https://youtu.be/-p4ufHaQDhw

Baltimore Mayor .. “we gave them space to destroy “

DEA: Prescription drugs stolen in Baltimore flooding the streets

http://fox2now.com/2015/06/25/dea-prescription-drugs-stolen-in-baltimore-flooding-the-streets/

The open-air drug markets of Baltimore are flush with new product this summer. The source, at least in part, is more than 30 pharmacies and clinics looted in riots following the death of Freddie Gray in police custody.

More than 175,000 doses of opiates and other prescription drugs were stolen and are now on the streets, according to the Drug Enforcement Administration. Enough Oxycodone, Suboxone, Morphine, Fentanyl and other drugs says the DEA to keep the city’s drug users high for a year  – A gift from the Mayor ?

In a city with a large heroin-addicted market, the influx of looted drugs is adding to the problems facing police and city officials already struggling to deal with a sharp rise in shootings and murders. Law enforcement officials believe the new flow of prescription pills will breed new addicts and more violence. Many of those addicts will turn to cheaper heroin from the open drug markets later.

In response to the city’s plea for help, the Drug Enforcement Administration and other federal agencies are seeking to prosecute the leaders of gang and drug dealing organizations.

Gary Tuggle, who grew up in Baltimore’s east side and worked as a Baltimore cop, says his agency has drawn a list of potential suspects. Before taking over the agency’s Philadelphia office, Tuggle led the DEA’s efforts in Baltimore. He allowed CNN to tag along for a first-hand view of the drug markets and his agency’s effort to thwart them.

Back when Tuggle was a Baltimore police officer more than a decade ago, he recalls “the street purity of heroin was 2-5%. Today we are seeing purity levels up to 80-85% and then some cases, a kilo of heroin would cost $140-160,000. Today you can get it for between $65 and $70,000 so you see the economics of it when you have a level of supply and level of demand that uses that inventory its literally bringing the cost down and purity levels up.”

According to the DEA, prescription opiates can go for as much as one dollar per milligram and it doesn’t take long for users to run out of money to support their prescription habit, eventually turning to the imported black tar heroin from Mexico or powder heroin from Asia, which is much stronger and cheaper.

In the neighborhoods surrounding where Freddie Gray was initially arrested, more vacant homes are appearing, more shops are closing, which means “the drug dealers have the corners for themselves,” according to Tuggle.

According to the DEA, the influx of drugs on the streets is inflaming turf wars between gangs and independent drug dealers who are competing for territory, which is vital to a drug dealer’s revenue stream.

“In some cases you have the gangs taxing other gangs or independent drug dealers,” Tuggle says. Other times, gangs feel their territory is being threatened, which leads to a disruption in the balance of power and “that’s only going to lead to violence.”

That partly, police say, explains the 42 murders in May, Baltimore’s deadliest month in 15 years.

Signs of the fresh supply of drugs are visible, Tuggle tells CNN during a ride past Baltimore’s heaviest drug-trafficked sections.

The alleys — or “dips” as they are known to law enforcement — where most of the deals used to go down are largely empty. Because of the thinner police presence in the area, they are free to operate in the open.

In one neighborhood of row-houses about two miles from the tourist attractions of the Inner Harbor neighborhood, it’s not long before cars come to a stop in front of two pedestrians engaged in an alleged drug deal in the middle of the road.

“Twenty-five years ago when I grew up here, you didn’t see open air drug deals,” Tuggle said. “That was something you didn’t see, you had to go into the alleys to find those deals. Today as you’ve seen, it happens in the open.”

In some areas, the presence of the DEA agents in unmarked cars are quickly noticed.

“Five-O,” some called out. Lookouts immediately alerted the dealers and customers to the presence of law enforcement. Some were kids, agents said, as young as 10 years old paid $50-$100 a day to ride their bikes on corners and whistle at the first sight of police or suspicious, unmarked cars.

