Andreas Lubitz and the Ethics of Confidentiality

Matt Freeman DNP, MPH

“How are things at home?” It can jumpstart a conversation about emotional health, giving the patient a chance to have control over how little or how much he or she would like to disclose. My own variation has been, “How is your mood and your stress level?” Patients often say, “the usual amount of stress.” Others become tearful. Others find an unexpected opportunity to share what is happening in their lives.

I do not know what Andreas Lubitz would have said. Perhaps he would have talked about his dashed hopes to marry Kathrin Goldbach, or his reported frustration with flying shorter fights rather than the more prestigious long-haul routes with Lufthansa. But he might have said nothing at all.

16343704274_3ab4532dfd

I think back to the handful of patients I have had in my career who have been commercial pilots. I even remember chatting with one of them about his mood. He was exhausted by his schedule, his pay was abysmal, and his wife was also a pilot, thereby putting a great strain on their marriage. As is the standard of care with a patient with a mood disorder, I asked, “Have you had any thoughts of hurting yourself or others?” He said no.

 

What if he had said yes?

The rules for breaching patient confidentiality vary by country and—in the US—by state. But there is a consistent theme: plan, means, and intent. If my own patient had been specific with his plan and time range, I would have probably been able to get him admitted to mental health facility, and—in collaboration with others—most likely able to contact the airline’s medical department.

But what if he just said, “Sure, I have thoughts of hurting myself? Sometimes I wonder what would happen if the plane I was flying crashed.” I would be asking a lot of questions at that point, probably consulted with a mental health provider, but if he expressed this in vague terms—a melancholic fantasy—it would have been inadequate to sever our private doctor/patient relationship. I could urge him to see a therapist, encourage antidepressants, invite a short-interval follow-up, discussed what actions to take if he felt increasingly suicidal or homicidal, but my powers would have ended there.

All of us fear another Germanwings 9525 or Egyptair 990, but suicides are notoriously difficult to predict. If the European or American governments suddenly required all pilots to answer the question, “Are you having thoughts of hurting yourself or others?” before flying, the answer would be “no.”

12788608924_744f87b888_b

Egyptair Boeing 767-300, similar to the aircraft that crashed near Nantucket on 31 October 1999

 

Actively suicidal patients, particularly men, typically keep their plans closely guarded.  It is not too difficult for a severely depressed patient to outfox a standardized depression inventory, even the probing questions of a therapist or primary care provider.

Although the details of Andreas Lubitz’ medical history are still blurry, he could have just said, “No, I do not feel like hurting myself or others.” There is no polygraph, “trick question,” nor blood test that would have predicted a murder-suicide. Psychologists usually have the ability to estimate behavior within a 48-hour window, but that depends on the patient disclosing a lot of information.

From media reports, Andreas Lubitz had some red flags: a previous history of a mood disorder, recent treatment, a trigger (the breakup), and reportedly erratic behavior. How many pilots, truck drivers, those whose jobs require firearms or access to explosives would meet a similar description?

 

Who is the client?

My first practice out of school was in occupational medicine. I often saw truck drivers, firefighters, police officers, air traffic controllers, and others who needed medical examinations for employment. In the overwhelming majority of cases, the goal was to ensure that I “rubber stamped” the paperwork.

US law requires that any medical examination be conducted post-offer. In other words, the patient had already been given the job, and it was my responsibility to ensure that there were no barriers. The medical examination did not serve to address health concerns, prevent illness, nor screen for disease. It served an administrative purpose.

Although most patients take it in stride, some view it as a marked invasion of privacy with no benefit to public safety. It is indeed awkward, unpleasant, or threatening to answer detailed health and mental health questions, disrobe, get poked and prodded, all because an employer requires it.

Regulatory bodies, like the Federal Aviation Administration and Federal Motor Carrier Safety Administration stipulate guidelines for these examinations. But healthcare providers are faced with a dilemma: if pilot, driver, firefighter, or other examinations are part of one’s livelihood, it would be dangerous to have a reputation for saying “no.” This could lead to unemployment for the patient and a vacancy for the employer.

8990405191_f01b659063_o

The client for these examinations is not the patient himself or herself. The client is the employer and/or the government agency. Patients therefore lack the comfort of a private and established doctor/patient relationship. When a patient comes to see me on his or her own for routine medical examination, it is a “health-seeking behavior,” and he is or she is perhaps more likely to share more extensive thoughts about mental health, substance abuse, and other problems.

There is one further problem: patients can sometimes shop around. Pilots and drivers seeking medical certification can go to any FAA or DOT-approved healthcare provider. If the first examination does not go well for some medical reason, the pilot or driver can merely hope that the next examiner does not ask the same questions, conducts a less thorough examination, or the patient might just be a bit less truthful in his or her responses.

 

There is no clear flight path ahead.

Loosening confidentiality laws raises many ethical concerns. Psychological screening may be helpful but has the peril of self-disclosure: an affirmative answer to a screening question can cost one his or her livelihood.

Environmental mitigation, such as ensuring two personnel in the flight deck has the rather obvious dark side: Lubitz could have incapacitated a pilot or flight attendant seated to his left and continued to crash the plane. In the US, pilots and flight attendants do not pass through checkpoints to detect weapons in many airports since they travel through “Known Crew Member” (KCM) ID checkpoints.  In fact, many pilots are Federal Flight Deck Officers (FFDOs), who are permitted to carry firearms on board.

9803510073_f4840c4126_b

Amid the grief and fear in the aftermath of the crash and its investigation the most salient call is one for dialogue. Ethicists, mental health professionals, occupational health providers, and primary care providers need to open a greater discussion about suicidal and homicidal behavior. Although a statistical rarity, the consequences are catastrophic. Now is the time to talk more about protecting privacy while protecting the public, ensuring access to care, and guaranteeing further research in suicidology.

 

 

 

Advertisements

Pseudoscience at Gate B6

Matt Freeman DNP, MPH

It was mid-morning on a Saturday. I had only hand luggage, and had checked in online the day before. I arrived at the small airport exactly one hour before departure. I was a bit annoyed that the flight was delayed, but otherwise not expecting too much trouble. It was a 90-minute flight on a 70-seat regional jet. Only one other flight, also a small regional jet, was departing from the same section of the airport.

By my best estimate, there were 80 passengers in line for the security checkpoint. Most seemed to be leisure travelers: families with little kids, older adults. There was an abundance of sunburn and golf shirts.

16435789200_b5314b2c52_b

The queue inched along. As I looked around, anxiety was escalating. There was a lot of chatter about missing flights; several people were in tears knowing that they would certainly have their travel plans fall into disarray.

Twelve Transportation Security Administration (TSA) staff were working: one checking identity cards, two on either side of the x-ray machine, one operating the metal detector, seven chatting with each other, and one walking his way through the increasingly antsy crowd.

“What is the province of your destination?” He asked the woman next to me.

“Province?”

“Yes, which province? British Columbia? Ontario?”

Confused, the woman replied, “I’m going to Houston. I don’t know what province that’s in.”

The TSA agent scoffed. He moved on to the next passenger. “The same question for you, ma’am. What is the province of your destination?”

The woman didn’t speak, handing over her driver’s license and boarding card, assuming that was what he wanted. He stared back with disdain.

 

There are no flights from this airport to Canada.

 

When it was my turn, I volunteered, “I’m going to Texas, not Canada.”

“What are the whereabouts of your luggage?” He asked.

“Their whereabouts? My bag is right here next to me.”

“Yes, what are its whereabouts?”

 “It’s right here.”

“And that’s its whereabouts?”

This was seeming like a grammatical question.

“And about its contents? Are you aware of them?”

“Yes,” I replied, quizzically.

He moved on.

3034047588_b53bb1b71f_b

I missed my flight. The woman next to me met the same fate. She cried. I cringed. We pleaded with the airline agent for clemency. The plane pushed back from the gate with many passengers waiting to be asked about the whereabouts of their belongings or their province of destination.

The agent asking the strange questions and delaying the flights was a part of  “SPOT.”

 

The SPOT Program

In 2006, the TSA introduced “SPOT: Screening Passengers by Observational Techniques.” The concept was to identify nonverbal indicators that a passenger was engaged in foul play. Two years after the program started, the US Government Accounting Office (GAO) declared that, “no scientific evidence exists to support the detection of or inference of future behavior, including intent.”

The absence of evidence did not dissuade the TSA. Neither did another study in 2013, in which the GAO reported, “the human ability to accurately identify deceptive behavior based on behavioral indicators is the same as or slightly better than chance.”

The Department of Homeland Security, which oversees the TSA, has its doubts as well. The DHS inspector general reported in 2013 described the SPOT as follows: “[We] cannot ensure that passengers at United States airports are screened objectively, show that the program is cost-effective, or reasonably justify the program’s expansion.” It is now three years since that statement, but the TSA is still playing the game, aware that they have no data nor agency backup to support their efforts.

SPOT is expensive too. The GAO reported that the program has cost more than $900 million since its inauguration. That is just the cost of training staff and operating the program, not the costs incurred by delayed or detained passengers.

 

The “Science” Behind Behavioral Techniques

The SPOT program was developed by multiple sources, but there is one most prominent psychologist in the field: Paul Ekman PhD.

Ekman published Emotion in the Human Face, which demonstrated that six basic human emotions: anger, sadness, fear, happiness, surprise, and disgust, are universally expressed on the human face. Ekman had travelled to New Guinea to show that facial expressions did not vary across geography or culture.

Ekman’s theory was undisputed for 20 years until Lisa Feldman Barrett PhD showed that Ekman’s research required observes to select from the list of six emotions. When observers were asked to analyze emotions without a list, there was some reliability in the recognition of happiness and fear. The other emotions could not be distinguished.

When confronted with skepticism from scientists, Ekman declined to release the details of his research for peer review. Ekman claims that his work is on the radar of scientists from China, Iran, and Syria, so it would be dangerous for him to disclose his findings. I guess I should not publish here that the atomic weight of hydrogen is 1.008 atomic mass units. Syrians could find out! Everyone, hide your physics and chemistry textbooks!

Charles Honts PhD attempted to replicate Ekman’s findings at the University of Utah. No dice. Ekman’s “secret” findings could not be replicated. Maria Hartwig PhD, a psychologist at City University of New York’s John Jay College of Friminal Justice, described Ekman’s work as, “a leap of gargantuan dimensions not supported by scientific evidence.”

The TSA’s own adaptation of Ekman’s work into SPOT is scientifically challenging because it can only be tested on those pretending to be terrorists. In other words, any attempt at scientific application of SPOT evaluation is based on those who are already engaged in deception. Even Ekman himself describes the TSA’s testing of his research as “totally bogus.”

hqdefault

 

Maybe I can boil this down: we have a psychologist whose research was refuted. And even the defamed psychologist has argued that the TSA’s application of his already dubious evidence is “bogus.”

When asked directly, a TSA analyst pointed to the work of David Givens PhD, an anthropologist and author. Givens has published popular works on body language, but Givens explained that the TSA did not specify which elements of his own theories were adopted by the TSA, and the TSA never asked him.

 

The TSA’s Response

When asked for statistics, TSA analyst Carl Maccario cited one anecdote of a passenger who was “rocking back and forth strangely,” and was later found to have been carrying fuel bottles that contained flammable materials. The TSA described these items as, “the makings of a pipe bomb,” but there was no evidence that the passenger was doing anything other than carrying a dangerous substance in his hand luggage. There was nothing to suggest that he planned to hurt anyone.

A single anecdote is not research, and this was a weak story at best.

When the GAO investigated further, they analyzed the data of 232,000 passengers who were identified by “behavioral detection” as cause for concern. Of the 232,000, there were 1,710 arrests. These arrests were mostly due to outstanding arrest warrants, and there is no evidence that any were ever linked to terrorist activity.

