[when opening a patients records] a pop-up would appear, asking about a patient’s level of pain. Then, a drop-down menu would list treatments ranging from a referral to a pain specialist to a prescription for an opioid painkiller.
Click a button, and the program would create a treatment plan. From 2016 to spring 2019, the alert went off about 230 million times.
The tool existed thanks to a secret deal. Its maker, a software company called Practice Fusion, was paid by a major opioid manufacturer to design it in an effort to boost prescriptions for addictive pain pills ...
Its existence was revealed this week thanks to a government investigation.
I see people here who don't seem to get why this is unethical. So let's be crystal clear.
Doctors are simply opening a patient's record, for whatever reason. This patient may not even be sick or need any medication. The doctor has to deal with a pop-up, and if they interact with it, they get presented with various options. Both options mentioned in the news report are likely to increase opioid addiction.
The problem is not in what order the options are presented, or what the default is. It is a problem that the treatment plan it creates was not created by the patient's primary doctor, but this is not the biggest problem. The problem is that a pop-up appears, forcing doctors to choose 230 million times between opioids or no opioids.
A large portion of the tech industry rests on the justification that users are to blame when unethical user interface design does what it's supposed to and shunts some statistically predictable fraction of users towards choices that are not in their best interest.
I think that nobody involved in any side of that argument (the people writing the justification and the people reading it) actually believe it is true. It's just some noise some person came up with to argue in bad faith why they should be allowed to keep doing bad things if it is good for their wallet.
...but then programmers wouldn't be able to assert innocence and powerlessness. They might have to make decisions that would limit their income or result in consequences.
True but it’s a lot easier to say no as a civil engineer with both legal and professional bodies backing you than currently.
It’s a trade off and it wasn’t something that happened over night it took centuries of disasters for civil engineering to become the way it is, software outside of academia is a minnow by comparison.
We may get there but it’ll take a successive series of software disasters to get to it sadly.
Even still it's not clear why that's an issue. Let's say that I've come up with a drug that treats a relatively unknown disease detectable through blood tests. So I go to Practice Fusion and pay them to develop a pop up that triggers when it sees a blood test indicative of the disease my drug cures. It seems like a win for everyone.
The only real difference I see is that opioids are on the balance probably harmful to patients. But that's an issue with the drugs and their recommended usage, not with the creation of the alert (assuming its recommendations followed accepted practice)
As in you don't understand the need for the anti-kickback statute?
I am not hear to defend it, but I happened to be an attorney on a Qui Tam case (i.e. whistle blower case, which are some of the judgments in the US) revolving around anti-kickback and stark laws.
In short "Russian money" was being funneled into the US to set up pharmacies in Russian immigrant neighborhoods, the engaged in some real bad behavior (patients didn't pick up Rx, they would still bill medicare, then they would relabel and fill future Rx with the already paid med and get a 2nd payment for the meds...other acts included cash payments to doctors to send patients their way). They also engaged in what I felt was not "bad" behavior, they would deliver meds and give the patients a "goody bag" with things from the old country (caviar, hometown news papers, etc...). One pharmacist noticed their supervisor the acts violated the law, and he was fired in retaliation (he is the whistle blower). Before the lawsuit CVS bought the Russian backed chain for well over $100M.
I myself never thought the free goody bag was so outrageous and even think that it is good customer service, but its still unlawful. The law has nothing to do with the type of Rx, or really the Rx at all, its about the unlawful bribe/rebate.
This is called Clinical Decision Support and there are many good implementations of it; the probably comes when you use a CDS framework to implement non-clinical decisions, e.g. to promote opioid prescriptions via a kickback deal as Practice Fusion did.
> But, “if you want to model electronic health records as a for-profit system and not regulate them as such and force doctors to be on them, it’s almost inevitable that they’re going to be manipulated.”
If by manipulated he means continually improved through competitive pressure to on the whole deliver a better experience for less cost than the competition, then sure.
All drugs are always on the table for doctors to choose from. It’s their responsibility to choose wisely and responsibly, even in the face of for profit nudges to behave a certain way.
You might not have realized it, but doctors are just mere humans like everyone else. As such they are not magically immune to outside influence.
Also, I believe our interpretation of the quote differs quite a lot from mine. I read the original quote as: the doctors get manipulated. This reading seems to be incompatible with your response.
Its pretty clear thats not what he means at all. He means manipulated by having unneeded highlu addictive drugs pushed on people who don't need them, many times destroyinh their lives in the process. That manipulation. Why are you being purposefully dense?
I hope everyone now understands why every seemingly-batshit conspiracy regarding the crack/cocaine epidemic exists: because there truly are people in this world who would absolutely stoop so low.
And a reminder to the people realizing how bad a drug epidemic can be now that it's hit close to home: opioids primarily hit middle class families with the means to get prescription drugs at all, and have largely been treated in public discourse as a tragic public health crisis. No imagine how devastating a similar crisis would be to people with a fraction of the resources and who were constantly demonized in the media.
We have to do better by each other so we can be better to ourselves.
Leaving ethics aside, 230M alerts to prescribing doctors for $1M seems like a steal for pharma co.
“Employees estimated internally that the drug company could add almost 3,000 patients and bolster opioid sales by as much as $11.3 million through the partnership. Under the contract, the drugmaker paid Practice Fusion almost $1 million”
I was also surprised quite a bit to find out that advertising is a thing in the programs of doctors in Germany. The regulating body sets as a rule that an ad-free version needs to be available as well. So there’s also a bit of fault on the doctors deciding to save few euros and taking the version with ads.
This is just another pattern that's entirely predictable. Given a free ad-full version and a paid ad-free version, people will mostly pick the version with ads. There may be many reasons for it - through introspection of my own (old) Android purchasing habits, I can recognize at least:
- not being rich enough to spend money on things I don't have a good reason to,
- the perceived value of a piece of software being very small at the beginning, so paying up front is risky
- the belief in my ability to ignore ads on the margin, which doesn't change the fact that ads work over time, and work at scale.
Point being, this pattern is at this point perfectly predictable, so we can treat it as a law of nature - the same way gas molecules don't have to be dispersed throughout the room, they just tend to with very high probability. That's why I'm in favor of banning "free, ad-supported" as a business model, on the grounds of it being statistically harmful to the end-users and anticompetitive (if your competitor does it, you'll be forced to follow suit).
In Germany, pharamceutial companies use young attractive women to pimp their products to doctors, and its not uncommon for doctors to be visited 7 or 8 times a month by these representatives.
It should be noted also, that prostitution is legal in Germany.
This is a perfect example of how free markets fail when profiteering is not aligned with the user in mind.
Their sole purpose is to increase sales of their pain medication. The best way to do that is to advertise your drug to people who can push them, and even better if you can wear them down into making shitty decisions that involve them buying your drug.
