Association of Health Care Journalists

(03/28/2008)

10:09

Hello!
I've arrived at the conference and am getting settled in. There are some great sessions coming up today, and as always it will difficult to choose.

Friday March 28, 2008 10:09

10:12

The first session I'll be attending is about mental health and violence.
Here is the description from the conference info:
VIOLENCE AND MENTAL ILLNESS: HOW STRONG IS THE LINK?
After the Virginia Tech shooting, journalists must keep a step ahead of the common wisdom when covering stories about mentally ill people and violence. Is violence inevitable or an aberration among the mentally disabled? Can we predict who will become violent? What can be done to treat or restrain mentally ill but potentially violent individuals? A psychiatrist, a medical sociologist, and an advocate for the mentally ill clarify the facts and explicate the controversies.
Panelists:
• Robert Bernstein, Ph.D., executive director, Bazelon Center for Mental Health Law
• Jeffrey Swanson, Ph.D., professor in psychiatry and behavioral sciences, Duke University School of Medicine
• E. Fuller Torrey, M.D., founder and president, Treatment Advocacy Center
• Moderator: Aaron Levin, senior staff writer, American Psychiatric Association

Friday March 28, 2008 10:12

10:16

The session starts at 11:00...I'll be back then.

Friday March 28, 2008 10:16

10:18

[Standby] The next session starts at 11:00am (eastern).

11:07

Friday March 28, 2008 11:07

11:07

Harvey Rosenthal is sitting in for Robert Berstein.

Friday March 28, 2008 11:07

11:13

Jeff Swanson:
Three questions about violence and mental illness:
1) Prevalence- How common is violent behavior in persons with mental ilness compared to those w.o mental illness?
2) Prevention- How much does treatment lower violence risk?
3) Prediction- Can mental health professionals accurately forecast future violence individual patients?

Friday March 28, 2008 11:13

11:19

Prevalence- There are 3 important and informative ways of talking about risk of violence:
1) Absolute risk- probability in a certain group that violence will occur
2) Relative risk- how does that probability compare to the prob of violence in other groups
3) Attributable risk- takes into account the risk factor, but also the number of people who have it
NIMH Epidemiologic Catchment Area Study (1990)

Friday March 28, 2008 11:19

11:21

There are many other risk factors involved that contribute to violence that make it hard to understand and prevent:
younger age
male
lower ses
substance abuse
major mental disorder
history of arrest
history of psychiatric hospitalization

Friday March 28, 2008 11:21

11:21

(ses= socioeconomic status)

Friday March 28, 2008 11:21

11:23

MacArthur Violence Risk Study: Violent behavior trends after hosptial discharge - over time (a series of follow up sessions determined) the rates of violence goes down

Friday March 28, 2008 11:23

11:24

Effects of treatment (outpatient)
the more treatment, the lower the rate of violence
(Also inthe MacArthur study)

Friday March 28, 2008 11:24

11:25

In a study of homocides in the UK, it was found:

27.5% Prevetable & Predictale
37.5% Prevetable not Predictale
35% Neither Prevetable nor Predictale

Friday March 28, 2008 11:25

11:26

We have to take into account "hindsight bias" though!

Friday March 28, 2008 11:26

11:28

- most people with MI do not commit violent acts; serious violence is rare
-violent behavior is associated with MI
-violence by people with MI may be caused by multiple variables
-difficult to predict, but could be prevented in many cases by improving treatment effectiveness, outreach to those who reject treatment

Friday March 28, 2008 11:28

11:31

Legal leverage such as involuntary outpatient care may be efective in imrpoving treatment, but must be combined with regular services

Harvey Rosenthal (filling in for Berstein):
Press coverage is critical to mental health care -

Friday March 28, 2008 11:31

11:33

"The Mentally Ill" is not a social group- "we don't all know each other" It is instead, people with mental illness.
People with MI are more likely to be victims of violence, rather than perpetrators.

Friday March 28, 2008 11:33

11:35

Mental health community is in a civil rights movement. Growing up, he says, I only read about african Americans whenthey did something violent, so I thought all african americans were violent. The same issue is facing people with MI.

According to the Daily News:
494 murders in NY,
but, its not reported that 4-6 were committed by people with MI

We should ask:
-what kind of services were they getting?