Agents say drug users know which parts of town are best for heroin or other drugs: from the Sandtown area, with a booming heroin market, to the streets outside the historic Lexington Market in downtown, where prescription opiates have shown up, according to agents. Agents say the drug users are easy to pick out because of their tell-tale “nod,” some leaning over precariously without falling over during their high.

Outside a methadone clinic, teeming by 8 a.m., the streets and alleys were buzzing. Agents say at least some in the crowd were dealers and users either attempting to ween themselves off the opiates, or immediately selling daily methadone dose for a quick buck to spend on more heroin.

Tuggle says that law-abiding residents of areas most affected by the drug dealing are victims of drug users who come from all over the region. The DEA is now circulating pictures of up to 70 individuals they say are directly responsible for the surplus of looted drugs.

“At the end of the day these communities have very, very decent people, hardworking people who want to work and educate their families and support their families. But at the end of the day you would see what I call piranha. A lot of these people dealing in these neighborhoods are not from these neighborhoods. Some of them have nice homes in the suburbs or they live in high rise apartment sin downtown Baltimore. So they come into these communities to take advantage of these communities.”

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Teens, adult arrested in Indianapolis pharmacy robbery ring

http://www.wthr.com/story/29380299/teens-adult-arrested-in-indianapolis-pharmacy-robbery-ring

INDIANAPOLIS – Indianapolis Metro Police say they’ve broken up a robbery ring that targeted Indianapolis pharmacies. An adult and three teens were arrested.

A day doesn’t go by without hearing about another CVS or Walgreens robbery, but it’s not money the crooks want. They’re after prescription drugs they can sell on the street. Investigators say the suspects they captured may be responsible for ten or more robberies.

Most of the robberies involved teenagers who police suspect have been recruited to take part in the robberies.

Shortly after 2:00 pm on Father’s Day, two officers working undercover outside the Walgreens on E. 38th St. became suspicious about a 15-year-old girl and 14-year-old boy entering the store. The boy acted as a lookout while the girl handed the pharmacist a robbery note demanding pills.

Police have dozens of young suspects like these caught on camera in pharmacy robbery after pharmacy robbery. In this case, the suspects took off running into the apartment complex next door, where police say 25-year-old Kadeem Wright waited in their get away car.

Witnesses pointed out the car that sped out of the complex. When stopped by officers, police reportedly found the robbery note, a loaded handgun and clothing worn in other robberies caught on camera.

Now police say the 25-year-old, the 15-year-old girl and boys 17 and 14 years old may be responsible for four to ten area pharmacy robberies.

Investigators are sending this case to the FBI Violent Crimes Unit for possible federal charges against Kadeem Wright.

There are more robberies like this one involving teenage suspects, including an incident at the Post Road CVS in Lawrence. Since January 1st, around 100 incidents like the one described above have been caught on camera.

What helps is the video snapshots where detectives have reportedly matched up clothing worn in different hold-ups. Now with the recent arrests, police hope to at least put a dent in the pharmacy crime wave.

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Nurse Practitioner Admits Accepting Drug Company Kickbacks

http://www.courant.com/health/hc-nurse-indictment-0625-20150623-story.html

Alfonso was a high prescriber of the painkilling drug fentanyl in 2012 and 2013, writing 782 prescriptions for it, more than twice the number of the next highest prescriber.

If you do “the math” on this statement…presuming that she wrote for 30 days supply for each Rx.. She did work in a PAIN CLINIC… she had some 30-odd pts on Fentanyl.. what sounds worse 30 pts on Fentanyl or 782 Fentanyl Rxs in two years? Now that the DEA has mandated that all C-II must be no more than a 30 days supply… it will only make the “raw numbers” look worse…  was that intentional ? Looks like the Pharma, their sales rep are going to get a pass.. They did the crime… not even going to have to pay a fine.. and NO ONE FROM THE CORPORATION GOES TO JAIL.

HARTFORD — A Derby nurse practitioner identified as the state’s highest Medicare prescriber of potent narcotics has admitted taking kickbacks from a drug company in exchange for prescribing pain medication.