The free market can't fix this problem because it's hidden (intentionally) and because what the company wants is not what the user wants. The only recourse is legislation.
Fascinating. So your saying the user must be aligned for the free market to work?
How about employers choosing from a set of health insurance plans you can choose from? That’s a misalignment no?
If I could get a coupon to buy my own insurance I may choose something better for me from an entire marketplace of plans. Instead I get stuck with the calculated decisions of people I don’t know trying to optimize their own profits while satisfying a set of people with very different needs and risk profiles than myself.
I've said this before on HN and I'll say it again.
Every C-level exec that was aware this happened and let it happen should be charged with a single count of involuntary manslaughter for every patient who had an opioid overdose that was prescribed pain medication by this system.
This is not acceptable, and people's heads should roll.
Nope, they just lied about their addiction potential. Intentionally getting someone addicted to a drug can’t in any way be seen as forcing them to take it.
I don’t think that’s an accurate statement, and is a misattribution of responsibility.
The responsibility ultimately rests with the person who puts the drug in their own body. You can make an argument that their physician is in a position of trust, and that some responsibility lies with their prescribing it.
Extending it out to the workers of the vendor is as silly as extending it out to the workers of the keyboard vendor.
Based on the court documentation in this case it's very accurate (CEO and directors on down are all implicated via emails); and I know via a friend that at least one team at Practice Fusion declined to build this feature.
It’s definitely not like extending it to the keyboard manufacturer, that’s the reddest of red herrings. They intentionally signed off on a feature that encourages a physician (in a position of trust) to prescribe opioids. The keyboard or tools to build the software had absolutely nothing to do with this unethical decision. It was a ux design decision which they all certainly knew what its intention was (or they were incompetent af).
Your argument rationalizes literally every dark pattern in ux that has ever existed. No of course there isn't a gun to anyone's head here. That's not the point that anyone is arguing. The point is that it encourages someone in a position of trust to act against a patient's interest. They at least share blame with the physician. I'd say most of the blame, because if this feature didn't exist, the physician wouldn't act against the patient's self interest. The world isn't black and white, it's why manslaughter exists as a crime and why we don't just have murder.
Would this same logic apply to other jobs? For example, do people who brew beer make the choice to kill others? If the drunk drivers add a level of indirection that prevent blame, then why doesn't the same happen with the doctors in this case?
Gun manufacturers? People who build cars that have a known higher fatality rate? People who build swimming pools (look up how many kids die to swimming pools a year)? People who sell unhealthy food? People who make tech/video games that result in less physical activity?
If I make sports cars, odds are I also like to drive sports cars.
People who build swimming pools swim. People who sell junk food buy junk food. People who make video games play video games.
The people in your examples are all selling things they probably want to be able to buy. Perhaps you disagree with their decisions, but they are acting out of a good-faith belief that the things they make are good.
No one wants to have someone try to get them hooked on opioids.
Follow the Golden Rule.
(Maybe the junk food and video games examples are different, since some foods and games are deliberately addictive.)
> (Maybe the junk food and video games examples are different, since some foods and games are deliberately addictive.)
Yes and no. I'm not sure who and where sells true junk food; the usual culprit - McD, KFC - sell food that's unhealthy in the long run, but it's also cheap, tasty and quick to get, making it desirable in many different situation.
(Also, frankly, I think McDonald's may be better for you than equivalents from a "normal" restaurant. Large fast food chains are ridiculously optimized, but they have standards to meet and an individual location doesn't have the freedom to screw with it. Meanwhile in a random restaurant, I always have to worry how cheap they get with the ingredients and their process, and whether e.g. the meat I'm getting was actually grilled, or was just microwaved and then decorated with grill marks. I don't know anyone currently working on the "back end" of a typical restaurant, but from second-hand reports I keep hearing, I'm not reassured about quality.)
And "videogames" as a product category is too broad for this consideration. On one end of the spectrum you have beautiful, engaging videogames designed by passionate creators who absolutely build what they'd like to play. On the other end, you have the bottom-feeding Zynga-like garbage that's essentially gambling in disguise, designed from grounds-up to screw players over.
I'd argue it's actually MUCH worse than simply killing people (which is already pretty staggeringly bad).
The constant push to privatize and let market forces drive medical interactions is CRUSHING trust in the system.
Let's take an example patient, Sally.
Sally goes to see her doctor, she's got some minor knee pain, but nothing serious. As a result of this profit motivated system, her doctor is likely to try to prescribe her expensive pain killers.
She doesn't really think she needs them, but she gets the prescription anyways since she trusted her doctor. Now Sally is actually lucky - no addiction issues, no real problems with the meds. She just decides to stop paying for them after a while since she didn't really think she needed them. AND SHE WAS RIGHT.
Now she's got a nagging thought in the back of her head - Why did my doctor ask me to buy this thing? I didn't need it.
Next time Sally hits the doctors office she's got her kids in tow and the doctor recommends several vaccines. Not super expensive, but not cheap. Normally she'd just trust the doc and say sure. But last time she was burned and paid for something she didn't need.
So this time she decides to do some googling and hits a whole host of anti-vax propaganda. Things that say kids don't need them, they're expensive and risky.
So she opts out.
----
We see this happen everywhere in medicine right now. Things like:
- The dentist that "finds" a cavity at the last minute to fill even though everything has been fine, and the patient doesn't normally have cavities.
- The physician that runs a whole slew of expensive tests for a simple issue
- The dermatologist who wants to do a biopsy on the mole that's been fine for years and doesn't look any different.
Each interaction like this - Where the patient feels more like a walking wallet than a person - they erode trust. Rightfully so, in my opinion.
The end result is whole swathes of disillusioned people who no longer trust the medical system. The consequences become staggering for society as a whole when this trust is gone.
---
I don't think it's any accident AT ALL that the most common group to believe the anti-vax rhetoric is the upper middle class. They're the patients most likely to have disposable income that can be targeted with schemes like this. And while those people are horribly wrong, their gut instinct is SPOT ON. They're being targeted financially and it's bullshit.
My partner is a new doctor in an underserved lower class area. The hospital is barely getting by from lack of resources, and on top of all that, the patients are often mistrustful and hostile. You work frantic 12 hour days for a lower middle class salary, and have patients accusing you of profiteering.
Of course my partner understand how her patients got that way and doesn't blame them. Exactly as you said. It's terrible.
The problem is the US health care system. In a civilized nation, doctor orders a medical test, you get the medical test and you are not charged $1000+ for it. Prices are regulated. US health care system is very predatory. Even if the doctor had the right intentions and you go to scammy place for tests the experience will be negative.Then, if you can't make the payment and are ashamed to call and negotiate the bill it will go to collections.
I honestly feel the US healthcare system is a complete joke. I am losing respect for doctors because they are a part of it.
