Friday, June 22, 2018

Have They Finally Got to You? - the Firing of Dr Gu

Introduction - Dr Gu's History of Activism Made Him Unpopular at Vanderbilt

We first wrote in February, 2018, about the plight of Dr Eugene Gu, a surgical resident at Vanderbilt University Medical Center (VUMC).  Dr Gu has a history of political activism, resulting in being  blocked on Twitter by President Trump after Dr Gu criticized him online, until a court forced Trump to unblock him on First Amendment grounds.  After Dr Gu posted a photography of himself kneeling in support of the protest of football player Colin Kaepernick, the mother of a pediatric patient apparently refused permission for Dr Gu to treat her child based on the kneeling post, and VUMC responded by suspending him.

Dr Gu Fired

The story reappeared in the media in June, first in the Duke University Chronicle, then in the Tenneseean and USAToday.  From the latter,

A Tennessee doctor who became a social media sensation because of statements on President Donald Trump, racism and Colin Kaepernick - and who later sued the president over First Amendment rights - is losing his job at Vanderbilt University Medical Center.

Dr. Eugene Gu, 32, a Vanderbilt surgery resident, said Friday that Nashville's biggest hospital is ending his five-year residency after only three years.

Technically, Vanderbilt has decided not to renew his contract with the hospital, Gu said, but he argues the effect is 'no different than being fired.'

Dr Gu argued that the reason he was effectively fired was that VUMC disapproved of his political views as expressed on social media.

'The take-home message here is that there is an unwritten rule for surgical residents and that is rule is, always make your program look good and always make your hospital look good, and often that means stay silent,' Gu said.

VUMC denied that:

Vanderbilt said in an email statement Friday that the decision not to renew Gu's contract was not a result of his criticism of Trump, his lawsuit, or his public opposition to racism. The hospital has said previously that all disciplinary actions against Gu relate to his work performance and professionalism.

'Regarding other allegations that Dr. Gu is making about the Medical Center, I would ask that you please consider these as allegations and nothing more,' John Howser, a spokesman for the hospital, said in the email. 'To date, we have not engaged in a point by point rebuttal of Dr. Gu’s many claims over the past two-plus years. At this time we will continue to maintain this stance.'

VUMC, however, has not provided any clear evidence of deficient performance or insufficient professionalism.  The Duke Chronicle article noted arguments that Dr Gu made suggesting that it may not have had much such evidence.  First,

After an appeal, a May 17 letter to Gu from VUMC General Counsel Michael Regier—delivered at the request of Jeffrey Balser, president and CEO of VUMC—cited a 'lack of sufficient improvement in performance and conduct in key areas' after the probation. The letter, which was obtained by The Chronicle, indicated that the most "significant areas of concern" were 'patient care, communication, and medical knowledge.'

However, Dr Gu cited one example of a criticism of his performance that seemed rather trivial.

when he was serving on consult call, meaning he would respond to any surgical needs throughout the night. There was a patient for whom he was supposed to identify the course of treatment—which he did, correctly, as he did with the imaging and other relevant details. His colleagues, nevertheless, 'nit-picked' Gu about 'every little detail on the case'—claiming he didn’t 'dot all of his i’s and t’s' by not providing the patient’s height and weight—which Gu said were irrelevant.

Also, he noted that

Kyla Terhune, the residency program director for general surgery, was two-faced in her interactions with him. A text message obtained by The Chronicle showed that Terhune wrote 'Nice presentations' to Gu after he spoke at the Veterans Affairs Medical Center Tumor Board. He said she complimented him for his performance after going through two surgeries for him. But when it came time for performance review, Terhune said his performance was 'terrible' in those same instances, Gu noted.

Given the local and social media attention this story has received, one might wonder why, if VUMC had such a strong case against Dr Gu, it has avoided ever airing any details about it.

Furthermore, the article noted an apparent anomaly in the narrative of how the patient's mother came to complain about Dr Gu.

Before the story broke, VUMC declined to comment more than a dozen times, saying that it does not comment on personnel matters. After it was published, Howser wrote in a statement that Gu did not need to change his political views.

'Dr. Gu has never been told that he must change his political views or the substantive content of his personal participation on social media platforms,' the statement read. 'He has been advised of the need to adhere to VUMC’s social media policy, which requires that persons who are identified as representatives of VUMC clearly state that their views are their own. He has also been advised that resident physicians should be professional and respectful in their interactions and communications with and about one another.'

