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Primary care doctors say the greatest obstacle they face in prescribing opioids to treat chronic pain is scrutiny from regulators and law enforcement, according to a survey released earlier this year.

But that fear is misguided, says a study in the September issue of Pain Medicine, the journal of the American Academy of Pain Medicine.

Researchers reviewed nine years of medical board and local, state and federal law enforcement charges against doctors for improperly prescribing opioid analgesics. They found that 725 doctors were accused of criminal or administrative offenses from 1998 to 2006. The figure represents about one-tenth of 1% of practicing physicians, or one of every 954 doctors.

“The conclusion of our study is that there is risk [in prescribing opioids]; we’re not denying that,” said study co-author Myra Christopher. “But the risk is manageable and the risk has been exaggerated.”

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Measles are coming back. The Centers for Disease Control and Prevention reported that measles outbreaks have reached a peak not seen since 1996. By late August, 131 cases had been confirmed in 16 states.

Almost half of the cases occurred in children who had not been vaccinated because their parents claimed religious or personal exemptions to vaccine mandates.

“This measles outbreak may be a warning shot,” said Paul A. Offit, MD, chief of the infectious diseases division at the Children’s Hospital of Philadelphia. “We now have communities that have a lack of herd immunity. That puts children at risk.”

Other physicians and public health experts are echoing Dr. Offit’s concern. They say states are making it too easy for parents to exempt their children from the vaccines required for school entry. As scientifically unfounded information about vaccine risks swirls around the Internet and among parents, experts say the exemption rate is bound to grow.

But others worry that toughening the opt-out process, or just talking about mandates, could lead to an even greater loss of public trust in the immunization system.

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A new study of medical weblogs says anonymity, negative comments about patients and product promotions often prevail.

The July 23 Journal of General Internal Medicine study of 271 blogs authored by physicians and nurses found that more than 40% of such blogs are published anonymously and describe individual patients. About one-third contain negative comments about the medical profession, and 18% comment negatively about patients.

The study also found that 17% of the blogs include enough information for patients to identify themselves or their physicians. While violations of patient privacy were rare, three blogs showed recognizable photos of patients, and eight displayed patient radiographs.

The study’s lead author, Tara Lagu, MD, MPH, said blogs are a welcome development because they allow doctors to communicate freely, but they present a challenge to medical professionalism.

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Forty-four states now merit a grade of “C” or higher for policies that support appropriate medical use of opioid analgesics while controlling diversion and abuse, according to a report card published in July by the University of Wisconsin Pain & Policy Studies Group.

The report is the fifth by the group since 2000, when 24 state policies earned a “C” or better. Seven states saw their grades improve from 2007 to 2008, and no state’s grade has worsened since 2000. Five states — Kansas, Michigan, Oregon, Virginia and Wisconsin — have “A” grades.

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The American Psychiatric Assn. has appointed a work group to identify the industry money it receives, what the funds pay for and whether to go without them. The Ad Hoc Workgroup on Adapting to Changes in Pharmaceutical Revenue was appointed last spring and is set to report to the APA’s board of trustees in October.

The move comes on the heels of intense news media and congressional scrutiny of potential conflicts of interest posed by drug- and device-makers’ support of clinical researchers, medical education programs and practicing physicians.

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One physician had the social skills of a 2-year-old, said a nurse in an anonymous survey on disruptive behavior published last year. A cardiologist was upset by phone calls and told a nurse it was not her job to think, just follow orders — a squabble that delayed treatment for a patient with a heart attack. On the other hand, a doctor complained about an increasing lack of respect from nurses who frequently challenged or flatly disobeyed clinician orders.

The Joint Commission is calling on hospitals to crack down on “disruptive” health care professionals, over concerns that such behavior impacts patient care. A new commission standard taking effect in January 2009 will require hospital administrators to adopt codes defining disruptive behavior and develop procedures to discipline medical staff and other health professionals who behave badly.

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In March, a patient at Park Nicollet Methodist Hospital in the Minneapolis suburb of St. Louis Park underwent surgery to remove a cancerous kidney. But the next day, a hospital pathologist reported no evidence of cancer in the kidney that was removed.

