If there was an anti-AIDS pill, who would get it?

Remember our discussion about the implications of knowingly exposing someone to HIV? I think it’s interesting to revisit that analysis in light of the recent news about Truvada, a drug that potentially reduces risk of HIV infection– it appears to be safe and effective, and a panel will make a recommendation to the FDA this week.

It’s an interesting question– of course, we “know how” to prevent HIV without using drugs– i.e., don’t have unprotected sex, don’t share needles, etc– but we also know that the virus spreads anyway for all kinds of reasons. I can think of a few scenarios where a drug would be useful: people who are high-risk and will not or cannot change their sexual practices or drug use (this may be seen as a harm-reduction strategy), or, perhaps more importantly, for people who are routinely sexually coerced (think of women in cultures that do not allow them to refuse). Of course, there are lots of obstacles– it’s expensive, there are side effects, it’s not completely effective, we don’t know the long-term issues– but still, it’s a very exciting idea.

HIV disproportionately affects marginalized groups. Could a drug like Truvada help to change the sense of victimization associated with some HIV infections? Can we avoid a repeat of the original fiasco associated with HIV drugs, their expense, and the witholding of available treatment based on inability to pay?

How many nurses do we need?

California has a law (in effect since 2004) that mandates nurse to patient ratios in hospitals. 1:5 on medical/surgical floors, 1:3 in labor and delivery, and 1:2 in ICU. It’s the only state to have a law like that, and the law has been greatly criticized by some, including the Governator. It’s in the news now because a study was just released finding huge benefits to the law, by comparing California to Pennsylvania and NJ, where there is no such law and the ratios are higher.  Other states are considering similar laws — are they a good idea? [Nurse would like to add here that the study was done out of her alma mater, UPenn, and give mad props to her undergrad advisor, lead author Linda Aiken!]

Nurse: There’s nothing new or controversial about that fact that a better nurse-patient ratio is better for patient care and for nurse satisfaction. it’s plain common sense. this study kind of proves what we already know, in a way. if you are responsible for fewer patients, you have fewer tasks, fewer patients to mix up, fewer meds to pass, and more time to ogranize and assess. all of these things should reduce errors and improve outcomes, it seems fairly obvious. i know just with the way my workflow is, additional patients leads to less thorough work.  overall, i’m glad they did a study that can be cited.

Lawyer: Agreed — having good, well-documented numbers on your side can only help. Especially when you have a legislative body trying to make rules on a topic none of them really know anything about.

Nurse: But the interesting piece is whether there’s any advantage or, more interestingly, disadvantage to having the ratio legislated instead of enforced by a body like the joint commission, which accredits hospitals. laws can be much more rigid, which isn’t a good thing.

Lawyer: Very true. It’s also not a black-and-white thing — laws can be written in lots of different ways. This one has the following features:

  • The law itself doesn’t set the ratios. It directs the health department to create regulations setting ratios. (This is normal. It’s also good, because the health department is likely to know more about this than the state senate, AND because it’s much easier to change.)
  • It requires the health department to review the regulations after 5 years and report on recommended changes.
  • It specifically provides flexibility for rural hospitals that may have different needs from most hospitals.
  • It calls for a minimum — and notes that additional staff may be required, based on clinical judgment.
  • Though the state is requiring local governments to implement this program, it is providing no funding.
  • This is a criminal law. It isn’t totally clear to me who would be liable for its violation.

Nurse: I wonder how these laws effect things like taking lunch breaks. everywhere i’ve worked, a nurse covers another nurses’s patients over break, essentially doubling her load for that half  hour. the law requires another nurse without a patient load to do it– charge nurse, manager, or specific RN to cover breaks. that could be costly! or again, because laws are more rigid, a hospital could be in violation when they’re really doing the best they can at any given moment. staffing is tricky, even if you have enough nurses in general. i know there have been times when i’ve been assigned 3 ICU patients for a while even though our ratio is 1:2, and i was comfortable with it because of the level of acuity. there are also times where that would be clearly inappropriate.