In the kneeling photo, one cannot make out that his badge says Vanderbilt Medical Center on it, even when zoomed in on. Gu's Twitter bio had no reference to Vanderbilt, though he had tweeted about Vanderbilt seven times prior. Twice, he tweeted that his views communicated on Twitter do not represent VUMC.
Yet Vanderbilt, after first suspending Dr Gu, ended his residency prematurely.  Since surgical residency normally lasts five years, it seems reasonable to say Dr Gu was fired, and that such Vanderbilt's action will likely damage his career.  Since Vanderbilt has not provided any convincing evidence that Dr Gu was incompetent or unprofessional, one is left with the nasty suspicion that it fired him because refused to stay silent about political beliefs that did not accord with those of Vanderbilt leadership.


This story suggests that in our current political era, health care professionals, particularly trainees or others at the bottom of the totem pole, may be increasingly beholden to the political sensibilities of their bosses, and hence increasingly wary of espousing political views that run counter to those of their bosses. 

While it is reasonable for residency programs to require their trainees to be professional, since when did "professional" mean stifling political views that might offend hospital corporate leadership?

As we wrote in February,

 It may not be unreasonable to expect physicians and physician-trainees, as medical professionals, to avoid getting into political arguments with patients.  However, it is unreasonable to expect physicians to avoid making any public political comments that could ever be expected to offend any patient or relative.

And this case also raises the question of whether it was the patient's mother's offense, or the Department Chairman's offense, that mattered.

Attempts to censor political speech in academia are unfortunately not rare (see the website of FIRE, the Foundation for Individual Rights in Education, for many examples).  However, they have not seemed to be that frequent in medical education. (Our most recent example before this case was from 2015.)

I wonder, though, if the ongoing attacks on free speech and the free press (e.g., look here and here) by the current President and his cronies are emboldening censorship in US society.  The President does set the tone and agenda for the country.  A president who personally threatens free speech and a free press will encourage other would-be censors to crawl out of the woodwork. 

We will only be able to restore the freedoms promised in our Constitution, and ostensibly inherent in the nature of academic organizations, if we can get a new president who upholds the worth of these freedoms, and actually will preserve, protect and defend the Constitution of the United States.

Musical Interlude

Some lyrics from Dr Wu, Steely Dan, by Fagen and Becker

Are you with me Doctor Wu
Are you really just a shadow
Of the man that I once knew
She is lovely yes she's sly
And you're an ordinary guy
Has she finally got to you
Can you hear me Doctor

Tuesday, June 12, 2018

Dander Still Up. Drowning in Great Dismal Swamp. Film at Eleven.

Maybe this is the last in my series of dander-raising essays, as recent national and world events have most definitely left so many of us with a raging case of TDS. (Trump Derangement Syndrome, look it up it's a thing).

So many damned browser tabs sitting there open. So little time.

Or maybe not. Who knows. Where are all these suicides coming from?

My editor keeps telling me, "don't let it make you paralytic." Hey, I'm trying.

Just sensing a kind of coalescence in all the corruption our bloggers keep writing about. How do we even differentiate these activities across so many sectors of society. We were going to see our swamp drained. He promised. But instead there's just this big brand new bodacious cesspool. There it is in all the revolving-door sectors. Federal government. Private sector. Health care non-profits and even academia.

Just read back over recent weeks and months of this, your favorite blog.

The coalescence of corruption is certainly made easier by our enjoyment of a remarkable and possibly quite barmy Confabulator-in-Chief. He's just sort of paved the way for what one pundit recently characterized as a sort of race-to-the-bottom. No corruption is too small (cone of silence? nifty office furniture? wipe out environmental health? give Big Pharma another bye?). Or, of course, too large.

None of this is terribly new, just the way it's all melded into what the cancer biologists call a syncytium. There are no winners and losers in all this. Just a lot of organelles swimming around and causing havoc at our expense. Just a bunch of top-level narcissists and then, under them, a phalanx of careerist stronzi streaming out of academic backwaters and think tanks to grab their fifteen minutes of ... what?

Surely not fame, unless you're looking for a spot on an SNL cold open. Microphone time maybe? Let's call out a few of them.

The careerist gets fifteen minutes, max, by the way. The turn-over in government, especially, in the federal executive, is many-fold that of any previous administration. If this were tennis we'd all have whiplash. Everybody seems to be trying to find their own inner Scaramucci.

Just now, in fact, it seems to've gelled intoone great big scandal. Adam Serwer in The Atlantic: "there is only one scandal." While the Chest Thumper-in-Chief runs around doing what he does best--sullying the western world and laying down cover for his army of swampy miscreants--the careerists continue to run up a debt whose bill will surely come due. Of course by then, so many will have cashed out. Guess who'll be left to pay the tab. You, me, our sickest, our poorest. Mother Earth.

In the private sector it may take years for the ins and the outs to get in and then back out. But of late in both Big Pharma and in Health IT, both the revolving door and the Invasion of the Body Snatchers (aka baleful effect of activist investors and hedge funds) have taken their toll and we pick up the pace. Most recent casualty: Bush family scion and alleged wife-beater Jonathan B, thrown out of possibly the most innovative, but not quite profitable enough, athenahealth EHR company he once founded. Offed just now by the Elliott organization, which is headed up in turn by ultra-right political donor Peter Singer. (Here and here and pretty much everywhere--don't get stuck in his cross-hairs.)

