What Does Shulkin’s Firing Mean for the VA?

David Shulkin MD, Secretary for Veterans Affairs (VA), was finally fired by President Donald Trump ending long speculation (1). Trump nominated his personal physician, Ronny Jackson MD, to fill Shulkin’s post. The day after his firing, Shulkin criticized his firing in a NY Times op-ed claiming pro-privatization factions within the Trump administration led to his ouster (2). “They saw me as an obstacle to privatization who had to be removed,” Dr. Shulkin wrote. “That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”

Former Secretary Shulkin’s tenure at the VA has had several controversies. First, as undersecretary of Veterans Healthcare and later as secretary money appropriated to the VA to obtain private care under the Veterans Access, Choice, and Accountability Acts of 2014 and the VA Choice and Quality Employment Act of 2017 appears to have been largely squandered on administrative salaries and expenses rather than hiring healthcare providers to shorten VA wait times (3). Second, Shulkin took a trip with his wife to Europe eventually ending up at Wimbledon to watch tennis (4). The purpose of his trip was ostensibly to attend a London Summit with senior officials from the United States, the United Kingdom, Canada, Australia, and New Zealand to discuss topical issues related to veterans. Although the summit occurred over 2 1/2 days, Shulkin and his wife traveled for 11 days at the taxpayer expense including a side trip to Denmark.

“The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war,” Dr. Shulkin wrote (2). “Working with community providers to adequately ensure that veterans’ needs are met is a good practice. But privatization leading to the dismantling of the department’s extensive health care system is a terrible idea.” Going on Shulkin states that, “Unfortunately, the department [VA] has become entangled in a brutal power struggle, with some political appointees choosing to promote their agendas instead of what’s best for veterans … These individuals, who seek to privatize veteran health care as an alternative to government-run VA care, unfortunately fail to engage in realistic plans regarding who will care for the more than 9 million veterans who rely on the department for life-sustaining care.”

However, the VA for many years has engaged in a relentless expansion of administration at the expense of healthcare. In the absence of sufficient oversight, Shulkin and VA Central Office did little to curb this trend (3).

Assuming he is confirmed, what will Ronny Jackson, Shulkin’s replacement, do? It seems likely that he will do exactly what Shulkin alleges and Trump apparently wants, i.e., privatize VA healthcare. Whether Jackson will be able to bend the large VA bureaucracy towards privatization is another matter given his lack of healthcare administrative experience. Shulkin may also be right that privatization may only reward select people and companies with profits rather than improving veterans’ care. Regardless, healthcare is more expensive than not delivering healthcare, so the price will probably rise. Time will tell, but something needs to be done. To paraphrase former VA undersecretary Ken Kizer, it is time for another “Prescription for Change” at the VA. 

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Rein L, Rucker P, Wax-Thibodeaux E, Dawsey J.  Trump taps his doctor to replace Shulkin at VA, choosing personal chemistry over traditional qualifications. Washington Post. March 29, 2018. Available at: https://www.washingtonpost.com/world/national-security/trump-ousts-veterans-affairs-chief-david-shulkin-in-administrations-latest-shake-up/2018/03/28/3c1da57e-2794-11e8-b79d-f3d931db7f68_story.html?utm_term=.7bcfe44b4ff6 (accessed 3-30-18).
2. Shulkin DA. Privatizing the V.A. will hurt veterans. NY Times. March 28, 2018. https://www.nytimes.com/2018/03/28/opinion/shulkin-veterans-affairs-privatization.html (accessed 3-30-18).
3. US Government Accountability Office. Better data and evaluation could help improve physician staffing, recruitment, and retention strategies. GAO-18-124. October 19, 2017. https://www.gao.gov/products/GAO-18-124 (accessed 3-30-18).
4. VA Office of Inspector General. Administrative investigation: VA secretary and delegation travel to Europe. Report No. 17-05909-106. February 14, 2018. Available at: https://www.va.gov/oig/pubs/VAOIG-17-05909-106.pdf (accessed 3-30-18).

*Dr. Robbins has received compensation for providing healthcare to veterans under the VA Choice Act.