Lawyer: I wonder if the health department’s regulations on the subject could address that. I’d be curious to see the actual regulations, though I haven’t been able to dig them up.

Nurse: The Cal Nurses’ Association puts out some fact sheets in favor of ratios. They’re responding to arguments that this law is costly to strapped hospitals– well, I think. The extra cost from errors, hospital acquired infections, and other effects of understaffing are greater than the costs of adequate staffing– if we can prove that! The Penn study doesn’t quite manage to, but they’re on the right track.

Lawyer:  Oh, long-term savings. How elusive. How alluring. We’d have long-term savings from all kinds of things if only we could get them passed. I want benefits NOW!

Nurse: Another interesting question is how they arrived at the ratios they chose: 1:5 for a general floor, 1:3 for L&D, and 1:2 for ICU. It doesn’t appear that a prior study showed this was optimal, but rather it was chosen as seeming attainable and safe based on current practices. I don’t know this for sure, but I’m speculating. Is it ethically possible to do a study on this? It would be hard to control for variations without knowingly creating a high-risk and a low-risk group.

Lawyer: I think it’d be a tough sell to study it in an actual experiment, where things are manipulated, but you could probably look at data and do your best with the stats. Statisticians can control for all kinds of variables to find what they want the right result.

I’m also curious about other ways to accomplish this. (The legislation clearly worked; California saw a large increase in number of nurses. But we just had a good look at law-making and how it can go terribly wrong.) Incentives, rather than requirements? Do it in all the public hospitals, and let private hospitals do as they will? No matter what, the benefits seem such that it’s worth pursuing. Once again, California taking the lead. (A few of our crazy laws actually turn out to be good ideas. . .)

Quickie: Can you prove WHY you got sick?

One of the things I’ve been studying in law school (torts again. Hi, Professor Engstrom!) is how you can prove that somebody else’s bad behavior actually caused your injury — rather than merely preceding it and being capable of causing it. This mainly comes up in the question of your trying to make them pay for your care (and possibly compensate you for your pain and suffering.)

We generally agree, these days, that agent orange caused a whole lot of health problems for the people who were exposed to it while the US used it in Vietnam. We can also be fairly certain that some of these vets would’ve had some health problems by this age, with or without agent orange. So… which ones is the VA particularly responsible for? If we made vets prove causation, the way we make most people filing tort claims prove it, they simply wouldn’t be able to. (And most of those who tried were denied, getting sicker and sicker as they tried to navigate an impossible appeals process.) To solve this problem, the Department of Veterans Affairs compiled a list of diseases known to be caused by agent orange, and if a vietnam vet presented with one of those diseases, well, okay, claim approved. (Yes, I know, oversimplified.)

The reason it’s in the news this week is that they’re adding a couple of diseases to the list. Three diseases, actually. (So reported by NYT.) And the VA is all, “Look! We’re making it easier for veterans to get the care they deserve!”

Um, okay.  Yes, you are making it easier for a few veterans to get the care they deserve. But your health care is still pretty terrible. Long waits, denials, etc, etc. This is a baby step, guys. Don’t start flying your Mission Accomplished banner.

So I ask: Is this even a good way to address the problem? Presuming that agent orange caused certain diseases, thus streamlining claims for those veterans who were in Vietnam and have those specific diseases? Is it just a good band-aid, when what we really need is a much better, much different system? Is it a bad band-aid, making things just good enough to scrape by while allowing us to ignore the greater change that needs to happen?

Ping-Pong Post: Repatriation

Reader Sam wrote in asking us to discuss the issue she came across in this article.

It concerns a court decision recently made in Florida state court that upheld a hospital’s actions when it deported an illegal immigrant from Guatemala for whom they had been caring for several years without any payment, when they could not discharge him because no nursing homes would take an illegal immigrant not eligible for medicaid (and hence, no chance of reimbursement for the care.)