Heather Alfonso, 42, of Middlebury, pleaded guilty Tuesday in U.S District Court in Hartford to receiving $83,000 in kickbacks from January 2013 until March 2015 from an unnamed pharmaceutical company that makes a drug used to treat cancer pain.

In pleading guilty, Alfonso admitted that the money she was paid influenced her prescribing of the drug, according to the U.S. attorney’s office for Connecticut, which is handling the case.
Among Most Prolific Drug Prescribers In U.S., CT Nurse Surrenders Licenses

The charge of receipt of kickbacks in relation to a federal health care program carries a maximum term of imprisonment of five years and a fine of up to $250,000. U.S. District Judge Michael P. Shea scheduled sentencing for Sept. 17.

Alfonso, an advanced practice registered nurse (APRN) at the Comprehensive Pain and Headache Treatment Center in Derby was identified in recent C-HIT stories as the state’s highest Medicare program prescriber of Schedule II drugs — potent narcotics with a high potential for addiction and abuse. She was among the top 10 prescribers in the country in 2012 and was the highest prescriber in Connecticut in 2013, writing $2.7 million in prescriptions.

Her prescribing habits in 2012 and 2013 did not appear to attract scrutiny until earlier this year, when a probe by the drug control division of the Department of Consumer Protection led her to surrender her state and federal licenses to prescribe controlled substances. She has since left the pain center, a spokeswoman there said. Her nursing license is under investigation by the state Department of Public Health.

Neither Alfonso nor Dr. Mark Thimineur, an anesthesiologist who is medical director of the Derby pain center, could be reached for comment Tuesday evening.
According to the U.S. attorney’s office, Alfonso prescribed an array of controlled substances to clients of the treatment center and was a “heavy prescriber” of a drug used to treat cancer pain, racking up more than $1 million in Medicare claims for that drug alone.

Interviews with several of her patients, who are Medicare Part D beneficiaries and who were prescribed the drug, revealed that most of them did not have cancer, but were taking the drug to treat chronic pain, the U.S. attorney’s office said. Medicare and most private insurers will not pay for the drug unless the patient has an active cancer diagnosis and an explanation that the drug is needed to manage the patient’s cancer pain.

The U.S. attorney’s investigation revealed that the manufacturer of the drug paid Alfonso as a speaker for more than 70 “dinner programs,” at a rate of about $1,000 per event.

“In many instances, the dinner programs were only attended by Alfonso and a sales representative for the drug manufacturer,” according to a statement from U.S. Attorney Deirdre M. Daly’s office. “In other instances, the programs were attended by individuals, including office staff and friends, who did not have licenses to prescribe controlled substances. For the majority of these dinner programs, Alfonso did not give any kind of presentation about the drug at all.”

Daly said the investigation by her office is ongoing. The U.S. Department of Health and Human Services Office of the Inspector General, the FBI and the Drug Enforcement Administration are assisting in the probe.

Payment records compiled by the news organization ProPublica show that Alfonso received multiple payments for consulting and speaking from the drug company Cephalon, now owned by Teva Pharmaceuticals, in 2012 and 2013. Those records do not extend past 2013, however, so it is not known which drug company is involved in the federal charges. ProPublica does not list any other drug company payments to Alfonso.

Alfonso was a high prescriber of the painkilling drug fentanyl in 2012 and 2013, writing 782 prescriptions for it, more than twice the number of the next highest prescriber.

Alfonso came to the attention of state medical regulators last summer, when she was reprimanded by the Board of Examiners for Nursing for providing narcotic pain medications to a patient seven times without personally examining the patient, instead “inappropriately” relying on an unlicensed assistant, state records say. She paid a $2,000 fine and took courses in safe prescribing and delegating work duties, but was allowed to continuing practicing without restrictions.

