Brain Blogger » Law & Politics http://brainblogger.com Health and Science Blog Covering Brain Topics Fri, 20 Feb 2015 00:15:36 +0000 en-US hourly 1 http://wordpress.org/?v=4.1 Psychiatric Malpractice Lawsuits and Their Causes http://brainblogger.com/2015/02/09/psychiatric-malpractice-lawsuits-and-their-causes/ http://brainblogger.com/2015/02/09/psychiatric-malpractice-lawsuits-and-their-causes/#comments Mon, 09 Feb 2015 12:00:34 +0000 http://brainblogger.com/?p=18413 Psychiatric treatment is often a difficult process for both doctor and patient. Because of this, strict guidelines have been set out to help doctors make the right diagnoses and prescribe the proper treatments, while providing the best standard of care for patients, and protecting the patient and other individuals from harm.

However, this does not always occur and patients are continually at risk because of errors made by health care professionals. Medical malpractice in the psychiatric fields is as common as other medical fields and often involves more than just the traditional doctor or patient.

Common forms of psychiatric negligence

  • Failure to conduct a proper suicide risk assessment. The standard of care requires physicians to conduct a proper risk of suicide assessment on every potentially suicidal patient. If a doctors fails to properly assess the patient considering all the relevant factors such as patient history, age, gender, sexual orientation, employment and living standards, then he is at risk for potential litigation.
  • Failure to prevent a patient’s suicide. If a proper suicide risk assessment has been performed and it has been determined there is a legitimate risk of suicide, a doctor must take steps to prevent that suicide from occurring. If he fails in this task, he could be judged guilty of malpractice.
  • Improper diagnosis or treatment. While some people believe that many psychiatric diagnoses are ill-defined, this is simply not the case. Any mental health professional should be able to come to a definitive diagnosis assuming the proper patient assessment has occurred. However, if an improper diagnosis is made or if a doctor prescribes the incorrect treatment, a patient or their family have a strong case for malpractice against the doctor or mental health professional.
  • Failure to warn. Extending further from the traditional doctor and patient relationship, courts have ruled that if a patient makes threats during sessions against another person, the clinician has a duty to warn this person of the potential threat if they believe it is credible. This can often be a difficult determination for the clinician as he/she must balance doctor/patient confidentiality versus their responsibility for the safety of others. If a patient acts on these threats, the victim’s families have a reasonable malpractice case to pursue.
  • Boundary violations. It has been established there must exist a boundary between the healthcare professional and their patients. If the professional violates these boundaries or attempts to use his/her position as a means to, for example, illicit sexual encounters with their patients, he/she are guilty of malpractice and maybe even other felony crimes.
  • False repressed memories. One of the most common treatments patients undergo is the process of revealing past memories that have been repressed. Many psychiatric health care professionals believe these memories to be the source of the mental health problems for many patients. If false memories are revealed and it causes irreparable harm to the patient or other individuals, the mental health care professional can be held liable for creating these false memories.

Malpractice case studies

Prosenjit Poddar, a student from Bengal, India, was rebuffed by Tatiana Tarasoff who wanted to see other men.  Poddar withdrew and became increasingly antisocial. Tarasoff left for South America and Poddar began to improve even seeing a psychologist. During his sessions, he confided in his psychologist revealing a plan to murder Tarasoff. When she returned, he stopped seeing his psychologist and carried out the plan he had told him about. Neither Tarasoff or her family received any warnings about the threat.

Tarasoff’s parents later sued the psychologist and other employees of the University of California. The court found that that a mental health professional has a duty to not just the patient, but also any individuals that have been threatened by the patient.

In Syracuse, New York, Joe Mazella, a well respected and popular high school coach, committed suicide after spending three years in the care of physicians and being prescribed antidepressants. After his death, his widow filed a lawsuit against the doctors treating him. Attorneys for the widow argued that Mazella would not have wanted to end his own life and the combination of negligence and low quality of care by the doctors along with three years on antidepressants that are known to cause suicide led to the beloved coach taking his own life.

The Supreme Court of the state of New York found that both doctors who treated Mazella were negligent and held one of the doctors liable for his death awarding the widow $800,000 for the loss of her husband’s income, $200,000 to his youngest daughter and $100,000 to each of his oldest daughters. In addition, $324,000 in interest was added to bring the total to $1.524 million.

Conclusion

Courts are increasingly recognizing the standard of care required for mental health care professionals and, in some areas, their responsibilities can extend far beyond just their patients. These cases represent just a small part of the malpractice cases facing mental healthcare professionals.

It is important for every mental health care professional to provide the highest standard of care possible at all times and to maintain the safety of not only their patients but any individuals that have been threatened by the patient. Failure to provide this type of care is grounds for malpractice and mental health care professionals should and are often held liable for these mistakes.

Image via Paul Matthew Photography / Shutterstock.

]]>
http://brainblogger.com/2015/02/09/psychiatric-malpractice-lawsuits-and-their-causes/feed/ 0
Sexting – Just A Bit of Fun? http://brainblogger.com/2015/01/09/sexting-just-a-bit-of-fun/ http://brainblogger.com/2015/01/09/sexting-just-a-bit-of-fun/#comments Fri, 09 Jan 2015 12:00:35 +0000 http://brainblogger.com/?p=18146 Sexting is becoming a widespread phenomenon. It is the exchange messages or “sexts” with explicit sexual content in the form of text, photos or videos through a digital device such as a smartphone. Is it just a bit of fun, or something more dangerous?

The exchange of nude or semi-nude photos is amongst the most common ways of sexting, and is regarded as a form of auto-pornography. According to some researchers, people claim to do it “for fun”, “as a present”, as a form of foreplay or – especially among the young – as a result of peer pressure.

Sexting has been a matter of much debate in recent years and some governments have introduced specific laws regarding it. Part of the problem is that amongst the young population, sexting is increasingly common and in an attempt to explore their sexuality, they could be contributing to the production and possession of child pornography.

But sexting is not only a practice amongst the young. Adults of all ages are also increasingly engaging in sexting. In the media it is a common topic, and glossy magazines encourage women to send sexts to their partners to “spice up the relationship” and provide tips as to how to send “dirty messages” via smartphones. But adults are not exempt from the risks of putting themselves in dangerous situations by sexting.

Is it safe?

Sexting is widely considered as risky behaviour and a growing problem that can cause serious embarrassment and have undesirable social or even legal consequences. For example, sexting can pose a risk for extortion or “sextortion”, harassment and can lead to bullying in the young.

In specific situations, such as harassment after sexting, the law can enforce criminal charges and this has already resulted in criminal prosecutions. If sexting involves a young person, the legal consequences can be very severe as the content may constitute child pornography. However, the laws are not clear in many countries and it can be difficult to use multimedia material to prove accusations.

Bullying among the young is also a delicate matter related to sexting, which has proved difficult to tackle.

Sexting can be a form of intimacy in a relationship and if this intimacy is broken by the partner through sharing with third parties, there can be severe consequences. There have been reported cases of young people committing suicide after their nude photographs had been distributed to others.

These events can also affect the professional opportunities of the people implicated, since they can damage personal reputations.

In a society in which the use of technology is implicated in our most private behaviours, it is necessary to stay informed and educate the young about the possible consequences of sexting.

Once we post material online we relinquish control over it. This content can truly end up anywhere. For this reason, sexting cannot truly be considered safe under any circumstances.

References

Ferguson, C. (2010). Sexting Behaviors Among Young Hispanic Women: Incidence and Association with Other High-risk Sexual Behaviors Psychiatric Quarterly, 82 (3), 239-243 DOI: 10.1007/s11126-010-9165-8

Mitchell KJ, Finkelhor D, Jones LM, & Wolak J (2012). Prevalence and characteristics of youth sexting: a national study. Pediatrics, 129 (1), 13-20 PMID: 22144706

Image via Champion Studio / Shutterstock.

]]>
http://brainblogger.com/2015/01/09/sexting-just-a-bit-of-fun/feed/ 0
The Concept of Race in Science – A Debate http://brainblogger.com/2014/12/16/the-concept-of-race-in-science-a-debate/ http://brainblogger.com/2014/12/16/the-concept-of-race-in-science-a-debate/#comments Tue, 16 Dec 2014 12:00:24 +0000 http://brainblogger.com/?p=17891 Race is a label. Race does not exist. Race is still an issue. These are some of the apparently contradictory statements that we can find in the debate, a subject with renewed tension in the US after a series of shootings of unarmed “black” men in the US by “white” policemen.

Race is a slippery concept, and an uncomfortable one, because it is related to the marking of differences and divisions among human beings in a society that is supposed to be advanced enough to acknowledge the importance of equality.

Its use is an act of classification that immediately sets boundaries between people and defines an environment in which discrimination can occur. For many, race is a concept based on stereotypical, perceived differences of language, body or ancestry which have their roots in colonialist views.