 

What Criteria Are Used in the SPOT Program?

In 2015, The Intercept published the TSA’s worksheet for behavioral detection officers.

spot-referral-report-1.jpg

I was obviously in deep trouble.

“Stress Factors” (one point for each)

  • Avoids eye contact with security personnel (why do I need to make eye contact?)
  • Excessive clock watching (yep; it was getting late.)
  • Face pale from recent shaving of beard (I shaved that morning.)

 

“Fear Factors” (two points for each)

  • Constantly looking at other travelers or associates (People were crying. Why would I not be looking around to see what was going on? Was I supposed to stare straight ahead? Nope. Can’t do that; staring also racks up points on the worksheet.)
  • Scans area, appearing to look for security personnel (I was wondering why they weren’t working.)

 

“Deception Factors” (three points for each)

  • Appears to be confused and disoriented (I was asked bizarre questions that required clarification)

 

I earned eight points, which assigned  me to the highest risk category. If one followed the paperwork, I should have been referred for extensive screening and law enforcement was to be notified.

It would have been hard to find passengers in the line who did not exceed five points required to warrant a referral for additional screening.

Considering that the criteria include yawning, whistling, a subjectively fast “eye blink rate,” “strong body odor” and head turning, just about everyone reaches the SPOT threshold.

Mercifully, I was sent on to the screaming TSA agent at the metal detector and the man who was angry that I did not have a laptop. I was spared further scrutiny.

 

The Risk of Scoring

Looking past the absence of evidence, there are further problems with the SPOT worksheet. “Scored” decisions can detract common sense. For example, I have often lectured on suicide assessment. There are several analysis tools to help a clinician determine if a patient should be admitted to the hospital or allowed to go home. I always teach, “whatever you do, do not assign a score.” This offers a false sense of security without real clinical application. It doesn’t matter if a patient only gets a five out of 20 if he takes his own life after you discharge him or her.

 

The Fourth and Fifth Amendments

The Fourth Amendment protects Americans from “unreasonable” search and seizure. But airport security falls under the category of a “consent search,” which is voluntary. The Fourth Amendment does not apply because the search is conducted outside the setting of an arrest, and the passenger has “consented” to a TSA search.

  1. The courts ruled that a passenger consents to inspection either by presenting his or her identification and boarding card to the TSA, or by placing his or her belongings on an x-ray conveyor belt. The SPOT interviews take place before either of these steps, when passengers have not yet entered the TSA’s “custodial” area.
  2. The extent and detail of the search is not explicit. A reasonable passenger would have the expectation that he or she will be subject to some form of inspection of their hand luggage, a metal detector, or a full body scanner. Is it reasonable to assume that passengers can expect to be interviewed?

 

What about the Fifth Amendment? Since the Bill of Rights does not apply at the checkpoint, a passenger could easily self-incriminate.

  1. TSA staff are not law enforcement officers and have no powers of arrest. But they use the term “officer” and wear badges. (This has been subject to controversy by bona fide law enforcement officers.) The notion of a “consent search” is by no means explicit at any checkpoint.

 

Conducting an interview with the appearance of a law enforcement role exploits a loophole. There is no Fourth Amendment because the interview is not conducted by a law enforcement officer. There is no right to an attorney, no right to remain silent because the interviewer merely has the appearance of a police officer.

The bottom line: the TSA is not actually law enforcement but they do have the power to prevent a passenger from boarding an airplane. One has to submit to SPOT investigation in order to fly. Even if one has not even begun the screening process on constitutional grounds, and even if the nature of one’s consent is by no means informed.

Above all, the “search”—the interview—has not been shown to be any better than chance alone at detecting a dangerous passenger.

images 

Low-Hanging Fruit

My friend Grace is a great physician. She is a warm, brilliant, and talented colleague. We have been friends for decades. She grew up in the Midwest to all-American parents. She has an amazing sense of humor and a charming personality.

Grace went to visit her parents in Michigan, and flew there without incident. On her way home, a SPOT agent saw her in line at the entrance to the security checkpoint.

She was pulled aside, taken to a separate room, and interviewed by two TSA staff with seemingly meaningless questions. Her boarding card had not been flagged; she was taken out of line before she had even entered the screening area.

She missed her flight.

Rattled and confused, Grace called and asked what could have happened. We agreed that she was a target for several reasons: attractive, thereby capturing the interest of male TSA agents, who could have her alone in a room and get to know her. And we agreed that she was “low-hanging fruit:” someone who would be articulate enough to answer questions, unlikely to unleash anger, and unlikely to question the TSA’s judgment.

The TSA denies that SPOT agents have a quota to follow. But SPOT agents have stated that they were under the impression that a promotion was more likely if they pulled more passenger aside.

This was not about security, not quite in line with a “consent search,” and really had to do with either getting a promotion or perhaps scoring a date.

 

SPOT Around the World

Since the 1980s, the US Government has required US air carriers to conduct profiling techniques for flights destined to the United States. This applies to flights form designated “higher risk” points of origin: anywhere mostly Europe, South America, and the Middle East.

Using techniques comparable to the SPOT program, security contractors conduct interviews at the check-in counter and boarding gates. Many European carriers use the same system for flights from the developing world to Europe.

The largest contractor, ICTS, and its affiliates, claim to follow an Israeli model of threat detection: behavioral analysis. The company was founded by Israeli security “experts,” and theoretically models its behavioral profiling system following an Israeli model.

Their track record abysmal.

In 1988, passengers checking in at Frankfurt Airport for Pan Am flight 103 were questioned by security staff, supposedly looking for behavioral profiles akin to SPOT techniques. The staff spoke inadequate English to understand responses. They were given stickers to identify passengers who should be subject to further scrutiny (“selectees,”) but the screening staff did not even know what a “selectee” was, so they just assigned the stickers at random. Two hundred forty-three passengers and 16 crew died when a bomb exploded aboard the second segment of the flight.

Lockerbie_disaster_memorial

On 21 December 2001, Richard Colvin Reid checked in at Terminal 2A at Paris Roissy/Charles de Gaulle Airport. American Airlines’ contract security agents were wary of Reid’s appearance and evasive answers to their questions. After consultation with the French Police, Reid was given a ticket for a flight the following day. He boarded American Airlines flight 63 with his shoes loaded with plastic explosives.

Seven years later, Umar Farouk Abdulmutallab passed through a document inspection and security interview by KLM contract security staff in Lagos. He was then interviewed and searched by Delta Air Lines’ contract security agent, ICTS, at Amsterdam Airport Schipol. The interview did not arouse enough suspicion to warrant further search or inspection, and Abdulmutallab boarded Delta Air Lines flight 253 with explosives in his underwear.

Delta_Security_Stickers

At least Reid and Abdulmutallab did not harm anyone.

 

Can this Work? Common Sense Behavioral Detection

On 14 December 1999, “Benni Antonie Noris” arrived in Port Angeles, Washington in a green Chrysler 300M. Customs officer Diana Dean asked where he was headed. In broken English, Noris stated that he was headed to Seattle for a “business trip.” This made little sense since there are far more direct ways to travel from Vancouver to Seattle. Noris was fidgeting, jittery, and sweating. He began fidgeting and squirming, hiding his hands. His form of identification was a Costco Card.

Port

Port Angeles, Washington

It did not require a SPOT form to give Diana Dean an indication that this driver’s behavior was atypical.

The driver was unable to articulate his plans in Seattle nor where he was staying. Dean described him as acting “hinky” (I had to look that word up in a dictionary. It should clearly be in wider use.)

Inside the trunk of his car, Dean kept the conversation going as she and a colleague inspected his car. It was loaded with nitroglycerine.

The driver turned out to be Ahmed Ressam, known as “The Millennium Bomber.” Ressam was on the verge of executing a plot to blow up Los Angeles International Airport on New Year’s Eve.

Diana Dean did not need a SPOT training notice a problem. This is a man who used his Costco card as identification and hid his hands. No need for “behavioral detection” techniques. Dean modestly claimed it was “dumb luck.”  It was not luck; she just identified remarkably aberrant behavior. This was not a checklist of someone blinking too fast or having shaved recently. This was a wise customs agent thinking, “This guy just used a Costco card as identification.”

 

The Israeli Method

As an Israeli national, I became accustomed to the envied security techniques employed at Israel’s four commercial airports.

The agents employed by the Israeli Airports Authority (IAA) do indeed “profile” passengers, but their efforts are often quicker, easier, and seem far more like the “Diana Dean Technique.”

IAA staff rank passengers from “1” to “6,” with the higher then number indicating the greatest amount of suspicion. I have only ever earned a number “1,” so I speak from the least intrusive end of the spectrum.

Instead of attempt to ensnare me in a trap with questions about the whereabouts of my bags or my province of destination, the questions are usually reasonable and fast. “Where have your bags been since you packed them?” “Did anyone give you anything to take with you?” “Are you carrying anything that could be used as a weapon?”

In some cases, the agents attempt to asses if a passenger is Jewish, but this is conducted in a roundabout way so as to circumvent religious profiling. Foreign travelers are asked, “Do you belong to a religious congregation?”

But the question is partially helpful as there are many Christian and Muslim tourists in Israel. Those travelling with a Christian tourist group are unlikely to arouse much suspicion.

In fact, I have only seen a few passengers earn a number “6.” These were American Christian young adults, who mentioned that they had travelled to Jordan, and they were given CDs by an acquaintance to bring back to the United States. They did not know was on the CDs. That is a case for Diana Dean. “You do not know the guy who gave these to you, nor do you know their what is on them?” I would have been skeptical too.

The IAA is cautious about race and religion. The worst attack on Israeli air transportation took place in 1972 at Ben Gurion Airport. Twenty-six people were killed. The assailants were Japanese, posing as tourists. Since that attack, the IAA has attempted to include ethnicity and religion only as components of its screening process.

520078150_86ebddab0f_o

Although many have published horror stories, the overwhelming majority of passengers do not encounter anything extraordinary at Israeli airports. The agents are usually young, bubbly, right out of their army service, and eager to show off any language skills they may have acquired.

There is no “show.” There are no badges, nobody is called “officer,” and the goal is clear: keep the airport and flights safe.

The staff joke, make small talk, and are typically make an effort to help those who are elderly, infirm, or traveling with small children. The goal is to screen for problems but do so expeditiously and without pretending to be anything other than airport security.

I have heard stories, especially from non-Jewish tourists, who were subject to greater questioning or detailed searches of their hand luggage. But I have never heard of a missed flight due to semantic tricks about the whereabouts of one’s luggage.

Although I do defend every aspect of Israel’s government, racial tensions, or the Palestinian conflict, I can say with certainty that I would not have missed my flight due to trick questions about the whereabouts of my bags or to which province I was headed. If I was running late, I am confident that the IAA staff would have done their best to mitigate the problem.

 

Is There a Better Answer?

Israel does not publish statistics, and I could not tell you if their system is any better. The difference is one of attitude: most of the IAA staff are kind, calm, and not interested in hassling anyone.

Moreover, Israeli airports protect their perimeters. There are two checkpoints before even entering Ben Gurion Airport. This reduces the risk of one of the TSA’s glaring loopholes: long lines of passengers waiting to enter a security checkpoint. It seems like a situation ripe for an attack. And it has happened before: in 1985, 19 people were killed and 100 wounded when terrorists attacked the TWA and El Al check in desks at Rome and Vienna Airports. The TSA lives in the strange assumption that only “sterile” areas of the airport are subject to an attack, thereby ignoring enormous public spaces.