This issue has a couple of roots–

1. Is healthcare a universal human right?

Well, yes, duh, if you ask nurse. Of course, access to care is hugely varried, and status, money, and luck pay a huge role in who gets what kind of care. (Article 25 of the UN Universal declaration of human rights: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.)

Lawyer: Okay. We can take that as given. The problem is that health care costs money. And long-term health care costs a lot of money. I know, I know, you were going to get to that. But I don’t think you can really answer one question without the other. Is it meaningful to have a right to something that isn’t feasible? Even if it’s feasible for this patient, what about everyone who happens to be brain-injured and still lives in Guatemala? Why does this guy have more of a right to be in a US hospital than they do?

Further: I think there’s a substantive difference between emergency medical care and long-term medical care. That’s why we have EMTALA (the law that requires emergency rooms to treat people regardless of ability to pay.)

2. To whom is the government ultimately responsible? Only its citizens?

Lawyer: I think the emergency vs. long-term distinction comes into play here. If the government is ultimately responsible to all people, then hey, everyone, c’mon in, get your free drugs, get your food stamps! We can’t do that – even if we wanted to. We do allow plenty of refugees to enter the country – we’ll get people out of a crisis – but we’re not responsible for the standard of living of everyone in the world. That’s a crude, oversimplified way of putting it, but get the picture?

3. Who is paying?

Nurse: So there are different kinds of situations here. If an immigrant is being deported after being stabilized in the hospital, it is essentially punitive. It’s a “gotcha”, in a way, and it’s fairly clear-cut that this would create a huge disincentive for seeking treatment, even in vey grave conditions. If you believe as I do that health care is a right, then this is not ok.  Another case is slightly more complicated: what about an immigrant who is critically ill, essentially on life support. A hospital has been caring for him, but he needs a long-term, permanent skilled nursing facility. None will take him because the government will not provide reimbursement for the care of an undocumented immigrant. [Lawyer: note that this is the situation described in the article above.] The hospital has been providing care without payment for months, even years. In this case, can the patient be sent back to a facility in his country of origin? It’s not as clear-cut. There are limited resources — the patient doesn’t need an ICU bed, he needs long-term care. That’s what he’ll get if he’s sent back– but is that, like the other case, a kind of abuse of the situation? Don’t know. . .

Lawyer: I don’t know what kind of cross-talk among governments can be generated on this topic. I mean, obviously a small, poor country can’t just take over what the US government was doing for the person – but at a certain point, isn’t that person the responsibility of the government of his home country? Doesn’t Guatemala have to pick up the ball?

Thanks to Sam for suggesting this topic. Got a topic for Nurse & Laywer? Comment here! We’ll take it up!

What do docs know about policy?

The New York Times is running an interesting article about members of congress who are doctors. One of the first things they point out is that they don’t all agree, so I’ll be the first to confess to having sort of lumped doctors together in the past, saying things like “Doctors like this measure.” Sorry, guys. Um, law students like diet coke. Right? All of us?

Of course, this spring, republican docs in the house actually formed a “doctors caucus.” Which suggests that they might be banding together a little more firmly than the Times’s individual interviews suggest. Why are there 11 republicans and only 5 dems? Tough to say. Anyone?

The upshot seems to be that they pretty much all agree (and have seen with their own eyes) that we need a new plan — but just like the rest of us, they can’t agree on what it should be. My first instinct, given that info, would be to say that it’s simply not a medical question. But thinking about it more, I’m wondering if this isn’t a reflection of the almost intractable complexity of this problem. Every one of these doctors has had different experiences, and the solution that would help the patients one of them has seen might leave another’s in the lurch.