The surgical site had been marked, and the surgeon and operating room team did the
recommended “time out” briefing to confirm the plan before surgery. The problem: Weeks before the surgery, the side of the patient’s body with the diseased kidney was wrongly identified in the patient’s medical chart.

Officials at Park Nicollet told the patient and family about the error and apologized for it. Days later, the Minneapolis Star Tribune ran a story headlined, “Wrong kidney removed from Methodist Hospital cancer patient.” But the scoop was not planted by an aggressive trial lawyer or dug up by a resourceful investigative reporter. Rather, officials at Park Nicollet decided to go public with the mistake.

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Chicago — It’s a relatively simple case, Dr. Murphy told the ethics consultants he met with in June. A Spanish-speaking, 65-year-old woman of Mexican descent presented with a large growth in the soft tissue of her lower torso. He suspected it might be cancer and wanted to order a biopsy, but was worried the woman’s daughter — who handled interpreting duties — would try to shelter her mother from the bad news.

“It’s crazy,” Dr. Murphy said. The patient “needs to be involved in her own health care decisions at some level.”

When the daughter, Ines, stepped in to meet with the same ethics consultants, Michael Bliss and Jeffrey Loebl, tension filled the room.

“I know how she is,” Ines said of her mother. “When my dad was really ill — he had cancer — she used to say to me all the time, ‘You shouldn’t tell someone they have cancer.’ She’s right. Knowing that information doesn’t help you get better.”

The case represented a clash of cultures. On one side was Dr. Murphy’s medical culture of patient autonomy; on the other was the patient’s cultural preference to be left in the dark. Slapped on top was a healthy dose of strained relations that left the ethics consultants flummoxed on how to satisfy everyone.

Perhaps it’s a good thing the scenario was just pretend.

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Chicago — A panel appointed by President Bush that met here in June appears set to endorse some form of societal obligation to provide health care access to all.

The meeting was part of the President’s Council on Bioethics initiative examining the ethical underpinnings of approaches to reforming the nation’s health system and covering the estimated 47 million uninsured Americans. A report is likely to be issued after the November election.

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The idea of paying physicians more for providing guideline-based care has taken the American health system by storm in the last decade. Today, more than 150 pay-for-performance programs are centered on the notion that rewarding evidence-based care is key to improving health care quality.

But research shows there is a fundamental problem with the P4P programs: They have had little to no impact on quality. That is the conclusion of many studies, including a new analysis of quality incentives, published in the July/August Health Affairs. It compared 81 Massachusetts physician groups eligible for quality incentives with 73 that were not.

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The American Medical Association officially apologized in July for its history of excluding black physicians from membership, for listing black doctors as “colored” in its national physician directory for decades, and for failing to speak against federal funding of segregated hospitals and in favor of civil rights legislation.

“The AMA failed, across the span of a century, to live up to the high standards that define the noble profession of medicine,” said AMA Immediate Past President Ron Davis, MD, in a commentary published in the July 16 Journal of the American Medical Association.

The apology came in response to an AMA-appointed expert panel’s report on the historical racial divide in organized medicine, “African American Physicians and Organized Medicine, 1846-1968: Origins of a Racial Divide,” also published in JAMA.

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Starting in January, drug detailers will have a lighter load to carry when they visit physician offices. That is when new industry guidelines take effect that bar them from leaving behind drugmaker-branded pens, notepads, coffee mugs and other reminder items.

The ban, announced July 10, is the biggest change the Pharmaceutical Research and Manufacturers of America laid out in a revised code on interactions with physicians and other health professionals. The PhRMA code says reminder items “may foster misperceptions that company interactions with health care professionals are not based on informing them about medical and scientific issues.”

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A group of 16 hospitals last month announced a collaboration on a 21-month patient safety initiative to eliminate preventable birth injuries in their facilities, building on the success of an effort spearheaded by the Institute for Healthcare Improvement.

Three in 1,000 deliveries involve serious perinatal injuries that can result in cerebral palsy, birth asphyxia or permanent neurological disability, said officials involved in the initiative. Many of these can be prevented if physicians follow evidence-based guidelines and do a better job recognizing when infants are in distress, initiating timely cesarean births, properly resuscitating depressed babies and appropriately using labor-inducing drugs and vacuum or forceps, they added.

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