This is a bit off topic, but I recently changed my health plan. I was on a state plan before. I asked the insurance rep what happens when I go to the ER on a state plan in another state. She said, "well if its in an emergency you are fine, but if its not then you will be responsible for 60%" or something crazy. How the hell can I decide what is an emergency? I am not a medical professional. It is complete bullshit to put that on a individual but this is what they want. The insurance company will blame you and say it was not emergency to save money.
Prices should be ‘regulated’ by REAL price transparency and consumer choice! The prices will self regulate based on the market.
AND insurance can be privately bought to protect against the chance that you get stuck with something expensive. Just like insurance against your house burning, car crashing, or dealer getting a blackjack.
The idea that regulating the price through government will lead to more efficient system with lower costs and better outcomes is a fallacy. Even NASA is being outdone by private space exploration. Government regulation simply can not compete with a truly free market where consumers have access to information, prices, and can make decisions for themselves.
CHOICE is what is required to optimize the solution. Regulation is mostly a fallacy. Regulation is required for certain protections, but not a reliable means to get the system to deliver the optimal outcomes and the lowest costs.
I would only add the caveat that under a free market system single-payer may still be more appropriate for emergency care, since you can't make a consumer choice in the middle of having a stroke. The fallacy that healthcare is a monolithic field which can necessarily be equally served across the board by any particular regime is catastrophic to the debate. There are completely different requirements, limitations, time scales, etc. between an ER, a family practice, a specialist pediatric cancer ward, a cosmetic surgery clinic, etc.
I can think of a time about 125 years ago that it was significantly more likely that execs of the company would end up with a bullet in their head or their loved ones kidnapped and ransomed for such shenanigans. (Note; This is obviously bad and I'm not advocating for it, but it's more than just "no jail time and you have to sell your third and fourth house to pay the fine".)
it's been a few thousand years, but maybe the Code of Hammurabi might be of assistance
If a builder builds a house for someone, and does not construct it properly, and the house which he built falls in and kills its owner, then that builder shall be put to death.
I want to think this is bad, but the way it is described here doesn't really seem like a dark pattern to me. Maybe if "perscribe opiods" was the first or default selection, it would seem worse
It's a dark pattern because it was placed there at the behest of pharmaceutical company that paid for it to be placed there because it would benefit their sales, and not because it would be good for the patient. So it doesn't really matter how it was implemented, it's unethical from the start. The only variable is to what degree.
It was built to be defensible/deniable. The fact that it was paid for by a pharma company is the problem. A doctors workflow shouldnt really be cladestinely influenced by a pharma company
> A doctors workflow shouldnt really be cladestinely influenced by a pharma company
Yet it has always have been so. Doctors are the gatekeepers of drug delivery, so big pharma has always pressured them. Doctors didn't push back (much) because they're too busy to keep up with pharmacology developments on their own, so the drug companies have offered such "education" as a helpful "service". (Said service always conveniently neglects to describe the benefits of older, still-useful drugs because they don't make any money.) The innovation of the 80s was the legalization of prescription drug advertising, which effected an additional pressure source for doctors to prescribe certain drugs: Their patients.
Now this happens where the software doctors are forced to use puts even more pressure on doctors. People talk about the evils of big pharma all the time, but most have no idea how great the evil really is.
Doctors, or at least some, are their partners in crime:
>Opioid manufacturers are paying U.S. doctors huge sums of money for speaking, consulting, and other services—and the more opioids a doctor prescribes, the more money he or she gets paid by those same manufacturers, according to a new analysis from Harvard T.H. Chan School of Public Health, Harvard Medical School (HMS), and CNN.
>The study found that, in 2014 and 2015, opioid manufacturers paid hundreds of doctors sums in the six figures, while thousands more were paid over $25,000.
>“I don’t know if the money is causing the prescribing or the prescribing led to the money, but in either case, it’s potentially a vicious cycle. It’s cementing the idea for these physicians that prescribing this many opioids is creating value,” said Michael Barnett, assistant professor of health policy and management at Harvard Chan School, in a CNN.com article. Barnett co-authored the study with Anupam Jena of HMS.
Some Doctors are absolutely devoid of morals and ethics, just like some teachers, some developers... some everything's - I think it's misleading at best to pull out a study as refutation that involved hundreds of doctors in a country of 300 million.
My entirely anecdotal experience has been that most Doctors aren't in it for the ferrari, but instead are trying to help improve people's lives.
I agree that does seem to be the real problem. Though I'd really like to see the alert myself to see what kind of dark patterns they may have used to incline the user to select the opiod option
Prescribing extended release opioids (which are known to be _highly_ addictive, even when used "appropriately") should never be the first choice for pain management. It should never have been presented as an equal option with non-pharmaceutical and non-opioid interventions.
> The San Francisco-based company was founded in 2005 and became known for its unique model of providing free, ad-supported health-records software to independent doctors.
This is a dark pattern. Pharmaceutical companies already have undue influence over what doctors prescribe. Embedding ads within a records system risks biasing both diagnosis and prescription.
A murder trial for an MD who was over-prescribing opioids just started in my city [1].
How are the developers of this software not being criminally charged? It literally seems like the same thing and if nothing else, they made it easier for doctors to potentially kill people and face charges themselves.
I think punishing the engineer would be much less practical than the CEO. There will always be an engineer (perhaps a remote contractor) who will build this.
> I think punishing the engineer would be much less practical than the CEO.
Of course. I wouldn't really ever consider engineers to be to blame - they could whistleblow of course, but the people that inked the deal and brought it to the engineers should be held responsible.
If we can't hold the tech industry responsible for this, what hope do we have holding them responsible for murkier issues like privacy/data collection?
edit: by "developers" in my parent post, I meant "the EHR company"
A fundamental part of engineering accreditation in most countries is ethics and enforcing the fact that you are to blame for the things you build and you are obligated to raise objection.
Also, you can be involved in the development of such things and not really be aware of what's going on. Like, you could be the front-end developer that presents the options returned from an API, or the back-end developer that just returns options from the DB and maintains the CRUD site for people to assign treatment X for ailment Y.
The person who ended up pushing opioids as a treatment for ∀y is very likely not an engineer.
“ The San Francisco-based company was founded in 2005 and became known for its unique model of providing free, ad-supported health-records software to independent doctors.”
I thought we have some of the most expensive doctors in the world, why can’t we get paid ehr software? The ceo responsible for this mess is Tom Langan. Why we are not able to put him in jail for a year is still a mystery. This is pure evil.
In retrospect doesn't seem like a very big surprise that they would resort to something like this as Practice Fusion was initially launched as free for a long time, and costed only $99 per month later.
One should be increasingly wary of using free software for crucial applications and sensitive data. Being HIPAA compliant isn't enough.
There's a regulatory body called POC3 (https://www.poc3.org) for communication device (and software) providers who make money from pharmaceutical ads to lay down ethical guidelines. Hopefully a body like this should be formed for partnerships between pharmaceutical companies and EHR (& similar) software products too.