Given the amount of air travel to, from, and within the United States, I doubt that questioning passengers would ever work. The TSA lacks the organization, multilingual skills, and service mentality of the Israel Airports Authority.

9152102803_40009f1ea9_b

A crowded checkpoint at Seattle/Tacoma International Airport: mobs of people who have not been screened for weapons

The TSA already has one answer, but they chose not to use it in my case. I am a member of the Department of Homeland Security’s “Global Entry” program. This means that I was subject to a background check, interview, and fingerprinting. The Department of Homeland Security vetted my credentials and deemed that I did not present any extraordinary risks, and could therefore use its “PreCheck” lane. But this airport had decided to close its PreCheck lane that day. And their SPOT agent had no knowledge that I had already been vetted through databases and fingerprints… arguably a more reliable system than having him determine if I blinked too rapidly.

Until 2015, the PreCheck program also meant that one need not pass through a full-body scanning machine, in part because the machines are famously slow and inaccurate. They are particularly problematic for those with disabilities and other medical conditions. But the TSA decided that it would switch to random use of full body scanners even for those passengers who had already been vetted. Lines grew longer; no weapons have been discovered.

 

Looking Forward

  1. The SPOT program has been proven to be ineffective. There is no rational reason to keep it in place.
  2. There must not be quotas or incentives for detailed searches and questioning in the absence of probable cause.
  3. Passengers consenting to a search should have the right to know what the search entails, particularly if it involves odd interrogation techniques that can lead to missing one’s flight.
  4. The TSA should respect previous court rulings that the search process begins when a passenger consents to being searched. Asking questions outside of the TSA’s custodial area of the airport is questionable for legal reasons.
  5. Reduce lines. The attacks in Rome and Vienna were more than four decades ago, but that has not dissuaded the TSA. Get the queue moving quickly, thereby reducing the opportunity for an attack.
  6. Stratified screening, such as he PreCheck program, makes sense. But it TSA staff elect to ignore the program, then it is no longer useful.

 

 

References

Benton H, Carter M, Heath D, and Neff J. The Warning. The Seattle Times. 23 July 2002.

Borland J. Maybe surveillance is bad, after all. Wired. 8 August 2007.

Dicker K. Yes, the TSA is probably profiling you and it’s scientifically bogus. Business Insider. 6 May 2015.

Herring A. The new face of emotion. Northeastern Magazine. Spring 2014.

Kerr O. Do travelers have a right to leave airport security areas without the TSA’s Permission. The Washington Post. 6 April 2014.

Martin H. Conversations are more effective for screening passengers, study finds.  The Los Angeles Times. 16 November 2014.

The men who stare at airline passengers. The Economist. 6 June 2010.

Segura L. Feeling nervous? 3,000 Behavioral Detection Officers will be watching you at the airport this thanksgiving. Alternet. 23 November 2009

Smith T. Next in line for the TSA? A thorough ‘chat down.’ National Public Radio. 16 August 2011.

Wallis R. Lockerbie: The Story and the Lessons. London: Praeger. 2000.

Weinberger S. Intent to deceive: Can the science of deception detection help catch terrorists? Nature. 465:27. May 2010.

U.S. Government Accountability Office. TSA Should Limit Funding for Behavioral Detection Activities.  GAO-14-159. Washington, DC, 2013. http://www.gao.gov/products/GAO-14-159.

US House of Representatives. Behavioral Science and Security: Evaluating the TSA’s SPOT Program. Hearing Before the Subcommittee on Investigation and Oversight. Committee on Science, Space, and Technology. Serial 112-11. 6 April 2011.

All images designated as public domain

©2016

Diet Coke with Two Straws: The Story of an Armchair Stalker

Matt Freeman DNP, MPH

 

“This is hard to talk about,” said Tony, looking toward the floor.

It was Tony’s second visit. He had come in with a somewhat benign visit a month prior, complaining of shoulder pain. He was perhaps “testing the waters,” and had come back to discus his true concerns.

I recall him as largely nondescript: a 30-year-old manager of a large retail store. He had a condominium in a solidly middle class neighborhood, proud to be close with his family and wife. He told me how he was looking forward to playing football with his brothers.

“It’s so personal.” Tony gazed at the floor. His eyes starting to tear.

This was familiar territory for me. I had my money on erectile dysfunction, a diversion from marital fidelity, a gambling problem, sexual thoughts about about other men. None of the above. I was entirely unprepared.

“I wear women’s clothes.”

This was still not an overwhelming story for me. I had worked with heterosexual cross-dressing men before.

“My wife’s clothes.”

This just got a bit more complicated.

 

“It’s because of Jill. Jill Payne.”

“Who?

“Jill Payne. WNTN?”

 

I was stumped.

 

Exasperated, Tony explained that Jill Payne was a local news anchor. He was shocked that I had never heard of her.

Set

Tony explained that he had been going with his wife to purchase clothes for her that matched those of Jill Payne. She rarely watched the news, so she did not recognize that her clothes matched those of the news anchor.

In his wife’s absence, he would wear the dresses and suits while scouring the internet for photos and videos of Jill Payne.

Tony shared a small scrapbook of Jill Payne photos. Almost combusting with anxiety, he began to spill endless details of Jill Payne’s life: where she was born, her favorite restaurants, the names of her children.

As he composed himself, I asked a few critical questions. Tony had no interest in hurting Jill Payne. He knew her neighborhood but not her house, and he did not have sexual thoughts about Jill Payne. He also had no thoughts of being “trapped” in a man’s body. Tony just wanted to feel as close to Jill Payne as possible.

Tony initially seemed to hope that I would help facilitate further connection with Jill. He explained that Jill’s husband was a physician, and perhaps I knew him. Furthermore, was under the impression that Jill’s husband was Jewish, and he began questioning me about my religion, hoping to glean as much information as possible. I deflected.

WWNY

My first concern was for Jill Payne’s safety. Tony denied any plan, intent, or means to hurt her. He denied any attempts to visit her home or the television station. The action of stalking was not part of his life, at least not for the moment.

I felt desperate to call Jill Payne. But I could not. From a confidentiality standpoint, I had no grounds to breach the provider/patient relationship. To make a call to Jill Payne, Tony would need to have expressed a clear intent to harm her. Tony did not meet the legal criteria for a so-called “Tarasoff Warning,” or duty to warn a potential victim of violence.

I was unsettled, and I collaborated with a physician and two psychologists. They all agreed that the best course of care would be to find a therapist for Tony, maintain rapport, and monitor his stability.

 

“Most Likely to Be Stalked”

Jill Payne has probably gone through this before. Amy Jacobson, a news broadcaster, said, “Everyone has a crazy guy. It’s expected.”

Although statistics are hard to find, women on local news channels have been described as the “most likely to be stalked.” It has been described as a “job-related hazard.”

Park Dietz MD, PhD, MPH is a forensic psychologist known for his testimony in high profile murder and stalking cases, including John Hinckley Jr. and Jeffrey Dahmer. Dietz’ view is that those who stalk news reporters are seeking status, fame, and glamor… a means of compensating for his own sense of self.

Dietz characterizes the typical news reporter stalker as single, male, under- or unemployed, lacking intimate relationships, and with a poor sense of self.

Indeed, Tony was a lonely man. Although married, he worked at night while his wife worked during the day. Lacking intimacy and purpose, he did not just aspire to have Jill Payne’s possessions. He aspired to be Jill Payne.

 

Artificial Intimacy

I remembered an ad for the local news when I was a child. The female half of a news anchor team spoke of her adoration for the male anchor. “He always brings me my Diet Coke the way I like it… with two straws.”

A neighbor was visiting a city across the country and was taken by an ad for the local news team. “He always brings me my Diet Coke the way I like it… with two straws.” The two straws were an invention of the national network’s marketing office.

DietCoke

 

Local news anchors are touted as part of the community. They are neighbors.  They have the illusion of being friendly, familiar, and approachable. And all of this is engineered through advertising. The “two straw” preference was somehow a way to make the anchors seem nonthreatening and amiable.

This is not to say that Jill Payne is anything but pleasant; I would have no way of knowing.

Family TV

 

The frequency of exposure compounds the situation. The local news anchor is in one’s living room or bedroom at least five days a week. She closes her broadcast with “Thanks for joining us. See you tomorrow.”

Tony knew that Jill Payne could not see or hear him. But she was a part of his everyday life. In fact, her current broadcasting schedule is weeknights at 5:00, 5:30, 6:00, and 11:00.

Michael Zona MD, a psychiatrist in Boulder, Colorado, explained that the most beautiful women are not typically the objects of such affection. Instead, it is the “girl next door.” The obsessed stalker may find that it would be within the realm of possibility that this woman would want a relationship with him.

A higher-profile celebrity in Manhattan or Hollywood might have appeared to be “off limits” to Tony. Jill Payne’s hometown sensibility and geographical proximity made her a more appealing target.

Stations

Obsession as a Function of Narcissism

Reid Meloy PhD, a forensic psychologist, describes a “narcissistic linking fantasy.” This can actually be a part of healthy human behavior: the thoughts of love, admiration, being liked, and complementing one another. The self-serving need for love and admiration are not pathologic.

Narcissistic linkage fantasies become troublesome when the fantasy involves someone who cannot reciprocate. Jill Payne never knew that Tony existed. But he could view this as a form of rejection. Although—to my knowledge—he never contacted her, he might find a postcard from the news channel to be dismissive. Jill was not recognizing the depth of his affection. He had spent a major proportion of his life devoted to Jill; she would not reciprocate.

Jill Payne comprised Tony’s sense of self, so anything that could be perceived as a slight by Jill would be an attack on Tony’s already damaged self worth.

 

From Obsession to Stalking

Tony was an “armchair stalker.” He never admitted to following Jill Payne, meeting her, or making plans to do so. But there was certainly a risk.

Although the prediction of future violence is almost impossible, I doubt that Tony would have ever tried to harm Jill Payne. In fact, I think that his fear of rejection was somewhat protective (for Jill) since he would do everything possible to avoid a slight from Jill.

But if his life disintegrated further: if his marriage dissolved, he developed a mood disorder, or other instability, he was certainly at risk for irrational or dangerous behavior.

ActionNews

After the News

I doubted that Tony was struggling with his gender identity nor with wearing women’s clothes. His true distress was about an impossible love, and obsessional  behavior. But he was at ease talking about his obsessional behavior as a function of cross-dressing. It was tangential way for me to get him connected with a psychologist. I consulted by phone with a psychologist who specialized in gender issues, and he was willing to consult with Tony. The psychologist was out of Tony’s insurance network, and he could not afford the cost of the visit.

I moved to a new city not long after I started working with Tony. I transferred Tony to the care of a colleague. He never followed-up.

I searched the internet for news stories under Jill Payne’s real name and the word “stalker.” No hits. She is still an anchor ten years after I worked with Tony.

 

References

Meloy R. The Psychology of Stalking: Clinical and Forensic Perspectives. Cambridge, MA: Academic Press. 2001.

Wise J. Most Likely to Be Stalked. Psychology Today. 8 October 2010.

 

©2016

All images public domain

The names “Tony,” “Jill Payne” and the station “WNTN” are pseudonyms.

 

 

 

 

 

In and Out of Network: The $900 million annual cost of provider credentialing

Matt Freeman DNP, MPH

“Are you ‘in networkwith Blue Cross? Cigna? Humana? UnitedHealthCare?”

My office gets these calls all day, every day. According to The Washington Post, the average wait time to see a family practice physician is 66 days in Boston, 24 days in Atlanta, and 23 days in Seattle. Dallas was the lucky city with an five-day wait.

New medical schools have scrambled to open; there have been increased enrollments in physician assistant and nurse practitioner programs. Professional schools are working harder than ever to recruit, educate, and graduate primary care providers.