Cite as: Robbins RA. What does Shulkin's firing mean for the VA? Southwest J Pulm Crit Care. 2018;16(3):172-3. doi: https://doi.org/10.13175/swjpcc052-18 PDF 

Guns, Suicide, COPD and Sleep

Within the past year two tragic events, the shootings in Las Vegas and Florida have renewed the debate about guns. The politics and the money that fuels the political debate have sharply divided politicians. As tragic as these mass shootings are, deaths by suicide far outnumber the loss of live in these shootings. In 2014 suicide was the tenth most common cause of death with 42,826 lives lost (1). Half of the suicides were by firearm (21,386).

The medical profession has traditionally been reluctant to speak about politically sensitive issues such as abortion, sexuality, and guns. However, beginning early in this millennium some medical societies such as the American Academy of Pediatrics, the US Preventative Services Task Force and even the Department of Veterans Affairs were suggesting physicians ask patients about gun behavior, but a few patients complained (2-5). There were some anecdotal reports of patients feeling “pressured” to answer questions about guns (5). One grumbled that it was invasion of privacy. The National Rifle Association also viewed the medical community’s gun-related questions as discriminatory and a form of harassment. In 2011, the Republican-controlled Florida legislature, with the support of the then and still state’s Republican governor, Rick Scott, passed restrictions aimed at limiting physician inquiries about gun ownership and gun habits. Under the law, doctors could lose their licenses or risk large fines for asking patients or their families about gun ownership and gun habits. Fortunately, this law was struck down by the 11th U.S. Circuit Court of Appeals (5). The Court ruled in 10-1 decision that the law violated the First Amendment rights of doctors and did nothing to infringe on the Second Amendment right to bear arms.

Eight health professional organizations and the American Bar Association have released a call for action to reduce firearm-related injury and death in the United States (6). Specific recommendations include the following:

• Criminal background checks should be a universal requirement for all gun purchases or transfers of ownership.
• Opposition to state and federal mandates interfering with physician free speech and the patient–physician relationship, such as laws preventing physicians from discussing a patient's gun ownership.
• All persons who have a mental or substance use disorder should have access to mental health care, as these conditions can play a significant role in firearm-related suicide.
• Recognition that blanket reporting laws requiring healthcare providers to report patients who show signs of potentially causing serious harm to themselves or others may stigmatize persons with mental or substance use disorders and create barriers to treatment. The statement urges that such laws protect confidentiality, do not deter patients from seeking treatment, and allow restoration of firearm purchase or possession in a way that balances the patient's rights with public safety.
• There should be restrictions for civilian use on the manufacture and sale of large-capacity magazines and military-style assault weapons, as private ownership of these represents a grave danger to the public.

Our national professional societies including the American Thoracic Society, the American College of Chest Physicians and the Society of Critical Care Medicine have all endorsed this call for action to gun violence (7).

Editors of the Annals of Internal Medicine have recently urged physicians to sign a formal pledge committing to having conversations with their patients about firearms (8). The Annals campaign began in the wake of the Las Vegas shooting and gained momentum after the February 14 school shooting in Parkland, Florida. So far nearly 1000 physicians have signed the pledge (9).

People who commit firearm violence against themselves or others often have notable risk factors that bring them into contact with physicians. We in the pulmonary, critical care and sleep communities are positioned to prevent some of these deaths. Patients with chronic diseases including COPD and sleep deprivation are known to be at higher risks for suicide (10,11). By inquiring about guns during these patients’ clinic visits, we may be able to identify potential problems and prevent some deaths.