Friday March 28, 2008 11:35

11:36

There is a lot of stigma, poverty, you're told- you'll never have children, don't go too far, you'll never have a job

Friday March 28, 2008 11:36

11:40

There is not a system that is attractive and engaging. We have a system that expects failure. When people with MI are given the diagnosis, they are given a very bleak prescription (by the system). Heavy emphais on medication, forced intervention....So when people (with MI) resist treatment they are in many cases reaching for sanity!
Successful treatment programs have offered housing first, rather than forcing medication or treatment...
There have been many cases in NY lately of violence by people with MI - they were in treatment, but treatment was failing them.

New York Association of Psychiatric Rehab Services

Friday March 28, 2008 11:40

11:41

Forced treatment forces people back into the same bad services.
The real story is govt's putting services back on the streets in real and deilverable ways.

Friday March 28, 2008 11:41

11:42

NYAPRS outlines 5 key stages of intervention:
-initial outreach and engagement
-crisis diversion
-police response
-court diversion
-jail/prison re-entry

Friday March 28, 2008 11:42

11:44

E. Fuller Torry - Treatment Advocacy Center
- 2 million people with seer MI not treated
- mainly b/c they don't think they are sick

Friday March 28, 2008 11:44

11:46

anosognosia - losing insight, awareness of illness (associated with the illness itself)

Friday March 28, 2008 11:46

11:47

subset of the untreated individuals, about 40,000 are dangerous to themselves or others
- account for about 30% of chronically homeless
-account for about 10% of jail and prison inmates
-at least 1/3 of them are seriously victimized

Friday March 28, 2008 11:47

11:48

Between 5-10% of such individuals commit a violent act each year

8 major US studies....
MacArthur Violence Study:
- 951 followed for one year after discharge
-262 of them committed 608 acts of serious violence, including 6 homocides

Friday March 28, 2008 11:48

11:49

People with severe MI who are untreated are responsible for at least 5% of all homocides in the US

Friday March 28, 2008 11:49

11:50

(In the European studies it is closer to 19%)

Friday March 28, 2008 11:50

11:51

People with MI are disproportionately responsible for certain homocides:
-family members
-children
-mental health professionals
-clergy
-public figures
-rampage murders

Friday March 28, 2008 11:51

11:52

Solution is simple:
Make sure people with MI get treatment.
Recognize anosognosia
Focus on subset most likely to be dangerous

Friday March 28, 2008 11:52

11:54

Methods of guaranteeing that people get medication:
-directly observed therapy
-long acting injection
-implantable medication device
-assays of blood and urine

Friday March 28, 2008 11:54

11:55

"The paramount civl right of the patient should be that of adequate treatment"
-Stephen Rachlin

Friday March 28, 2008 11:55

12:00

Speakers are invited to respond to each other's presentation:

Response by Harvey Rosenthal:
Agree that people have a right to treatment. Substance abuse is the biggest indicator of violence - why are we not forcing drug abusers and alchoholics into treatment?

Many people stop taking medication b/c its not working, or b/c of side effects, not just b/c of denial.

Dr. Torrey- we assume that people with drug and alchohol abuse are making informed decisions
I agree strongly that we are in need of services. WE are wasting tons of money.

Jeff Swanson - There is a very important tension in mental health and the law - one way to characterize it - concerns about paternalism and coersion.

Friday March 28, 2008 12:00

12:05

Q&A time:

What about family support or interventions for families of people with MI?

Swanson- finding in a study, about family committment. We looked at an association between violence and frequency of contact with family/friends, and found no association. Then we stratefied it to include people who were high functioning. In the group with severe disturbance, people who had more contact w/family and friend were more likely to be violent. For those who were higher functioning, more contact correlated with less incidence of violence.

Friday March 28, 2008 12:05

12:07

Rosenthal- There is some talk in NY about creating a family response team.

Friday March 28, 2008 12:07

12:11

Is there research about violence with people who live at home, with dementia or brain injuries?
Torrey- I'm not an expert inthe area, but I'm aware of the growing awareness....can be associated with the use of anti-psychotics....we have to look at whether these are the best solutions...