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Overprescribing pain medication can have serious consequences

http://www.caringlawyers.com/blog/2015/06/overprescribing-pain-medication-can-have-serious-consequences.shtml

Apparently the view of this law firm is that over prescribing opiates is MALPRACTICE…but.. failure to properly treat a chronic pain pt.. is a non-issue ? Is intentionally throwing a pt into withdrawal a serious injury ?

Many Pittsburgh residents will need a prescription pain medication at least once in their lives. Surgery, injuries and other circumstances can lead to a person needing pain medication. Doctors have the responsibility to provide these medications in an accurate and appropriate manner. Most of the time this happens, but occasionally medication errors occur.

Most doctors agree that there is a problem with the overuse of prescription pain medication but the majority believe they themselves do not overprescribe the medication. The National Institute on Drug Abuse has shown that between 2000 and 2010 the use of prescription drugs has nearly doubled in the U.S. The drugs lead to abuse and addiction for many patients. These painkillers include hydrocodone, codeine, morphine and oxycodone. The drugs work by blocking the feeling of pain for patients but they can also lead to withdrawal symptoms, cravings and mood swings.

Doctors need to know how to safely prescribe pain medication and to make sure their patient is receiving benefit from the medication and is not becoming addicted. Taking the time to learn their patient’s symptoms can help doctors make sure they are making the right decision in prescribing medication or if there is a better route to take.

Patients and their families who believe they have been harmed by a prescription medication error may want to speak with a legal professional skilled in medical malpractice. An attorney can review medical records and medication records and determine what caused the serious injury. Compensation may be available for medical expenses, pain and suffering and other damages.

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Chronic pain sufferers caught in the middle of efforts to fight prescription drug abuse

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https://youtu.be/dm6xexu_wJY?t=3m32s

DEA agent who stole from Silk Road—and extorted DPR—pleads guilty

Carl Force is the second of two feds arrested in March to plead guilty.

http://arstechnica.com/tech-policy/2015/06/dea-agent-who-stole-from-silk-road-and-extorted-dpr-pleads-guilty/

Carl Force, a DEA agent accused of stealing hundreds of thousands of dollars from the Silk Road drug-trafficking website while he investigated it, will plead guilty, according to court papers filed Monday.

Force is one of two federal agents who were arrested in March on charges of stealing from the Silk Road, then the Web’s largest drug-trafficking site. The other agent, Secret Service agent Shaun Bridges, agreed to plead guilty last week.

Sentencing will occur at a later date. Force has asked to formally enter his guilty plea on July 1.

“French Maid” and “Death From Above”

Force used multiple online personas to interact with Ross Ulbricht, the founder and mastermind of Silk Road, who went by “Dread Pirate Roberts” online. In his capacity as an undercover agent, Force controlled the “Nob” account, used to bust dealers, and enticed Ulbricht to set up a fake “hit” against a former admin. He also created a second account, unknown to his superiors, called “French Maid.”

Both accounts were used to offer Ulbricht inside information about the government’s investigation of Silk Road. Ulbricht paid both Nob and French Maid for such “counter-intelligence,” but it isn’t clear what, if anything, was ever delivered.

Force accepted two payments, worth a total of around $90,000 in bitcoins, as Nob. He accepted a single $100,000 payment as French Maid.

Operating under a third personality, “Death from Above,” Force tried to extort Ulbricht for $250,000, saying he knew his identity. But Force didn’t know who Ulbricht was—he handed over personal information connected to an earlier suspect, and the extortion attempt failed.

During the investigation, Force also moonlighted for a “digital currency exchange company” called CoinMKT. Force used his position as a DEA agent to help the company do criminal background checks, and at one point, he froze $297,000 worth of Bitcoin in the account of a CoinMKT customer, later transferring it to his own personal account.

Both Force and Bridges worked on a Baltimore-based task force investigating the site and knew each other, but were apparently running wholly separate scams. Bridges used admin credentials to lock Silk Road dealers out of their accounts and then drained their bitcoins. That turned out to be the more lucrative scheme, as it garnered Bridges some $820,000.