The healthcare industry is VERY conservative. Even the thought of moving EHR hosting to the cloud was a huge effort. Things in this industry are simply done at a different pace. Even digitization of medical records required millions of dollars in federal incentives (the carrot), and even more money at stake for not adopting (the stick).
I think this creates an interesting discussion on the part of the designers and programmers. Did they understand that what they were building was going to increase opioid dependence? Did they ask about it?
And, the most interesting question of all: If they found out that was the case did they try to justify building it to themselves in some way?
Full disclaimer: I have built software that I had ethical reservations about myself. I am in no way a saint, I don't claim to know what I would've done in the same situation but I think it's for the benefit of software development to acknowledge that we do make ethical decisions when we build things and that the solution to something as complicated and diverse as ethics is not to just ignore it.
To be fair to the developers and designers: how exactly would they know that the inclusion of "opioid prescription" as an item in that list would help fuel a an opioid epidemic? Hindsight is 20/20, but would you expect them at the time to think, "If we include this as an option in this list, it will contribute to a nationwide epidemic of opioid abuse and countless deaths"? Honestly, I think it's a stretch, especially if they weren't aware of a deal with opioid manufacturers being the reason for it in the first place.
It would be one thing of some product manager came to them and said, "since a large opioid manufacturer has paid us a lot of money, we're going to implement this feature in order to increase unnecessary opioid prescriptions" but I would be surprised if that happened. "We're going to implement this feature to help doctors pick the right treatment for a patient's pain."
Someone here is evil and deserves what's coming, but I don't know that it necessarily would have been readily obvious to those implementing it. In fact, it would likely have been preferable to conceal the true nature of it lest any of them have any moral qualms or objections.
I'm not trying to negate your question, either. I think it's a good question to ask and consider.
> If we include this as an option in this list, it will contribute to a nationwide epidemic of opioid abuse and countless deaths?
Give. me. a. break!
At a minimum they should ask, "What are the potential downsides? How extreme are they? How can we determine how likely those potential downsides are?"
I'd expect every junior PM to ask _that_ series of questions about any product decision in any market.
There's a reason clinical trials have protocols for early termination. Not understanding that early termination is a thing when building a social app is one thing, but they're building EMR software!
Must be nice to work in a place where a developer has complete influence through the entire process. Every place I've worked has been so large that a single developer can only work on a very minute segment of the code unless they are very senior. I'm guessing the bulk of developers work at large companies and have experiences much closer to mine.
This tool was probably built by several teams of developers working somewhat isolated. Someone built a system that allows for treatments to be suggested for certain ailments, another team did the UI, another testing, then there was probably completely separate team of people in charge of determining what to suggest for as treatments. This treatment team was very likely not staffed by developers at all.
Which of these groups are responsible here? Do I need to be pushing back with every dialog option I create with data from a database? Ask my PO, "what are we going to do to ensure that nobody puts dangerous options in the db?" I'm being serious, if you're blaming the developers for this, then you should make suggestions that are appropriate for the real environment most of us work in; that is: we're often a very small cog in a very large machine with no view of the big picture.
I’ve never been a big fan of the “I don’t know what my software does—I just move JSON around” excuse. As professionals, we need to be aware of the intended use of the things we make, and that includes weighing the ethical implications.
We also need a professional ethical vow with teeth like the Hippocratic Oath that allows tech professionals to push back against demands to write unethical software, but that’s a topic for another thread.
I don't disagree. But my point was that it's not always clear what the implications are. Sometimes it's more obvious, sometime it's not. We also don't know what the "intended" use of this feature that was presented to the people who made it was. They could very well have been deceived as to it's true nature.
This could very easily have been presented and sold to a team in a way that does not make it immediately seem like something evil.
The bottom line is that developers and designers are not professionals, who would have to accept responsibility for their products. It is in the best interests of developers and designers not to be professionals and not to accept responsibility in cases like this.
A standard argument for this state of affairs is that it is in the best interest of society to allow developers and designers this freedom from responsibility, because of all the shiny new products. In which case you have to accept incidents like this---you can't make an omelette without breaking a few eggs.
I'm a doctor. During medical school and residency, I was taught in good faith that "only as much as necessary" opioid was OK to give and wouldn't create dependence - it was only an "excess" of opioid that would cause a problem. So under the banner of reducing the suffering of our patients, and a mandate to reduce patient-reported pain scores, opioids flowed relatively freely.
Now we know that was a terrible idea with devastating consequences. But we didn't know better and truly thought we were doing right by our patients. It's hard to imagine a programmer without medical training could be blamed.
The problem is things have gone to far the other way now.
Those with Chronic Pain are now committing suicide (as did my wife) when they are let to suffer.
The CDC itself stated in April of 2019:
"CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain
Some policies, practices attributed to the Guideline are inconsistent with its recommendations"
Sadly the medical community is not getting that message due to this mater now becoming political.
We posted at the same time, see my comment above yours about the documentary Pain Warriors.
Dr Mark Ibsen is one of the five stories. He lost everything for helping those with Chronic Pain. Five of his patients killed themselves when he was no longer able to prescribe. The medical board said he was over prescribing, that blood is on the boards hands. The arbitrator/judge in the case said that Mark did not do anything wrong, yet The System destroyed him.
Yes it is a rough field. I see it every single day in advocating for those that the Medical Establishment has forsaken.
There are bad doctors, there are bad people writing medical software as this thread explains. They need dealt with.
Pain Warriors documentary about Chronic Pain and medical establishment teaser is on my YouTube channel.
Read the reviews of those that have seen the full movie previews.
> Now we know that was a terrible idea with devastating consequences.
Practice Fusion knew that at the time. Internal emails released as part of the legal process make it clear that this feature was designed to get previously "opioid naive" patient (people not previously prescribed opioids) hooked on extended release opioids. This was specifically done to address the falling rates of ERO prescriptions, which the pharma company described as being due to "political reasons".
US negligence law encourages physicians to follow "the medical standard of care." This means doing what they are taught in medical school shields MDs from liability until the standard of care changes. The law discourages MDs from deviating from "standard" practice because doing so removes the "standard of care" liability shield.
The software developers are not protected by the "standard of care" shield. The software developers, like just about every other profession are held to a higher standard than MDs, namely "ordinary care" or "reasonable care".
Is a software company taking reasonable care to avoid harm when it builds a software feature that secretly encourages doctors to issue dangerous prescriptions? I don't know -- doesn't sound like it to me. Though there are probably a few plaintiff's attorneys willing to find out how a jury thinks about it.
Going through medical school and years of post-doc training makes physicians less responsible than people with no medical knowledge whatsoever? Yikes! If this is true, I hope the AMA lobbyists who bribed that turd onto the books were paid well for their evil deeds...
It's probably also not great for patients with rare diseases, that physicians are penalized for trying to solve problems no physician has solved before.
