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Last 50 Editorials

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

More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS
Equitable Peer Review and the National Practitioner Data Bank 
Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
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
VA Administrators Breathe a Sigh of Relief 
VA Scandal Widens


For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine.



Guidelines, Recommendations and Improvement in Healthcare 

“You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.”-Thomas Sowell

Reference as: Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37. (Click here for PDF version)

In the February, 2011 Critical Care Journal Club two articles were reviewed that dealt with Infectious Disease Society of America (IDSA) guidelines (click here for Critical Care Journal Club). The first by Lee and Vielemeyer (1) reviewed the evidence basis for the 4218 IDSA recommendations and found that only 14% were based on Level 1 evidence (data from >1 properly randomized controlled trial). The graph summarizing the data in Figure 1 of the manuscript is exemplary in its capacity to communicate the weak evidence basis for many of the IDSA recommendations.

A second study by Kett et al. (2) examined the outcomes when the American Thoracic Society (ATS)/IDSA therapeutic guidelines for management of possible multidrug-resistant pneumonia were followed. The authors found a 14% difference in survival when the guidelines were followed, but surprisingly, the survival was better if the guidelines were not followed. Dr. Kett and colleagues are to be congratulated for their candor in reporting their retrospective analysis of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. The ATS/IDSA guidelines (3) state that “combination therapy should be used if patients are likely to be infected with MDR pathogens (Level II or moderate evidence that comes from well designed, controlled trials without randomization…”. However, the ATS/IDSA guidelines go on to state, “No data have documented the superiority of this approach compared with monotherapy, except to enhance the likelihood of initially appropriate empiric therapy (Level I evidence…from well conducted, randomized controlled trials)” (4).

The problem comes with the interpretation and implementation of these and other guidelines. Some, usually inexperienced clinicians or nonclinicians, seem to believe that following any set of guidelines will enhance the “quality” of patient care. Not all guidelines or studies are created equally. Some are evidence-based, important, correct and likely to make a real difference. These usually come from professional societies and are authored by well-respected, experts in the field whose goal is improve patient outcomes. As suggested by Kett’s article even these guidelines may not be infallible. Other guidelines are not evidence-based, unimportant, incorrect and can border on the trivial. These are often authored by nonprofessional, nonexperts to create a “political statistic” (5) rather than improve patient care.

If some guidelines are bad, how can those be separated from the good? We suggest 5 traits of quality guidelines: 

  1. The guideline’s authors are identified and are well-respected, experts in the field appropriate to the guideline.
  2. The authors identify potential conflicts of interest.
  3. The evidence is graded and supported by references to relevant scientific literature.
  4. The guidelines state how they selected and reviewed the references on which the guidelines are based.
  5. After completion, the guidelines are reviewed by a group of reasonably knowledgeable individuals (for example the IDSA Board of Directors) that can be identified and are willing to risk the reputation of themselves and their organization on the guidelines.

Even with the above safeguards guidelines may be non-evidence-based, unimportant, incorrect or trivial, and if so, implementation may be at best a waste of resources, or at worst harmful to patient care. We ask that guideline writing committees show restraint in authoring documents which are little more than their opinions. Not every medical question, especially the trivial and the unimportant, needs a guideline. Furthermore, we would ask an endorsement from professional organizations that only guidelines based on randomized clinical trials be given a strong recommendation. As pointed out by Lee and Vielemeyer (1) only 23% of the IDSA guidelines were supported by randomized trials while 37% of strong recommendations were supported only by opinion or descriptive studies.

IDSA states on their guidelines website, “It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to the guidelines listed below to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances” (6). Despite this and other disclaimers, guidelines often take on a life onto themselves, frequently carrying the weight of law, regardless of the supporting evidence. We call for professional societies to end the practice of strongly recommending those guidelines based on opinion. Such practices have led and will continue to lead to systematic patient harm. Only those guidelines based on strong evidence should be given a strong recommendation. If the professional societies believe an opinion on a particular issue is appropriate despite a lack of evidence, a different designation such as recommendation or suggestion should be used to clearly separate it from a guideline.  The term guideline should be reserved for those statements that are evidence-based, important, and almost certainly correct and can make a real difference to patients.