The corruption investigation was underway but still secret when Ulbricht went to trial in January of this year. Ulbricht’s lawyer argued, and continues to argue, that because Ulbricht was prevented from talking about the corrupt agents, his client didn’t get a fair trial. Prosecutors countered that the investigation had to be kept secret, as it was still underway, and convinced US District Judge Katherine Forrest that the Baltimore-based investigation of the corrupt agents was kept wholly separate from the New York-based investigation that proceeded to trial.

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Online doctor visits can be easy, but Congress thinks they increase costs

http://www.washingtonpost.com/national/health-science/online-doctor-visits-can-be-easy-but-congress-thinks-they-increase-costs/2015/06/22/a1d830ce-0eb9-11e5-a0dc-2b6f404ff5cf_story.html

Donna Miles didn’t feel like getting dressed and driving to her physician’s office or to a retailer’s health clinic near her Cincinnati home.

For several days, she had thought she had thrush, a mouth infection that made her tongue sore and discolored with raised white spots. When Miles, 68, awoke on a wintry February morning and the pain had not subsided, she decided to see a doctor. So she turned on her computer and logged on to www.livehealth.com, a service offered by her Medicare Advantage plan, Anthem Blue Cross Blue Shield of Ohio. She spoke to a physician, who used the camera on Miles’s computer to peer into her mouth and who then sent a prescription to her pharmacy.

“This was so easy,” Miles said.

Nearly 20 years after such videoconferencing technology has been available for health services, fewer than 1 percent of Medicare beneficiaries use it. Anthem and a health plan in western Pennsylvania are the only two Medicare Advantage insurers offering the virtual visits, and the traditional Medicare program has tightly limited telemedicine payments to certain rural areas. And even there, the beneficiary must already be at a clinic, a rule that often defeats the goal of making care more convenient.

In 2012, the latest year for which data are available, Medicare paid about $5 million for telemedicine services — barely a blip compared with the program’s total spending of $466 billion, according to a study in the journal Telemedicine.

“The very advantage of telehealth, its ability to make care convenient, is also potentially its Achilles’ heel,” Ateev Mehrotra, a Rand Corp. analyst, told a House Energy and Commerce subcommittee last year. “Telehealth may be ‘too convenient.’ ”

But the telemedicine industry says letting more beneficiaries get care online would reduce doctor visits and emergency care. Industry officials, as well as the American Medical Association, the American Hospital Association and other health experts, say it’s time for Congress to expand use of telemedicine in Medicare.

“There is no question that telemedicine is going to be an increasingly important portal for doctors and other providers to stay connected with patients,” former Surgeon General Richard Carmona said in an interview.

Some health experts say it’s disappointing that most seniors can’t take advantage of the benefit that many of their children have.

“Medicare beneficiaries are paying a huge price” for not having this benefit, said Jay Wolfson, a professor of public health, medicine and pharmacy at the University of South Florida in Tampa. For example, he said, telemedicine could help seniors with follow-up appointments that might be missed because of transportation problems.

Aetna and UnitedHealthcare cover telemedicine services for members younger than 65, regardless of whether enrollees live in the city or in the country. About 37 percent of large employers said that they expect to offer their employees a telemedicine benefit this year, according to a survey last year by Towers Watson, an employee benefits firm. About 800,000 online medical consultations will be done in 2015, according to the American Telemedicine Association, a trade group.

Medicare’s tight lid on telemedicine is showing signs of changing. In addition to Medicare Advantage plans, several Medicare accountable care organizations, or ACOs — groups of doctors and hospitals that coordinate patient care for at least 5,000 enrollees — have begun using the service. Medicare Advantage plans have the option to offer telemedicine without the tight restrictions in the traditional Medicare program because they are paid a fixed amount by the federal government to care for seniors. As a result, Medicare is not directly paying for the telemedicine services; instead, the services are paid for through plan revenue.