Yep, if safer or more effective innovative techniques become known, US MDs are not expected to practice them until those innovations become accepted as the standard of care. Other industries/professions don't get that break.
That would absolutely be a valid reason to build the service like that; the medical community thought that only an excess of opioids would be a problem, and it directly improves the numbers they're evaluated on.
However, once the medical community gets wise to what an awful idea that was, I hope that when the software providers hear about this they try to figure out a way to mitigate the damage they're causing. This feature was added in 2016.
Though, I think we agree that you cannot make an ethical decision on which action you should take unless you have any idea of what the consequences of your actions will be.
> It's hard to imagine a programmer without medical training could be blamed.
Sure, but I would have expected that there would have been some perplexities by the actual doctors when they were presented these popups at each patient data access.
According to the "statement of facts" the US Attorney's office released, this action resulted in "tens of thousands" of additional prescriptions of highly addictive extended release opioids. Without a doubt this resulted in lives and families destroyed.
I'm not sure the fine is "small" though (not that any fine could be sufficient), Practice Fusion was acquired last year for "only" $100M.
As a non-American I'm also curious about the mass necessity of opioid painkillers to begin with. From what I hear, people are prescribed opioids post surgery etc. which is bonkers to me as a foreigner. I'm a middle aged person and I have never seen anyone using opioid painkillers anywhere in my life. They give stuff to you when you are having surgery, and when you are in hospital's care, but something very extraordinary has to happen here to have access to those medications outside of a hospital setting. In the USA it seems to me like most people are prescribed these painkillers at least once in their life between 1-50 years but here, it is very exceptional and people are doing just fine.
>As a non-American I'm also curious about the mass necessity of opioid painkillers to begin with.
The necessity is a result of big pharma lobbying activity, there is generally no medical necessity for opioids.
Big pharma money ensures things like marijuana remain a class 1 narcotic at the federal level meaning there is no known medical uses of the "drug." This allows pharma regulatory capture for their opiates which makes doctors, pharma, pharmacies and insurance money, so it simply becomes the norm to prescribe patients these highly addictive and euphoria inducing painkillers. So long as the patient remains insured, can pay and claims they are in pain, the Doctor will give them their drugs.
One astonishing fact is nearly 90 of the top 100 opioid prescribing doctors are in Florida, and 85% of all oxycodone a highly addictive variety of opioid therapy is prescribed in Florida.
In 2007 an oral surgeon gave me a prescription for opioid painkillers after a wisdom tooth extraction, just in case I needed it for pain. The pain wasn't very bad and I never filled the prescription, but in retrospect giving me that prescription in the first place was just crazy!
Another doctor gave my wife an opioid painkiller prescription upon hospital discharge after a normal childbirth, just in case she needed it. Also never filled or used.
In the past few years doctors and pharmacists have become more aware of the risks and now write fewer opioid prescriptions. But for a while it was totally out of control. (I don't think either doctor was using Practice Fusion.)
this is to prevent you from going to the ER and getting an enormous bill.
sometimes after tooth extraction a condition called "dry socket" can develop and it will cause enormous pain. opioids solve that until your next regular visit to a doctor.
otherwise you could feel terrible pain and go to ER in the night with all the consequences
if teenagers wanna get wasted, they will find plenty of junk on the streets. That's why kids should have parental oversight.
You may fill the prescription with opioids - but you dont have to use them. I went to dentist couple times, and filled the opioid prescription once just in case, but never used them.
Worse, I went in for a consultation prior to having my wisdom tooth removed.
I was on the fence whether to have the procedure done or not. The doctor used the fact that I would be prescribed “really good painkillers” as an incentive for me to schedule the procedure.
You're premise is likely incorrect. As a non-American there is a very good chance there is an opiate available over the counter with no prescription in the form of codine.
That graph puts things in perspective. It turns out that I'm living in a country where opioids are not very available compared to other nations. Here you can't even get cough syrup with codeine in it without a prescription and even then doctors won't generally prescribe that.
I don't think something like a short-term prescription for low dose codeine/acetaminophen cough syrup is really a big deal. Stuff like that can even be over the counter in a lot of developed countries.
My wife used to work on an EMR that basically did the opposite of this - if a patient came in, and the dr was going to prescribe opiates, it would pop up a big window saying "Are you sure? There is potential for abuse..." for patients with a history of abuse (not sure what it did for other patients).
It's very du joure to talk bad about Epic (and certainly not without reason re: HHS healthcare interoperability proposed rules) but they have been a huge success from a business perspective. The reason why they provide EHR support for the majority of large healthcare system hospitals is that they provide a lot of flexibility to implimentation.
If you want the ability to support some very unique functionality, they will find a way to help support it. In a business that is almost nothing but edge cases (almost all of healthcare is complex, which is why you need 8+ years of training), you need lots of custom software behavior to fit these needs. The UCSF switch from GE healthcare to Epic about a decade ago is the prime example of what value Epic. [1, 2].
Epic is far, far away from what us MDs imagine when someone mentions the benefits of EHRs.
For starters, if one could make an EHR that just only attempts to also help practitioners in the trenches instead of just the billing dept. that would be stellar!
So 'the value EPIC brings' is huge... for anyone but care providers, thank you very much.
Sounds like I have a problem with anything making my job more painful.
The actual problem has nothing to do with nation-focused issues. With healthcare liberalization came competition, and therefore search for the cheapest solution. Problem is, in healthcare we have slaves (called residents) and what's cheaper than an educated slave? So actually, even european EHRs follow the 'for-billing' model because it's far easier to just dump the work on the residents.
EHRs are the whip with which we 'encourage' human healthcare providers.
Small independent practices are a dying market anyway. Provider organizations are all consolidating in order to achieve economies of scale (especially for EHRs), provide comprehensive services to patients under one roof, and achieve greater pricing power when negotiating with payers. Plus most physicians prefer being employees; they just want to practice medicine without the additional administrative hassle of running a small business.
Its true that running independently is getting more difficult, but that's not "on the market" but on the insidious regulations around insurance, malpractice law, etc.
A doctor can't open up an office and tend to patients with pen and paper anymore, and they have to pay thousands of dollars a month to systems that are truly terrible to be compliant.
Medicine is also a team sport now. Caring for patients with complex conditions requires coordination with multiple other practitioners. Exchanging paper records with them just isn't practical or safe. Plus if the doctor has to write a prescription, doing it on paper is so error prone as to border on malpractice.
*If they want to accept Medicare dollars (and usually private insurance just follows Medicare). I remembered some South Western (I want to say Arizona) specialty clinic that basically didn't accept insurance and had pen and paper charts still.
Now you're right in that traditionally Epic has served larger healthcare systems and tertiary hospitals, (hell they have even been known to turn down customers), but I think there's potentially a bit of role reversal on the horizon. Some Epic deployments have been creeping into community groups through licensing agreements [1, 2]. Probably makes more sense if you want your clinic pop to have greater access to tertiary services. It's something I would keep my eye on within the EHR business space.