Ah, yes, these are the glory days for the Big Families. Donorship gets you a whole party of your own. The Prince-DeVos family, the Koch family, the Uihlein family, the Mercer family. And Las Vegas Gambling Tycoon Sheldon Adelson, who almost single-handedly handed Binyamin Netanyahu an unearned win in Jerusalem.

Their common goal: effacement of government, Ron Reagan's great "problem child," in favor of its replacement the Great Dismal Swamp.  (In fact much of the real GDS, out of North Carolina, was actually bought up by Betsy DeVos's brother Erik to train Blackwater mercenaries.)  So now, on to the Great Dismal Swamp of outsourced everything. Outsourcing, along with the revolving door and the Anechoic Effect, these form the inner dynamic, the secret history of what's happening now. Outsource security. Outsource VA health care. (See my earlier blog on a secretary's attempt to resist that.) Outsource public education. Outsource, or at least deregulate, clinical trials of unproven drugs. Privatize, don't shade your eyes (apologies to Tom Lehrer).

(Note that in the course of all this privatizing the common weal, these Big Dogs not infrequently can turn on each other. Singer turns on Bush. Koch the Elder turns on Koch the Younger. The dollar is king and the beat goes on and Throw Momma From the Train.)

Other major features of this secret history:
  • The Scorching of the Earth. Both literally (health consequences of climate change), and figuratively: the flaming rhetoric of the careerists. The most glaring recent example, albeit outside of our health purview, White House National Trade Council Director and temporary-in-from-the-cold academic Peter Navarro, awarding "a special place in hell" to Canada.  (Wait, what?!? Canada?) Why? Because it dared to cross his new boss. Cross the boss, thump the chest. Ten points for the thumper, zero points for the country--either one. We'll learn later this year, and again in 2020, whether there's enough of the vaunted "base" left to be snookered by all this guff. The chest-thumpers may discover a special place in hell meted out to folks closer to home. The charlatans. The quislings. Pretty clear now who they all are.
  • The Swamp-Ooze of the Careerists. Navarro's one high placed example. Another newly high-placed with a more direct impact on health care, and also flaming the air waves, is National Economic Council Director and former CNBC correspondent Larry Kudlow. In the recent presidential travels Kudlow did not speak cosmologically of heaven and hell, but only politically. He called Canada's measured response "betrayal." On health insurance, he's agin it. It kills jobs, per Mr. Kudlow. And he ought to know how things really work, right? In 2007 he famously predicted the continued success of an earlier deregulatory GOP economic policy suite in that once-great organ National Review. William Buckley turned over in his grave. The headline read: "Bush Boom Continues." The following tag line: "you can't call it a recession." (Emphasis his.) The date: December 10, 2007. (Despite which, get well quick Larry. Maybe find a less stressful job would help.)
  • Health and the Environment. Ah, yes, and in environmental health we have Scott Pruitt heeding HMV while lining his own pockets and lobbying for his wife's Chick-fil-A franchise (honest I can't make this stuff up), all the while dumbing down any expertise on health. This dumbing down and anti-science motif pervades the Great Dismal Swamp. Never before has there been such a dearth of scientific, pedagogical, or health expertise in any of the departments that so direly need those capabilities. Interestingly, the small-bore corruption of these characters seems more prominent in the upper, Pruitt-like, echelons than in the Small Fry. Or are we just not hearing about the little guys?
  • Lesser Careerists. You can't have a syncytium without both big and little organelles. The little guys are actually among the more damaging, as they tend to be true believers with claimed expertise that goes poof when examined closely. Among the most famously wrong-minded recent ones we have the Press Secretary herself, Ms. Sanders, who from the depths of her health policy experience pronounced last fall that “I can’t think of anything worse than having the government be more involved in your health care instead of less involved.” Oh, Miss Sarah, I can. Even more peculiar is the role of the rather more obscure Ms. Katy Talento, of the White House Domestic Policy Council. She gets to act as conduit and house pundit for the new HHS secretary Alex Azar. It's fascinating. In several easily-reached venues she's described, by self or others, as "an epidemiologist." Harvard's master of science (not MPH) degree in epidemiology and public health can be obtained, as she did, in something between three and twelve months. Not exactly a board certification. Then she went on to build her career in ideological rightist causes and organizations, including anti-abortion campaigns and one notable set of pronouncements on the supposed link of birth control to miscarriage.