It is ironic, but hardly surprising, that Florida, a state known for a series of gun-rights laws and its “Stand Your Ground” self-defense law (5), is the site of the latest mass shooting. The shooter, Nikolas Cruz, by all descriptions could have readily been recognized as a potential threat. Perhaps if he had been identified and an intervention performed before the Florida law banning physicians from discussing guns when the he was 12, a tragedy could have been avoided. As Florida Sen. Marco Rubio recently found out, the times may be changing (12). Politicians should keep their politics out of the clinic, hospital and physician-patient relationship. Those who do not, and especially those who by their actions put our patients in peril, do so at their own political risk.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Centers for Disease Control and Prevention. Suicide and self-inflicted injury. March 17, 2017. Available at: https://www.cdc.gov/nchs/fastats/suicide.htm (accessed 3/2/18).
2. American Academy of Pediatrics. Gun violence prevention. Available at: https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/pages/aapfederalgunviolencepreventionrecommendationstowhitehouse.aspx (accessed 3/2/18).
3. United States Preventive Services Task Force. Guide to clinical preventive services. Available at: https://www.ataamerica.com/arc1/users/pdfforms/Guide%20to%20Clinical%20Preventive%20Services.pdf (accessed 3/2/18).
4. Department of Veterans Affairs. Firearms and dementia. August 2017. Available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2731 (accessed 3/2/18).
5. Alvarez L. Florida doctors may discuss guns with patients, court rules. NY Times. February 16, 2017. Available at: https://www.nytimes.com/2017/02/16/us/florida-doctors-discuss-guns-with-patients-court.html (accessed 3/2/18).
6. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015 Apr 7;162(7):513-6. [CrossRef] [PubMed]
7. American College of Physicians. More than two dozen organizations join call by internists and others for policies to reduce firearm injuries and deaths in U.S. ACP Newsroom. May 1, 2015. Available at: https://www.acponline.org/acp-newsroom/more-than-two-dozen-organizations-join-call-by-internists-and-others-for-policies-to-reduce-firearm (accessed 3/2/18).
8. Wintemute GJ. What you can do to stop firearm violence. Ann Intern Med. 2017 Dec 19;167(12):886-7. [CrossRef] [PubMed]
9. Frellick M. More than 1000 doctors pledge to talk to patients about guns. Medscape. March 1, 2018. Available at: https://www.medscape.com/viewarticle/893307?nlid=121033_4502&src=wnl_dne_180302_mscpedit&uac=9273DT&impID=1572032&faf=1 (accessed 3/2/18).
10. Goodwin RD. Is COPD associated with suicide behavior? J Psychiatr Res. 2011 Sep;45(9):1269-71. [CrossRef] [PubMed]
11. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. [CrossRef] [PubMed]
12. Associated Press. Sen. Marco Rubio changes stance on high-capacity magazines after Florida school shooting. Time. February 22, 2018. Available at: http://time.com/5171653/marco-rubio-large-capacity-magazine-parkland-shooting/ (accessed 3/2/18).

Cite as: Robbins RA. Guns, suicide, COPD and sleep. Southwest J Pulm Crit Care. 2018;16(3):138-40. doi: https://doi.org/10.13175/swjpcc039-18 PDF

The Dangerous Airway: Reframing Airway Management in the Critically Ill

Intubation is one of, and perhaps the, highest risk procedures a critically ill patient can require, and the practice has largely been extrapolated from knowledge gained from airway management in the operating room (OR). Trouble arises when one encounters challenges with placing the tube or performing mask ventilation, termed the ‘difficult airway’. The difficult airway in the OR is relatively rare yet can be catastrophic when it is encountered unexpectedly. As a result, significant resources are devoted to developing task forces, guidelines, new devices and airway adjuncts to help manage the difficult airway and prevent avoidable complications. Outside of the OR, the difficult airway is encountered more frequently and with potentially devastating consequences. Reflexively, it is easy to blame the increased incidence on the skill of those managing airways as airway management has historically been viewed as a laryngoscopy problem--difficulty for us is the source of risk for the patient. Many facilities relegate airway management to an on-call anesthesiologist, leading to a significant variability in training and skill in airway management; and physicians skilled in life support but cannot safely put their patients on life support. Newer devices have led to a significant reduction in the difficulty with laryngoscopy, and it is becoming increasing clear to us that the terminology related to airway management outside of the OR should be reconsidered. Airway management outside of the OR commonly starts with the difficult airway because of the severely altered physiology, thus the importance of first-attempt success. Our current definition of the difficult airway lacks complete appreciation of the risks in these patients by focusing on the difficulty with laryngoscopy for the operator. For airway management of critically ill patients outside of the OR to positively impact patient outcomes, we must broaden our understanding of the risks associated with intubation.

There is no doubt that the difficulty one experiences in performing mask ventilation, laryngoscopy or tracheal intubation puts the patient at risk of untoward complications. However, limiting the focus to this traditional definition neglects the danger to the patient, which can occur in the absence of any technical difficulties. There is a strong association in the published literature between the number of intubation attempts and procedural complications (1-3), however there is also a significant risk of complications despite successful first-attempt tracheal intubation (i.e., no difficulty) (3). Thus, skillfully performing laryngoscopy and tracheal intubation that succeeds easily on the first attempt in a patient with physiologic derangements presents significant danger with airway management. This derangement may relate to a host of physiologic or pathologic issues and the resulting danger to the patient often relates to the consequences of hypoxemia or hypotension. To reduce the danger to the patient, careful attention is required to prepare the patient for induction, laryngoscopy and transition to positive pressure ventilation with emphasis on preoxygenation, maintenance of oxygenation and hemodynamic optimization.