Also, my previous comment was in response to no one liking Epic though, so certainly on topic.
They've been a huge success for the wrong reasons. Its very much a rent-seeking driven business: vendor lock-in, big contracts with government money, etc. What they do would be considered anti-trust if it weren't that government paid them to do it.
You can build an ehr with google docs if it were legal. But it isn't.
Worked for Epic after the dot-com crash, as they were finishing up their Verona headquarters. I will tell you one good thing about it: underground parking. That matters in Wisconsin.
All of the good things I could tell you that I remember about Epic have zero relationship with the software they sell. And none of them could stop me from leaving, because the software was the job. It was all essentially gold spray paint on a turd.
It's made in Visual Basic, and it literally cannot interact with its own versions. Hospitals have different versions of the same system in the same building and cant exchange information.
Every app has to start somewhere and will after a while be outdated. Whatever problems EPIC has are most likely not because of VB but because of bad management. I work in medical and I see almost every day management decisions that will lead to future software problems but nobody in leadership understands or wants to understand. Have a problem? Just throw the cheapest offshore team you can find at it. Repeat that a few times and you have a completely incoherent architecture. You will get this result with any stack.
I certain wouldn’t advocate using VB for new code. All I am saying is that the real problem is not the stack.
This is only my individual anecdote, but when I switched between two EPIC-using care providers (Kaiser->Anthem/Sutter), once I provided consent they pulled all my records over and 5 minutes later I was talking to a new doctor who had all the info from my previous doctor.
That’s because their customer is the institution, not the provider. The experience of the end user is probably not even in their top 3 priorities (similar to other enterprise software like Atlassian).
I can't imagine what kind of reaction you'd get to asking a medical provider to use specific software. As a patient, you're not a doctor, it's not your wheelhouse, it really isn't your place to tell them how to fulfill their job function, even if that software isn't in your best interest -- because the latter point will be quickly lost to the former.
Changing EMR’s is an enormous amount of work and money, regardless of practice size. There isn’t even a standard way to transfer records between them, though I think the ACA created a phased plan to improve interoperability between systems.
When I worked in a small practice that had converted from paper to electronic records, we didn’t even bother scanning in all the legacy paper records. They just sat in the doctor’s basement at home until the required 7 years passed until they could be destroyed. I’m not sure what would happen if that same doctor had to switch EHRs. I would guess they’d just leave the records on the old system and keep paying for both.
The recommendation you are making here has nothing to do with software engineering though. If you were a healthcare software business executive though, I'd be more inclined to agree.
Besides Practice Fusion's shady deals with pharma companies, I'd be surprised if you could articulate the major differences between it & Epic with regards to how the doctor uses the software day-to-day. This isn't about being a subject matter expert as a software engineer; it's really about being a patient and advocating for what's best for you (which is the correct thing for any patient to do).
"Practice Fusion admitted to the scheme with an unnamed opioid maker, though the details of the government case closely match a public research partnership between Practice Fusion and Purdue Pharma Inc., which makes OxyContin."
Color me surprised that it's probably Purdue. Every asset that the Sackler family owns should be seized.
I remember the shock about 10 years ago when I saw that PracticeFusion wholesale-copied the website design of Mint.com and then just customized it to their own business[0]. It struck me as boldly unethical, and 10 years later this opioid popup scheme rings the same.
Perhaps we as an industry should just refuse to participate when the company clearly prioritizes profits over doing the right thing, or in this case killing patients.
That page looks to have been removed after Allscripts bought them. Part of the deferred prosecution agreement is that PF will have to have information about the prosecution on their website, so I'm looking forward to that.
Most software is streamlined automated bureaucracy. Not in the pejorative sense, but in the "basic infrastructure of a human enterprise" sense.
Seen that way, it's absolutely criminal for software to allow the highest bidder to inject arbitrary bias into this infrastructure. On the other hand, it's absolutely foolish for organizations, which in the paper days hand-grew their infrastructure, to not closely scrutinize the nervous system/potential-trojan-horse that they're taking off the shelf and installing right into their core.
There's a certain irony on how the U.S. has spent billions on the war on drugs, yet they still have a gigantic drug dealing problem, right under their nose.
People are using their government influence to rob citizens blind for their self-enrichment. The war on drugs was used to enrich police forces and suppliers while the opioid problem was for the benefit of the pharmacy and insurance companies.
It's not that ironic when you realize that some of it is causal: restricting the supply of dealers makes the remaining dealers more bold (and gives them more incentive to pay lobbying costs to encourage the government to keep the supply restricted).
They put pop-up stealth advertisements, targeted at your doctor, into your electronic medical record, so that he or she would get you addicted to painkillers.
Software developers did this. For drug money. That's just terrible, isn't it? They shouldn't have done that.
But even if the developers had ethical concerns, they had no recourse but to quit, and be replaced by someone else--who might get six months of work in before realizing that they are working for the baddies, and also deciding to either quit or die a little inside.
I would do that job. I would take that money. I don't get a stupidly-inflated Valley salary with bonus RSUs, and I have bills to pay. I don't have a union that can protect me from nonsense. I know it's wrong. I would do it anyway, because I have been screwed by every company I have ever worked for, such that I learned that my ethics don't matter. Money matters.
I want my kids to get an education without student loans, if they want it. I want to drive a car that isn't older than they are. And I want to retire before I die. My ethics would only keep me from that. Apparently, the companies that aren't managed by money-grubbing sociopaths just don't hire where I live. So if you don't want stuff like this to happen, make it actually mean something to have ethical objections, even for people working outside of California.
I build software that has probably contributed in a material way to human suffering. For far less money than a Silicon Valley developer might get paid to make a mobile app for on-demand dog-walking. Everyone in my building does it. Everyone in the building across the street does it. Companies that don't hurt people as part of their business model aren't hiring here. People that have a problem with it--or at least those who can't hide that they do--don't get the jobs.
So if you are currently on a high horse, I hope you enjoy the view from up there. You haven't yet used your influence to help other workers--those with nigh-nonexistent power as an individual to influence the corporate employers that reluctantly hire them, and then reserve the right to fire at any time for any reason, or no reason.
>But even if the developers had ethical concerns, they had no recourse but to quit, and be replaced by someone else
I'm not saying that everyone who touched the software should be indicted, but there were options beyond quitting. They could've told the customers, the news outlets, or the government.
Of course, when you're surrounded by people doing the same thing and nobody else is speaking up, it's not unreasonable to think you're the only one who sees it as shady.
Yes, by whistleblowing they would have gone from unemployed developers to unemployed developers in prison. FBI targets security researchers with no business connection to health software companies. [0] How much worse would it be for ex-employees?