    Came the time for Azar to prep his new boss on last month's Big Speech on reducing drug costs, Talento broadcast the news that "no ox would be gored." Said she, "This is a fearless president and he doesn't know or care why things have always been done. It's not like your typical Republican authorizing committee that protects this model that they helped write for decades...." Wait, one little thing. It didn't happen. The big play available, as I said in a previous post, would've been having Medicare bargain for prices. Instead--and clearly Azar could've tried and failed to get this--the Caregiver-in-Chief declared that drug prices in the US should come down by having other countries pay more. What so strange about this is not merely the absurdity of such a statement, coming from a former Pfizer top exec. It's the fact that here's a lower-level careerist who went straight into RNC speech writing and working for a right wing southern Republican (Tillis, NC), then became the "epidemiologist" for Mr. Azar.

    Hold the phone. Among all the young staffers willing to sell their souls to get the Big Show on their CVs--don't they know it's a shabby little show?--what about the wonderful lady who dissed the ailing John McCain as inessential (just now he's incredibly essential), because, after all, he's going to die soon? Out the door she went, but of course her Republican friends got her a soft landing. Her name is Kelly Sadler, a real comer. Or goner.
  • The Rise of the Druggists. Last but not least, part of the secret history that, now I see it, has really got the dander way up, is how in health care and health policy, Pharma's now fully the tail-that-wagged-the-dog. CVS is moving into health care--see Dr. Poses's recent posting on just how well that organization understands their responsibilities. Actually having pharmaceutical and pharmacy folks elbowing out health care professionals who understand professionalism, it's not a new thing. Philadelphia Big Donor Leonard Abramson founded U.S. Healthcare and made a mint when he discovered how easy it was to make Managed Care actually Denied Care, then, with this proof-of-concept, cashing out and selling to Aetna. That goes way back. More recently, though, the pace of They Come at Night has picked up, viz. the firing of David Shulkin MD at the VA and the hiring of Alex Azar at HHS. These clearly result from both the privatization motive and the Pharma tail wagging the dog. At least two of the three branches of the federal government understand the business model of Pharma. They don't come anywhere near understanding the professional ethics of doctors--even while relying on their personal physicians to exercise such ethics.
  • Business ethics in medicine, as practiced by Pharma, have been laid out in many, many places in this blog. I and others have laid the blame for a big chunk of the opiate crisis at the door of Purdue pharma and the Sackler family. I regret to remind that the early Sacklers were physicians. But they were first and foremost business folk, possessed of a truly novel business model, which may be called outright dissimulation. (For a fascinating and harrowing description of one high-functioning Ivy-League opiate addict's experiences at Yale, with all its Sackler money and Oxy pills traded on the New Haven Green, see this Guardian piece.)

    Actually, I've talked to a lot of pharma execs and they're often quite ethical and responsible. They have their hands full fighting off the PBM companies. They get singled out for their K Street spending, but many of them actually have rather low budgets for that, the recent Novartis scandal notwithstanding. Other execs blush at this Novartis nonsense and want nothing to do with it. I say all this mainly to point out some dreadful outliers. It's not just the brand name drug makers, either. Teva, the Israeli generics giant, is allegedly a real problem. As I write this, good old Ron Wilson, the Wisconsin Republican who just keeps on giving his gifts, is blocking his Ranking Member Claire McCaskill from obtaining information Teva's contributions to the opioid crsis. He's saying leave it to the courts.

OK, as I just hinted, I agree with you. None of this recent stuff is really secret. Not even really novel. It's just coalesced like never before into into a dismal swamp. (Orwellian doublespeak: yes, we've seen the swamp drained. Of what? What was he promising to drain? Yes, drained, if that meant getting rid of people ("Deep State"?) who know stuff. So people who don't know stuff can get on with the business of ripping us off.)

Hence in my current rant I just wanted to point to those commonalities that are, right about now, more egregious than ever. Honestly, they are. When the history is written, it will prove me right. Oh, wait, Alexander Hamilton wrote it already, hundreds of years ago.
When a man unprincipled in private life desperate in his fortune, bold in his temper, possessed of considerable talents, having the advantage of military habits—despotic in his ordinary demeanour—known to have scoffed in private at the principles of liberty—when such a man is seen to mount the hobby horse of popularity—to join in the cry of danger to liberty—to take every opportunity of embarrassing the General Government & bringing it under suspicion—to flatter and fall in with all the non sense of the zealots of the day—It may justly be suspected that his object is to throw things into confusion that he may “ride the storm and direct the whirlwind.”

Tuesday, June 05, 2018

Why Did CVS Health Betray its Charitable Giving Policy and Social Responsibility Agenda to Donate to a Sketchy Non-Profit Devoted to Trump's Agenda?

Many big health care organizations, including for-profit corporations, have high-minded mission statements, and proclaim their social responsibility.  Unfortunately, we have shown that many leaders of such organizations seem indifferent to these seemingly exemplary goals, and even exhibit mission-hostile management.