Patients may face danger in any of the three phases of airway management: preparation and planning, implementation of the plan, or post-intubation management. Each phase presents both patient and contextual factors that accumulates and potentially compounds danger. Incomplete preparation, prolonged attempts at tracheal tube placement, disturbed physiology, an unskilled operator in a familiar environment or a skilled operator in an unfamiliar environment all contribute to different phenotypes of complications.  All can lead to different phenotypes of complications. Contextual factors include issues such as provider skill, access to equipment and help, various biases and conditions that in part are defined as human factors and are well-known to influence patient outcomes. To help mitigate technical difficulty experienced by the clinician and danger to the patient, special attention must be paid to each phase of airway management.

There are three phenotypes of complications that can arise from tracheal intubation. While the incidence of complications increases with successive attempts, the etiology and opportunity to attenuate those complications differs (Figure 1).

Figure 1. Studies outside of the OR show increased complications with successive attempts, with 10-20% for first attempt, 40-60% for second attempt, etc. However, different phenotypes of complications likely contribute differently at each point during airway management and thus provide various clinical and research targets. Incomplete or inadequate preparation or planning results in avoidable intubation-related complications because of early depletion of oxygen reserve, leading to aborted attempts or adverse events earlier than expected (Green bars). Complications that occur due to difficulty with laryngoscopy, tube placement, or mask ventilation despite pre-intubation optimization and preparation increase with successive attempts (Red bars). This is the traditional “difficult airway.” Complications that occur because of altered physiology likely contribute to the majority of complications with 1 or 2 attempts. These patients are so physiologically disturbed (e.g., hypoxemic respiratory failure, RV failure, tamponade), that they are intolerant of any attempt, any apnea, or the transition to positive pressure ventilation. These are the patients that when they degenerate into cardiac arrest despite first attempt success, we tell ourselves that they were just really sick and there’s nothing we could have done.

Complications can arise from inadequate preparation such as preoxygenation, improper positioning or an incomplete plan. Other complications arise from true difficulty with laryngoscopy, tube placement, or mask ventilation despite adequate preparation. With both of these types of complications, repeated attempts can lead to airway injury and edema that can precipitate a can’t-intubate can’t oxygenate scenario, but also the risk is from an association with the depletion of oxygen reserve, hemodynamic consequences of hypoventilation, or aspiration of gastric contents leading to critical hypoxemia. It is this latter association that should be eliminated with an increased focus on danger. Some patients have physiologic challenges that increase the risk of complications with any attempt (i.e. the “physiologically” difficult airway). These disturbances can be so severe that despite optimal preparation, risk cannot be completely obviated. By better understanding the danger presented by these three phenotypes, there is potential to clinically and scientifically approach airway management in critically ill patients that we have not considered historically. To date, we have typically focused efforts on preventing complications related to difficult laryngoscopy, yet the most significant danger likely comes from incomplete preparation and unfriendly physiology.   

Continuing to use the ‘difficult airway’ nomenclature in the critically ill patient risks confusion and undue variability without addressing the overall danger. For example, does anticipating difficulty and altering the plan, which then results in no difficulty being encountered during the intubation qualify as a difficult airway? Should one write a note in the chart, register the patient with a database, and send the patient a letter notifying them of the difficult airway they were predicted to have, but yet did not have? This presents a Schrödinger’s cat paradox in that the airway is both difficult and not difficult at the same time. From a research perspective, the term ‘difficult airway’ can be fraught with ambiguity or error. Studies comparing devices, techniques, or methods often focus either on the anticipated difficult airway, which is poorly predicted, deliberately exclude difficult airway patients, or isolate one aspect while ignoring the others (e.g. apneic oxygenation while ignoring preoxygenation) (4-11). Conversely, focusing on laryngoscopy-related complications ignores significant danger in airway management from incomplete preparation and difficult physiology-related complications, especially considering most patients are intubated in the first two attempts. We should refocus our energies on mitigating the danger by optimizing the pre- and peri-intubation process. Research should focus on how to best reduce complications associated with multiple attempts and disturbed physiology, and eliminate complications related to poor preparation altogether. These efforts will elevate our expertise in placing patients on life support to the level our patients deserve.