Republicans and Democrats in Congress are also considering broadening the use of telemedicine; some of them tried unsuccessfully to add such provisions to the recent law that revamped Medicare doctor payment rules and to the House bill that seeks to streamline drug approvals.

This year, Medicare expanded telemedicine coverage for mental health services and annual wellness visits — when done in certain rural areas and when the patient is at a doctor’s office or health clinic.

“Medicare . . . is still laboring under a number of limitations that dis-incentivize telemedicine use,” said Jonathan Neufeld, clinical director of the Upper Midwest Telehealth Resource Center, an Indiana-based consortium of organizations involved in telemedicine. “But ACOs and other alternative payment methods have the possibility of changing this dynamic.”

AARP wants Congress to allow all Medicare beneficiaries to have coverage for telemedicine services, said Andrew Scholnick, a senior legislative representative for the lobbying group. “We would like to see a broader use of this service,” he said. He stressed that AARP prefers that Medicare patients use telemedicine in conjunction with seeing their regular doctor.

The American Medical Association has endorsed congressional efforts to change Medicare’s policy on telemedicine, as has the American Academy of Family Physicians. “We see the potential for it . . . to improve quality and lower costs,” said Robert Wergin, president of the academy and a family doctor in Milford, Neb. He said such technology can help patients who are disabled or don’t have easy transportation to the doctor’s office.

Anthem, which provides its telemedicine option to about 350,000 Medicare Advantage members in 12 states, expects the system to improve care and make it more affordable. “It’s also about the consumer experience and giving consumers convenience to be able to be face to face with a doctor in less than 10 minutes, 365 days a year,” said John Jesser, an Anthem vice president. Anthem provides the service at no extra charge to its Medicare Advantage members.

While seniors are more likely to have more complicated health issues, telemedicine for them is no riskier than for younger patients, said Mia Finkelston, a family physician in Leonardtown, Md., who works with American Well, a firm that provides the technology behind Livehealth.com. That’s because the online doctors know when they can handle health issues and know when to advise people to seek an in-person visit or head to the emergency room, she said.

“Our intent is not to replace their primary care physician, but to augment their care,” she said.

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No! It cannot be!…. Now, shall you deal with ME,…. and all the powers of HELL!

The pharmacist at Walgreens told me on my last visit on June 8th that she wants a treatment plan from my doctor on his letterhead and with his signature or she will refuse to fill my next prescription.  She went so far as to put her comments in their computer system so that anyone else filling my scripts would see the warning. I immediately notified my doctor’s office of the ultimatum. Their reply to me was to “find another pharmacy.” Obviously they are out of touch with the current atmosphere out there.

And what is this Pharmacist going to do with a TREATMENT PLAN ?… suggest or DEMAND that the prescriber change the pt’s therapy ? REDUCE IT of course,… Isn’t the starting, stopping or changing the medication that a pt is on.. PRESCRIBING… since it would appear that this particular Pharmacist doesn’t have a collaborative agreement with this pt’s presciber… prescribing would be OUTSIDE of the Pharmacy Practice Act.. and your basic practicing medicine without a license… ?

I have been told that WAG’s policy is that if ONE OF THEIR PHARMACISTS “black balls” a pt… no one pharmacist is allowed to fill a Rx for this particular pt… Could that be considered a environment of COLLUSION… or corporate policy is revoking the professional discretion of all 20,000 WAG’S Pharmacists. Professional discretion that is granted them by their education, license and the Pharmacy Practice Act ?

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Balancing Patient Care and Public Health

Do ‘the needs of the many’ ever outweigh ‘the needs of the few’?

http://www.medpagetoday.com/PublicHealthPolicy/Ethics/52225?xid=nl_mpt_DHE_2015-06-20&eun=g578717d0r

Physicians are increasingly being asked to balance the interests of their individual patients with those of the public at large — for example, when they are considering prescriptions for antibiotics or for ultra-expensive cancer therapies for patients who might benefit from them but also might not. In the first case, the public danger is promotion of drug-resistant organisms; in the second, it’s the increased cost that ultimately everyone bears through insurance and Medicare taxes.