Unfortunately, new primary care providers face massive barriers with insurers.

A licensed healthcare provider cannot just send a bill to an insurance company and expect a check in the mail. Insurers require that the provider undergo a credentialing process, which officially takes about 90 days, but it can take 180 days or more. Or the insurer may be “closed” and not allow the physician, physician assistant, or nurse practitioner to join the network at all.

 

Why Being “In Network” Matters

Even if seeking care for myself, I look to see if the healthcare provider I wish to see is within my insurance network. I am well aware that I have a $4,500 deductible and “in network” providers, and a $6,900 deductible and 50 percent co-insurance for “out of network” providers. In other words, I have to pay half the cost of the patient visit up to $6,900 if I see someone outside of my insurer’s network.

For the first time, the federal government is helping consumers find this information as well: beginning in January 2016, www.healthcare.gov will now allow consumers to find specific clinicians before deciding on a health plan to join.

waitingroom2

 

What is Credentialing?

Credentialing is the process used by health insurers to permit a healthcare provider to become a part of their “network” or “panel.” It involves a review of the provider’s credentials and approval of a committee. It is estimated to cost $900 million annually. (That figure is limited to physicians, and does not include physician assistants or nurse practitioners, who go through the same process.)

Insurers rightfully want to provide their enrollees with high-quality care. They seek to verify that the providers “empaneled” in their networks are appropriately educated, board certified, and do not have licensure sanctions or malpractice cases indicative of a pattern of poor quality of care.

The insurers state that they depend on “primary source verification,” meaning that they will not accept a photocopy of a diploma, transcript, or board certification. They want the information directly from the academic institution or certifying body.

Although this appears to be a logical step to prevent fraud, insurers are overlooking the fact that state boards require this information in order to issue a license. For example, my state licenses required a copy of my transcripts, proof of an internship, proof that I passed all my of board exams, written letters from the academic programs from which I graduated, fingerprints to be processed by the FBI, and a search of the National Provider Data Bank for licensure sanctions and malpractice cases.

If all of this is required to be licensed, why would an insurer need to repeat the process? Thus far, nobody has been able to answer that question.

 

The Process Starts Over Every Time a Provider Moves.

After months of “primary source verification,” a provider faces the same process from the beginning if he or she moves practices. Insurers tie each provider to a federal tax identification number. The minute that changes, credentialing has to start over.

Insurers may have specific requirements like hospital admitting privileges, “on call” services, accommodations for disabled individuals, and so forth. Likewise some practices offer a wider array of services than others, but these are small changes. Why would an insurer need to re-verify that a degree, certification, or license have been issued just because a provider moved to a new practice?

I have been re-credentialed by insurers at least three times even though my degrees, certification, and license did not change.

 

The Failed Solution

In 2002, the Universal Provider Datasource began. This gave healthcare providers and insurers are central databank of credentialing documents: certifications, employment history, diplomas, licenses, and so on.

The idea was that a provider has a unique code with the databank, and he or she then grants insurers access to his or her information. No need to fill out page after page of the same questions.

But it actually serves no clear purpose. The Universal Provider Datasource, now part of the Council for Affordable Quality Healthcare is a self-report system. Clinicians submit their information, attest to its legitimacy, but it is not verified.

Instead of streamlining the system, it just adds an additional step to a cumbersome process.

 

Even “Primary Source Verified” Information is Wrong

I am “in network” with one particular large insurer. Patients can select me as their primary care provider, and I show up in their list of available PCPs. But the information listed is wrong. Despite careful “primary source verification,” I am listed in the wrong specialty, and the system shows me as having been in practice for three years (I have been in practice since 2004.) Perhaps their “primary sources” included imagination and fuzzy math.

I suggested that they change my specialty in particular (they listed in my family practice, which I am not.) They did not change anything. It is unfortunate that I appear less experienced than I am based on their web site, but perhaps I should be willing to accept that as a compliment to my youthful appearance.

 

Pills

 

The Closed Network

A number of large insurers have shut the door to new primary care providers. Despite the shortage, these companies have decided that their patients should pay more.

For example, two insurers in my area are “closed” to new providers. The refrain I often hear is, “I called my assigned primary care doctor, and the wait to get in was three months.” It’s just as common as, “The office said that they will not see me because I have not been in for 18 months.” That leaves the patient with the option of paying the higher costs of an urgent care, the emergency department (for a non-emergency), or the expense of seeing an “out of network” provider, which is typically double the out-of-pocket cost.

When I looked at one particular “closed” network, I searched on their web site for primary care providers within 15-mile radius. Most of the names were listed two or three times, so it took a while to filter the list. Then I cross-checked the names against the state registry: one had a cancelled license and lived more than 2,000 miles away, one specialized only in geriatrics, another was a kidney specialist, several were cardiologists. Good luck finding an actual primary care provider.

 

Closed Networks Erroneously View Primary Care Providers as Interchangeable

The relationship between a patient and his or her primary care provider is reassuring, potentially life-saving, and a critical component of disease prevention and management. Everyone has different needs: some primary care providers specialize in certain areas: women’s health, people with HIV, patients who speak a primary language other than English, the elderly, LGBT populations, the hearing impaired, etc.

Although insurers claim that they “consider” providers with special skills or experience for closed networks, this is—at least anecdotally—untrue.

 

Is this this Anticompetitive?

Yes. The system favors large conglomerates.

The balance of power lies with the largest provider groups and healthcare institutions. For example, when hospitals merge, they end up with two departments offering the same service: two groups of surgeons under the same umbrella holding company. The two provider groups have greater bargaining power with insurers.

Established practices do not want the networks to be open either. For example, a study of Florida hospitals demonstrated marked price increases beyond inflation and without accounting for changes in quality of care.

Insurers could also argue that they may open networks based on patient quality data. A closed network might be swayed into accepting a new primary care provider if he or she demonstrated high marks for meeting the standard of care for diabetic patients. But what if the practice has comparatively few diabetics? Or what if the practice inherits a large number of poorly controlled diabetics, and the patients’ data will give the illusion of substandard care.

 

 

Financial Motivation for Fewer Credentialed Providers

Insurers have great interest in keeping their networks small. If there are too many providers, the insurers might face the threat of demand for higher compensation. In 2002, a law suit against Aetna, Anthem BlueCross/BlueShield, and Humana was filed by physicians in Cincinnati. The physicians argued that they were reimbursed below acceptable rates. Humana settled for $100 million and agreed to increase its reimbursements by up to 30 percent.

An even larger network would have meant even greater bargaining power against Humana, and an increased threat to their ability to reimburse below the market rate.

 

Failure of Antitrust Legislation

The courts have been reluctant to take action against anti-competitive action by insurers. Some states enacted “Any Willing Provider” legislation, which mandates that any qualified provider must be allowed to participate in a network. But a decision by Justice Scalia argued that the Employee Retirement Income Security Act (ERISA) pre-empts “Any Willing Provider” laws. Therefore “Any Willing Provider” laws in 27 states apply only to state-regulated policies, not self-funded insurance plans (those typically offered by large employers.) Furthermore, in many cases, the “Any Willing Provider” legislation is limited to pharmacies and pharmacists.

 

How Could This Be a Threat to Public Health?

1. Delays in diagnosis and treatment

Imagine that you or a loved one has an early, brewing pneumonia: fever, chest pain, maybe a little short of breath, profound fatigue. If treated promptly with inexpensive antibiotics, it will not be pleasant, but it is certainly a survivable condition.

If the wait time is anywhere from five to 66 days, that could mean delayed diagnosis, delayed treatment, and the results could be life-threatening.

2. Excess Cost as an Impediment to Care

In the pneumonia scenario, one could argue “that’s why there is urgent care.” True, urgent care clinics and “convenient care” clinics (like those inside pharmacies and supermarkets) should be able to diagnose and treat pneumonia.

I had a look at the cost of going to one of these clinics. I searched on www.healthcare.gov for unsubsidized plans available within my ZIP code. I picked the first three plans from three different insurers.

  • Plan one: urgent care is not covered at all. It is considered a “non-emergent” use of an emergency facility.
  • Plan two: 20 percent co-insurance (in-network urgent care) 50 percent co-insurance (out-of-network.) The same service in a primary care office has a $10 copay.
  • Plan three: $50 copay per visit. The same service in a primary care office has a $30 copay.

Walgreens Healthcare Clinic lists its prices as $89 to $129 for evaluation and management of an illness. Depending on one’s insurer one may or may not be able to recover some of the expenditures from a visit to a “convenient care” clinic.

UrgentCare

 

3. Fragmentation of Care

Since credentialing starts over every time a provider moves, a healthcare provider cannot necessarily take his or her patients along. For example, say that a family practice physician is in a struggling group practice. She decides to break off from the group and open her own practice. Patients will have to wait until the physician is re-credentialed in her new practice. Even worse, if networks are closed, her patients will have to find a new family doctor, and they may face delays in finding the care they need.

4. Misused Funds

$900 million per year in credentialing costs is an unthinkable expenditure of healthcare dollars. The expenditure is often redundant, incorrect, and needlessly time-consuming. A “Gold” health insurance plan is estimated to cost $4,360 annually for the average person. If we standardized credentialing, we could translate that $900 million to “Gold” coverage for two million Americans, or reduce the deductibles and copays for those with high deductible plans that individuals and families cannot afford. We would also provide those consumers with access to a wider network of providers, offering timely care and—one hopes—fewer complications.

 


Potential Solutions

1. The infrastructure already exists.

The CAQH system already collects the requisite data for credentialing, but it is self-report. External verification companies, like Optum, could actually partner with CAQH to flag sections of a provider’s profile as independently verified.

My diplomas, therefore, would always have green check mark next to them, thereby eliminating the need for an insurer to check every time I move. After all, the day I earned by bachelor’s degree, my board scores, and my grade in pathophysiology are not going to change.

 

2. Centralize the “primary source verification” process.

Although insurers do not say so, it would be reasonable to assume that many contract with the same companies—like Optum—to conduct “primary source verification.” Why not allow transparency? Once a provider has been “verified” by one of these firms, there should be no need to repeat the process.

3. Charge an application fee.

Although I would hate to give even more money to insurers, motivated providers could be asked for—say–$100 or $150 for an expeditious review of their credentials.

Insurers concede that their “network” and “credentialing” meetings are held monthly. So this would meant that a new provider could be “verified” and ready to work within six weeks rather than six months.

 

4. Closed primary care networks imperil public health and impair consumer choice. Open the networks.

The shortage of primary care providers is well-documented, and this problem is going to get worse. Insurers should not be fearful of having to pay providers fairly if their networks grow.

Two of the “closed” networks had estimated operating revenues of $15.1 billion and $12.33 billion in 2015. Their financial security is not at risk.

 

References

Bernstein, L. US Faces 90,000 doctor shortage by 2025, medical association warns. The Washington Post. 3 March 2015. https://www.washingtonpost.com/news/to-your-health/wp/2015/03/03/u-s-faces-90000-doctor-shortage-by-2025-medical-school-association-warns/. Accessed 31 December 2015.

Bonfield T. Humana settles doctors’ lawsuit. The Cincinnati Enquirer. 24 October 2003. http://www.enquirer.com/editions/2003/10/24/loc_choicecare24.html. Accessed 30 December 2015.

Noble A. Any Willing or Authorized Providers. National Conference of State Legislatures. 5 November 2014. http://www.ncsl.org/research/health/any-willing-or-authorized-providers.aspx. Accessed 2 January 2016.

Porter ME & Treisberg E. Redefining competition in health care. Harvard Business Review. June 2004. Accessed 2 January 2016.