Friday March 28, 2008 12:11

12:18

How do you get people who believe that theydon't need intervention the help that they need?
Swanson- fromthe legal perspective there are only two ways, one dealing with capacity and one dealing with violence. From a clinical perspective, there are ways to reach out to people, through persuation.
Torrey- If they are functioning, you might want to leave it. Representative payee or some kind of assisten outpatient treatment.
Rosenthal- engage them, start with a relationship, start withthe goals the person has, recognize obstacles (maybe their thinking, their sleep, etc)
Xavier Amador book

Friday March 28, 2008 12:18

12:18

http://www.amazon.com/not-sick-dont-need-help/dp/0967718929/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1206721069&sr=1-1

Friday March 28, 2008 12:18

12:20

Torry- The stigma is caused bythe violence - so until we can treatment MI and prevent the violence, we can't touch the stigma!

Friday March 28, 2008 12:20

12:23

Rosenthal- One way to fight the stigma is to report on stories of people with MI who are recovering. We only get covered when we kill somebody - what's up with that?

Friday March 28, 2008 12:23

12:25

[Standby] We are between sessions. I will be back online shortly.

2:46

Welcome back- lunch was very interesting. During lunch there was the following:
ROUNDTABLE SESSION
ELECTION 2008: WHICH WAY HEALTH REFORM?
With health reform once again on the agenda before Congress and on the campaign trail with the presidential hopefuls, join us over lunch for this discussion. Leading health policy experts from the left, middle and right will debate the widely varying options facing lawmakers and voters. The moderated discussion will include time for questions from the audience.
Panelists:
• Karen Davis, president, The Commonwealth Fund
• David Himmelstein, M.D., associate professor of medicine, Harvard Medical School
• Tom Miller, resident fellow, American Enterprise Institute
• Julie Barnes, deputy director, health policy program, The New America Foundation
• Moderator, Julie Appleby, reporter, USA Today

Friday March 28, 2008 2:46

2:47

There wasn't room for my chicken AND my computer, so I had to take notes the old-fashioned way.
I'll try to sum them up now;

Friday March 28, 2008 2:47

2:51

To start, the moderator, Julie Appleby, gave each of the panelists 3 minutes to make their case for what to do with health care reform.

David Himmelstein is a physician in Boston and supports reform. He quoted a very interesting (and scary) statistic. 50% of bankruptcies in the US are caused by medical expenses, whether from illness or injury. 75% of those bankruptcies are filed by people WITH insurance. He says $350 billion is wasted in paperwork and bureaucracy related costs.

Friday March 28, 2008 2:51

2:55

Karen Davis is with the Commonwealth Fund and says they have 5 aspects to health care reorm that the next president must consider:
1) Everyone must be covered
2) There is a cost problem - how doctors are padi
3) There is a need for regular care (whether patient centered, through networks, or whatever)
4) There must be a narrowing of the variation in the quality of coverage. Resources exist now to narrow that gap (ICTs, public info, etc)
5) There has to be national leadership to drive this change. There needs to be both public and private sectors invovled and working together

Friday March 28, 2008 2:55

2:58

Julie Barns, from the New America Foundation says their mission is to preach hope and dispel fears, that health care reform is possible. She encourages the journalists in the room to be positive when speaking about reform - that it will:
- cover all Americans
-reduce costs
-improve quality

It has to be comprehensive, though, not incremental. She suggests we need to pay doctors based on the quality of care, not the quantity. (doctors would be rewarded for spending more time with patients, making follow up calls before more appointments would be needed, etc)

Friday March 28, 2008 2:58

3:01

Tom Miller, with the American Enterprise Institute saw things much differently. He says we need to strengthen incentives for health care and better manage our "health care portfolio."

We need to improve both the up and down streams -
Up stream - population needs to become healthier before they visit the doctors, better public education, public health awareness is needed
Down stream- Doctors need to measured on their efficiency

Friday March 28, 2008 3:01

3:06

As I'm sure you can imagine, the discussion got pretty heated, and the conversation moved quickly. Too quickly to take adequate notes (esp with paper and pen).

After some back and forth, the moderator asked each panelist to tell what they thought was the single biggest impediment to health care reform:

Friday March 28, 2008 3:06

3:07

David Himmelstein: corporations! big pharmaceuticals, insurance companies, etc.

Friday March 28, 2008 3:07

3:08

Tom Miller: Thinking it is someone else's job.

Friday March 28, 2008 3:08

3:09

Karen Miller: Costs - how will we pay for it?

Friday March 28, 2008 3:09

3:12

Julie Barnes: Lack of cooperation - everyone (public and private) needs to be involved in the conversation

Friday March 28, 2008 3:12

3:13

I believe this roundatble was recorded - I will try to locate that and see I can get a link to it here.