We contacted a variety of healthcare professionals via e-mail to ask:

Can physicians ethically withhold treatments from patients when benefit is not guaranteed but there is a definite adverse impact on the public at large?

How should physicians strike the correct balance?

The participants this week are:

James E. Bailey, MD, MPH, FACP, professor, medicine and preventive medicine and director, Center for Health System Improvement at the University of Tennessee Health Science Center in Memphis

Marc I. Leavey, MD, primary care specialist at Lutherville Personal Physicians, a Mercy Medical Center Community Physician Site in Lutherville, Md.

Thomas L. Horowitz, DO, a physician in private practice in Los Angeles

Peter J. Rice, PharmD, PhD, BCPS, FAPhA, professor, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora

Zubin Damania, MD, founder and CEO, TurnTable Health, a direct-pay primary care clinic in Las Vegas

A Question of Ethics

James Bailey, MD: “All healthcare workers are ethically bound to work for the benefit of their patients to the best of their ability, and ‘at least do no harm.’ These mandates require us to only offer treatments that on balance offer more benefit than harm to the individual patient. Balancing benefits and harms is often difficult in cases like chemotherapy for terminal cancer where potential benefits are small and harms can be great. But where harms clearly outweigh benefits, physicians are obligated to protect their patients from these dangerous treatments. In my experience, most treatments that have an adverse impact on the public at large present more harm than benefit to the individual patient as well.”

Marc Leavey, MD: “Putting the physician in the role of actively and singularly withholding treatment is to place that physician in an impossible situation. One’s personal ethics, and the mores and beliefs of the patient and population involved all play roles. Today, the patient is often an active participant in healthcare decisions, and may take a personal or altruistic posture. The physician treating that patient has a moral and ethical duty to the patient at hand, to do the best that can be done, to not harm the patient, to be true to his or her training. While balancing the needs of the one patient in front of the physician with the amorphous future, with yet undiscovered solutions that may impact it in the future, one needs to avoid getting trapped in the popular line from Star Trek, ‘The needs of the many outweigh the needs of the few.'”

Thomas Horowitz, DO: “Part of a physician’s obligation is the public health responsibility. Reporting is the cornerstone. However, antibiotic stewardship and immunization compliance has become a big issue. Our obligation is to explain to the patient the ‘why’s. But we should do the right thing.”

Evolving Attitudes

Peter Rice, PharmD: “Making decisions in the best interest of individual patients is the foundation of our medical system. In my experience, physicians are strongly committed to their patients, whose care holds the highest priority in the decision making process. That being said, both physicians and patient attitudes are evolving over such topics as antibiotics; physicians and pharmacists are educating, and patients are beginning to understand that it is in the best interests of all to reserve antibiotics for patients who require them and can benefit from them. It is appropriate for all healthcare professionals to remain advocates for their patients while maintaining good stewardship so that treatments are used effectively, are equitably available, and remain effective for future patients.”

Zubin Damania, MD: “In the old days of Health 1.0 (most of the 20th century), doctors treated the patient at hand in a very autonomous way, and systemic considerations seemed a fairly low priority. Currently in Health 2.0, these wider issues roar back with a vengeance and doctors are asked constantly to think of the public and systemic impacts of decisions. Of course, the reality is that many are just trying to survive the increasing workloads and administrative burdens and don’t really have the time to elicit the deeper patient motivations, or educate patients on the lack of utility or potential personal or systemic downsides of treatments or testing. Ethically, I think we have a responsibility to consider these aspects, but our current system doesn’t support the process.”

Leavey: “The question of withholding treatment when there is a poor likelihood of successful outcome has been a part of medicine for ages. In history, with many treatments of limited efficacy, there was often less weight to the decision. The patient may pass the crisis and survive, but the physician’s role was primarily passive or supportive. With the advent of more accurate diagnoses and effective treatments, that role becomes much more significant. The concept of triage, originating on the battlefield but now a part of everyday hospital emergency care, is predicated on being able to tell who is the “sickest,” and who may be so gravely injured or ill that palliation and comfort care are all that can be offered.”