For example, the “Hispanic race” is a product of the power and influence of Spanish colonisers over the dominated groups in America, while the “African American race” is a label related to the migrants who were taken to America often as a result of the slave trade.

If race is considered as a product of domination and inequality, then we should avoid the term. But we can’t, because it is still a big issue in the so-called “developed world”, as can be seen with the recent unrest in the US. If we do not refer to race or the racialization of groups, as an unresolved issue related to discriminatory practices and inequality, then how can we address it?

Even in the field of neuroscience, and as an attempt to be inclusive, most scientific studies regarding genetics and biological psychiatry choose to identify the “race” of the participants.

The simple act of identifying someone’s race is an act of marking differences and consolidating the use of the concept itself. The use of race has often been replaced by the use of other concepts to classify people, such as “culture”. Such terms possess complex problems of their own since they are also broad and require interpretation.

For some scientists the only way of dealing with the concept of race is avoiding it entirely but some speculate that this will merely leave them in a state of denial. Others suggest that it may create functional limitations which are at least bureaucratically useful.

Some scientists such as Heinz are optimistic in this regard and state that genetic research will soon provide such detailed, personalized information that classifications such as race may come to be regarded as increasingly cumbersome and relatively meaningless.

References

Morning, A. (2006) ‘On Distinction’, Is Race Real? Accessed 20 March 2010.

Heinz A, Müller DJ, Krach S, Cabanis M, & Kluge UP (2014). The uncanny return of the race concept. Frontiers in human neuroscience, 8 PMID: 25408642

Image via Nickolya / Shutterstock.

]]>
http://brainblogger.com/2014/12/16/the-concept-of-race-in-science-a-debate/feed/ 0
Waterboarding the Brain – The Neural Effects of Enhanced Interrogation Techniques http://brainblogger.com/2014/12/11/waterboarding-the-brain-the-neural-effects-of-enhanced-interrogation-techniques/ http://brainblogger.com/2014/12/11/waterboarding-the-brain-the-neural-effects-of-enhanced-interrogation-techniques/#comments Thu, 11 Dec 2014 19:32:41 +0000 http://brainblogger.com/?p=17904 The Question of Morality vs. The Question of Efficacy

The recent Senate Intelligence Committee report detailing the CIA’s use of enhanced interrogation techniques (EITs) like waterboarding has reinvigorated debate over the appropriateness of such methods for counterterrorism efforts. Many protest the use of EITs on moral or legal grounds, citing the inhumanity of the physical and emotional pain imparted by these tactics. Further corroborating protesters’ arguments is ample scientific evidence demonstrating that the aversive effects of exposure to stressors like those involved in EITs are not limited to the duration of those experiences. Instead, enduring high stress circumstances can lead to life-long struggles with post-traumatic stress disorder (PTSD), anxiety, and depression, effects that are likely mediated by physiological changes in the amygdala, an area of the brain that processes emotional information.

Given the harm associated with EITs, it is perhaps important to assess whether EITs provide the desired outcome of enhancing national security. Indeed, harming an individual to spare no one is morally distinct from harming an individual to save many. Though we may determine that neither case is acceptable, the former case is clearly less acceptable than the latter.

Unfortunately, the actual impact of EITs is not clear. Defenders of EITs claim that EITs are critical tactics that have helped the United States thwart terrorist attacks, while opponents argue that the techniques have not significantly contributed to actionable intelligence. Because there are few data that can be used to address the efficacy of EITs as they are currently employed, it may be helpful to draw upon behavioral science research to identify any potential for these EITs to fulfill their stated goal of extracting valuable information.

Are Enhanced Interrogation Techniques Effective?

What are the critical brain processes that determine whether a prisoner will divulge constructive information to his interrogators?

Memory – To convey accurate information, memory must be intact.

Some arguments against the efficacy of EITs have focused on the deleterious effects of stress and sleep deprivation on memory and have pointed to imaging studies that suggest that people suffering from PTSD have different patterns of activation in areas of the brain involved in memory compared to those without the disorder. These arguments emphasize the potential for those undergoing EITs to supply false information.

Much of the literature on the effects of stress and sleep deprivation on memory actually show that these factors influence working memory and diminish the ability to learn new information. However, it is possible that memories of the past could also be affected, particularly if those memories are complex or not stably encoded in the brain. Nonetheless, it is unlikely for stress to demolish highly engrained information. Given that such information, such as the names of family members or close friends, may be valuable for counterterrorism, arguments against the efficacy of EITs that are built on the impact of stress on memory are perhaps not highly convincing.

Executive Functions – The surrender of withheld information may be facilitated by disruption of executive functioning.

The scientific research that is probably most relevant to the efficacy of EITs is that addressing the effects of stress on executive functions. Stress significantly affects the prefrontal cortex (PFC), which is critical for these functions. Executive functions that are likely relevant for those undergoing EITs are the disciplined control over behavior and the ability to keep track of different versions of fact sets.

When the PFC is damaged, people have a harder time regulating their behavior and tend to resort to behavior that is more habitual and less goal-oriented. Thus, it could be argued that the stress-induced diminution of discipline could increase the likelihood that withheld information becomes shared. Nonetheless, there is no evidence to suggest that the extreme measures that appear to accompany EITs are necessary to induce the type of stress needed for this effect.

Motivation – Choosing to share information requires that one deem the value of sharing that information as higher than the value of not sharing that information.

If we consider the effects of EITs on motivation and valuation, the argument of their effectiveness begins to crumble. Stressful circumstances, particularly those that may be interpreted as life threatening, elicit what is known as the fight or flight response, in which the body’s physical and mental resources are focused on escaping or demolishing the perceived threat. In the case of EITs, these responses likely manifest as instincts to survive and to avoid pain.

Some researchers have suggested that those enduring EITs are motivated to talk because time spent talking is time where interrogation, and the associated stress and pain, are avoided. These researchers further claim that there is little correlation between the accuracy of information provided and the degree of pain endured. When this is the case, there is clear incentive to talk but no added value of providing truthful information. Even if we could articulate how EIT practices could incentivize the sharing of accurate information, the argument for the justification of EITs would still suffer from our inability to illustrate how these practices are superior to others that would be considered more civilized.

How Can We Ensure National Security Without EITs?

Behavioral science suggests that the potential for EITs to lead to the acquisition of accurate actionable intelligence is limited. Thus, there is great potential to develop a new system for procuring desired information that is superior to current EITs in both a moral sense and a practical sense.

A significant weakness of EITs is that they are not conducive to scientifically rigorous experimentation. Ethical considerations prevent us from conducting controlled human studies on the impact of EIT implementation, which precludes optimization of these approaches. However, research from a number of disciplines, including neuroscience, computer science, psychology, and economics provide considerable insight into how to affect decision making. If we apply this knowledge to build new innocuous systems for interrogation, we have the opportunity to collect data and optimize these systems accordingly.

In addition to providing general information on the efficacy of specific negotiation tactics, this type of research could also uncover details on how to customize interrogation to individual cases. For example, neuroscience research demonstrates that stress differentially affects male and female decision making tendencies, suggesting that different coercive approaches could be strategically targeted to men and women.

Conclusion

It is difficult to condone EITs given that the aversive neural effects do not appear to be accompanied by significant societal benefits. Further, even if we could establish moral grounds for EITs, our focus should be on how to effectively obtain the information we need to keep our citizens safe. EITs are not conducive to science-backed optimization because they do not allow for controlled experimental manipulations. On the other hand, other persuasive tactics, which may be equivalent or superior to EITs in their efficacy, can be experimentally tested and improved upon as more data are collected. Employing the scientific method to understand specific effects of different coercive techniques could allow us to more effectively acquire the information needed to keep our nation secure.

References

1          Amat, J. et al. Medial prefrontal cortex determines how stressor controllability affects behavior and dorsal raphe nucleus. Nat Neurosci 8, 365-371, doi:10.1038/nn1399 (2005).

2          Arnsten, A. F. Stress signalling pathways that impair prefrontal cortex structure and function. Nature reviews. Neuroscience 10, 410-422, doi:10.1038/nrn2648 (2009).

3          Bremner, J. D., Krystal, J. H., Southwick, S. M. & Charney, D. S. Functional neuroanatomical correlates of the effects of stress on memory. Journal of traumatic stress 8, 527-553 (1995).

4          Dias-Ferreira, E. et al. Chronic stress causes frontostriatal reorganization and affects decision-making. Science 325, 621-625, doi:10.1126/science.1171203 (2009).

5          Elbert, T. & Schauer, M. Burnt into memory. Nature 419, 883, doi:10.1038/419883a (2002).

6          Fernandez, M. et al. Brain function in a patient with torture related post-traumatic stress disorder before and after fluoxetine treatment: a positron emission tomography provocation study. Neurosci Lett 297, 101-104 (2001).