Friday March 28, 2008 3:13

3:14

I wasn't able to get into the presentation by Michael O Leavitt, the secretary of Health and Human Services - the room was packed!

Friday March 28, 2008 3:14

3:15

The next session I'll be attending is:
TEACHING THE PUBLIC WHAT TO EXPECT IN A GOOD DOCTOR
Some doctors are better than others. Some are downright dangerous. Yet patients don't get much help telling them apart, and dangerous doctors can fly under the radar for months or years. Journalists play a pivotal role in helping readers and viewers understand physician quality, and sound the alarm when bad doctors surface. What makes a doctor good or bad? How do you piece together a "bad" doctor's record from regulatory records and lawsuits?
Panelists:
• Sir Donald Irvine, C.B.E., M.D., F.R.C.G.P., FMedSci, former president, General Medical Council, United Kingdom
• Ridgely Ochs, staff writer, Newsday
• Peter J. Pronovost, M.D., Ph.D., F.C.C.M., professor, Johns Hopkins University, School of Medicine, Department of Anesthesiology and Critical Care, Medicine and director of the Quality and Safety Research Group
• Moderator: Theo Francis, staff writer, The Wall Street Journal

Friday March 28, 2008 3:15

3:16

[Be Right Back Countdown]

10 minutes

Friday March 28, 2008 3:16

4:28

I'm discovering that there are parts of this hotel that don't have good wireless reception, and that last session was in one of those areas!

Friday March 28, 2008 4:28

4:36

Sir Donald Irvine spoke about what is happending in the UK about reforming medical regualtions.
Our systems (the US and UK) tolerate indifference and mediocrity.
The regulatory system hasn't changed in decades but the medical profession has. Our tolerance for error is now greater.

What are we doing about it?
Trying to move from reaction-based regulations to proactive moves.

Asked people "what makes a good doctor?"
*knows what s/he is talking about
* relatable
* treats me with respect and dignity

In the last 10 years, inthe UK, they've been working on this basis to make changes in
-regulation
-medical education
-arrangement of employment

Medical education in the UK is based on the best pracices research
By about 2010 all doctors in the UK will be re-licensed to demonstrate fitenss to practice

Patients want the system to take care of it- they don't want to have to research doctors themselves, it should be taken care of by the system.

A pilot goes through up to 100 checks during his/her career, but a physician can go through none.

Also, multi-source feedback is a method, giving doctors feedback from patients and peers

This would not have happened in the UK if it weren't for the press bringing medical errors to light, enraging the public so that they demand change.

Friday March 28, 2008 4:36

4:42

How do we measure safety?
We go to Consumer Reports before we buy a car, and we look at several attributes, then make our decision.
How do we decide on a doctor?

There are three things to remember:
1) Its not quality of care, its qualities of care (plural!) There are domains of quality: technical, service, cost/efficiency

2) Quality is a team sport - team of health care providers in the system

3) Methods of measuring technical quality are neither robust nor standardized. Especially when they are self-disclosed. In a recent google search for hospital safety, one hospital's website reported they had "elliminated infections." This is not presented as data - what infections? for how long? It is obviously marketing.
Compare how we measure quality in financial fields - GAAP, CFOs...

Hospitals report different things, in different ways - comparison is impossible.

Friday March 28, 2008 4:42

4:46

Ridgely Ochs, from Newsday had a few tips for reporters following tips on these kinds of stories:

Info resources:
Physician profiles (in NY)
Lawsuits
Joint Commissions
State Dept of Health
To find names of patients -death notices, obits, clips in weeklies, lawsuits, etc

The hardest thing is to determine the difference between bad medicine and bad luck. Often she'll take the information she has to a doctor (not related to the case) to get his/her opinion on the facts.

Friday March 28, 2008 4:46

4:47

Friday March 28, 2008 4:47

4:47

One more session for today. It may be in the room with little/no internet reception, so I might be back in 15 minutes, or in about an hour.

Friday March 28, 2008 4:47

4:48	[Standby] Depending on internet reception, I'll either be posting again at 5 or 6:15.

1:49

So, it turns out the internet connection was not as available as I thought.
I will be typing out the notes from the last sessions I attended as regular blog posts.

Sunday March 30, 2008 1:49

1:49

Thanks!

Sunday March 30, 2008 1:49

1:49

This Live Blog has now ended.

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