A recent example involving CVS Health provided an unprecedented example of mission-hostile management, or something worse.

Introduction: CVS Health and the Promotion of Social Responsibility

CVS Health is a huge corporation that runs a large chain of pharmacies, many of which contain MinuteClinics, touted as quick albeit limited sources of primary care, staffed by nurse practitioners.

It thus employees numerous health care professionals with strong professional values.  For example, the American Pharmacists Association has a code of ethics which includes respecting the covenantal relationship between pharmacists and patients, promoting "the good of every patient," acting with "honesty and integrity," serving "individual, community and social needs."

CVS Health proclaims its "social responsibility." This includes "keeping the planet in balance," and making "quality health care more affordable, more accessible and more sustainable."

CVS claims to act socially responsible by making charitable contributions for

improving health and health care nationwide. We support programs that improve access to health care services, provide chronic disease management and promote smoking cessation and prevention.

That seems fine and dandy, but then....

CVS Will Stop Funding America First Policies After Three of its Leaders were Revealed to Have Made Racist, Misogynistic, and pro-Nazi Remarks

CNN reported on June 1, 2018, that 

CVS Health said Friday that it would no longer donate to America First Policies, a nonprofit group that works to promote President Donald Trump's agenda, after CNN and other outlets reported racist comments made by staffers of the organization.

The details were,

[Carl] Higbie has a history of making racist, sexist, Islamophobic and anti-LGBT comments. Some of his more inflammatory statements were that the 'black race' had 'lax' morals and that Americans should be allowed to shoot undocumented immigrants crossing the border with Mexico. Following CNN's January report, Higbie resigned from his position as chief of external affairs for Corporation for National and Community Service, which manages volunteer services for the federal government. He joined America First Policies in March.

Higbie initially apologized for his remarks but later defended them and said they were taken out of context.

John Loudon, a policy adviser for the group, has also made inflammatory comments about Muslims and women, CNN's KFile reported in May, such as calling Barack Obama 'the Islamchurian candidate' and joking about 'crack whore Dem voter.'

In May, Mediaite reported that Juan Pablo Andrade, another America First Policies adviser, praised Nazis and said that, 'The only thing the Nazis didn't get right is they didn't keep f***ing going!' Andrade claims the video is out of context and he was quoting someone else. He has said he is looking for the full video, which would exonerate him.
One wonders if CVS Health had vetted America First Policies prior to making its contribution, since the presence in the latter's leadership of three such people suggest there just could be a bit of a corporate culture problem.

In any case, the CVS Health response came courtesy spokesperson Carolyn Castel:

Comments made by employees of America First Policies that were reported after we made our contributions are unacceptable to us. We have zero tolerance for discriminatory actions or behaviors, and as such we will not be making contributions to this organization in the future.

CVS Health's denial of further donations to America First Policies seemed admirable, but begged the question of why it made its initial donation.  In the Providence Journal, Brian Amaral reported on June 1 that  CVS justified its initial contribution to America First Policies as a way to “to support the tax cuts signed into law last year,” saying that it “supported this legislation and used the tax savings it created to invest in the growth and success of our employees,...”

However, that rationale seemed at best very loosely related to CVS Health's stated policy of making donations to improve health and health care.  I suppose that perhaps if tax cuts did lead to happier CVS employees, the indirect result would be better health care.  However, at least the purpose of the contribution did not seem in direct conflict with the stated goals of CVS charitable giving.

Nonetheless, the result of the CVS Health contribution to America First Policies seemed retrospectively a spectacular case of mission-hostile management.

But wait, there is more.

America First Policies Also Advocated Multiple Positions at Odds with CVS Health's Support of Social Responsiblity

As noted above,  CVS Health suggested that it supported America First Policies because it was dedicated to tax reforms that would result in increased CVS Health's revenues.  Their website does list "tax cuts that put America first," as one of its issues.

CVS Health's comments suggested that this is America First Policies' only issue.  It is not.  The America First Policies website lists advocacy on 13 other issues.

One is "repeal and replace Obamacare."  In particular,

America First Policies believes Obamacare is a disaster, burdening our country with rising premiums, unaffordable deductibles, fewer insurance choices, and higher taxes. Congress needs to repeal and replace this law, including rescinding the individual mandate and eliminating taxes that drive up costs,

This issue certainly has to do with quality and accessibility of health care.  However, whether most CVS Health employed health care professionals, or customers think that dismantling the Affordable Care Act would lead to better or worse, or more or less accessible health care is doubtful.  Certainly CVS Health management did not explicitly justify how supporting America First Policies was informed by the company's stated objectives for charitable giving that supports health and health care.