7          Ferry, B., Roozendaal, B. & McGaugh, J. L. Role of norepinephrine in mediating stress hormone regulation of long-term memory storage: a critical involvement of the amygdala. Biol Psychiatry 46, 1140-1152 (1999).

8          Flor, H. & Nees, F. Learning, memory and brain plasticity in posttraumatic stress disorder: context matters. Restorative neurology and neuroscience 32, 95-102, doi:10.3233/rnn-139013 (2014).

9          Henckens, M. J., Hermans, E. J., Pu, Z., Joels, M. & Fernandez, G. Stressed memories: how acute stress affects memory formation in humans. J Neurosci 29, 10111-10119, doi:10.1523/jneurosci.1184-09.2009 (2009).

10       Hermans, E. J. et al. How the amygdala affects emotional memory by altering brain network properties. Neurobiology of learning and memory 112, 2-16, doi:10.1016/j.nlm.2014.02.005 (2014).

11       Jones, D. Beyond waterboarding: the science of interrogation. New Scientist 205, 40-43 (2010).

12       Manikandan, S. et al. Effects of chronic noise stress on spatial memory of rats in relation to neuronal dendritic alteration and free radical-imbalance in hippocampus and medial prefrontal cortex. Neurosci Lett 399, 17-22, doi:10.1016/j.neulet.2006.01.037 (2006).

13       McNally, R. J. Psychological mechanisms in acute response to trauma. Biol Psychiatry 53, 779-788 (2003).

14       Mizoguchi, K., Kunishita, T., Chui, D. H. & Tabira, T. Stress induces neuronal death in the hippocampus of castrated rats. Neurosci Lett 138, 157-160 (1992).

15       Morgan, C. A., 3rd, Doran, A., Steffian, G., Hazlett, G. & Southwick, S. M. Stress-induced deficits in working memory and visuo-constructive abilities in Special Operations soldiers. Biol Psychiatry 60, 722-729, doi:10.1016/j.biopsych.2006.04.021 (2006).

16       O’Mara, S. Torturing the brain: On the folk psychology and folk neurobiology motivating ‘enhanced and coercive interrogation techniques’. Trends in Cognitive Science 13, 497-500 (2009).

17       O’Mara, S. On the imposition of torture, and extreme stressor state, to extract information from memory. Journal of Psychology 219, 159-166 (2011).

18       Parsons, R. G. & Ressler, K. J. Implications of memory modulation for post-traumatic stress and fear disorders. Nat Neurosci 16, 146-153, doi:10.1038/nn.3296 (2013).

19       Ray, W. J. et al. Decoupling neural networks from reality: dissociative experiences in torture victims are reflected in abnormal brain waves in left frontal cortex. Psychological science 17, 825-829, doi:10.1111/j.1467-9280.2006.01788.x (2006).

20       Reul, J. M. & Chandramohan, Y. Epigenetic mechanisms in stress-related memory formation. Psychoneuroendocrinology 32 Suppl 1, S21-25, doi:10.1016/j.psyneuen.2007.03.016 (2007).

21       Shin, L. M., Rauch, S. L. & Pitman, R. K. Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Ann N Y Acad Sci 1071, 67-79, doi:10.1196/annals.1364.007 (2006).

22       Sotres-Bayon, F., Bush, D. E. & LeDoux, J. E. Emotional perseveration: an update on prefrontal-amygdala interactions in fear extinction. Learning & memory (Cold Spring Harbor, N.Y.) 11, 525-535, doi:10.1101/lm.79504 (2004).

23       Thomaes, K. et al. Increased activation of the left hippocampus region in Complex PTSD during encoding and recognition of emotional words: a pilot study. Psychiatry research 171, 44-53, doi:10.1016/j.pscychresns.2008.03.003 (2009).

24       van den Bos, R., Harteveld, M. & Stoop, H. Stress and decision-making in humans: performance is related to cortisol reactivity, albeit differently in men and women. Psychoneuroendocrinology 34, 1449-1458, doi:10.1016/j.psyneuen.2009.04.016 (2009).

25       Vermetten, E., Vythilingam, M., Southwick, S. M., Charney, D. S. & Bremner, J. D. Long-term treatment with paroxetine increases verbal declarative memory and hippocampal volume in posttraumatic stress disorder. Biol Psychiatry 54, 693-702 (2003).

26       Xenakis, S. N. Neuropsychiatric evidence of waterboarding and other abusive treatments. Torture : quarterly journal on rehabilitation of torture victims and prevention of torture 22 Suppl 1, 21-24 (2012).

27       Yen, P. M. Waterboarding is not torture: a physician’s response. Lancet 371, 1838, doi:10.1016/s0140-6736(08)60795-3 (2008).

Image via jerryjoz / Shutterstock.

]]>
http://brainblogger.com/2014/12/11/waterboarding-the-brain-the-neural-effects-of-enhanced-interrogation-techniques/feed/ 0
Are Guns in the Hands of the Mentally Ill Really the Problem? http://brainblogger.com/2013/11/25/are-guns-in-the-hands-of-the-mentally-ill-really-the-problem/ http://brainblogger.com/2013/11/25/are-guns-in-the-hands-of-the-mentally-ill-really-the-problem/#comments Mon, 25 Nov 2013 12:00:52 +0000 http://brainblogger.com/?p=15611 In an effort to appear pro-active in pushing for stronger gun control legislation, some opponents to stricter gun laws, as well as some political leaders, have turned the spotlight on mental illness as a primary concern surrounding mass shootings. But is this focus misplaced?

On April 20, 1999, as news stations across the country broke through regularly scheduled programs, shots continued to ring out at Columbine High School in Colorado. Still reeling from the devastating consequences of this mass shooting, exactly one month later, the echo of gunfire was heard, this time at Heritage High School in Georgia.

Since this time, the violence has continued in what appears to be a cancer spreading across the United States, the effects of which have gun control advocates and civil rights advocates at odds with each other. As legislators struggle to find a cure to this malevolent disease, managing gun control laws in relation to individuals suffering from mental illness has quickly becoming a focal point of the debate.

Over a decade after the Columbine shooting, Americans were faced with the loss of more lives in the mass shooting at Virginia Tech on April 16, 2007. The tragedy resulted in the deaths of 32 students and faculty members along with 17 non-lethal injuries. Gun violence would continue through the years with little progress made in controlling this vicious cycle, until America was once again slammed in the face with another mass shooting on a school campus. This was not just any school, but an elementary school. On December 14, 2012, the quiet town of Newton, Connecticut would lose 20 children and six adults in what some speculate as an avoidable tragedy.

The general rhetoric of the NRA and other political supporters holding the line against stricter gun legislation lobby that the real issue is keeping guns out of the hands of the mentally ill. Yet, there is evidence that suggests this line of thought is inaccurate. Studies reveal that individuals with severe mental illnesses, a small percentage in overall comparison, perpetrate approximately one in 20 violent crimes.

It is not as though American political leaders have never passed legislation in an attempt to control the availability of guns to the mentally ill. Congress passed the Gun Control Act in 1968, making it illegal for individuals that had been committed, involuntarily, to a mental hospital or that had been determined mentally “defective” (a term commonly used during that time) to purchase a gun.

Later, legislation via the 1994 Brady Violence Prevention Act, extended the 1968 Gun Control Act exclusionary clauses regarding mental illness (along with initially the same verbiage), and added provisions to include a waiting period to purchase a handgun in hope of better ensuring proper background checks of potential buyers.

The insinuation that placing stronger reporting mandates on mental health clinicians alone will drastically reduce the number of violent acts committed using a gun, is simply unsubstantiated. Also, the totality of legislation, such as the New York Secure Ammunition and Firearms Enforcement Act of 2013, focuses on past, current, and future individuals seeking mental health services. The law mandates mental health professionals to report patients that may potentially harm others as well as themselves.

The outcome of such action could prove to be less of a deterrent to gun violence and more harmful to individuals with mental illnesses. It has the potential of leading to wrongful identification of potentially violent patients and a systematic response whereby individuals who need mental health services withdraw from treatment or forego treatment out of fear of being reported as mentally unstable. Further, it simply violates doctor-patient’s confidentiality as well as the overall privacy of patients.

Many gun rights advocates and political leaders often quote the Second Amendment to the Constitution as evidence supporting the right to bear arms. Yet, there seems to be little concern by the same individuals regarding breaching patient confidentiality also afforded to individuals, including psychiatric patients, provided under the protection of the Health Information Portability and Accountability Act (HIPAA). Still, the push for more stringent gun control legislation focusing on individuals with mental health illnesses is one that is supported by both advocates of gun rights and gun control.