Jarrod M Mosier, MD^1,2,; George Kovacs, MD³; J. Adam Law, MD⁴; John C Sakles, MD¹

¹Department of Emergency Medicine, University of Arizona. 1609 N. Warren Ave, Tucson, AZ 85724

²Division of Pulmonary, Allergy, Critical Care, and Sleep. Department of Medicine, University of Arizona. 1501 N Campbell Ave, Tucson, AZ 85721

³ Departments of Emergency Medicine, Anaesthesia, Medical Neuroscience, Dalhousie University, Halifax, NS B3H 3A7

⁴ Departments of Anesthesiology and Emergency Medicine, Dalhousie University, Halifax, NS B3H 3A7

References

1. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71-8. [CrossRef] [PubMed]
2. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607-11. [CrossRef] [PubMed]
3. Hypes C, Sakles J, Joshi R, Greenberg J, Natt B, Malo J, Bloom J, Chopra H, Mosier J. Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications. Intern Emerg Med. 2017 Dec;12(8):1235-43. [CrossRef] [PubMed]
4. Griesdale DE, Chau A, Isac G, Ayas N, Foster D, Irwin C, Choi P, Canadian Critical Care Trials G: Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial. Can J Anaesth. 2012;59(11):1032-1039. [CrossRef] [PubMed]
5. Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Crit Care Med. 2015 Mar;43(3):636-41. [CrossRef] [PubMed]
6. Driver BE, Prekker ME, Moore JC, Schick AL, Reardon RF, Miner JR. Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Acad Emerg Med. 2016, 23(4):433-9. [CrossRef] [PubMed]
7. Janz DR, Semler MW, Lentz RJ, et al. Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. Crit Care Med. 2016;44(11):1980-7. [CrossRef] [PubMed]
8. Janz DR, Semler MW, Joffe AM, et al. A multicenter randomized trial of a checklist for endotracheal intubation of critically ill adults. Chest. 2017 Sep 14. pii: S0012-3692(17)32685-5. [CrossRef] [PubMed]
9. Semler MW, Janz DR, Russell DW, Casey JD, Lentz RJ, Zouk AN, deBoisblanc BP, Santanilla JI, Khan YA, Joffe AM et al. A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults. Chest. 2017;152(4):712-2. [CrossRef] [PubMed]
10. Semler MW, Janz DR, Lentz RJ, et al. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med. 2016 Feb 1;193(3):273-80. [CrossRef] [PubMed]
11. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video Laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial. JAMA. 2017;317(5):483-93. [CrossRef] [PubMed]

Cite as: Mosier JM, Kovacs G, Law JA, Sakles JC. The dangerous airway: reframing airway management in the critically ill. Southwest J Pulm Crit Care. 2018;16(2):99-102. doi: https://doi.org/10.13175/swjpcc004-18 PDF 

Linking Performance Incentives to Ethical Practice

Health spending is a huge part of the United States economy as it is a large business. We all have seen increasing inclusion of corporate practices in health care. One such inclusion is the incentive programs which have at their core the goal of production of the desired behavioral outcomes directly related either to performance output or extraordinary achievement. However, management influence on the organization’s ethical environment and culture can inadvertently encourage or endorse unethical behavior despite the best intentions. One way would be failing to link performance incentives to ethical practice. When leaders create strong incentives to accomplish a goal without creating equally strong incentives to adhere to ethical practice in achieving the desired goal, they effectively set the stage for ethical malpractice. Incentivizing ethical practice is equally important as incentivizing other behaviors (1). In the health care industry, unlike in the sales industry, professionalism and patient care are not like sale numbers and the costs of not providing excellent care can be serious. When emphasis is more about good performance numbers than accurate performance numbers, hospital accreditation reviews may result in, issuance of orders that are impossible to fulfill, or finding scapegoats to blame in a crisis. This can have powerful effects in shaping the organization’s environment and how staff members perceive the organization, their place in it, and the behaviors that are valued. Ironically, it isn’t unusual for leaders to assume all is fine from an ethical perspective when in fact it may not be. Research has shown that the higher in the organizational level the healthier the perceptions of organizational ethics is perceived (2).