Potter W. Health insurers watch profits soar as they dump small business customers. The Center for Public Integrity. 25 January 2015. http://www.publicintegrity.org/2015/01/26/16658/health-insurers-watch-profits-soar-they-dump-small-business-customers. Accessed 2 January 2016.

ValuePenguin. Average Cost of Health Insurance (2015). http://www.valuepenguin.com/average-cost-of-health-insurance. Accessed 2 January 2016.

 

All photos public domain

©2016

Squeezed: Four Decades of the Juice Myth

Matt Freeman DNP, MPH

Tamara

I used to live down the street from a juice stand named “Tamara.” The juice was mouth-watering: whatever combination you could imagine. The passion fruit had a perfect tang, the grapefruit was sour, the oranges were ripe and sweet. Situated at the corner of Dizengof Street and Ben Gurion Boulevard, “Tamara” was the ideal location in Tel Aviv. It was easily accessible en route to the beach, on the way back from the beach, or while out for a stroll.

“Don’t you wish we invented, Tamara?” asked my friend, Ariel. “They just have a shack, some fruit, and they hire good-looking students to serve up the juice for the equivalent of US $6.

Ariel and I would chuckle at the juice bar across the street, which was staffed by a schlubby guy. He ne never had any customers. The Tamara brand exuded refreshing youthfulness.

Tamara never claimed to be anything but a juice bar. They served juice that tasted good; just a refreshing treat. They offered no illusion that they were serving some sort of magical elixir. To my knowledge, Tamara does not serve wheat grass.

An acquaintance, Nadav, made an odd claim about Tamara. “It’s a good place for smokers,” he explained. “They need the anti-oxidants so they do not get cancer.” Although not a smoker himself, quitting smoking did not seem to be on Nadav’s radar as a disease prevention strategy. And that’s when I started to think more about juice.

 

“I’ve gone back to juicing.”

I greeted one of my patients recently, and I asked how he had been feeling. “I’m in much better shape. I’ve gone back to juicing.” Paging Nadav.

In fact, many have embraced versions of Nadav’s scientific misconceptions. Oprah Winfrey, Mehmet Oz, Gwynneth Paltrow, and others have extolled the virtues of “juicing” as the key to a healthy weight and a healthy life. Forget flu vaccine, hand washing, seatbelts, or other self-explanatory measures to protect one’s health. The answer lies in juice.

Where does this appeal come from? Why has it been so sustainable?

Juice and Cleansing

Juicing—retail or homemade juice consumption—is frequently associated with the notion of “cleansing.” There are pervasive references for the need to cleanse the liver and colon.

Amid other functions, the liver converts fat-soluble toxins into water-soluble versions, which can be tossed into the colon via bile or into the kidney for excretion in urine.

The colon removes water and absorbs some nutrients, particularly vitamin K, B12, thiamine, and ribovlavin.

The liver and colon do this regardless of what one eats or drinks. In fact, the concept of “detoxifying” the liver is not a possibility. The liver itself detoxifies, so it cannot be detoxified by an external source.

Catherine Collins, a National Health Service dietitian at St George’s Hospital in London put it best. “It’ll probably give you a chance to reassess your drinking habits if you’re drinking too much. But the idea that your liver somehow needs to be ‘cleansed’ is ridiculous.”

4302673343_1a8eaffa7e_b

The liver would actually be dysfunctional if it were to be detoxified.

Cleansing advocates argue that toxins accumulate and line the interior of the colon. Moreover, these invisible toxins are weight-bearing and cleansing therefore leads to weight loss.

This is false. The colon is actually full of perhaps trillions of microbes: bacteria, fungi, and protozoa. In fact, the bacteria in the colon serve to produce a small but significant proportion of vitamins.

Bowel obstructions can form from a variety of sources, but this is really just a version of constipation: not an accumulation of “heavy toxins.” A total detoxification of the colon would be disastrous in terms of eliminating beneficial bacteria (so called “normal flora.”) Microbes, by definition, are “microscopic,” and so they just cannot be large enough to contribute to body weight.

 

The Origins of Fruit- and Juice-Based Diets

According to restaurant analyst Andrew Freeman, the most significant introduction of juicing in popular culture was the Beverly Hills Juice Club in 1975. (I know Andy Freeman. He is a great guy. But we are not related—at least as far as we know.) Coincident with a resurgence of American “vitamania” in the late 1970s, juice became allied with the notion that it is a gateway to missing nutrients, and thus a ticket to better health.

The Beverly Hills Juice Club also shortly predated the “Scarsdale Medical Diet,” introduced in 1978. A bestseller, the Complete Scarsdale Medical Diet was the first “ultra low calorie diet.” Although not juice-specific, the Scarsdale Medical Diet permitted “sliced fruit: as much as desired.”

 

The Complete Scardsale Medical Diet

The Complete Scardsale Medical Diet was the invention of Herman Tarnower MD, a cardiologist. Whether deliberate or not, Tarnower’s low-carbohydrate, low-calorie, but fruit-permissive diet was remarkably reinforcing. Diet followers enjoyed significant weight loss at the beginning of their adoption of the diet plan. It is, in fact, the same technique used by pretty much any popular diet: caloric restriction. By swapping half a grapefruit for a meal, Scarsdale dieters were limiting themselves to fewer than 1,000 kilocalories per day.

The body responds with as one might expect in a state of starvation: it digs into energy stored as glycogen. Glycogen itself is connected to water, so there is a substantial fluid loss during the first week or two. The grapefruit or unlimited sliced fruit are not magic: it is just fluid loss.

One of Tarnower’s diet followers was his girlfriend, Jean Harris. Headmistress of the Madeira School in McLean, Virginia, Harris was losing extra pounds on the Complete Scarsdale Diet.

There was one additional element that “completed” the diet: amphetamines. Tarnower was prescribing speed for Harris, which undoubtedly led to further weight loss. The drugs also contributed to her shooting Tarnower to death in 1980. (Not to name drop again, but Jean Harris and I grew up on the same street.)

Over the coming decades, various reincarnations of The Complete Scarsdale Medical Diet surfaced. All of them followed the same caloric restriction model.

Fruit and juice, however, came to the forefront with The Beverly Hills Diet.

 

The Beverly Hills Diet

Introduced in 1996, the Beverly Hills Diet was another bestseller. The diet was the invention of Judy Mazel, who had no formal education or credentials in nutrition or the health sciences.

The first ten days of the Beverly Hills Diet are limited to fruit. The diet actually encourages diarrhea, claiming that it is a sign that the diet is working. Just like the others, the fluid loss from diarrhea provides an immediate—but not sustainable—weight loss. The starvation-based approach of The Complete Scarsdale Medical Diet seems benign in comparison with a diarrhea-based diet. According to the World Health Organization, diarrhea is the seventh leading cause of death worldwide (1.5 million deaths per year.)

I cannot help but recall my friend Kristen’s stories from med school. She had gone on some sort of educational program to Ecuador. She referred to a particular item at the breakfast table as “diarrhea juice.”

The Beverly Hills Diet later gave way to the Atkins, South Beach, and Paleo diets, all of which are variations on the caloric restriction theme.

 

Juice as a Nutritional Superpower

The combination of fruit-based diets and the Beverly Hills Juice Club evolved into the idea of “juicing.” This became an accessible option as household juicers became more affordable and retailers began selling wider varieties of juice combinations. Pomegranate/açai/blueberry smoothies are available at convenience stores. A countertop juicer sells for under $50.

No longer the domain of the Beverly Hills Juice Club, “juicing” became an option for everyone.

Authors of diet books were quick to capitalize on the availability of juice. One name emerged above all others: Joseph Mercola DO.

6950418373_5478de8eb7_b

Dr. Mercola and the Juice Miracle

On his web site, http://www.mercola.com, Joseph Mercola extols may benefits of juice, particularly how it is preferable in comparison with whole fruits and vegetables. Mercola claims that juice is preferable because, “most people have impaired digestion as a result of making less-than-optimal food choices over many years.” Mercola does not explain the pathophysiology behind his claim: would French fry consumption in the past lead to an inability to digest a banana?

Mercola’s argument is that juice permits one to “pre-digest” nutrients thereby facilitating their absorption. The notion of “pre-digestion” plays upon the same idea that previous dietary indiscretions are irreparable, and that one must consume nutrients in liquid form only.

Mercola has some particularly bizarre claims about juice. He states that it increases energy by “optimizing” the body’s pH. The acid/base balance in the body is complex and constantly adaptive system. The stomach’s buffering mechanisms allow juice to remain acidic in the stomach, but this does go beyond the stomach. If the stomach could not buffer juice, our bodies would be in miserable acidic states. Optimal pH is maintained by the body regardless of what one eats or drinks.

Mercola’s acid/base claim connects with his even more curious assertion that juice provides the body with “structured water,” and “living water.” In an insult to those who have studied the most basic chemistry class, Mercola explains that juice comes as H2O2 not H2O.

H2O2 is hydrogen peroxide. If one were to drink it, it just turns to foam, and eventually just to water. Water does not come in living or structured forms; water is always one oxygen atom and two hydrogen atoms.

 

Juice and Immunity

Mercola argues that juice “supercharges” the immune system, implying that a hyper-responsive immune system is favorable.

Immunity actually only comes two ways: deficient and adequate. There is no “supercharge” to the immune system. In fact, an inappropriately responsive immune response occurs in autoimmune diseases, in which the body attacks itself. These include systemic lupus erythematosis, scleroderma, Hashimoto’s thyroiditis, and others. The “supercharge” is to one’s detriment. Allergies, for example, a result of a “supercharged immune system.”

Commercial juice retailers are a bit more subdued. Jamba Juice argues that its Zinc and Antioxidant Boost “helps support your immune system” with a footnote, “These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease.” Tropicana omits the disclaimer, stating that an eight-ounce glass of its orange juice, “helps to support a healthy immune system.”

The only plausible way to argue “immune system support” from orange juice is that one might be spared from getting scurvy.

Mercola has a strange an futuristic explanation: “…juice supercharges your immune system” with “phytochemicals and biophotonic light energy.” I do not even know how to respond to that other than by asking, “what?”

Beet_juice-01

An antioxidant “boost” is not just dubious, it is dangerous. Nadav’s “smokers need juice” theory is problematic because antioxidants can actually exacerbate lung cancer and increase the risk of death from cardiovascular disease. Antioxidants were long believed to reduce certain activity on the surface of cancerous cells. It seemed like a good idea until the Carotene and Retinol Efficacy Trial (CARET), in which people who were at high risk for lung cancer (smokers, those with a history of asbestos exposure) were given beta-carotene supplements. The CARET trial stopped before its planned end date because those participants who received antioxidant supplements had more cases of lung cancer. (Sorry to break the news to Nadav.)

 

Juice and Alzheimer Disease

Mercola states on his web site, that juice can “Support your brain health. People who drank juices (fruit and vegetable) more than three times per week, compared to less than once a week, were 76 percent less likely to develop Alzheimer’s disease, according to the Kame Project

On the surface, the Kame project looks like a powerful endorsement for juice. In a study of 1,836 Japanese Americans in King County, Washington, who were followed for nine years. Those participants who drank juice once or twice per week had a hazard ratio of developing probable Alzheimer disease of 0.26. Those who did not report juice consumption had a hazard ratio of 0.84.

But a hazard ratio isn’t a measure of relative risk. Relative risk is the probability of an event occurring in an exposed group (juice drinkers) compared with an unexposed group (those who did not drink juice twice a week). For example, smokers have a relative risk of 20 of developing lung cancer: their risk twenty times that of nonsmokers.