As the battle continues to ensue over protecting the rights of gun owners and protecting the health and safety of innocent citizens, there is little doubt that something must be done to reduce the overwhelming statistics relating to gun violence. Most professionals within the mental health field support continued efforts to effectively reduce the risks of gun violence at the hands of a severely mentally ill individual. It is through this support that the mental health community believes more doors will open providing greater opportunities in the funding and treatment of individuals suffering from many forms of mental illness.

References

Fazel S, & Grann M (2006). The population impact of severe mental illness on violent crime. The American journal of psychiatry, 163 (8), 1397-403 PMID: 16877653

Friedman, R (17 December, 2012). In Gun Debate, a Misguided Focus on Mental Illness. The New York Times.

Swanson J (2013). Mental illness and new gun law reforms: the promise and peril of crisis-driven policy. JAMA : the journal of the American Medical Association, 309 (12), 1233-4 PMID: 23392291

Webster, D. and Vernick, J. (2013). Reducing Gun Violence in America: Informing Policy with Evidence and Analysis. Baltimore, Maryland: The Johns Hopkins University Press, 2013. ISBN 10: 1-4214-1110-5.

Image via Sandra Matic / Shutterstock.

]]>
http://brainblogger.com/2013/11/25/are-guns-in-the-hands-of-the-mentally-ill-really-the-problem/feed/ 6
Following the Bouncing Affordable Care Ball http://brainblogger.com/2013/10/07/following-the-bouncing-affordable-care-ball/ http://brainblogger.com/2013/10/07/following-the-bouncing-affordable-care-ball/#comments Mon, 07 Oct 2013 15:01:56 +0000 http://brainblogger.com/?p=15490 Even before the passing of the Patient Protection and Affordable Care Act (PPACA), more commonly referred to as the Affordable Care Act (ACA), the bill was surrounded by argument, anger, disenchantment, and all out refusal to comply. The bill was also surrounded by as much support, honor, and celebration. Yet, many Americans, health professionals, and general population alike, are as confused today as to its inevitable outcome, as they were before the ACA was passed.

Since the enactment of the ACA in March 2010, there have been approximately 40 attempts to overturn the piece of legislation. One of the most recent attempts came in September 2013, as Republican Party members vowed, once again, to retaliate with a government shutdown. This constant battling between political parties has led to approximately seven bills within the Act to either be repealed completely or altered in some manner.

In its initial stages, the ACA promised hope in providing quality healthcare to every citizen in the United States. This included psychiatric care, a component in many health insurance policies that is included more as an afterthought than a viable program within the policy. Efforts were made to streamline ICD and CPT diagnostic and billing codes, as well as increase Medicare Advantage payments to insurers by 2014. Yet the battle continues surrounding whether to increase or decrease these payments.

Still, many hold out hope that the ACA will indeed, provide expansion and improved care to the most vulnerable people in the country. As there is a higher prevalence of mental illness among individuals in lower income brackets, expanded coverage should greatly improve medical outcomes for these individuals. The ACA is set to expand eligibility for Medicaid as well as provide federally subsidized health insurance benefits for those living up to 138% of the federal poverty line.

The Department of Veteran Affairs is well aware of the growing need to provide not only medical care but also consistent mental health services to its growing number of veterans and service members. Enhanced medical services are provided to veterans through the VA healthcare system. These services are provided for up to five years after discharge from active duty. Although many veterans are still eligible for services, active duty personnel are considered first priority, leaving many veterans seeking treatment outside VA centers or going without treatment.

The ACA is designed to expand coverage through Medicaid for veterans who are uninsured. Reports indicate that approximately half of the 1.3 million veterans that are uninsured will be eligible for Medicaid expanded coverage along with an addition 40% that will qualify for subsidized coverage due to the ACA.

Proponents of the ACA suffered somewhat of a loss in the delaying of the mandated employer provided health insurance. Originally set to roll out in 2014, employers were given another year to make necessary preparations in offering and providing health insurance options to full-time employees if the business had 50 or more full-time employees on its payroll. Currently, the mandate is set to take effect in 2015, leaving many employees who thought they would be provided health insurance through their employer, scrambling to make other arrangements.

There is some relief provided through the Health Insurance Marketplace — scheduled to roll out October 1, 2013. The website provided by healthcare.gov offers information relating to locating each individual state’s health insurance marketplace/exchange, health insurance options, information for businesses, and how to make the program work the best for each individual. In the coming months, this website will prove to be a much-needed resource as more individuals struggle to meet and comply with the health insurance mandate resulting from the enactment of the ACA and the fall out of the continued dissention among political parties.

References

Chretien JP, & Chretien KC (2013). Coming home from war. Journal of general internal medicine, 28 (7), 953-6 PMID: 23435767

Golberstein E, & Busch SH (2013). Two steps forward, one step back? Implications of the Supreme Court’s health reform ruling for individuals with mental illness. JAMA psychiatry (Chicago, Ill.), 70 (6), 567-8 PMID: 23553230

American Psychology Association, (2013). Current Procedural Terminology (CPT) Code Changes for 2013: The Basics.

Image via A Katz / Shutterstock.

]]>
http://brainblogger.com/2013/10/07/following-the-bouncing-affordable-care-ball/feed/ 0
Change on the Horizon for Psychiatric Medicine http://brainblogger.com/2013/06/19/change-on-the-horizon-for-psychiatric-medicine/ http://brainblogger.com/2013/06/19/change-on-the-horizon-for-psychiatric-medicine/#comments Wed, 19 Jun 2013 11:00:23 +0000 http://brainblogger.com/?p=14809 Fear and uncertainty has plagued the implementation of the Affordable Care Act (ACA) since its inception. There have been wins and losses on both sides, and medical professionals across the country have had growing concerns that the continued battle amongst political parties would increase the gap between quality care and reimbursements. Recent events indicate more changes directly related to psychiatric medicine are on the horizon.

One of the greatest victories for both the insurance industry and health providers has been achieved with the announcement that the Obama administration has moved to increase Medicare Advantage payments to insurers by 3.3 percent for 2014. This falls on the heels of the Administration’s initial endeavor to cut those same reimbursements by 2.2 percent in 2014. Meanwhile, the field of psychiatric medicine remains vulnerable to new changes implemented through the ACA, such as the recently released ICD-10 and CPT code modifications.

The mandated ICD-10 and CPT code changes has only proven to further increase the problematic issues the public faces in finding, receiving, and paying for mental health services. A 2008 survey conducted by the AMA evidenced that of the psychologists consulted, 33% of their clients paid for their services out of pocket, leaving 67% of service payments made through billing insurance companies. It should be noted that most of these were claims filed with programs funded by federal, state, and local governments.

The ACA has taken measures to try and serve the needs of U.S. citizens who require assistance and treatment from mental health professionals. Mandates are now in place requiring insurance carriers to include comprehensive options for mental healthcare within each health insurance plan. This should result in a large reduction in the growing number of individuals who forgo necessary mental health treatment due to financial constraints.

And yet a major issue remains enticing more private practice mental health professionals to accept both public and private health insurance. In an effort to provide mental health professionals with a better understanding of the ICD-10 and CPT code changes, the APA released a series of documents summarizing major CPT code changes that directly affect the field of psychiatric medicine. Here is a brief summary of these documents (important links to these changes can be found in the references):

  • Document 90862 has been deleted in one of the biggest CPT code changes. It has been replaced with the appropriate 99xxx series E/M code, which requires more documentation, even up to 11 separate elements. The 90862 code paid lower than a 99214 E/M code for Moderate Complexity.
  • Replace 90801 (Initial Psychiatric Evaluation) with:
    • 90791 (and 90785 report with interactive complexity when appropriate): Psychiatric diagnostic evaluation without medical services.
    • 90792 (and 90785 report with interactive complexity when appropriate): Psychiatric diagnostic evaluation with medical services. New patient E/M codes can be used instead of 90792.
  • Replace 90802 (interactive diagnostic initial evaluation) with:
    • 90791 and 98785 report with interactive complexity
    • 90792 and 98785 report with interactive complexity
  • Replace 90804, 90816, 90806, 90816, 90808, 90821 to be used in all settings (in relationship to time with patient and or family) with:
    • 90832: 30 minutes psychotherapy
    • 90834: 45 minutes psychotherapy
    • 90837: 60 minutes psychotherapy
    • Report with interactive complexity and 90785 when appropriate in all three cases
  • Replace 90810, 90823, 90812, 90826, 90814, 90828 to be used in all settings (in relationship to time with patient and or family) with:
    • 90832: 30 minutes psychotherapy
    • 90834: 45 minutes psychotherapy
    • 90837: 60 minutes psychotherapy
    • Report with interactive complexity and 90785
  • Replace 90805-90809, 90817-90822 Psychotherapy & Evaluation Management (E/M) with:
    • Proper E/M code (not chosen based on time) and 90833 add-on code for psychotherapy 30 minutes
    • Proper E/M code (not chosen based on time) and 90836 add-on code for psychotherapy 45 minutes
    • Proper E/M code (note chosen based on time) and 90838 add-on code for psychotherapy 60 minutes
    • Report with interactive complexity and 90785 when appropriate and/or required
  • New Psychotherapy for crisis 90839 and 90840
  • Replace 90857 Interactive group Psychotherapy with:
    • Group psychotherapy 90853 and report with interactive complexity 90785
  • These CPT code modifications present major changes that will directly affect the fields of psychiatry and psychotherapy. This is the first time in almost two decades that CPT code changes have been directed specifically to psychotherapy services. Although some professionals may find it tedious and difficult to make the change, the overall compatibility of the codes and processes will link to those already used by primary care physicians, as well as other service providers.