Richard A Robbins MD, Allen R Thomas MD, and Robert A Raschke MD



  1. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind infectious diseases society of America practice guidelines. Arch Intern Med. 2011;171:18-22.
  2. Kett DH, Cano E, Quartin AA, Mangino JE, Zervos MJ, Peyrani P, Cely CM, For KD, Scerpella EG, Ramirez JA. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study.  Lancet Infect Dis 2011 Jan 19. [Epub ahead of print].
  3. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.
  4. Paul M, Benuri-Silbiger I, Soares-Weiser K, Liebovici L. Beta-Lactam monotherapy versus beta-lactam–aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and metaanalysis of randomised trials. BMJ, doi:10.1136/bmj.38028.520995.63 (published March 2, 2004). Available at URL (accessed February 11, 2011).
  5. Churchill, Winston. London, UK. 1945. as cited in The Life of Politics, 1968,  Henry Fairlie, Methuen, pp. 203-204.
  6. Infectious Disease Society of American. Standards, Practice Guidelines, and Statements Developed and/or Endorsed by IDSA. Available at URL (accessed February 12, 2011).

COPD, COOP and BREATH at the VA 

Reference as: Robbins RA. COPD, COOP and BREATH at the VA. Southwest J Pulm Crit Care 2011;2:27-28. (Click here for PDF version)

The February 2011 Pulmonary Journal Club reviews a study by Rice and colleagues (1) of high-risk COPD patients (click here for Pulmonary Journal Club). This review was authored by Kevin Park who also authored an ACP Journal Club review (2). In Rice’s study a single educational session, an individualized care plan, and monthly case-manager telephone calls, resulted in a 41% decrease in hospitalizations and emergency room visits and a nonsignficant trend toward decreased mortality.

Rice’s study was supported and conducted in the Veterans Integrated Service Network (VISN) 23 (Minnesota, Iowa, Nebraska and the Dakotas). The COPD patients in this study were recruited and followed primarily using the VA computer system. The study represents a potential model of data-based management leading to improved patient outcomes. The authors; Robert Petzel MD, then VISN 23 Director (now Veterans Healthcare Administration Undersecretary); and Janet Murphy, then VISN Primary Care Service Line CEO (now VISN 23 Director) are to be congratulated for their insight into conducting and supporting this study. Unfortunately, many VA administrators are not as far-sighted and restrict or place unreasonable obstacles to investigators’ access to VA data. VA administrators at the National, VISN and local levels should be encouraged to follow Dr. Petzel’s and Ms. Murphy’s lead in utilizing the VA computer system to conduct studies such as Rice’s.

At the time this study was ongoing, a similar study was also being conducted through the VA Cooperative studies program known as Bronchitis and Emphysema Advice and Training to Reduce Hospitalization (BREATH) trial (3). Like Rice’s study, the BREATH study incorporated self-management education, an action plan, and case-management to decrease the risk of hospitalizations due to COPD. However, in contrast to Rice’s study, the patients in BREATH had all been hospitalized within the past year and likely had more severe underlying COPD. Although this multi-center, randomized study which was planned for 5 years was on target for recruitment (425 subjects), it was cancelled after about 2 years. The reasons for the cancellation were never shared with the site investigators (of which this editor was one). It seems unlikely that a behavior study such as BREATH would result in a significant medically adverse outcome to mandate study cancellation. However, if such an outcome occurred in BREATH, it would throw the largely positive results of Rice’s study into question.

Richard A. Robbins MD, Editor, SWJPCC


1. Rice KL, Dewan N, Bloomfield HE, Grill J, Schult TM, Nelson DB, Kumari S, Thomas M, Geist LJ, Beaner C, Caldwell M, Niewoehner DE. Disease Management Program for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial. Am J Respir Crit Care Med 2010;182:890-6.

2. Park K, Robbins RA. ACP Journal Club: A COPD disease management program reduced a composite of hospitalizations or emergency department visits.  ACP Journal Club 2011;154:JC3-5.

3. Accessed 2/9/2011.


SWJPCC: The first three months 

Reference as: Robbins RA. SWJPCC: The first three months. Southwest J Pulm Crit Care 2011;2:1-2. (click here for PDF)

During the Arizona Thoracic Society meeting on 1-18-11 a report was given to our sponsoring organization regarding the progress of the SWJPCC. Below is a synopsis of the report along with a link to a PowerPoint slide presentation at the end.

Planning for the journal began in August, 2010 with discussions at the Arizona Thoracic Society.  Several decisions were made at that meeting: 1. To proceed with the creation of an on-line journal; 2. To adopt the name Southwest Journal of Pulmonary and Critical Care; 3. To emphasize clinical medicine; 4. To peer review all manuscripts; and 5. To accept no sponsorship from organizations with a potential conflicts of interest such as hospitals, pharmaceuticals companies, etc. unless it was clear that such sponsorship was unrestricted.  During September and October, 2010 a web site manager was hired, Eric Reece from Bethesda, MD; the domain registered; a website created; and editorial board established. The first posting was an editorial on October 16th, 2010 and our first manuscript was submitted on November 7th, 2010.  This manuscript was peer reviewed, revised, and posted on November 11th 2010. During 2010 we posted 8 articles: 2 in Imaging; one in Proceedings of the Arizona Thoracic Society; one Pulmonary Journal Club; two Critical Care Journal Clubs; one Sleep Journal Club; and one Editorial.  At the suggestion of Stuart Quan, a member of the editorial board, volumes and page numbers were assigned to each publication for ease of reference and the reference is given under the title of each posting.