Another issue addressed by America First Policies is "securing our border."  In particular, the organization advocates for

a wall to stop illegal immigration and drug smuggling; putting an end to sanctuary cities; and deporting illegal aliens with criminal records.

These issues seem to have nothing directly to do with health care, or with the company's stated reasons for charitable giving.  Many people might argue that these objectives could harm the health care, at least of some immmigrant groups.

So far, it is not clear why CVS Health really chose to donate to America First Policies.

But wait, there is more...

America First Policies Appears to be a Partisan Political Operation of Dubious Legality

A Political Agenda from the Start

A few more minutes of Google searching reveals that America First Policies has an advocacy agenda that seems in direct conflict with the CVS committment to social responsibility, and that America First Policies does not in the least resemble the sort of charitable organization that CVS says it intends to fund.   Recall that CVS says that the purposes of its charitable giving are

improving health and health care nationwide.

We support programs that improve access to health care services, provide chronic disease management and promote smoking cessation and prevention.

Yet when America First Policies was started, initial coverage, like this AP report from January, 2017, per WJLA, said it was a political operation.

Six of President Donald Trump's top campaign aides have banded together to start a nonprofit called 'America First Policies' to back the White House agenda.

In addition,

'Some of the same like-minded individuals who put their energy into getting Mr. Trump elected are now going to be part of a grassroots group to go out there and help with the agenda, help the White House be successful,' [former Trump campaign digital director Brad] Parscale said.

Was it about improving health and health care?

America First Policies will conduct research into public policies and promote Trump's favored causes, such as dismantling and replacing President Barack Obama's health care law and changing immigration policies.
Again, many would argue such actions could harm health and health care.

For a Non-Profit "Social Welfare Organization," Doing Political Polling May be Illegal

In March, 2018, CNBC did a long investigative article on America First Policies political polling operation.

Last summer, America First Policies took an unprecedented step for a politically allied nonprofit: It started using three top polling firms from Trump's 2016 presidential campaign to produce a steady stream of Trump-focused polls, strategy memos and reports that continue to this day. The three firms initially put their own logos on the polling they did for the group, but over time the America First Policies logo gradually replaced theirs on some of the documents.

CNBC reviewed many of the polls it conducted. One example of an obviously political poll was

A September poll showed that America First Policies was exploring ways to defeat Arizona Republican Sen. Jeff Flake in a primary, a month before Flake, a Trump critic, announced his retirement.

Note that America First Policies worked closely with a political polling firm which was founded by a close Trump associate who now works in the White House, but somehow obtained an ethics waiver  allowing her to continue working with this firm.

The America First Policies polling effort operates as a network of coordinated groups, with two lesser-known firms, National Research Inc. and Baselice & Associates, working alongside a well-known Washington firm, The Polling Company, which was founded by former Trump campaign manager-turned-White House counselor, Kellyanne Conway.

When Conway sold her firm in September 2017, The Polling Company had already been working for America First Policies for more than two months, judging from the company's logo on polls that it conducted for the group in June and July.

Conway was granted a special ethics waiver last June so she could engage in 'communications and meetings' with former clients of The Polling Company without violating Trump's two-year ban on communications with former employers or clients. Conway has been called the 'Trump whisperer' for her ability to influence the often mercurial president. In a 2016 interview with MSNBC, she described herself as a 'discreet advisor' to Trump who was expected to use her data and strategy experience to help Trump craft his message.

CNBC interviewed ethics experts on the legality of what America First Policies was doing.

'AFP is doing the type of polling that would typically be done by a presidential campaign or a major party committee like the RNC or the DNC,' said Brendan Fischer, an election law expert at the nonprofit Campaign Legal Center. 'So even though they claim to be committed to a set of issues, the available evidence here indicates that they're operating as a polling shop for the president.'


Stephen Spaulding, a former special counsel at the Federal Election Commission and now director of strategy for the nonpartisan watchdog group Common Cause, agreed. 'There are ample grounds here to investigate whether America First Policies has been raising money that's subject to limits and disclosure requirements because it's being used for political purposes,' he said.

Finally, the article suggested that America First Policies was a way for wealthy donors, who could be individuals or corporations, to fund Trump's political agenda while hiding their identities and circumventing legal limits on direct political contributions.

'So you have a situation where large donors are contributing to America First Policies with the understanding that their secret donations are going to be seen as valuable by the president, because this group appears to work so closely with the White House,' said Campaign Legal Center's Fischer. 'And because these donors are secret, the public and Congress will never know if the White House later took action to advance a donor's interests.'

So it appears that CVS Health was one of those wealthy corporate donors who was secretly giving to a obviously political operation, possibly to be seen as "valuable to the president," which may be a way of saying to bribe the president?

America First Policies' Founders Included Shady Characters

The early AP article about the founding of America First Policies stated that the people involved included,

The group includes Trump's digital and data director Brad Parscale, onetime deputy campaign manager Rick Gates and two campaign advisers to Vice President Mike Pence, Nick Ayers and Marty Obst.