    References

    American Psychiatric Association, Current Procedural Terminology (CPT) Code Changes for 2013: The Basics.

    American Psychological Association, Insurance Module, 2008 APA Survey of Health Service Providers, (2009, August).

    Kaiser Health News, Medicare Boosts Rather Than Cuts Payments To Advantage Plans, (2013, April 2).

    Image via Krivosheev Vitaly / Shutterstock.

    ]]> http://brainblogger.com/2013/06/19/change-on-the-horizon-for-psychiatric-medicine/feed/ 2 Medicare Reimbursement – What’s the Latest? http://brainblogger.com/2013/03/17/medicare-reimbursement-whats-the-latest/ http://brainblogger.com/2013/03/17/medicare-reimbursement-whats-the-latest/#comments Sun, 17 Mar 2013 11:00:45 +0000 http://brainblogger.com/?p=14430 Even with the continued political debate over the economics of the Affordable Care Act (ACA), there remains an even more dominating concern. Great concern remains for the actual viability of the overall Act as it applies to providing access to quality care to all US citizens; more specifically, the continued debate over Medicare reimbursement rates.

    The mandate to ensure the availability to quality care while also containing and reducing the cost of healthcare in the United States remains an illusion to those entities tasked with this accomplishment. Nevertheless, since the passage of the ACA, there have been both macro and micro level changes within the industry specific to Medicare reimbursements.

    Primary macro-level changes that have affected the healthcare delivery system can be noted in cost containment reforms to reduce Medicare and Medicaid spending through restructuring payment reimbursements. This has led to a surge in the implementation of Accountable Care Organizations (ACOs) and the Patient Centered Care Models. It is believed that ACOs are the greatest hope for the much needed and desired delivery system reform.

    Operational changes affected by administrative simplification initiatives have taken a critical role in the fiscal solvency, directly affecting the revenue streams for providers and clinicians. Many are facing long and unexplained delays in reimbursements for their clients who are Medicare beneficiaries. The implementation of the HIPAA Version 5010’s deadline initially set for January 1, 2012, has come and gone, leaving practices that were unsuccessful in fully implementing the change faced with extreme delays in reimbursements. The Centers for Medicare and Medicaid Services (CMS) provided a PDF updated document addressing some of the concerns linked to the delayed reimbursements on March 2, 2012. The implementation deadline was then pushed to June of 2012. News on the front indicates that CMS has initiated a program with Emdeon to research the viability of implementing the HIPAA Transaction Version 6020.

    Another area of great concern within the healthcare community is the implementation of the ICD-10 codes, along with the consistent HIPAA transactions updates. The push for greater access to information by creating wide-spread HIT systems has created a lack of cohesion within transferring systems. Looming implementation deadlines add to an already stressful environment for practicing clinicians who are struggling financially as a result of the delayed reimbursements from Medicare.

    In February 2013, with CMS struggling to overcome a growing level of negative response from practicing clinicians regarding the overall Medicare program, the agency announced continued implementation changes provided through the ACA. These efforts include a proposal to update the 2014 rate-book to mirror the most current Fee-For-Service (FFS) costs, alignment restructuring changes of Medicare Advantage (MA) benchmarks with Medicare FFS costs, and basing some of the MA payment on the quality of the plan. In addition, CMS has proposed a 1.5% increase above the 2013 MA plan payment for 2014, resulting in a 4.91% total adjustment.

    Most likely, the continued efforts by health care professionals and organizations to express the ongoing discontent among clinicians regarding the overall state of the Medicare program, served as a catalyst for CMS’ 2013 legislative proposals, which included much needed provider payment incentives. With approximately 92% of Medicare beneficiaries enrolled in the voluntary Medicare Part B program, this should relate to a greater volume of pay-outs for provider incentives in effecting higher levels of quality care. As Medicare Part B assists in covering mental health services primarily provided outside of a hospital setting, this translates into greater opportunity for mental health clinicians who enroll as Medicare providers to offer their services.

    As the political debate continues over the ACA, many practicing clinicians remain focused on issues regarding the Medicare program. CMS recognizes the need to ensure cooperation within the health care industry to ensure greater access to quality care for all US citizens as mandated under the ACA. As such, this should continue to effect both macro and micro level changes within the health care industry specific to Medicare reimbursements.

    References

    Leibenluft RF (2011). ACOs and the enforcement of fraud, abuse, and antitrust laws. The New England journal of medicine, 364 (2), 99-101 PMID: 21175308

    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013, February 15). Details for Rate Year: 2014.

    U.S. Department of Health and Human Services, Centers for Medicare and
    Medicaid Services, (2012, March 4). Medicare Advantage Rates and Statistics.

    U.S. Department of Health and Human Services, Centers for Medicare and
    Medicaid Services, (2012, June). Medicare and Your Mental Health Benefits.

    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2012, March 7). Version 5010 and D.0 & 3.0.

    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013). Fiscal 2013 Budget in Brief: Strengthening Health and Opportunity for All Americans.

    Image via S_L / Shutterstock.

    ]]>
    http://brainblogger.com/2013/03/17/medicare-reimbursement-whats-the-latest/feed/ 2
    Legislative Changes in Research http://brainblogger.com/2013/03/05/legislative-changes-in-research/ http://brainblogger.com/2013/03/05/legislative-changes-in-research/#comments Tue, 05 Mar 2013 12:00:59 +0000 http://brainblogger.com/?p=14279 Many changes in the overall scope of research and development have come to pass since the initial implementation of the Patient Protection and Affordable Care Act (ACA). Although the majority of conversation regarding the ACA is centered around the health insurance mandate, for many in the field of medicine, the impact of this act is much more far reaching than has previously been discussed. The ACA has provided a greater platform for funding research and development programs, as well as promoting positive changes in providing greater access to these findings.

    The medical community continues to maintain a high profile in discussion that will further impact the roll-out of the ACA. In particular, the American Academy of Neurology (AAN), has created its own resources to assist members in discovering alternative payment methods, as well as engaging in incentive programs that assist in avoiding payment penalties. Through the efforts of the AAN and other health care agencies and professionals, not only can the interests of the general public be preserved, but also the professional and business interests of those medical entities will remain intact.

    The issue of access to research and technology has once again reared its inquisitive head in an effort to spark greater continuity within the research community. On February 14, 2013, the Fair Access to Science and Technology Research (FASTR) was introduced to Congress as H.R. 708 and S. 350. Supported by both the American Library Association (ALA) and The Scholarly Publishing and Academic Resources Coalition (SPARC), the bill is designed to provide a platform for greater sharing of publicly funded research articles. It is believed that by opening access to these findings, a higher level of productivity in science and technology research, as well as a higher level of academic achievement can be attained.

    Since the passage of the ACA on March 23, 2010, The Agency for Healthcare Research and Quality (AHRQ) continues to remain vigilant in its efforts to clarify challenges faced within the healthcare industry. Most recently, the European Federation of Neurological Societies released new guidelines for the diagnosis and management of Alzheimer’s disease, which has been included in the AHRQ data base. Primary issues addressed include providing an evidenced-based, peer-reviewed statement of guidance for practice to psychiatrists, geriatricians, and clinical neurologists, as well as qualified physician specialists charged with the care of patients with Alzheimer’s Disease.

    The ACA also includes several provisions to direct discretionary spending toward specific components that increase the production and productivity of high-risk disease management, such as Alzheimer’s Disease and Parkinson’s Disease. The ACA increased discretionary spending on a number of fronts, opening the door to greater research possibilities. Section 10409 of the ACA allocated approximately $10 million in 2012, with an additional $50 million requested in 2013 for biomedical research. Under Section 10409 these changes reflect the establishment of a Cures Acceleration Network (CAN) program, overseen by the Office of the NIH which will award cooperative agreements, contracts, and/or grants to support the development of treatments for conditions and/or diseases that may be considered uncommon, and where market incentives are deficient. Eligible recipients include both private and public participants, research institutions, biotechnology companies, pharmaceutical companies, research institutions, higher education institutions, medical centers, patient advocacy organizations, academic research institutions, and disease advocacy organizations.