I believe that one of the reasons this issue is so difficult to find common ground on is that everyone has personal experience with it. Even gun control or abortion affects only some portion of the population, but we all have health care experiences, and we all know we will need health care in the future, and it’s difficult for most people to completely put aside their personal experiences in trying to design a big-picture system. If you have a wealth of personal experiences (say, because you are a physician and have been seeing patients get screwed by this system every day for thirty years), how can you see it all in the clearest way possible?

Don’t get me wrong. These “in the trenches” stories are essential. If no one is paying attention to the actual things that befall actual people when the system breaks down, we don’t stand a chance. But it’s awfully tempting to believe that what we’ve seen with our own eyes is somehow more important than other problems out there.

By the way: to my knowledge, there are no nurses in congress. Hey, nurse! Wanna run for congress?

Supreme Court Score Card Wrap-up

Well, the 7th of the cases on nurse-and-lawyer-type-things is Safford USD v. Redding, which we already discussed at great length. What really struck me about this case is that there may, in fact, have been a hard-line argument to make about the search being justified in terms of protecting the students from a drug problem, and they didn’t end up making it. In other words, rather than carrying the logic of a situation to the extreme, as some of the Justices sometimes do, they managed to look at it at face value and say, this isn’t right. So amen to that.

On the whole, this set of cases paints an interesting picture of the court. They’re giving people more right to sue companies who may have done them wrong (Wyeth; Altria) and they’re looking at certain questions with more of a common-sense view than they might when the facts are plain (US v. Hayes; Safford v. Redding). But they’re also getting caught up in procedure, especially when things look a little murky,  at the expense of what seems clearly right (DA v. Osborne; AT&T v. Hulteen.)

Am I thrilled? That might be going too far. But I am excited to see what the Court’s newest member will bring, not so much in her vote, but in her contributions to argument and her ability to shape the debate.

Supreme Court Score Card #4

Have off from work today? Great! More time to read Nurse & Lawyer!

United States v. Hayes Oh, this one might make your head spin a little. It’s a question about domestic violence. That’s health-related, right?

The question is, in order for a misdemeanor crime to be considered domestic violence, does the domestic relationship between the victim and offender have to be an element of the actual language of the crime the offender is convicted for, or does the fact that there is a domestic relationship involved, regardless of the statute under which the person is convicted, qualify it?

This matters because if it IS a domestic violence-specific misdemeanor, then the offender may never carry a firearm. If not, he might be able to.

Basically, some jerk beat his wife, and then, since he was actually convicted of battery, not wife-beating, he claimed that restrictions placed on domestic violence offenders didn’t apply to him. The court ruled, 7-2, that if the relationship exists, it was domestic violence, regardless of the fine details of the actual conviction. (Thanks, Justices Roberts and Scalia. You really got our backs.)

Lawyer says: Decency Win!

Supreme Court Score Card #3

Moving along nicely here! This was actually the first case argued this term. Way to get things rolling, gentlemen and lady!

Altria v. Good It’s sort of about smoking, so it’s fair game, right? The question is basically whether smokers can go to court to challenge labeling of cigarettes as light, low-tar, or low nicotine. (Boring legal issues abound – does federal law/FTC policy preempt state laws about deception, etc.)  During the appeal process, the federal government jumped in – on the side of the smokers who wanted to sue! Take that, Philip Morris! The decision was that federal guidelines DO NOT shield the cigarette makers and prevent the smokers from suing under state laws. If they think the marketing was deceptive, they can sue to their hearts’ content.

Lawyer says: Goliath-killing Win!

Supreme Court Score Card

Well, the good people of SCOTUS just wrapped up their term and now get a nice long summer vacation. (Or a long rest-of-life vacation, if you’re Justice Souter.) But nurse & lawyer are still hard at work! Of the 83 cases decided by the Supreme Court this term, these lucky 7 addressed health care-type issues. For the next week, Lawyer will review one case each day with a brief summary and an even briefer opinion!