It takes a great deal more than high ideals and good intentions to have ethical authority. It requires commitment and a proactive effort to achieve high standards. If executives are to meet the challenge of fostering an ethical environment and culture, it’s essential that they cultivate the required specific knowledge, skills, and habits. More and more, the public expects its leaders to hold themselves and their employees accountable and high on that expectation is ethical practice.

A focused example is the current opioid crises. In 2004 Centers for Medicare & Medicaid Services added pain scale as the 5^th vital sign. Subsequently, both the Department of Veterans Affairs and The Joint Commission mandated a pain scale as the 5^th vital sign (3-8). These pain scales ask patients to rate their pain on a scale of 1-10. The Joint Commission mandated that "Pain is to be assessed in all patients” and would give hospitals "Requirements for Improvement" if they failed to meet this standard (8). The Joint Commission also published a book in 2000 for purchase as part of required continuing education seminar (8). The book, sponsored by the opiate manufacturer Purdue Pharma (maker of oxycodone), cited studies that claimed, "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addictive side effects "inaccurate and exaggerated." The health organizations used patient satisfaction scores for Performance Incentives and some patients who were addicted or on their way to becoming addicted would complain to administrators when they did not get drugs they were seeking.

No one excuses the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, intrusion by unqualified bureaucrats, administrators and politician’s incentivizing more pain medications and punishing appropriate care likely contributed to the current crisis. In November 2017 four cities in West Virginia teamed up to file suit against The Joint Commission over the organization’s handling of pain management standards (9). In healthcare, physicians must advocate for their patients, build trust, insist on high standards of care, and participate creatively in improving the health care system in a fiscally responsible way (10). We should hold firm to pressures from manufacturers, administrators, and medical boards s to do what is in the best interests of our patients. Preserving the standards of professionalism in medicine while maintaining the highest levels of ethical standards has the best chance of healing this opiate epidemic. Let's maintain the trust and professionalism of our discipline during this crisis. 

F. Brian Boudi, MD

Associate Editor, SWJPCC

References

1. Wynia MK. Performance measures for ethics quality. Eff Clin Pract. 1999;2(6):294-9. [PubMed]
2. Treviño LK. Ethical culture: What do we know? Fellows Meeting, July 2003, Ethical Research Center. Available at: www.ethics.org/download.asp?fl=/downloads/Ethical_Culture_Summary.pdf; last accessed December 18, 2006.
3. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995 Apr;82(4):1071-81. [CrossRef] [PubMed]
4. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005 Jul 25;165(14):1574-80. [CrossRef] [PubMed]
5. National Pain Management Coordinating Committee. Pain as the 5Th vital sign toolkit. Department of Veterans Affairs. October 2000. Available at: https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf (accessed 2/22/17).
6. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117 [CrossRef] [PubMed]
7. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540. [CrossRef] [PubMed]
8. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 2/22/18).
9. Sullivan W, Plaster L. Four West Virginia cities sue The Joint Commission. Emergency Physician Monthly. December 5, 2017. Available at: http://epmonthly.com/article/four-west-virginia-cities-sue-joint-commission/ (accessed 2/22/18).   
10. The unspoken challenges to the profession of medicine. Boudi FB, Chan CS. Southwest J Pulm Crit Care. 2017;14(6):222-4. [CrossRef]

Cite as: Boudi FB. Linking performance incentives to ethical practice. Southwest J Pulm Crit Care. 2018;16(2):96-8. doi: https://doi.org/10.13175/swjpcc036-18 PDF 

Brenda Fitzgerald, Conflict of Interest and Physician Leadership

Barely noticed in the news last week was Brenda Fitzgerald’s resignation as director of the Centers for Disease Control (CDC) after only 6 months on the job (1). Her resignation came one day after Politico reported that she bought shares in a tobacco company one month after assuming the CDC directorship (2). The stock was one of about a dozen new investments that also included Merck and Bayer (3). Fitzgerald had come under criticism by Senator Patty Murray for slow walking divestment from older holdings that government officials said posed potential conflicts of interest (1). While serving as director of the Georgia Department of Health, Fitzgerald owned stock in five other tobacco companies: Reynolds American, British American Tobacco, Imperial Brands, Philip Morris International, and Altria Group (4).