> But even if the developers had ethical concerns, they had no recourse but to quit, and be replaced by someone else--who might get six months of work in before realizing that they are working for the baddies, and also deciding to either quit or die a little inside.
They have another option. Organize and push back.
But when FAMG employees organize to push back on unethical behaviour that they are asked to be complicit in, much of HN tends to accuse them of all sorts of nasty things.
> I would do that job. I would take that money. I don't get a stupidly-inflated Valley salary with bonus RSUs, and I have bills to pay. I don't have a union that can protect me from nonsense. I know it's wrong. I would do it anyway, because I have been screwed by every company I have ever worked for, such that I learned that my ethics don't matter. Money matters.
You've identified a perverse incentive that requires punitive counter-incentive in response. Someone in your position will think twice about doing that job if by doing so, their freedom and ability to take care of their kids is put in jeopardy.
Of course, there needs to be punitive incentives at the top so that such that low-level employees are not pushed to act in ways that lead to results such as these.
The Uncle Ben Parker Contrapositive applies: with no power comes no responsibility.
As long as "at will" employment exists, then no contract terms exist, and no labor law can stick to the employer, so long as they are willing to lie whenever there is no contradictory evidence. If the employee gets fired for asserting their rights in the law, and the employer can say it was an "at will" termination, the employee has no effective recourse or remedy.
If you criminalize the work that I do, you are just getting me fired for no HR-disclosable reason (again), and the company will have that work done in another jurisdiction.
If you aren't putting c-level executives and/or board members in prison, and forcibly restructuring or dissolving corporations, you aren't doing anything to protect me, the worker. And if you are placing legal liability on me, personally, I definitely will not testify against my superiors. I know the feces roll downhill.
I was about to be incredulous, but I actually do believe that you would rather have me fired and put in prison, and my dependents thrown in the gutter, than to have a software workers' union or stronger federal labor laws that might possibly protect me from an arbitrary dismissal if I tell my boss "What you are asking me to do is unethical." Thanks for that.
Thank you for putting it these terms. I do agree with your overall point. Perhaps I worded my view poorly. I am more in favor of software engineers having the same liability that engineers in other fields have. If a civil engineer signs off on plans for a bridge that gets people killed, liability will fall upon their employer and the engineer themselves. In that sense, there are incentives for both the employer and the engineer not to design structures that cause harm.
> If you aren't putting c-level executives and/or board members in prison, and forcibly restructuring or dissolving corporations, you aren't doing anything to protect me, the worker.
Agreed.
> I was about to be incredulous, but I actually do believe that you would rather have me fired and put in prison, and my dependents thrown in the gutter, than to have a software workers' union or stronger federal labor laws that might possibly protect me from an arbitrary dismissal if I tell my boss "What you are asking me to do is unethical." Thanks for that.
On the contrary, I am in favor of unionization and stronger labor laws in IT.
And let me tell you, it's really great for the self-esteem, too.
As long as people keep giving tax cuts to the rich and undermining labor law, it's only going to get worse. Kids are still in cages. Presidents are still corrupt. And I'm too much a coward to withdraw my support of the system for your benefit, just because I don't want my family to be insecure about food and shelter again. I don't want to move yet another 1100 miles for work. I want to feel like I matter, but I really don't.
If you feel like you have the choice to not do what I do, then you also have the power to help me have the same choice. Will you use it?
I believe opioid addiction is not well understood among general practitioners. Here in the UK, they accept as common sense that your patient won't get addicted if they're taking opioids for pain.
Similarly for ADHD, when I was started on meds my psychiatrist reassured there was no risk of addiction because I had ADHD. In practice, whenever I spend more than 3 days without them I get terrible headaches.
Wow, less than 50 years of internet and already people are designing software to manipulate doctors into recommending opioids. Just think what might happen with younger peoples.
Enough people have pointed to the problems of for-profit healthcare and drug markets in the comments but I'd also want to stress that this is also an issue of privacy. These patient informations should never have made it through so many hands and there should be no pop-up ads in a doctors record file.
Before anyone complains about burdensome regulations, these are the situations were respecting people's information prevents deaths an family tragedy.
If a doctor is unable to think independently of a pop-up recommendation for a drug, the doctor should have his/her license taken away. This should be the next step in the process for real social justice.
I don't think the crimes technically qualify as a capital crime despite the major and obvious ethical and moral lapses. Even with more blatant and callous examples like "miracle mineral solution" (read: bleach as medicine for internal use) fraudsters don't reach that level. Nor even "knowingly selling possibly tainted products". Not a lawyer but I think it essentially would call for say deliberately adding cyanide to your products to be outright murder.
Please don't post like this to HN. You may not owe better to the person who did a thing, but you owe better to this community if you're participating here.
Always good to throw the line developers under the bus and let the executives get away with it.
I mean, as a developer, I'm always going business to business to pitch my dark-pattern UI features to companies and by gosh I just wish someone would stop me!
I don't wish that the developer to get run over by a bus, but I also don't buy that the line developer shouldn't be held accountable if they know that what they were doing is wrong. I don't care what your job is, we all must be good humans and have ethics and standards and say no if what we have been told to do is wrong even if it means losing our job. It would of course be terrible, but in the long run, the world would be better off.
So the manager has no idea it would kill people, but the developer does? All developers are now well-versed in medical ethics and would never need a lawyer?
Show me a well-known whistleblowing route that would give you protections for bringing this forward. Let’s pretend only the people pulling the trigger are the only ones who should go to jail in this case, and developers are the last and only defense that society wants for its software. You can do full stack, why not handle being a lawyer at the same time?
As I understand it, a developer could implement this without any knowledge of the secret deal: when opening a patients records a pop-up should appear. That's basically what the physicians would know after a using it for while too.
Sure, not every developer who worked on the application needs to know what would cause the modal to appear and what possible messages it might have.
But I think it likely that somewhere there was a developer who knew what that there was a query | logic function checking the patients pain relievers status etc. and a developer knowing that in the database the text came back with hey you should give this guy some oxy.
And I bet those developers talked together in implementing things so they knew stuff, but over time other people knew stuff too because there were probably little bugs like - the extra oxy recommendation text overflows in the patient suggestions window. or stuff like that.
maybe not everyone that worked on it was fully aware but there was some people that must have been like 99% aware, based on my experience in working in lots of different sized companies over the years.
Probably a developer somewhere in the process would have figured it out, but it’s possible they just built some abstraction for showing rx recommendations when certain conditions are met. The specific medications and conditions could be controlled through a CRM or admin interface without the knowledge of devs as to what actually goes in.
For complex business support software, are pop-up messages usually written by developers? What about the various translations of those messages? Don't these all just sit in .po files somewhere? This seems like more of an "analyst" task to me.
hmm, but rereading you are right someone could implement this without knowing about the secret deal, but different people are different and I have definitely worked with people who would say "why this" and then "business wants it", "hmm, that only makes sense if X or Y", heck I might even do it sometimes just trying to think about why things are put together the way they are - but you're right, some people won't, so maybe the developers who implemented it all never stopped to think "but why?"