As the New York Times reported in February, 2018, Rick Gates pleaded guilty to the federal crimes of financial fraud and lying to investigators,

A former top adviser to Donald J. Trump’s presidential campaign has agreed to cooperate with the special counsel inquiry into Russia’s interference in the 2016 election after pleading guilty on Friday to financial fraud and lying to investigators.

The adviser, Rick Gates, is a longtime political consultant who once served as Mr. Trump’s deputy campaign chairman

Note that Mr Gates had previously been charged with many more crimes,

The deal came as the special counsel, Robert S. Mueller III, has been raising pressure on Mr. Gates and Mr. Manafort with dozens of new charges of money laundering and bank fraud unsealed on Thursday. Both men were first indicted in October and pleaded not guilty.

By that time, it was likely that Mr Gates was increasingly involved in America First Policies.  As of March, 2017, an article in Politico noted that,

Rick Gates, a former Trump aide who served as Paul Manafort’s deputy, is increasingly involved day-to-day [in America First Policies].
Also, Brad Parscale, the 2016 Trump campaign digital director, was involved with Cambridge Analytica's highly questionable operations on behalf of the campaign.  Per a New York Times article of March 17, 2018

Under the guidance of Brad Parscale, Mr. Trump’s digital director in 2016 and now the campaign manager for his 2020 re-election effort, Cambridge performed a variety of services, former campaign officials said. That included designing target audiences for digital ads and fund-raising appeals, modeling voter turnout, buying $5 million in television ads and determining where Mr. Trump should travel to best drum up support.

A New Yorker article published on March 21, 2018 stated,

Cambridge Analytica contractors worked with Trump’s digital team, headed by Brad Parscale and Jared Kushner. Alongside all of them were Facebook employees who were embedded with the Trump campaign to help them use Facebook’s various tools most effectively—including the so-called 'dark posts,' used to dissuade African-Americans from showing up to vote. Did any of them know that the data that Cambridge Analytica was using to target voters, craft ads and blog posts, and determine Trump’s travel schedule came from millions of American Facebook members whose data had been taken without consent and sold for a million dollars—what Cadwalladr is calling a massive data “breach”? 


CVS Health says it donates to charity to improve health and health care, and that it has a social responsibility agenda to again improve health and keep the planet in balance.  Yet it secretly donated to a "social welfare" organization that explicitly was devoted to upholding the Trump agenda, founded by former Trump campaign officials, at least two with questionable ethics, one of which  pleaded guilty to federal crimes, and which ran a political polling operation that may have been illegal.  When its donation was discovered, and the racist sayings of two, and apparently pro-Nazi sayings of another of the organization's leaders were exposed, CVS then said it would not donate further.

Why did CVS Health donate to America Health Policies in the first place?

Given what transpired, at least CVS Health should immediately explain the reasons for this donation, and why it was made despite its obvious conflicts with CVS Health's stated policies and mission.

CVS Health should also disclose whether it has made any similar donations in the past, and what its policy on donations will be in the future.

Until such disclosures are made, we are left with further, exceedingly troubling questions.

Was this merely a case of severe and mission-hostile (mis)management?  However, it is difficult to believe that CVS Health managers did not know what the purpose of America First Policies was, and who its leaders were.

Was the donation to America First Policies an effort to cozy up to the Trump regime, arguably the most conflicted and corrupt presidential administration (look here), in hope of securing economic favors for CVS Health and/or its managers?

Did the donation somehow otherwise support top CVS Health managers' self-interest?  Given that President Trump has failed to condemn white supremicists and neo-Nazis (look here), and has recently proclaimed he is above the law, and thus called by editorialists a president who would be a king (e.g., here in the New York Times), are CVS Health managers closet monarchists, authoritarians or fascists?

Is this case unique?  Are other corporations that proclaim their social responsibility secretly funding groups like America First Policies?  Are these corporations thus covertly undermining not only patients' and the public's health, but the foundations of the American republic?

The frogs must figure out how to get out of the pot of now boiling water.

Friday, June 01, 2018

The Stealth Shutdown of the US Agency for Healthcare Quality and Research (AHRQ) National Guideline Clearinghouse

The Quiet Announcement of the Shut Down

Apparently as of late April, a terse announcement appeared on the website of the US AHRQ National Guideline Clearinghouse:

The AHRQ National Guideline Clearinghouse (NGC, Web site will not be available after July 16, 2018 because federal funding through AHRQ will no longer be available to support the NGC as of that date. AHRQ is receiving expressions of interest from stakeholders interested in carrying on NGC's work. It is not clear at this time, however, when or if NGC (or something like NGC) will be online again. In addition, AHRQ has not yet determined whether, or to what extent, the Agency would have an ongoing role if a stakeholder were to continue to operate the NGC. We will continue to post summaries of new and updated evidence-based clinical practice guidelines until July 2, 2018. For any questions, please contact

There was no further explanation.