    The NIH continues to reach out to the medical community in an effort to provide much needed funding for research and development. Both the government and the private sector recognize the continued need for progressive and consistent tools for advancement in chronic disease management. Although primary focus remains centered on the health insurance mandate, the stage has been set to increase both funding and transparency in biomedical research and development.

    References

    American Academy of Neurology (2013), The Patient Protection and Affordable Care Act Largely Ruled Constitutional: Now What?.

    American Library Association (2013)., The Fair Access to Science and Technology Research (FASTR).

    Redhead, C., Colello, K., Heisler, E., Lister, S., Sara, A. (2012, October 1). Discretionary Spending in the Patient Protection and Affordable Care Act (ACA). Congressional Research Services (R41390).

    U.S. Department of health and Human Services, Agency for Healthcare Research and Quality (n.d.). National Guidelines Clearing House: EFNS guidelines for the diagnosis and management of Alzheimer’s disease.

    Image via Mesut Dogan / Shutterstock.

    ]]>
    http://brainblogger.com/2013/03/05/legislative-changes-in-research/feed/ 4
    Politics of Persuasion, Persuasion in Healing http://brainblogger.com/2011/08/22/politics-of-persuasion-persuasion-in-healing/ http://brainblogger.com/2011/08/22/politics-of-persuasion-persuasion-in-healing/#comments Mon, 22 Aug 2011 12:00:23 +0000 http://brainblogger.com/?p=7024 If there is anything I know a lot about, it’s persuasion. I don’t mean to say that I am a genius sales person or politician, but I had a big lesson about psychotherapy some years ago. I edited a book about persuasion and did a lot of literature research in the process. I realized just how many persuasion techniques I was using as a therapist—in addition to those that I (and many other therapists) were aware of (e.g., Ericksonian hypnotic language and motivational interviewing in particular). Of the previously unconscious (on my part) techniques, one of the most important is priming, which means activating implicit (unconscious, basically) memory, so that the person is more likely to experience a particular state, or evince a particular kind of behavior.

    Hand-in-hand with other techniques, you can really help lubricate the channel to a new chapter in a person’s life. Or, if you are a sales person, “help” the person buy something they don’t really need. I say this, not as an assault on sales people, but to point out that, if you must use such techniques to sell something, I must raise the ethical questions, “Why is such psychological firepower necessary to sell someone what they need? Are they resisting the truth? If so, who are you to have a higher truth?” Of course, those questions are merely red herrings. The answer is: follow the money.

    And it is in this spirit that I raise another question, “Why is so much psychological firepower needed on American political TV?” As a student of persuasion, I am observing very sophisticated techniques used very consistently; so consistently, that I have no doubt that there is training and networking toward perfecting them. I’m also sure that, just as I am finding with psychotherapy, many of these political media types are more intuitive than studied in their skills. But why? Again, follow the money.

    Here one of my favorite (in a bad way) skills. Watch for them when you see people debating politics on TV or elsewhere.

    Targeted interruption: This is an amazing ability to know exactly when to interrupt the other party so they will not effectively get their points across. After years of watching this, I finally saw someone confronted on this behavior. But Noam Chomsky, a famous intellectual and linguist no less, was effectively undermined at the hands of an expert interrupter, William F. Buckley. Buckley was so talented, he almost made apartheid sound like it was a boon to civilization.

    An ethical use of interruption (and priming): A therapist may use forms of interruption to prevent a client from getting into a state of mind that would block them from succeeding at a task in therapy. For example, consider a couple that is on the verge of having a constructive dialog. They begin to fall into their characteristic conflict pattern. The man begins to feel rage. Family therapist Virginia Satir might put her maternal hand on his belly and say that she could feel the hurt in his voice. Not only did this interrupt the rage state, but it also primed the husband for vulnerable feelings. This created an opening for dialog, with constructive results.

    Would you like more examples? I could go like this all day! Comment, please.

    One of my reasons for wanting people to reflect on these techniques, is that much of the American public appears to be adopting the unethical and illogical methods of debating and presenting that they see on TV. As far as I’m concerned, this is one of the signs of the apocalypse (figuratively speaking, of course). Let’s all work to turn this trend around. Educate! Develop compelling ways to highlight and dispense with unethical moves! If anyone should pick up this mantle, I should think it would by psychologically-minded people, because you can see the meta-level communication such as manipulation of implicit memory.

    ]]>
    http://brainblogger.com/2011/08/22/politics-of-persuasion-persuasion-in-healing/feed/ 4
    Healthcare on the Hill or in the Home http://brainblogger.com/2011/05/21/healthcare-on-the-hill-or-in-the-home/ http://brainblogger.com/2011/05/21/healthcare-on-the-hill-or-in-the-home/#comments Sat, 21 May 2011 12:00:57 +0000 http://brainblogger.com/?p=6512 Our democracy was designed for the Members of Congress to reflect the will of the people. But who hasn’t complained over the same cup of coffee about both the cost of health insurance and the deficit? And did I hear one more complaint that all they do in Washington is squabble? Maybe Washington is behaving closer to the will of the people than we give them credit for.

    It turns out in a poll just released by the Kaiser Family Foundation that Congress is doing what Americans are doing: arguing along Party lines over the projected $500B deficit for 2012 and the future of Medicare, Medicaid, Social Security, and the Patient Protection and Affordable Care Act (PPACA). Those who are self-described Democrats prefer to keep or expand existing programs while self-described Republicans would prefer to see repeal with replacement or repeal outright.

    So is it any surprise that the Republican-majority House is passing legislation aimed at reducing or repealing these laws, while the Democratic-majority Senate is letting the legislation die in Committee?

    If you read through the tracking poll, at the very end of the write-up, you’ll find the interesting tidbit on PPACA:

    Since January, the share wanting to expand or keep the law as is has tricked up from 47 to 52 percent, while the share calling for repeal has declined from 43 to 35 percent.

    One has to wonder if the President will emerge the tiebreaker between the two, divided chambers, if he can manage to sway public opinion. The President has not underestimated the conflict — the White House website contains pages devoted to infomercial style videos and the Executive has spent money on advertising campaigns, including $3.1M for three commercials for Medicare staring Andy Griffith.

    With full implementation of PPACA not due until January 1, 2015, America may see changes yet. There are presidential and congressional elections in 2012, and congressional elections, again, in 2014. Neither the Republican majority in the House, nor the Democratic majority in the Senate should be considered safe.

    And about all that is clear at the moment, is that in spite of annual deficits and mounting long-term debt, American health care programs and entitlement benefits are here to stay — at least until the public changes the channel.

    References

    Kaiser Health Tracking Poll — April 2011. Public Opinion and Survey Research Program

    Personal Correspondence between Pamela Gentry and Tegan Millspaw. Department of Health and Human Services. 10/28/2010.

    ]]>
    http://brainblogger.com/2011/05/21/healthcare-on-the-hill-or-in-the-home/feed/ 4
    Translational Neuroscience – Untapped Potential for Education and Policy http://brainblogger.com/2010/10/10/translational-neuroscience-%e2%80%93-untapped-potential-for-education-and-policy/ http://brainblogger.com/2010/10/10/translational-neuroscience-%e2%80%93-untapped-potential-for-education-and-policy/#comments Sun, 10 Oct 2010 12:00:45 +0000 http://brainblogger.com/?p=5529 Recent decades have seen extraordinary advances in the fields of neuroscience, molecular biology, genetics, psychology, and cognitive science. In particular, the National Institutes of Health called the last 10 years of the 20th century the “Decade of the Brain.” Aside from the scientific advances made during that time, government agencies, foundations, and professional organizations put forth substantial efforts to increase public awareness about brain development and diseases. A growing number of neuroscientists indicate that these efforts need to be elevated in order for neuroscience findings to be translated into principles that can facilitate sound policymaking relevant to early childhood education.

    Ten years ago, the Institute of Medicine and National Research Council published a report entitled From Neurons to Neighborhoods: The Science of Early Childhood Development, in which great emphasis was placed on the need to utilize knowledge about early childhood development to ensure the health and well-being of young children. Many are now taking this further and emphasize what they call “Neuro-Education” – the utilization of scientific findings about learning and environments to create more effective teaching methods and curricula, as well as to influence educational policy.

    The lofty goals of Neuro-Education are deeply rooted in the knowledge that genes interact with both early experiences and environments to shape the structure and function of the developing brain. On this topic, neuroscience has been more informative regarding the negative consequences of these interactions in cases where, for example, early experiences and/or environments are less than ideal. For this reason, scientific contributions to policymaking have been focused on interventions in the lives of children facing considerable adversity. However, given the plethora of evidence suggesting that enriching early experiences have beneficial outcomes in terms of cognitive abilities, placing greater emphasis on this facet of policymaking holds considerable promise. In order for neuroscience to influence early childhood education and policy effectively, there must now be a focus on what can be done to increase the impacts of current educational interventions, as well as on how they can best be implemented. To this end, the power of critical periods in brain development, during which time experience has a particularly powerful influence, must be recognized and utilized as part of organized efforts to positively influence the cognitive, emotional, and social development of young children.