People in our line of work have a much greater ability to walk than others do.
A software engineer with only a few years of experience can leave and have a $100k+ job lined up in a matter of days or weeks. $150k+ if you're in NYC and $200k+ if you're in SF or Seattle.
Sticking around and implementing an evil feature is cooperation with evil.
It might take them longer to find similar employment elsewhere, though, so I'd suggest that their increased earning power is offset by the potential for longer periods of unemployment.
The products I work on, I know which customers are asking for which features. I also hear from the managers and BAs why features are requested. It's not a stretch to assume the developers in question knew what they were adding and who for. And at the very least they could intuit why.
What's really hard to imagine is developers implementing features without understanding what they're implementing.
Not saying they alone should be thrown under the bus, but shame on them!
So the BAs and managers know too, and a typical assumption is that they know before they ever talk to a developer. They have every opportunity to reject it themselves on ethical grounds before they ever talk to a developer. And yet, they still bring this known-ethically-bad feature to the developer and ask them to implement it!
If devs are talking and developing customer needs directly (a legitimate thing), then that is a situation where developers are the first ones who should be pushing back. But in companies where there are multiple layers before a feature reaches a developer? Devs should not be the ethical enforcement.
Why do you think only one person designed this? Why do you think the person who designed this is an engineer?
Even small apps have dozens of developers. I'm sure this one had many more than that. Is the problem the implementation of popup, the content, or something else? If this was a system that recommended treatments based on symptom, is the guilty party the person who wrote the query, "SELECT treatment FROM symptom_treatments WHERE symptom_id = ?" Or the person who put the result of that query onto a page? Or is it the person(s) who suggested opioid as a treatment for symptom_id 7?
I feel like you're making the problem comically simple to justify getting on your ethical high horse. Yeah, a group of people decided to pull this shit, but there's a very small chance that this decision was made by one engineer that frequents HN. Most likely it was made by senior executives who passed down bits and pieces to various teams to get the outcome they wanted.
I'd rather take a positive approach - and wish that the person would not be a coward and raise alarm bells, or that we had whistle blower laws and a substantial reward in place so whistle blowing was also incentivized.
Designing the tools that providers use to treat patients is exceedingly difficult and filled with moral hazards.
What makes this instance so pernicious is that it was involved in what is now a national crisis, but it's not very different to what a flu vaccination manufacturer could do, and which would raise no eyebrows in the eyes of the public or the government.
Medicine is one of those fields where the discrepancy of what patients think it is and what it actually is is wide enough to cause outrage at every single thing.
> Designing the tools that providers use to treat patients is exceedingly difficult and filled with moral hazards.
I don't doubt that—but I also have a lot of trouble believing that the people who designed this tool didn't know exactly what they were incentivizing. A UI designed with the user's interests in mind simply would not have come out this way.
The degree to which we've normalized the creation of dark patterns is scary.
the market will always gravitate towards products that scale, that's all drugs are. when you become more efficient it is intangible easily replicable things.
I think a quadrant based graph makes this more apparent and can influence public policy
Profit motive is great for simple products, ones that have few social implications, ones where defects or issues appear quickly. Maybe that used to be the case in medicine. But its not anymore.
Fluoroquinolone antibiotics such as Levaquin (no longer manufactured, only generics now [you can not sue the makers of generics in most states]), Cipro etc. should be removed from the market due to their devastating side effects.
My late wife's Journal was part of the 2015 FDA hearing about getting these restricted from doctors giving them out like candy. Alas all we got was yet more "Black Box" warnings that you and the doctors never see.
Karen ultimately killed herself from the Chronic Pain cause by the Levaquin and Cerebrospinal Leaks (CSF Leaks). Her saga is one of the five stories in the upcoming documentary Pain Warriors being released to distribution this spring.
I'm now up to 44 people that have told me that their own CSF Leak started after taking Levaquin, Cipro etc. Something that there is ZERO medical research on. The Leak doctors are aware of this as I spoke about it at their first ever CSF Leak conference.
Someone here will inevitably say "I took Cipro et.al just fine". Many people do take it may times until they have a reaction or they don't associate their new health problems with the delayed reaction months later.
Antibiotics in general are a good thing, however we must never assume they are safe in and of themselves without consequences.
Someone here will inevitably say "I took Cipro et.al just fine".
A lot of my childhood was spent in hospitals, and I've had a variety of antibiotics over the years. And anesthetics, I've become quite the connoisseur. I'm not allergic to anything, I've never had a reaction of any kind to any drug. Not even allergic to any foods. Bring on the shrimp and peanuts!
I was recently given Cipro. My entire back broke out in a rash. Not a devastating side effect, but after a lifetime of a variety of drugs of all sorts without any but the desired effect, it sure made me go "WTF? You sure this shit's safe?"
I thank you for sharing your story and I can't even imagine the pain your wife and you went through.
I do think that even though there are dangerous drugs, there are costs to making the use more expensive or harder to get. All drugs have side effects and some are truly devastating and the best way to handle that risk/reward tolerance is talking to a provider and managing it. The same way some drugs create dependence, the lack of them also cause enormous pain, and their increased price also create inaccessibility.
There is definitely a rampant culture of consuming pharmacological products in the US: maybe there are things that are causing the US society to be so dependent on drugs that can be addressed.
I've gathered all of the FDA warnings and some of the EU warnings (they say don't use them) at the link below.
The FDA itself says these should not be used until all other possibilities have been exhausted. Sadly the doctors are not getting the message and are giving them out like candy.
Cipro was a weird one; it was "omg last resort top of the line" there for a bit; then Amerithrax happened and the shit was being handed out like candy; and a few years later my dog gets it post-op "for the rest of her life".
I doubt the story of how that happened, the corruption and stupidity that enabled it, will ever make it out of the land of "conspiracy theorist ravings" ... but it should.
It's truly absurd, incredibly short-sighted even if one were to take the advantages at face value.
But the advantages are a microcosm of horror, too, like the ability to keep animals clamped in extremely constricted, filthy, stress inducing environments without the flesh literally rotting off their bones, while feeding them a diet (corn for cattle?!) which gives them ulcers.
The industrial farming practices are so disgusting I'm just lacking the words. Antibiotics should be a last resort, prescribed by a vet on a per-animal basis after other conditions are verified to be fine. There should be a clear financial incentive to keep farm animals healthy by default!
Click a button, and the program would create a treatment plan. From 2016 to spring 2019, the alert went off about 230 million times.
The tool existed thanks to a secret deal. Its maker, a software company called Practice Fusion, was paid by a major opioid manufacturer to design it in an effort to boost prescriptions for addictive pain pills ...
Its existence was revealed this week thanks to a government investigation.
Holy shit