Hazard ratios express the rate of an event occurring in one population (juice drinkers) versus a control population (non juice drinkers.) A test subject in a group with the higher hazard ratio has greater odds of reaching a specific endpoint first. In other words, the juice drinkers in the study had lower odds of developing Alzheimer Disease before those in the non-juice drinking group. A hazard ratio does not explain the extent of treatment benefit, so the dose of juice was not explained.

Furthermore, the Kame study only controlled for tobacco and alcohol use and a particular genotype found in Alzheimer Disease (ApoE). It did not control for significant predictors of dementia like family history or head trauma.

As an epidemiologist, one looks for certain key elements in research, such as a dose-response relationship and biologic plausibility. Mercola and the Kame study do not offer either of these core components of robust research.

Mercola’s claim that juice prevents Alzheimer Disease is not supported by the Kame study. The only possible claim is that there is evidence in one trial that drinking juice twice per week might forestall Alzheimer Disease in a specific population.

 

Joseph Mercola, the Questionable Advocate for Juicing

Perhaps Mercola is not the best advocate for juicing. Mercola was censured by the US Food and Drug Administration (FDA) in 2005 for making illegal claims about supplements. He then received a warning one year later, and the FDA warned him again in 2011. One would think that a single action form the FDA would lead one to back off, but Mercola’s supplement and book sales must be so lucrative that he is willing to look beyond censure.

Although his license remains active without sanctions, Mercola reputedly had a three-year battle with the Illinois Department of Financial and Professional Regulation, and he stopped practicing in 2012. In addition to his juice claims, Mercola opposes fluoridation, screening mammography, dental amalgams (fillings), and vitamin K administration to newborns. Although there are some debates about the appropriate ages and intervals for mammograms, these are not controversial subjects in public health.

Mercola’s allies are similarly problematic. His endorsements from a Dr. Andrew Saul are worrisome. Saul claims to have a “nontraditional PhD in ethology.” His other colleague, a Dr. Abram Hoffer, supported the use of niacin to treat schizophrenia. The research was later discredited because the diagnostic test to establish a diagnosis of schizophrenia was called into question.

Perhaps the juice industry would benefit from solid research rather than “expert” opinion from supplement profiteers like Joseph Mercola.

 

Is Juice Healthy?

Juice is not exactly a low-calorie, low-carbohydrate choice compared with soft drinks.

250 mL Serving Size

Carbohydrates kCal
Apple juice 28.97 110
Coca-Cola 35.18 105
Orange Juice 27.20 118
Pineapple Juice 32.18 140

 

One could argue that juice contains vitamins, which are not found in soft drinks. But a serving of apple juice, for example, contains only four percent of the recommended daily allowance (RDA) of vitamin C. It really is just sugar and water. It is true that other juices fair better in terms of vitamin C content, but vitamin C is found in a wide range of other foods contained in the typical Western diet.

Fresh-squeezed juice, however delicious, is also troublesome from a food safety standpoint. In fact, one of the first cases I was assigned as an epidemiology student was an outbreak of salmonella at a Florida resort. The CDC referred to outbreak location as “Theme Park A” (no prizes for guessing: it is in Orlando and has a mouse mascot.) The acid in juice was deemed to be protective, but the sweeter nature of fresh-squeezed orange juice meant that it was less acidic and thus less likely to contain salmonella. Outbreaks of Escherichia coli 0157:H7 and cryptosporidia have struck apple juice and apple cider. So much for “detoxification.”

 

Make no mistake, juice is delicious. I love fresh-squeezed juice from Tamara, I take the risk and buy unpasteurized orange juice—enjoying a small glass with my coffee in the morning. But it is not a detoxifying superfood. It is a nice dose of sugar when I wake up. But I am under no illusions. I could just as easily have Coca-Cola, it is not going to lead to weight loss, and it certainly is not going to detoxify anything.

 

 

References

Barrett S. FDA Orders Dr. Joseph Mercola to Stop Illegal Claims . Quackwatch. 6 September 2015. http://www.quackwatch.org/11Ind/mercola.html Retrieved 20 December 2015.

Cassell DK, Gleaves DH, The Encyclopeida of Obesity and Eating Disorders: Third Edition. New York: Facts on File. 2006.

Cook KA, Dobbs TE, Hlady W, et al. Outbreak of Salmonella Serotype Hartford Infections Associated With Unpasteurized Orange Juice. JAMA. 1998;280(17):1504-1509. doi:10.1001/jama.280.17.1504.

Dai Q, Borenstein AR, Wu Y, Jackson JC, Larson EB. Fruit and Vegetable Juices and Alzheimer’s Disease: The Kame Project. The American journal of medicine. 2006;119(9):751-759.

Fatsecret.com https://www.fatsecret.com/ Retrieved 23 December 2015.

Jamba Juice. http://www.jambajuice.com/menu-and-nutrition/menu/boosts/boosts. Retrieved 20 December 2015

Kelm H. A Reply To The American Psychiatric Association Task Force Report on Megavitamin and Orthomolecular Therapy in Psychiatry: The HOD Test” Orthomolecular Psychiatry 1978: 258–262.

MacVean M. Juicing Trend Still Going Strong in 2015. The Los Angeles Times. 29 January 2015. http://www.latimes.com/health/la-he-juice-20150131-story.html. Retrieved 19 December 2015.

Mercola J. Health Benefits of Juicing. http://articles.mercola.com/sites/articles/archive/2015/04/11/health-benefits-juicing.aspx

Mercola J. Juicing : How Healthy is It?http://articles.mercola.com/sites/articles/archive/2014/04/19/juicing-benefits.aspx Retrieved 20 December 2015.

Mercola, Joseph. Malpractice settlement 23 December 204, $387,925. https://www.idfpr.com/Applications/ProfessionProfile/ProfileDetails.aspx Retrieved 21 December 2015.

Mohammadi D. You can’t detox your body. It’s a myth. So how do you get healthy? The Guardian. 5 December 2014. http://www.theguardian.com/lifeandstyle/2014/dec/05/detox-myth-health-diet-science-ignorance. Retrieved 20 December 2015.

Omenn GS. Chemoprevention of lung cancers: lessons from CARET, the beta-carotene and retinol efficacy trial, and prospects for the future. 2007. European Journal of Cancer Prevention. 16:184-191.

Saul, A. http://www.andrewsaul.com/bio/. Retrieved 21 December 2015.

Tropicana. http://www.tropicana.com/#/trop_healthbenefits/hbMain.swf Retrieved 20 December 2015.

Watson R & Hodgekiss A. Fruit juice should not count in our five-a-day because some versions ‘contain as much sugar as fizzy drinks. Daily Mail. 10 February 2014
http://www.dailymail.co.uk/health/article-2555758/Fruit-juice-NOT-count-five-day-versions-contain-sugar-fizzy-drinks.html#ixzz3vCiNcpyB. Retrieved 23 December 2015

Wilson J. Juicing Pros and Cons. CNN 11 April 2014. http://www.cnn.com/2014/04/11/health/juicing-pros-cons/ Retrieved 20 December 2015.

World Health Organization. Top Ten Causes of Death http://www.who.int/mediacentre/factsheets/fs310/en/ Retrieved 20 December 2015

 

All images public domain

©2015

 

 

10 out of 10: The Risks and Misuse of Patient Satisfaction Data

Matt Freeman DNP, MPH

 

“10 Out of 10”

When I purchased a car some years ago, I remember it as a favorable experience. The saleswoman was organized, cheerful, and I was given a generous discount. But the experience left a bitter taste in my mouth. As I left, she said, “You will receive a survey soon. Be sure to give me  ’10 out of 10′ on everything or I will lose my job.”

It seemed a little hyperbolic. How could one survey wreck this woman’s livelihood?

A Vice President for the particular car manufacturer had gone to my school, and I decided to send him an email. He called me within the hour. “That’s not how this is supposed to work,” he said. “If we only got ’10 out of 10′ on everything, why would we bother asking?”

AutoShowroom

Aside from the expectation that all customers will give a perfect score, Likert scales are easily misinterpreted. One can picture “metrics” displayed in the break room of the auto dealership: “Our average satisfaction went up from a 9.0 to a 9.25 last month!”

This is miscalculation. One cannot take a mean or average score of Likert survey responses. Using means or averages makes an assumption of equidistance: the difference between a “7” and an “8” is assumed to be the same as the difference between an “8” and a “9.” There are statistical methods for analyzing Likert data, but these are often absent from social science research, so one would be unlikely to see robust statistical models at an auto dealership.

The greater question is, “What are you going to do with the information?” Let us imagine that the auto dealership was earning a “2” from most of its clientele. What can the sales personnel do to correct this? Be nicer? Offer candy? Flirt? The salespeople arguably have little control over the ratings that their customers submit. Perhaps there is a red flag if one salesperson uniformly gets lower scores than everyone else, but one would assume that there would be other indications of a problem, such as a poor sales record.

 

The “10 out of 10” Expectation is Dangerous in Healthcare

“Every patient after every visit.” It is a line I have heard from multiple directors of primary care services. “Everyone gets a survey.” The goal seems to be to a mass of data collection.

It is hard to see how this information would not be skewed. At one HMO where I was a patient, I was asked to check survey boxes before I had even met with the clinician who was to take care of me. Only the most daring patient would write anything negative while his or her doctor, nurse, or other provider was sitting right there.

One can see how the advance survey might work in a healthcare provider’s interest. A patient might be about to receive bad news: “Here, give me a 10 out of 10, and then I will tell you about your poor prognosis, or how I want you to quit smoking, why you need to exercise more, or whatever else you might not want to hear.”

Survey

In clinics where I have worked, patients were given slips of paper with Likert scores immediately after their visits. Although anonymous, the results were typically pointless: “20 people gave us ‘5 out of 5’ this week.” It provides a nice pat on the back, a reassurance to management that our patients appeared to be happy, and we could conveniently say, “We got the same great scores a year ago.”

Even those surveys that offered the option for narrative responses, these were not constructive. Patients might write, “Everything was fine,” or “I like nurse Beth.” Nice to know that Beth is appreciated, but there is nothing to do with this information.

 

Satisfaction and Wellness Can Be Inversely Related

In a study of 52,000 patients, researchers from the University of California Davis identified that patients with the highest satisfaction scores had a mortality risk 26 percent higher than less satisfied patients. The most satisfied patients were less likely to have emergency department visits, but were more likely to end up hospitalized, have greater healthcare costs, and be on more prescription medications.

There are multiple theories as to why the most satisfied patients are dying sooner. Researchers particularly identified prescription drug expenditures as an indication that patient expectation guides clinician behavior. A patient expects a certain medication, and is satisfied if the prescriber orders it without respect to cost, risk, or medical necessity.

The satisfied patient may also be hearing only what he or she wants to hear. In order to boost survey scores, providers may be ignoring more difficult conversations about adherence to medication regimes, lifestyle issues like weight or smoking, or similar concerns that could upset a patient.

One physician explained to me that he and his colleagues abbreviated their physical examinations because the momentary immodesty or embarrassment lowered their patient satisfaction numbers. It is rather like saying, “We stopped giving tetanus vaccines because patients might complain that their arms became sore.”

 

Pay for Performance

Two years ago, the Center for Medicare and Medicaid Services (CMS) began including patient satisfaction into hospital reimbursement. The stakes are high: about $1 billion in annual hospital payments is based upon responses to a 27-question patient satisfaction survey. The survey is not the only “pay for performance” measure used; hospitals and their staff are also evaluated on their adherence to standards of care, and other presumably measurable elements of patient care. The patient satisfaction survey accounts for 30 percent of the “pay for performance” payments.