    It is time for neuroscience to begin to realize its full translational potential in the world of educational policy. Children in the U.S. and beyond are not doing well academically. Arne Duncan, the U.S. Secretary of Education, called the state of education in America a national public health crisis. Importantly, some Neuro-Education initiatives have recently been established in order to begin to address these issues. In 2009, Dr. Thomas J. Carew, Professor of Neurobiology and Behavior at the University of California at Irvine, and then President of the Society for Neuroscience, created the Neuroscience Research in Education Summit, which gave rise to the creation of the Neuro-Education Leadership Coalition that is working to further the goals of Neuro-Education. Also, the Johns Hopkins University School of Education has established a Neuro-Education Initiative, which promotes the applicability of findings from neuroscience to inform and enrich educational practices. In addition, the Harvard Graduate School of Education offers master’s and doctoral degrees in Mind, Brain, and Education, which emphasize the applicability of the biological and cognitive sciences to pedagogy and public policy. Such efforts, however, are only a beginning.

    Neuro-Education provides a framework within which science can inform education and public policy through the application of knowledge gained across multiple disciplines that have not traditionally worked in collaboration. If efforts in Neuro-Education are implemented on a large scale, they may help produce children that are better learners who can rise to the challenges required for leadership in the 21st century. Some have even argued that Neuro-Education may be financially and socially rewarding because, if successful, it may result in reduced costs associated with remedial education, clinical treatment, public assistance, and even incarceration. The existence of so many potentially favorable outcomes of Neuro-Education suggests that we, as a society, cannot afford to continue to do without it.

    References

    Carew TJ, & Magsamen SH (2010). Neuroscience and education: an ideal partnership for producing evidence-based solutions to Guide 21(st) Century Learning. Neuron, 67 (5), 685-8 PMID: 20826300

    Shonkoff JP, & Levitt P (2010). Neuroscience and the future of early childhood policy: moving from why to what and how. Neuron, 67 (5), 689-91 PMID: 20826301

    Shonkoff JP, & Phillips DA, eds. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development (Washington, DC: National Academy Press).

    Society for Neuroscience (2009). Neuroscience Research in Education Summit: The Promise of Interdisciplinary Partnerships Between Brain Sciences and Education [PDF]

    ]]>
    http://brainblogger.com/2010/10/10/translational-neuroscience-%e2%80%93-untapped-potential-for-education-and-policy/feed/ 15
    You Have a Right to Choose if we Agree http://brainblogger.com/2010/02/19/you-have-a-right-to-choose-if-we-agree/ http://brainblogger.com/2010/02/19/you-have-a-right-to-choose-if-we-agree/#comments Fri, 19 Feb 2010 12:00:47 +0000 http://brainblogger.com/?p=3804 My first encounter with informed medical consent came as a young law student. I was assigned to assist a lawyer in the defense of an older man who had refused treatment for leukemia. His daughter objected, and asked the court to appoint her to be his conservator so she could compel him to undergo treatment.

    When the father spoke to my supervisor, his position became clear. His atypical choice was informed by his cultural background and personal character. An immigrant from Eastern Europe, he was adamantly against yielding control of his life to his daughter. He had tried the medicines, and found they sapped his strength and made him weak. He would rather go on strong for as long as possible and remain his own master.

    At the hearing, the lawyer told the judge that his client understood his illness and the prospect of oncoming death, and still chose for his own reasons to turn down further treatment. After confirming this with the man himself, the judge denied the daughter’s request, leaving him to live or die on his own terms.

    In the aftermath, it occurred to me that there had been no true issue concerning the man’s ability to comprehend the situation or express his feelings. Yet, he was still forced into a court fight because he decided to turn down treatment. Shouldn’t his clearly stated opinions be enough?

    Dr. Alec Buchanan of the Yale Department of Psychiatry evaluated the existing state of law and practice concerning informed consent and reported his findings in a paper in the Journal of the Royal Society of Medicine. Examining medical and legal approaches to the issue of capacity in such matters, he found that “mental capacity is not the sole determinant of what will happen when a patient chooses a course of treatment that doctors consider against the patient’s best interests.” Other factors included the views of relatives, “previous expressed views of the patient,” the opinions of medical staff, and the values of society as a whole.

    Buchanan pointed out that acceptance of a patient’s medical decision by professionals and family depends in part on the complexity and gravity of the issue. The harder the choice, or the more grave the potential outcome, the higher the level of scrutiny to which any choice will be subjected. Legal opinions have also followed this logic, holding that “the more serious the decision, the greater the capacity required.”

    Such scrutiny is in conflict with the value of autonomy, the ability of the individual to act freely in accordance with their own perceptions and belief. Buchanan says that in the context of medical consent, the importance of autonomy increases with the level of a person’s capacity.

    While it is clear that these observations correctly describe how the real world works, it is disturbing that they reflect true disrespect of individual autonomy. If it is acceptable to drag clearly lucid people into court to measure their mental capacity for medical consent, why not question capacity for other decisions? The potential outcome of a poorly chosen marriage might be a devastating divorce, with tragic paths for children of the union. A business contract might eventually lead to unforeseen results which could end in someone’s lifetime ruin. Yet we do not find clearly lucid individuals brought into court in advance so they may be judged as to their ability to make those decisions. At most, poor outcomes in domestic or business pursuits might result in a later determination of incompetence.

    Of course, in the area of medical treatment, a poor choice may result in permanent injury or death. For this reason, the law permits family, medical staff, and “other interested parties” the option of advance intervention in health care decisions. Such action is a direct negation of the individual’s right to choose in the most crucial and intimate of matters.

    How to both assure competence and maintain autonomy?

    From the standpoint of the medical profession, the appropriate emphasis should be on ethical and legal education for professionals to assure that the rights of individuals are not violated.

    From the standpoint of the patient, there is no substitute for a properly drafted advanced medical directive or power of attorney which clearly sets forth his or her specific desires and which names an individual who can honestly, quickly, and accurately discern a patient’s wishes in the context of medical treatment. Such an individual can sustain the decision of a patient if a question of capacity arises.

    The ability of a physician or of the state to override the wishes of a patient and to violate their body should be closely and exhaustively controlled. It should not depend on the subjective assessment of capacity made by someone else, regardless of their qualifications.

    Reference

    Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment Journal of the Royal Society of Medicine, 97 (9), 415-420 DOI: 10.1258/jrsm.97.9.415

    ]]>
    http://brainblogger.com/2010/02/19/you-have-a-right-to-choose-if-we-agree/feed/ 3
    Who Should Decide the Survivability of Newborns? http://brainblogger.com/2009/06/06/who-should-decide-the-survivability-of-newborns/ http://brainblogger.com/2009/06/06/who-should-decide-the-survivability-of-newborns/#comments Sat, 06 Jun 2009 16:37:10 +0000 http://brainblogger.com/?p=2781 Among the most controversial of medical issues is the resuscitation of newborns that are unlikely to survive. The Born-Alive Infants Protection Act (BAIPA), enacted in 2002, and the enforcement guidelines later issued by the United State’s Department of Health and Human Services (DHS) outlined clinical procedures to be used in the resuscitation and care of infants born between 20 and 24 weeks gestation. (A normal, full-term pregnancy is 37 to 42 weeks of gestation.) This act has gained remarkably limited attention, and many neonatologists are not familiar with the act or DHS guidelines concerning its enforcement. A recent study published in Pediatrics suggested that most neonatologists surveyed did not agree with the legislation, but that it did have the power to change medical practice if it was enforced.

    The BAIPA was initially understood to be antiabortion legislation, granting legal status to all live-born infants in the United States, regardless of whether birth was spontaneous, by Cesarean section, or induced by an elective abortion. Immediately after the passage of the BAIPA, the Neonatal Resuscitation Program Steering Committee issued an opinion that the law should not change neonatology practice with respect to the extremely premature infant. However, the DHS soon released enforcement guidelines that threatened investigations of violations of long-standing regulations — the Emergency Medical Treatment and Labor Act and the Child Abuse Prevention and Treatment Act — if any lay observer claimed that medical care was withheld from a newborn. The enforcement guidelines did not include a stipulation for a physician’s medical training and knowledge to prevail over the layperson’s observations. With the threat of hefty fines and litigation, many physicians and hospitals worry about the day when the BAIPA will actually be enforced.

    The last several decades have seen vast improvements in technology and understanding of neonatal physiology, but surprisingly minor improvements in the actual survivability of extremely premature and low birth weight babies. Much debate still surrounds the gestational age and birth weight limits used to identify an infant’s ability to survive outside of the mother’s womb. In most cases, survival of infants born at less than 25 weeks gestation is unlikely. Most practitioners agree that aggressive measures of resuscitation for newborns born at less than 23 weeks gestation is futile and unwarranted. In such cases, neonatologists are more likely to provide comfort care to the infant and the family until the infant dies naturally.