This announcement has been largely anechoic, noted only by a few blogs and websites, e.g. the American Bar Association.

The Importance of the National Guideline Clearinghouse

The shutdown is significant because the Clearinghouse was an important source of information on diverse practice guidelines useful to clinicians, but also to medical and health care educators and researchers.

It is noteworthy that AHRQ has recently endeavored to assure the trustworthiness of the posted guidelines. While guidelines have been long and widely touted as a way to improve the quality of health care, there have been continuing questions about their validity and usefulness. In particular, there was accumulating evidence that many available guidelines were biased by conflicts of interest, based on an incomplete sample of available evidence, and were not necessarily informed by rigorous review of the available evidence, as we discussed here

In response, in 2011, the US Institute of Medicine (IOM) published standards for trustworthy guidelines (look here).  These standards were more rigorous and better justified than any prevous attempts to assure guideline quality.

The summary of the IOM report included:

Most guidelines used today suffer from shortcomings in development. Dubious trust in guidelines is the result of many factors, including failure to represent a variety of disciplines in guideline development groups, lack of transparency in how recommendations are derived and rated, and omission of a thorough external review process. To be trustworthy, clinical practice guidelines should:
• Be based on a systematic review of the existing evidence;
• Be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups;
• Consider important patient subgroups and patient preferences, as appropriate;
Be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest;
• Provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of recommendations; and
• Be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.
Additionally, as reflected in the committee’s standards for developing trustworthy clinical practice guidelines, guideline development groups optimally comprise members without conflict of interest. The committee recognizes that in some circumstances, a guideline development group may not be able to perform its work without members who have conflicts of interest—for example, relevant clinical specialists who receive a substantial portion of their incomes from services pertinent to the guideline. Therefore, the committee specifies that members of the guideline development group who have a conflict of interest should not represent more than a minority of the group.
However reasonable these standards may have appeared, by 2012 the IOM standards were largely ignored (as discussed here).

Yet, in 2017, at least one study appeared suggesting that many guidelines in the Clearinghouse did not meet the IOM standards (look here).  That year the AHRQ proclaimed that it would start assessing guidelines' adherence to the IOM standards (look here).

This is noteworthy again considering that the standards have had otherwise unfortunately little impact.

And now it seems the AHRQ's worthwhile effort to disseminate guidelines whose trustworthiness can be assessed will end.


So it seems that the report on clinical practice guidelines emphasized two issues highly relevant to Health Care Renewal, the need for transparency in guideline development, and the need to avoid conflicts of interest affecting the development process.

Perhaps more because than despite that, as we noted above, by 2012 the IOM standards were largely ignored (as discussed here).  We speculated that these standards may have discomfited many people.  They could have cost a lot of medical societies considerable commercial funding, and a lot of health care professionals on guideline panels considerable personal wealth.  These standards could probably also have cost a lot of companies whose products and services were addressed by guidelines to lose revenue.  Their implementation could have cost too many people who are financially benefiting from the status quo too much money.  And these people, that is, leaders of professional societies dependent on commercial outside funding, health care professionals and academic used to financial support from commercial interests, and health care corporations are good at making sure their interests are not ignored, even if their interests conflict with those of patients, the public, and well-intentioned health care professionals.

The Trump regime has exhibited great coziness with those who lead large corporations, including health care corporations, and other such plutocrats (look here).  The Trump regime appointed a person who was a manager of commercial information technology firms, not a health care professional or researcher, as head of the AHRQ (look here).  So it should come as no surprise that the AHRQ leadership under that regime was unable to maintain a Guideline Clearinghouse that attempted to uphold such standards of guideline trustworthiness.

Now we will lose an important resource for teaching, research, and evidence-based practice, whose loss will make it easier to hucksters to promote drugs, devices, and programs that are not as efficacious or safe as advertised.  But the good times will continue to roll.

We could call for the reinstatement of the AHRQ National Guideline Clearinghouse.  Ah, but we may as well try and catch the wind.  

We have been writing about health care dysfunction since 2003, and publishing this blog since 2004.  A major concern all along has been how threats to health care professionals' core values generate  health care dysfunction.  Up through 2016, these threats came principally from large private health care organizations.  While the US government was not always as good at defending these values as it could have been, at least it rarely presented its own set of active threats.  Under Trump, that situation has been changing for the worse.  This is obviously hugely dangerous, (and made more so by the regime's threats to other core values of US society, to US law, and the US Constitution.)

To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force.  

Musical Interlude - Donovan, Try and Catch the Wind, 1973