“It gives you a window, I think, into her value system,” said Kathleen Clark, a professor of law focusing on government ethics at Washington University in St. Louis (2). “It doesn’t make her a criminal, but it does raise the question of what are her commitments? What are her values, and are they consistent with this government agency that is dedicated to the public health? Frankly, she loses some credibility.” Purchasing tobacco stocks by any physician is disturbing, even more so when done by the director of the agency that spearheads the US government’s efforts to reduce smoking.

The influence of money on healthcare legislation has become increasingly concerning. Merck, whose stock Fitzgerald purchased on August 9, has been working on developing an Ebola vaccine and also makes HIV medications (2,3). Bayer, whose stock she purchased on August 10, has in the past partnered with the CDC Foundation to prevent the spread of the Zika virus (2,3). Fitzgerald’s purchases of tobacco stocks represent just one more instance of a potentially inappropriate relationship between politicians and business. Previous research published in the Southwest Journal of Pulmonary and Critical Care (SWJPCC) demonstrated a correlation between tobacco company political action committee contributions and support of pro-tobacco legislation (5).

Fitzgerald’s ethics issues are apart from a broader assessment of her leadership at the CDC. She had no research experience while leading an organization where research is one of its primary functions. She had previously promoted anti-aging medications to her patients despite no evidence of their efficacy (6).  She made few public statements during her time at the CDC and waited 133 days before holding her first staff meeting. She was scheduled several times to testify before Congress but sent deputies instead.

Fitzgerald seems to represent a high-profile version of the obsequious physician executive (OPIE), i.e., a physician obedient or attentive to an excessive or servile degree (7). Like the OPIE at the local hospital, Fitzgerald may have been appointed not for skill as a leader but her compliance as a subordinate to her supervisors. It raises the question of who would want to be director of the CDC when the current administration has been openly hostile, targeting the agency for deep budget cuts.

Hopefully, the next director of the CDC will be less conflicted. Previously, the SWJPCC has published tobacco company PAC contributions to candidates for political office (5). At the request of the Arizona Thoracic Society we intend to do the same prior to the November 2018 elections (8). In the interim, you can check tobacco company PAC contributions to federal candidates on the Campaign for Tobacco Free Kids website or for contributions at the state level at followthemoney.org (9,10).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Sun LJ. CDC director resigns because of conflicts over financial interests. Washington Post. January 31, 2018. Available at: https://www.washingtonpost.com/news/to-your-health/wp/2018/01/31/cdc-director-resigns-because-of-conflicts-over-financial-interests/?utm_term=.05ee75769108 (accessed 2/3/18).
2. Karlin-Smith S, Ehley B. Trump's top health official traded tobacco stock while leading anti-smoking efforts. Politico. January 30, 2018. Available at: https://www.politico.com/story/2018/01/30/cdc-director-tobacco-stocks-after-appointment-316245 (accessed 2/3/18).
3. Fitzgerald B. Periodic Transaction Report | U.S. Office of Government Ethics; 5 C.F.R. part 2634 Executive Branch Personnel Public Financial Disclosure Report: Periodic Transaction Report (OGE Form 278-T). Revised 12/21/17. Available at: https://www.politico.com/f/?id=00000161-4804-d9fe-a9fd-5af5834d0000 (accessed 2/3/18).
4. Fitzgerald B. Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e). Revised 10/12/17. Available at:  https://www.politico.com/f/?id=00000161-4867-da2c-a963-cf770b6b0000 (accessed 2/3/18).
5. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
6. Levitz E. Trump’s CDC pick peddled ‘anti-aging’ medicine to her gynecologic patients. New York Magazine. July 10, 2017. Available at: http://nymag.com/daily/intelligencer/2017/07/trumps-cdc-pick-peddled-anti-aging-medicine-to-patients.html (accessed 2/3/18).
7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]
8. Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. [CrossRef]
9. Campaign for Tobacco Free Kids. Tobacco PAC contributions to federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions (accessed 2/3/18).
10. The National Institute on Money in State Politics. Money in state politics. Available at: https://www.followthemoney.org/tools/election-overview/?s=AZ&y=2016 (accessed 2/3/18).

Cite as: Robbins RA. Brenda Fitzgerald, conflict of interest and physician leadership. Southwest J Pulm Crit Care. 2018;16(2):83-5. doi: https://doi.org/10.13175/swjpcc029-18 PDF