    The decision to resuscitate a newborn that is unlikely to survive is a complex one that should involve physicians, other health care professionals, and parents. However, these decisions must also be made quickly. In these cases, timely and appropriate decision-making can decide whether an infant dies, survives with impairment, or survives intact. The consequences of the decisions — positive or negative –- are almost immediate. Medical professionals bring their judgment and experience, as well as perceived obligations and legal mandates to the decision-making; parents bring cultural, personal, ideological, and religious beliefs to the decision-making. Who should be permitted to make the final judgment of what treatment is in the best interest of the child?

    The American Academy of Pediatrics recommends that neonatologists perform complete prenatal consultations with parents in the likelihood of an extremely premature birth. Most physicians are comfortable discussing clinical issues with parents, but far fewer are comfortable discussing quality-of-life issues, expected long-term outcomes, or parental preferences. Physicians should provide parents with the medical information necessary for informed decision-making, and but should also foster parental involvement in the care of their child. A framework for newborn resuscitation may be necessary to clarify each practitioner’s role in the care of likely nonviable newborns, and to aid in decision-making, but the government should not be mandating medical procedures or making therapeutic decisions in a complex life or death decision of a child.

    References

    Campbell, D., & Fleischman, A. (2001). Limits of Viability: Dilemmas, Decisions, and Decision Makers American Journal of Perinatology, 18 (03), 117-128 DOI: 10.1055/s-2001-14530

    HUSSAIN, N., & ROSENKRANTZ, T. (2003). Ethical considerations in the management of infants born at extremely low gestational age Seminars in Perinatology, 27 (6), 458-470 DOI: 10.1053/j.semperi.2003.10.005

    Partridge, J., Sendowski, M., Drey, E., & Martinez, A. (2009). Resuscitation of Likely Nonviable Newborns: Would Neonatology Practices in California Change if the Born-Alive Infants Protection Act Were Enforced? PEDIATRICS, 123 (4), 1088-1094 DOI: 10.1542/peds.2008-0643

    Sayeed, S. (2005). Baby Doe Redux? The Department of Health and Human Services and the Born-Alive Infants Protection Act of 2002: A Cautionary Note on Normative Neonatal Practice PEDIATRICS, 116 (4) DOI: 10.1542/peds.2005-1590

    Lakshminrusimha S, Carrion V. Perinatal phsyiology and principles of neotal resuscitation. Clin Ped Emerg Med. 2008;9:131-139.

    Bastek, T. (2005). Prenatal Consultation Practices at the Border of Viability: A Regional Survey PEDIATRICS, 116 (2), 407-413 DOI: 10.1542/peds.2004-1427

    Partridge, J. (2005). International Comparison of Care for Very Low Birth Weight Infants: Parents’ Perceptions of Counseling and Decision-Making PEDIATRICS, 116 (2) DOI: 10.1542/peds.2004-2274

    ]]>
    http://brainblogger.com/2009/06/06/who-should-decide-the-survivability-of-newborns/feed/ 3
    Transparency in the Pharmaceutical Industry http://brainblogger.com/2009/03/30/transparency-in-the-pharmaceutical-industry/ http://brainblogger.com/2009/03/30/transparency-in-the-pharmaceutical-industry/#comments Mon, 30 Mar 2009 12:31:30 +0000 http://brainblogger.com/?p=2575 Law and Politics CategoryWith the intensifying call for transparency in corporate America, several pharmaceutical companies have announced plans to jump on the proverbial bandwagon early. In anticipation of the passage of the Physician Payments Sunshine Act in the U.S. Senate, Eli Lilly and Merck have announced plans to establish online registries of payments made to physicians. Additionally, Glaxo Smith Kline, Pfizer, and AstraZeneca will disclose charitable giving and change the way they financially support educational programs.

    CapitolThe Physician Payments Sunshine Act — a bipartisan piece of legislation introduced by Senators Chuck Grassley (R-Iowa) and Herb Kohl (D-Wisconsin) — was first introduced in 2007, but has failed passage to date. With ever-increasing scrutiny of government and corporate organizations, many expect the amended bill to pass successfully this year. The bill would require drug companies to submit a report to the Secretary of Health and Human Services detailing any payments, gifts, food, trips, samples, rebates, or other type of compensation given to physicians.

    While almost no one would argue that transparency in industry — any industry — is bad, and patients and the rest of the public have a right to know for whom their doctors are working, some income should be a private matter. Most professions consider the thought of having the details of all income given or received published on the Internet for general consumption anathema. Plenty of the work carried out by physicians for pharmaceutical companies is legitimate, and the particulars about the amount and quantity of honoraria or compensation are no one’s business except the person completing the work. Many physicians have already declared an end to any work with pharmaceutical companies if the payment details are released. This means that physicians may not be willing to participate in much-needed clinical trials or speak at conferences. These may be unfortunate consequences of a well-intentioned plan.

    The line between compensation and bribery becomes blurrier when conflicts of interest are present that affect patient care and professional responsibility. Any financial or proprietary agreement that makes a physician more or less likely to support a particular drug or product than he otherwise would creates an impression of distrust and weakens the medical establishment. Physicians receive support from drug companies in many ways: research support, assistance with manuscript preparation and publication, speaking fees, consulting services, grants, stocks, and many other material items. While many physicians argue vehemently that these arrangements do no harm to patients or the medical profession, and that a drug company can never unduly influence physicians, stacks of literature report otherwise. Not only are physicians, in fact, influenced by these relationships with the pharmaceutical industry, but also these relationships are driving up the cost of health care. For example, one study reports that physicians are many times more likely to prescribe a particular drug after meetings with drug company representatives or participation in conferences sponsored by the industry, even if that drug was not the best-choice agent. When newer, often more expensive agents, are prescribed, the costs to the patient and the insurance carriers increase unnecessarily.

    Safeguarding the public is paramount in today’s medical climate. Change is likely coming to the organization and structure of the American health care model, and the public is paying more attention to conflicts created by inappropriate relationships between physicians and drug companies. Americans spend approximately $200 billion annually on prescription drugs, and this is the fastest growing piece of the health care budget. Patients want to make sure that this money is being used appropriately and for the right reasons.

    Make no mistake: the pharmaceutical industry is not all bad. Certainly, modern medicine would not be where it is today were it not for the innovative research and development of the drugs and devices made possible by private pharmaceutical companies. Drug companies do provide low- and no-cost drugs to uninsured and indigent patients and do help fund professional meetings and medical journals that provide current and candid information. But, the industry is a for-profit business whose sole purpose is to make money. Like any for-profit company, the pharmaceutical industry seeks profits through wise investments. The investments, in this case, are relationships with physicians.

    Why do physicians engage in relationships that some deem, at the very least, questionable? Many are motivated by entitlement. One study reported that, despite strong efforts of medical schools to discourage gift taking from pharmaceutical companies, an overwhelming majority of medical students felt entitled to these gifts. Even those that reported being troubled by the gifts accepted them. Recognition and belonging motivates other physicians to accept the largesse offered by the drug industry. It is undeniably desirable to be recognized as an expert, or at least invited to a fancy steak dinner to mingle with colleagues. And, in this day of decreased reimbursement and increasing costs of medical education and business ownership, money is an irrefutable, and understandable, motivator for many physicians.

    Many academic medical centers and professional organizations, including the American Medical Association, support the new federal legislation and have previously renounced the idea of industry handouts. Gifts — in any form — from the pharmaceutical industry to physicians have the potential to compromise the objectivity of treatment decisions, increase the costs of health care, and erode the trust of the patient-physician relationship. While federal legislation disclosing financial details of these relationships may not be the answer, physicians need to carefully examine their own relationships with the pharmaceutical industry and consider the implications on their professional relationships.

    References

    Kondro, W. (2008). Pharma giants to create databases on gifts to physicians Canadian Medical Association Journal, 179 (11), 1118-1118 DOI: 10.1503/cmaj.081669

    LICHTER, P. (2008). Debunking Myths in Physician–Industry Conflicts of Interest American Journal of Ophthalmology, 146 (2), 159-171 DOI: 10.1016/j.ajo.2008.04.007

    MARCO, C., MOSKOP, J., SOLOMON, R., GEIDERMAN, J., & LARKIN, G. (2006). Gifts to Physicians from the Pharmaceutical Industry: An Ethical Analysis Annals of Emergency Medicine, 48 (5), 513-521 DOI: 10.1016/j.annemergmed.2005.12.013

    ]]>
    http://brainblogger.com/2009/03/30/transparency-in-the-pharmaceutical-industry/feed/ 9