ED.jpg

Hospitals have struggled because patient satisfaction is unpredictable. Furthermore, patients are not admitted to the hospital for a positive experience. “Do you think it is a great experience when I tell you that you have stage-four cancer and you may be dead in three months?” explained a chief nursing officer.

Another nurse executive recalled a patient who was fortunate to survive a stroke but complained that the meals in the hospital were too cold. Surviving a life-threatening illness and receiving high-quality care for a stroke still cost the hospital a pay cut because the food was not to the patient’s satisfaction.

HospitalFood

The circumstances can be far more hazardous than just lukewarm hospital food. A nurse questioned a South Carolina emergency department physician when he ordered hydromorphone (Dilaudid) for a woman with a toothache. Hydromorphone is a powerful narcotic that is actually used in executions by lethal injection. The physician explained that his patient satisfaction scores had dropped in the past month, so he was making any effort to please patients, even if it was a bizarre choice of an unnecessary and potentially hazardous medication.

A family practice physician explained to me that he prescribes codeine cough syrup to every patient with a cough “because they enjoy it.” Although not as potent or as dangerous as hydromorphone, codeine carries many risks, and should only be prescribed if the patient needs it, not for a good time.

Dilaudid

A Cheating Culture

A hospital executive explained to me that nursing staff were calling recently discharged patients to “coach” them on patient satisfaction surveys. Although the mechanism was unclear, there were rumors that the hospital staff found a method to ensure that the most problematic patients never receive the survey. When so much money is at stake, it is unsurprising that healthcare facilities would turn to dishonesty to manipulate survey results.

The manipulation of survey data is not unlike the scandal-fraught “pay for performance” efforts in public schools. Michelle Rhee introduced an elaborate pay for performance strategy when she became Chancellor of the District of Columbia Public Schools. Rhee had grand displays of $8,000 to $10,000 checks given to teachers and administrators when their students’ scores increased on standardized tests. Journalists from USA Today identified that teachers were “correcting” their students’ test responses. Once the District enacted a security policy that prevented tampering with test responses, the students’ test scores plummeted.

MichelleRhee

Michelle Rhee

 

The DCPS scandal was one of many. In 2013, Beverly Hall, Superintendent of the Atlanta schools, was indicted in a similar test manipulation scheme. When the financial stakes are so high, student achievement and ethics are cast aside. Dr. Hall herself received $500,000 in performance bonuses. She was described as a leader who, “allowed cheating—at all levels—to go unchecked for years.”

 

“Satisfaction” in the Healthcare Context

Aside from food served at the right temperature, how can healthcare providers and facilities ensure high satisfaction ratings and thus higher pay?

The first problem is that patients are usually sick! No relationship is going to feel particularly great if it is in the setting of an illness, needles, surgeries, tests, anxiety, and so forth. Furthermore, people who struggle with psychiatric disorders that affect interpersonal relationships are over-represented in primary care clinics. Studies have estimated an 18 to 26 percent prevalence of borderline personality disorder at a primary care clinics. That seems like an overstatement, but one could safely argue that a variety of psychiatric conditions are over-represented in those seeking primary health care.

If one is looking for favorable patient satisfaction survey results, looking to those who do not feel well or those with personality disorders would not be good choices.

IllPatient

In some instances, satisfaction survey tools and expectations are not designed by anyone with a healthcare background. In one practice where I worked, there was a “zero tolerance” policy for patient complaints. This is absurd. If one is ill, perspectives can be blurred: anxiety and depression can be exacerbated, patients and their families may seek to blame someone for an illness. Above all, the costs of healthcare can trigger complaints. I covered my own employees by “accidentally” failing to mention complaints. These were almost never substantive, and I often did not even bother telling the physician, psychologist, or nurse that anyone had bothered to complain. There was nothing to gain from the complaint other than anxiety and self-doubt.

I supervised one physician who was often the subject of complaints. Patients felt that he was not warm or engaging enough. He had a cerebral, introverted, and thoughtful approach. His medical judgment was sound, and he had a fantastic sense of humor. He had top-ranked credentials, and offered meaningful insight when we worked together as a team. What was I going to do with the complaints? Turn to him and say, “Change your personality. Watch this video about how to be more ebullient or I will cut your pay.” I never said a word to him.

Anyone who has worked as a healthcare provider or in healthcare management recognizes that “10 out of 10” from every patient is an unreasonable expectation.

 
“It Was a Pleasure to Participate in Your Care Today”

My Israeli colleagues were teary-eyed with laughter when they watched American instructional videos about how to improve their relationships with patients. The videos seemed to imply that one had endless time during visits, and that “canned” statements replaced authenticity. They were must amused by running consent narrative that was deemed to be satisfaction enhancing. “I would now going to look into you ear, is that okay with you Mrs. Johnson?” It is hard to imagine that Mrs. Johnson really cared that much; she probably just wanted her earache to go away.

A friend at a large university medical center is required to conclude every visit with, “It was a pleasure participating in your care today.”

Instructional videos, workshops, and guides designed to elicit higher patient satisfaction omit variation among clinicians as well as a critical force in the provider/patient relationship: authenticity. It seems self-explanatory that patients would rather converse with a real person rather than someone using pre-programmed speech and phrases.

Asking permission to look in someone’s ear or the odd expression of “pleasure” in participating in a patient’s care overlook the more critical role in better patient care: shared goals. One would assume that the most satisfied patients have their needs met. A patient may need to just talk, may just need pain control, or may need reassurance that his or her symptoms will improve with time. A savvy clinician seeks to establish to make shared goals and expectations.

I have worked with adolescents and young adults for 15 years, and I have seen thousands of patients for pre-participation examinations for athletics. My usual line is, “Are you the kind of patient who would like a ‘play by play’ explanation of what I’m doing, or have you done this a lot before, and would you prefer me to just ‘get it over with?” Patients almost invariably choose the latter. In other words, the patient’s goal is to just get out of there with their paperwork signed. That scenario is never presented in patient satisfaction training modules.

 

Weighing Medical Judgment, Ethics, and Scores

Sometimes the signature is not an option. Saying “no” is a part of medicine. What if the teenager or young adult does not meet the medical requirements for the particular sport? You can forget customer satisfaction. The patient (and probably his or her parents) just wanted a signature regardless of the sound reasons to be concerned about the patient’s health. Even if the answer is a request for prior records, a chance to talk with another healthcare provider, or an additional test, the visit is catastrophic from a satisfaction standpoint. Cheerleading practice starts this afternoon, and the doctor just told the cheerleader that she has to wait until the x-ray results are back because her wrist appears broken. There will not be a “10 out of 10” for the doctor that day, and he or she may face a pay cut because of it.

In a similar example, patients with sleep apnea are required to undergo a commercial driving license examination every year instead of every two years. If a healthcare provider wanted higher satisfaction scores, he or she would be wise to ignore the Federal Motor Carrier Safety Administration guidance and issue a two-year license. But this action puts patient expectation and satisfaction a priority over the safety of the patient and the public.

Like a teacher in Washington or Atlanta shortchanging students’ educations in exchange for financial incentives, a doctor can easily be lured by the threat of a poor survey response. Maybe he or she will “accidentally” overlook a broken wrist or sleep apnea, or just not examine the patient’s wrists or ask about sleep apnea. Then everyone can be happy about the outcome of the visit. Attention to medical ethics and the long-term consequences to individual and public health do not provide cash incentives.

Patients may ask for medications that may harm them, tests they do not need, approval to continue health-compromising behavior, unlimited access to their providers, and other unrealistic expectations. Of course one should say “no” with a combination of professionalism and problem solving. But the answer is still “no,” regardless of how gently and sensitively the message is conveyed.

 

Online Reviews

Satisfaction surveys  impact reimbursement directly. Online reviews can prevent patients from coming in the first place, equally affecting a clinician’s income livelihood.

Yelp.com is the leader in online reviews. As with all of its reviews, Yelp does not verify if a patient was even a patient at all. Anyone can write a review any time. Restaurant owners bemoan Yelp reviews in which customers complain about the salmon but the restaurant does not even serve salmon. The same applies in healthcare: a Yelp reviewer does not even have to have met the doctor better yet visited as a patient.

In my case, Yelp was an invaluable resource. Without any money paid to Yelp, I ended up getting ranked “#1 Best Doctor” in my city. Patients flooded in. But it was not really fair. I was happy to have the business, but the Yelp reviews had nothing to do with my clinical acumen, education, or other abilities. In fact, subsequent practices consulted my Yelp reviews when they made the decisions to hire me.

Yelp

Some cases were baffling: one woman wrote about a negative experience with me but continued to see me as a patient. Although I did everything possible to remain objective, I desperately wanted to say, “You defamed me in a permanent, public fashion, and now you want me to treat you?” I quietly ignored the review since Yelp is theoretically anonymous. This also exemplifies the over-representation of borderline personality traits or borderline personality disorder in primary care (borderline patients tend to follow the pattern of, “I hate you; don’t leave me.”)

Yelp could have easily broken my practice, income, and future employment. A handful of negative reviews, and five stars drop to four. Yelp and other online review sites have proliferated, so one can only hope that favorable reviews outnumber the duds.

 

Empowerment versus Manipulation

Patients who are aware of the financial implications of an unfavorable survey or Yelp review can influence the objectivity of their care, even if it is to their own detriment.

A friend told me of a patient who threatened his primary care provider with a negative online review. Consequently the practice overlooked the patient’s unpaid bills and withheld addressing his poor adherence to medications and markedly unhealthy lifestyle. He was to receive large discounts and only good news about his health.

Another former colleague faced a woman who snapped, “I’m going on line and telling everyone about you” because she did not receive the antibiotic she thought she deserved.

In the expanding dictionary of medical slang, the most frightening patients are referred to as “bcc.” This refers to the email selection of “blind carbon copy,” a patient who says nothing to his or her treating provider but submits a negative survey response or derogatory online review.

A friend outside of the medical profession asked me if I ever felt badgered in to ordering an inappropriate test or prescribing the wrong medication due to fears of a negative survey or review. “Absolutely!” I replied. He was shocked. “The customer is always right, even when the customer is a patient and you are trying to keep him healthy.”

Patient satisfaction is not to be confused with patient empowerment. The empowered patient is an active participant in his or her care, knowledgeable about his or her health status, assertive, asking questions, and willing to request a second opinion. This is reasonable and helpful.

My least favorite patients say, “Whatever you say.” I would much rather have a patient who is willing to say, “I was reading about this before I came in.” That way, I know what might be worrying the patient, what tests or medications the patient expects, and might shed light on a diagnosis or treatment that I had not considered.

The empowered patient is not threatening or manipulative like a “bcc.” He or she is honest and informed, and expectations are articulated. Above all, an empowered patient feels safe asserting his or knowledge, needs, concerns, or even misgivings. An empowered patient is not necessarily going to balk if a doctor contradicts what the patient anticipates.

The manipulative patient may or may not voice his or her expectations, unreasonable expectations, a personality disorder, or any other confluence of factors that can lead to dissatisfaction. This dissatisfaction can result in a form of “acting out:” the patient can argue that he or she has leverage in the form of surveys and reviews.

