pulmonolgists in the Middle Atlantic states of $226,000 (3,4). It seems unlikely that unless their financial status was healthy that the ACP could have afforded a luxury such as Dr. Weinberger.

Fisher notes that the study was conceived exclusively by the American Board of Internal Medicine and executed by their corporate partners at PearsonVue and Wolters Kluwer. However, PearsonVue had more than a minor role in the research and had access to the study registrants' names, addresses, and probably more (2). Each of the 825 physicians enrolled in the study received $250 from the ABIM Foundation. None of the participants were told about the financial benefits to the ABIM, PearsonVue, Wolters Kluwer, or their content creators for participation in this study.

The financial future of many of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) and the 18 approved medical specialty boards of the American Osteopathic Association (AOA) was in doubt until maintenance of certification (MOC) was conceived back in the 1980’s (2). Since then there have been multiple attempts to show MOC leads to better patient outcomes, but to my knowledge, no meaningful improvements have been shown (5-7). Furthermore, advertising for MOC programs with slogans such as “Is your doctor board-certified?” likely led to an erosion of faith in the medical profession. These MOC programs can largely be lumped with other money-making schemes such as continuing medical education and hospital recertification which are funded on the backs of physicians, are time-consuming and have not been shown to improve care.

According to Fisher (2), “conflicted research” as published in the Annals of Internal Medicine misleads the public and represents little more than a free advertising for the financial agendas of MOC organizations who benefit from the research. Furthermore, “…it sets and incredibly low (and untrustworthy) bar for all of academic publishing.”

Although this is strong language, Fisher is right. Disclosures need to be full and honest from all. Here are ours. The cost of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) is funded by the non-profit Phoenix Pulmonary and Critical Care Research and Education Foundation. None of the foundation board of directors, the editors, associate editors, staff, reviewers or authors receive any compensation. Our operating expenses are less than $5000/year and our income is dependent on donations to our foundation. We hope this reassures our readers that we have no hidden agenda and that what they read in the SWJPCC is honestly reviewed.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Lipner RS, Brossman BG, Samonte KM, Durning SJ. Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial. Ann Intern Med. 2017 Aug 15 [Epub ahead of print]. [CrossRef] [PubMed]
  2. Fisher WG. Fake news: Annals of Internal Medicine's disclosures. Dr. Wes. August 16, 2017. Available at: http://drwes.blogspot.com/2017/08/fake-news-annals-of-internal-medicines.html (accessed 8/17/17).
  3. CitizenAudit.org. American College of Physicians Form 990. 2014. Available at: http://pdfs.citizenaudit.org/2015_05_EO/23-1520302_990_201406.pdf (accessed 8/17/17).
  4. Peckham C. Medscape pulmonologist compensation report 2014. Medscape. April 15, 2014. Available at: http://www.medscape.com/features/slideshow/compensation/2014/pulmonarymedicine (accessed 8/17/17).
  5. Buscemi D, Wang H, Phy M, Nugent K. Maintenance of certification in Internal Medicine: participation rates and patient outcomes. J Community Hosp Intern Med Perspect. 2013 Jan 7;2(4). [CrossRef] [PubMed]
  6. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA.Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. 2014 Dec 10;312(22):2358-63. [CrossRef] [PubMed] 
  7. Gray BM, Vandergrift JL, Johnston MM, Reschovsky JD, Lynn LA, Holmboe ES, McCullough JS, Lipner RS. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. [CrossRef] [PubMed] 

Cite as: Robbins RA. Disclosures for all. Southwest J Pulm Crit Care. 2017;15(2):87-9. doi: https://doi.org/10.13175/swjpcc105-17 PDF 

Thursday
Aug172017

Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to Require Sleep Apnea Testing in Commercial Transportation Operators

In another move favoring business interests and against the common good, the Trump administration’s Department of Transportation announced recently that they are rescinding plans to require testing for obstructive sleep apnea (OSA) in train and commercial motor vehicle operators (1). As exemplified by its withdrawal from the Paris climate accords, this decision is another example of how the current administration disregards scientific findings and present-day events in establishing policy that will be detrimental to Americans.

Let us step back for a moment and briefly review the evidence that the Trump administration has ignored.