Finding the Correct Balance

Bailey: “Physicians can best strike the correct balance by practicing true evidence-based medicine and adequately considering potential harms as well as benefits to individual patients. Often I find that potential harms are inadequately considered. Doctors only like to think about the potential benefits of the therapies they offer. But we are obligated to offer all therapies where benefits clearly outweigh harms that a patient might reasonably access or which their insurance covers. As patient advocates, physicians should inform policymakers and the public about high-value healthcare where benefits clearly outweigh harms. This is the kind of care we need to work to make affordable for everyone.”

Horowitz: “Medical ethics require us to inform patients of the pro’s and con’s of treatments we believe will comfort or cure them. We should not offer treatments that are ineffective. It there is something that the general medical community believes is useful, but the provider does not believe in, then we are obligated to offer a discussion with another provider that may be able to give a second opinion. Ethics is community standard; when in doubt each facility has a bioethics committee that can help with these dilemmas.”

Rice: “Education plays an important role in balancing the appropriate use of medications. Patients may feel shortchanged if they leave a physician visit without a prescription, and the challenge is to let patients know that they are cared for even though no treatment is needed at the present time. For critical care and terminal patients, healthcare professionals can help patients and families understand and make very difficult decisions to pursue therapies that may not be effective while trying to optimize quality of life.”

Damania: “In Health 2.0, often we are asked to be arbiters of algorithmic medicine and this ignores the unique patient and story before us. It’s often in this story that we can find the correct decision. A vision of Health 3.0 provides the time and autonomy for physicians to truly practice an interpretive, shared decision-making model with patients — to get the story and understand the motivations of the patient, and then render advice that is based on an understanding of both the patient and the larger context into which they fit. This takes time, training, and a culture shift in which these sorts of relationship-based activities are valued as cost-saving, health-promoting, and ethical.”

Leavey: “The relationship between physician and patient is unique. Through the years I have seen patients require enormous services, from transplantation to brain surgery, without any guarantee of success. Their treatments have consumed resources that were of significant financial impact, and that would consume limited time, personnel, or supplies. They were individuals who looked at me with eyes that showed pain, concern, questioning, and trust. To abrogate that trust to an impact of unknown or indirect dimension would seem to go against the obligation of a physician to his or her patient. Shakespeare said it, “This above all: to thine own self be true.” Try not to act hastily, try not to yield to external pressure or arguments, keep an open mind to all aspects of the situation. Primum non nocere.”

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This  doctor used the analogy of you don’t wait until you run out of gas before you buy some..  I got a “new ride” a month ago and on my return trip from the FL BOP special committee meeting last week in Orlando… I had been on the interstate for several hours and was needing to get gas soon.. as I exited the interstate to a four lane state hwy for my final leg home.. I knew that there was a large truck stop at the interchange.. Being the tech nerd that I have always been.. my new ride has all those modern day high tech options.. I was down to abt 1/8 of tank and the in dash computer said that I had 30-40 miles to empty and I knew that even when it indicated ZERO MILES TO EMPTY .. that I had at least 2 gals in the tank.. or I had 10% of the tank capacity left. As I rolled off the interstate, up pops on the in dash video screen “YOU ARE GETTING LOW ON FUEL.. DO YOU NEED ME TO FIND YOU A PLACE TO GET FUEL ?  YES/NO ”

Imagine that.. my car … did not want me to run out of fuel… this car cared more about my well being than apparently this OB/GYN cared about this patient’s well being.  I guess that we can now officially declare that many in our healthcare system have LESS EMPATHY about their pt’s well being… than the artificial intelligence in my car has about the car’s driver.  If it hasn’t been clear before.. it is now… our healthcare system is IN THE CRAPPER !

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