 

Moving Forward

Reviews and surveys have become embedded in American culture, and they are unlikely to go anywhere. But there are a few steps that could help make better use of the data collected:

  • Satisfaction scores should never be tied to compensation. This leaves far too much room for cheating, and it can produce a culture in which patients are given inappropriate or even dangerous medications, tests, procedures, and advice.
  • “Every patient, every time” collects an extraordinary amount of data, but it is unclear about how this can be used to improve patient experience. As with any survey tool, the first question to ask is, “How are we going to act on the results after we analyze the data?”
  • “10 out of 10” from every patient is unreasonable, and is incompatible with safe, effective healthcare. As the auto manufacturer vice president put it, “What is the point of asking if you get a perfect 10 every time?”
  • Any use of Likert scores should employ sound statistical models.
  • Canned phrases like, “It was a pleasure participating in your care” can be demeaning to patients. These really just indicate that the healthcare provider went through a training course, and that he or she is likely subject to evaluation. Authentic, genuine, honest, and respectful communication should be the expectation.
  • Healthcare providers and their employers have to remember that Yelp and similar online review sites are not a reliable measure of provider performance. In fact, healthcare facilities and providers should take the lead by educating the public on how online reviews maybe skewed. I write this knowing that Yelp was invaluable to me as I built a practice.
  • Except in emergencies, patients overwhelmingly have a choice in providers and facilities. If a patient is dissatisfied, he or she would be wise to just seek care elsewhere. Just as if one did not like the steak served at a restaurant, it seems wiser to go somewhere else next time rather than berate the chef in a satisfaction survey.

 

References

Adamy J. US Ties Hospital Payments to Making Patients Happy. The Wall Street Journal. 14 October 2012. http://www.wsj.com/articles/SB10000872396390443890304578010264156073132. Retrieved 11 December 2014.

Falkenberg K. Why Raiting Your Doctor Is Bad For Your Health. Forbes. 2 January 2013. http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/. Retrieved 11 December 2014.

Fausset R. Central Figure in the Atlanta Schools Cheating Scandal Dies. The New York Times. 2 March 2015. http://www.nytimes.com/2015/03/03/us/central-figure-in-the-atlanta-schools-cheating-scandal-dies.html?_r=0. Retrieved 11 December 2014.

Fenton JJ, Jerant AF, Bertakis KD, & Franks P. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012; 172(5):405-411.

Gross R, Olson M, Gameroff M, Shea M, Feder, A, Fuentes M, Lantigua, M & Weissman M. Borderline Personality Disorder in Primary Care. Arch Intern Med. 2002; 162(1):53-60.

Whitmire R. The Bee Eater. New York, NY: Jossey-Bass. 2013.

©2014

All images public domain

Pathological Flyers

Matt Freeman DNP, MPH

Charging Lattes

The airline ticket from New York to Washington was $700. It was a trip from Midtown New York to a location near the Capitol in Washington.

The sensible options would have been a train or the one of the hourly shuttles from La Guardia to National.

“Sylvia,” an executive at a struggling nonprofit, insisted that she travel only on United Airlines, and she expected to fly in first class for the 40-minute flight. United does not fly “The Shuttle” between La Guardia and National Airports, and first class was not an option then. So she arranged for a ticket from Newark Airport to Dulles Airport, with limousines on both ends of the trip. This added almost 70 miles of extra time on the road between the airports and the city center, not to mention the airfare difference and cost of the limousines.

This was the final act of pathological frequent flying that led to Sylvia’s dismissal from her employer. For roughly a year, she had been flying once or twice a month from New York to San Francisco. The nonprofit had no office in San Francisco, but she would arrange to have meetings there. She never expressed any particular passion for San Francisco, no significant other who lived there, but she relished in the 2,500 frequent flyer miles she would accrue for each flight.

Although her social life was limited, she would invite friends or associates to lunch. Sylvia would insist on using her own credit card and obtaining cash reimbursement from her friends. The reason was to gain more miles with her credit card. She frequently bragged that she used her credit card at Starbucks every morning. A $4 “Grande” latte every morning could yield 1,460 miles… enough miles to go nowhere. It would require one latte per day for more than eight and a half years to redeem a restricted, one-way, economy class ticket within the 48 contiguous United States. But this was immaterial to Sylvia.

Starbucks

Photo: Starbucks

 

In fact, Sylvia had no grand plans for her miles. She was not a jetsetter, enjoying five-star hotels or luxurious first class flight rewards. Her interest was merely in accumulating the miles, and bragging about her “elite” status with United Airlines. Without a partner, close family, children, or other passions in life, the miles became a surrogate for her self worth. Her airline “status” was perhaps a substitute for a contribution to her community, science, education, the humanities, the welfare of others, or even a sense of self.

Sylvia’s behavior was pathologic. Her behavior met the definitions of psychopathology: unexpectedness, statistical infrequency, violation of social norms, impact on personal relationships and work, and significant personal distress.

This was not a woman who was enjoying an art of a good deal, a special perquisite for loyalty to an airline, the freedom of travel, or an interest in airplanes. Her attachment was to the miles themselves and nothing more.

Until her Newark-Dulles first class escapade, Sylvia figuratively “flew under the radar.” The American middle class knows all about frequent flyer miles. It is perhaps unusual to see someone without an airline-branded credit card or no frequent flyer account. It is not a violation of a social norm to want miles for a free ticket or an upgrade to first class. But a subset of the flying population, Sylvia included, is what one might consider to be a “pathological flyer.”

Many people in the world are fascinated by travel, planes, and flying. It is a part of their lives and personalities. These enthusiasts are experiencing flying as an ego-syntonic phenomenon: they are comfortable with themselves and their lives, and frequent flying is part of who they are. Sylvia’s desperation and obsession was likely to be disharmonious with her personality and values and thus ego-dystonic. She was suffering from her need for miles and status.

I am no stranger to this myself. I grew up loving airplanes. I have old airplane photos in my office. I enjoy travelling to visit my family and see the world. I enjoy looking out the window, watching shiny jets at the airport, and I do try to snag a good deal if I can fly in first class rather than the back of the plane. At family gatherings, we often find ourselves musing over the best options for flying from one place to another, which airline might offer better service, and what research we have accomplished online to figure this out. It is perhaps just our lifestyle living on four continents.

 

Airline “Status” as a Sense of Self

Subsequent to Sylvia, I became particularly fascinated when I observed a 50-something woman enter a loud, distressed, and histrionic tantrum at an airport ticket counter. The agent had forgotten to affix orange “priority” tags on her checked baggage. I speak from experience that such tags are usually meaningless, but they were a “tipping point” for this woman. She made an explosive tirade in front of the crowded terminal, making a point of her high-ranking status with the airline’s frequent flyer program.

tags

The treasured but meaningless orange tag

 

 

This woman frightened me. Her behavior was entirely dysregulated, she was impulsive, distraught, tearful, and inconsolable.

After she was escorted to an airline club, I spoke with an agent about her. “She’s lonely. We are like her family, so she expects us to be something more than an airline to her.” In a prior instance, she was incensed that the airline had no cake acknowledging her birthday.

The agent was insightful. “There are a lot of them,” she remarked. “It’s sad.” It turned out that this woman was going to Shanghai for a day… just to earn frequent flyer miles. As far as the airline knew, she had no business, friends, or interest in Shanghai.

When I returned from my trip, I presented her case in our weekly psychology case rounds. Although not our patient, I was equally fearful and fascinated by her behavior. The room rose with chatter. All of my colleagues had witnessed “pathological flyers.”

One of the psychologists on my staff compared it to gambling addiction. “She placed all of her chits into the frequent flyer game, and she did not get the payout she was expecting.”

I likened it more to histrionic narcissism. Narcissists cannot tolerate the smallest of slights, so failure to apply a meaningless orange baggage tag came across as an attack on her sense of her value as a person.

 

The Public and Private Worlds of the Pathological Flyer

In The Presentation of Self, Sociologist Erving Goffman defines human interactions in terms of a stage: front, back, and off stage. When living life on the “front stage,” people are aware that they are watched, in public, and they conform to social norms. But the anonymity of air travel erodes the front stage. Flyers—frequent and periodic—may lose this emotional regulation and go “off stage.” Like the problematic gambler who is otherwise living within social norms, pathological gamblers and flyers are easily disquieted when their expectations for winning are unmet.

Of course airports and airplanes in which people step “off stage,” to use Goffman’s analogy. The fatigue, stress of flying, and status-seeking certainly takes place at hotel reception desks, and most everyone can recall a histrionic display of entitlement involving the host or hostess of a restaurant. But the complexity and tension of flying lend themselves to maladaptive and disruptive behavior.

 

Exclusivity

There was a common theme among discussions of frequent flyer behavior: special treatment. Flyers’ war stories almost inevitably included the story of how a ticket or gate agent broke a rule, held a flight behind, or offered some sort of other perceived act of heroism because the traveler was of adequate frequent flyer elite status to warrant treatment better than “regular” passengers.

There is a sad reality to this “status” based world. The Association of Flight Attendants (AFA), the union that represents the Continental Airlines subsidiary of United Continental Holdings, explained that passengers with the highest level of frequent flyer status had an extraordinary power: a complaint from one of these passengers could result in immediate termination. Although the union and the airline are still debating this policy, it is a powerful reinforcement of the “status-holder” psyche: “I am a high level frequent flyer, and if you do not give me what I want, you can lose your job.” The missing orange luggage tags could have cost someone his or her job. Ironically, United’s erstwhile slogan was, “You’re the boss.”

El Al

Photo: El Al

 

 

In the pathologic flyer’s mindset, rewards are based on status not kindness, altruism, or reciprocity. The system limits “self” to a tier in a frequent flyer program. In the simplest form of behaviorism, the only incentives are to have more miles and more status. Conscience, ethics, and the superego are irrelevant. An airline agent’s willingness to reroute a passenger, upgrade someone to first class, or provide a hotel room in the event of a mishap is not based on the passenger’s need or altruism. It is a caste-based economy.

The caste divisions are dynamic. Airlines change their requirements for various levels of “status,” thereby adding to an anxiety over losing one’s perceived social capital in world of air travel.

This is a climate largely limited to flying. I receive a warm greeting from the cashier at the supermarket on my block, the staff at the post office are pleasant, the barista on my corner knows who I am, and says hello. If I were to be short on change one day, he would likely help out. The woman at the supermarket on my block in Tel Aviv went to the back to get me a fresher loaf of bread from the bakery yesterday. None of this was based on my “status.” It was a matter of being a customer in their establishment. And I am (usually) calm, smiling, and say hello to each of these people. There is no status system to dictate how I am treated. Whether I was going to spend 100 shekels or 900 shekels, the woman at the supermarket was going to make sure that I got the better loaf of bread.

Furthermore, a tantrum over luggage tags would be met with rolled eyes rather than a fear of losing one’s job. Outside of the world of flying, there are plenty of histrionic “Do You Know Who I Am?” explosions, and they are usually met with clenched teeth by bystanders rather than frantic attempts to prevent the customer from filing a complaint.

 

Moving Forward: Taking the High Road
One of the cornerstones of behavioral therapy is to allow the patient to share his or her decision-making. In the case of an impulse control disorder, like hoarding of compulsive shopping, the therapist asks the client to “talk through” his or her own decision-making. “Tell me why earning these miles is important to you. What are your plans for them? What do they mean to you?” “How is this affecting your life?”

This pathway to insight can be accompanied by the reality that airlines are not the same as families and relationships. Airlines exist to produce revenue for their owners and shareholders. Indeed there are millions of kind airline employees across the world, and they do want passengers to be happy with the service they provide, but this is a job, an effort to make money, and not the same as social and family relationships.

But the pathological flyer is unlikely to seek care. Unless noted by a concerned friend or family member, or if the flying leads to sad consequences like Sylvia’s loss of a job, it is not likely to present itself to a therapist or primary care provider.

The airlines are tacitly complicit in the perpetuation of this pathology. A pathologic flyer, however nettlesome to employees and other passengers, can generate tremendous revenue. Unlike a slot machine, an airline cannot place a sticker warning of the risk of “problem flying” or a toll-free hotline to call for help.

If anything, this is a call for further research. The public and healthcare providers should be cognizant of the pain of the pathological flyer, and be prepared to intercede.

©2014