Wyeth v. Levine: Oooh, remember this one from the early days of Nurse & Lawyer? The question was whether a drug company could be sued for damage caused by the on-label use of an approved drug. (In other words, for insufficient warnings on the label.) The drug company says that being FDA-approved should give them protection. But the patient – who lost an arm, by the way, to a gnarly infection — prevailed! The FDA requirements represent a MINIMUM – and are not sufficient to get the manufacturer off the hook.

Lawyer says: Patient Protection Win!

paging dr. rich!

USA has a new show called “Royal Pains” about a fired ER doc who starts a concierge practice in the Hamptons. Wha’ts up with these guys?

Nurse: The show is careful to make its protagonist a “good guy”– in addition to accepting lavish accommodations and bars of gold, he treats a dog walker and a fisherman, pro bono, and he contemplates the conflict between making money and doing good out loud, on camera. so i think they’re aware of the issues, and trying to kind of. . . skirt it?

There’s some interesting stuff out there, including USA’s page on the subject, and a bunch of blogs. (see this one, and another)

Some Issues:

**Does conceirge medicine create a two-tiered health system, with better care for the wealthy?

Lawyer: We have two-tiered systems in all kinds of other things. Is it wrong to run a private school? Is it wrong to be a lawyer in a firm instead of a public defender? One could argue that those types of services are just about as essential as medicine, and we’re perfectly fine with allowing people to pay huge amounts of money for exclusive service even though there’s a less-awesome public option available for everyone.

Nurse: But some would argue that health care is a human right, and paying for much better care is somehow icky. Should you be able to butt in line in the ER of a private hopital if you’re rich simply because the poor people could go somewhere else?

**Can people receive better care, including preventive care and chronic disease management, when it’s not based on insurance payments?

Nurse: I’ll tell you right now, yes.

Lawyer: It looks like in at least some states (Maryland, Washington), insurance commissioners have contemplated stepping in, claiming that charging a flat rate for unlimited services constitutes running an insurance company. And that sounds pretty much wrong to me. Insurance companies assume risk, right? And anyway, isn’t the whole point of this that it operates outside of insurance?


**Some PCP’s are switching to this model and dropping longtime patients who won’t pay a large retainer. Is this unethical?

Lawyer: Isn’t it always kind of unethical to drop patients without referring them to another clinician who can treat them?

It’s a difficult question because if resources were unlimited (i.e. there were plenty of doctors), then I wouldn’t see any issue with it. But we’re facing a shortage in a lot of places already, and if we’re talking about universal health care, it will be an even bigger shortage. (Is this where we renew the call for nurse practitioners to fill more of that role?)

Is it possible that there might be some middle ground?Doctors who treat the masses, but reserve a certain number of appointments for VIP patients, and/or work certain hours as in-house doctors and fancy places, but still maintain a practice a few days a week? It looks like this might create trouble with insurance companies, who won’t “share” the docs?

Nurse: General medicine is not a popular choice these days because specialties pay much better.

Lawyer: But then again, is it not better to be a g.p. to the rich only then to say fuck it, I’m gonna run a Ponzi scheme? Or be a plastic surgeon who specializes in nose jobs? At least this way, a small cadre of patients are being taken out of the waiting rooms of the remaining doctors.

For that matter, does someone who has the abilities needed have some moral duty to go to medical school because we have a shortage of doctors? It would be hard to argue that they do. But if if you’re arguing that a doctor has a duty to be a GP to anyone who needs one, aren’t you more or less saying the same thing?

Nurse: Well, not exactly, but I do think there may be a reasonable sense of duty. I feel like I’m answering a call of duty in a way by being a nurse when we have a nursing shortage.

**There’s a professional organization for docs with this type of practice. They have some interesting stuff on their site, www.simpd.org.

Lawyer: But the simpd site does oppose adoption of electronic health records. Which was interesting — it makes sense that for a doctor who basically works solo, it would be a different process than for a large hospital, but honestly, I can’t get behind it. bring a laptop, Dr. Richy Rich. If you charge so much, then you should be able to afford the software.