As of 1-24-11 we have had 1043 page views for an average of 35/day.  One hundred and forty-three unique visitors have visited the site for an average of 4 unique visitors/day.  Hopefully, this will continue to grow.

A special thanks to our authors and reviewers, the latter are listed below. Without their help SWJPCC could not function:  Mike Gotway, Manny Mathew, Vijay Nair, Allen Thomas, and Lew Wesselius.

For the future, we are planning a short synopsis of each Arizona Thoracic Society meeting which can be found in a new section titled "Arizona Thoracic Society Notes" under "Proceedings of the Arizona Thoracic Society" on the left hand portion of the home page. We hope to soon post material authored outside the Phoenix area and to proceed with full-length manuscript publications under the Pulmonary, Critical Care and Sleep headings at the top of the home page.

Richard A. Robbins, M.D. , Editor, SWJPCC

Powerpoint Slide Set


Why Start A New Pulmonary/Critical Care Journal? 

Reference as: Robbins RA. Why start a new pulmonary/critical care journal? Southwest J Pulm Crit Care 2010:1:1-2. (Click here for PDF Version)

With apologies to Paul McCartney, “You'd think that people would have had enough of [pulmonary and critical care journals]. But I look around me and I see it isn't so” (1). With the inception of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) we have several goals, not adequately filled by the present pulmonary and critical care publications.

First, the primary goal of the SWJPCC is pulmonary and critical care medicine fellow education. The American College of Graduate Medical Education has placed increasing requirements for clinical education in post-graduate medical education while simultaneously increasing the requirements for scholarly activity for fellows and faculty, yet restricting fellow work hours (2). It seems that these conflicting goals are unrealistic, unless clinical scholarly activity can be incorporated into a training program. In starting the SWJPCC, we hope to fulfill the scholarly needs of both fellows and faculty while emphasizing clinical medicine through the publication of such time honored activities as case presentations and reviews of the literature.

Second, peer-reviewed journals send articles out for review. While we will do the same, we have certain expectations of our reviewers. Unfortunately, reviewers are not always carefully chosen.  Sometimes inexperienced reviewers, feeling the need to establish themselves, indulge their own sense of self-importance by becoming “nagging nabobs of negativism” (3) demanding the answer to “the ultimate question of life, the universe and everything” (4) before a manuscript will see the light of publication. While emphasizing the highest medical journal standards, we realize that fellow and faculty time is limited and we hope to be reasonable regarding expectations of our authors.

Third, there has been a trend in some journals towards publishing articles emphasizing the “short-comings” of physicians while emphasizing the virtues of identifying these “faults”. For example, the New England Journal of Medicine published an article from a health regulatory organization (the Joint Commission), touting improved healthcare through administration of the pneumococcal vaccine to adults (5). This article implied that physicians who did not provide this vaccination to their adult patients were delinquent, and the Joint Commission’s efforts “corrected” this deficiency. However, previous publications have shown that pneumococcal vaccination in older adults results in a slight increase in the risk for hospitalization, but does not decrease mortality nor the risk for pneumonia (6), findings largely confirmed by a recent meta-analysis (7). Publication of articles substituting politics or opinions (especially when they are self-serving) for evidence-based care is not part of the mission of the SWJPCC.

Last, the SWPCC aspires to be a resource for practicing physician education, emphasizing case presentations, clinical articles, review articles, imaging, and journal clubs. We hope this journal will be useful for busy clinicians, assisting them in better serving the needs of their patients while also providing insight regarding practice matters of interest to the pulmonary and critical care medicine community.

With that, we begin.

Richard A. Robbins, M.D. on behalf of the Editors


  1. McCartney, Paul. “Silly Love Songs”. Wings at the Speed of Sound. Palorphone/EMI, 1976.
  3. Agnew, Spiro. San Diego, CA. 1970.
  4. Adams, Douglas. Life, the Universe and Everything. ISBN 0-330-26738-8.
  5. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.
  6. Jackson LA, Neuzil KM, Yu O, Benson P, Barlow WE, Adams AL, Hanson CA, Mahoney LD, Shay DK, Thompson WW; Vaccine Safety Datalink. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med. 2003;348:1747-55.
  7. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ. 2009;180:48-58.
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