  • It is well established that obstructive sleep apnea (OSA) can result in daytime sleepiness (2) and that sleepiness is detrimental to safe operation of a train or motor vehicle.
  • Many studies have established that persons with OSA have an increased risk of motor vehicle crashes (3).
  • Studies in commercial truck drivers have observed that this population has a high prevalence of OSA (4).
  • It is estimated that OSA costs the American economy $150 billion annually (5).
  • There now are relatively easy and inexpensive protocols to screen high risk individuals for OSA (4).
  • Obstructive sleep apnea is a treatable condition, and treatment mitigates OSA impairment in sleepiness and reduces crash risk (6,7). In contrast, non-compliance with treatment is associated with a five-fold increase in crash risk (6).
  • The costs of diagnosis and treatment are much lower than the costs that ensue when OSA persists untreated (5). For example, significant healthcare savings result from successful treatment of truck drivers (8).
  • Failure to recognize and treat OSA has resulted in several high-profile transportation accidents. The following are some recent incidents:
    • September 2016: A commuter rail train slammed into the station at Hoboken, NJ killing a female bystander and leaving a child without a mother. The engineer had undiagnosed severe OSA (9).
    • December 2013: A Metro North commuter rail engineer fell asleep and his train sped around a curve resulting in a crash that killed 4 and injured 70 (10). The National Transportation Safety Board determined that undiagnosed severe OSA was the probable cause of the accident. The lack of a policy which required sleep disorder screening was further determined to be a contributing factor (11).
    • September 2013: A Greyhound bus overturned on Interstate 70 because the driver fell asleep resulting in multiple injuries. The driver was later found to have untreated OSA (12).
    • June 2009: A tractor-trailer traveling at a high speed did not see stopped cars ahead on Interstate 44 resulting in a crash that killed 10 and injured 6. It was later determined that the truck driver had mild OSA contributing to fatigue (13).

Despite the weight of the aforementioned evidence, the current administration has chosen to ignore it in favor of letting private industry regulate itself implying the current regulations are sufficient. As illustrated by the incidents cited above, recent events have proven them wrong. As Sir Winston Churchill once said “Those who fail to learn from history are doomed to repeat it”. Continuing with the current policy will inevitably result in further preventable disasters and more loss of life.

What can be done? At the federal level, one should consider advocating to your own congressional representatives for reconsideration of this poorly considered policy. On a personal level, federal policy is ultimately guided by the “ballot box”, which is something to consider for the next election. Finally, be aware that the next time you are driving down the interstate, the truck or bus driver approaching you from behind may have untreated OSA!

Stuart F. Quan, M.D.1,2, Laura K. Barger, Ph.D.1, Matthew D. Weaver, Ph.D.1, and Charles A. Czeisler, Ph.D., M.D.1

1Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

Harvard Medical School, Boston, MA USA

2Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

References

  1. Federal Register. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. Last updated: 2017. Available at: https://federalregister.gov/d/2017-16451 (Accessed: August 10, 2017)
  2. Committee on Sleep Medicine and Research Board on Health Sciences Policy. Sleep disorders and Sleep Deprivation--An Unmet Public Health Problem. Washington, D.C.: National Academies Press, 2006; 404.
  3. Tregear S, Reston J, Schoelles K, Phillips B.Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009 Dec 15;5(6):573-81. [PubMed]
  4. Kales SN, Straubel MG.Obstructive sleep apnea in North American commercial drivers. Ind Health. 2014;52(1):13-24. [CrossRef] [PubMed]
  5. Anonymous. Hidden health crisis costing America billions. Underdiagnosing and undertreating obstructive sleep apnea draining healthcare system. Last updated: 2016. Available at: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx (Accessed: August 15, 2017)
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Cite as: Quan SF, Barger LK, Weaver MD, Czeisler CA. Saving lives or saving dollars: The Trump administration rescinds plans to require sleep apnea testing in commercial transportation operators. Southwest J Pulm Crit Care. 2017;15:84-6. doi: https://doi.org/10.13175/swjpcc102-17 PDF 

Disclosures 

Editor's note: In 2016 Dr. Quan authored an editorial titled "Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now" in SWJPCC. The editorial encouraged screeening of transportation workers for sleep apnea.