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Official Newspaper of the American College of Surgeons
Trauma surgeons up for emergency pediatric appendectomy
But a study of 220 children who had emergency appendectomies found only minor differences in outcomes between those operated on by a trauma surgeon and those by a pediatric surgeon.
“These results may be useful in optimizing the surgical workforce to care for a community,” said Derek B. Wall, MD, FACS, and Carlos Ortega, MD, FACS, of NorthShore University HealthSystem in Skokie, Ill. They noted that trauma surgeons in their group were asked to cover appendicitis in children aged 5-10 years because of the surgeons’ in-house availability and because of the difficulty pediatric surgeons often had in getting to the hospital in a timely fashion.
The study was done at Evanston (Ill.) Hospital, a Level 1 trauma center in the northern suburbs of Chicago. This trauma group were all board certified in general surgery, but none had received formal pediatric surgery fellowship training.
The study, published in the Journal of Trauma and Acute Surgery, evaluated appendectomies in children aged 5-10 years from January 2007 to December 2016. A total of 138 were performed by trauma surgeons, while 82 were done by pediatric surgeons. The patients operated on by trauma surgeons were more likely to be female (47% vs. 32%; P = .03), get to surgery more quickly (214 minutes from diagnosis vs. 318 minutes; P = .01), have a laparoscopic operation (70% vs. 55%; P = .04), have a shorter operation (40 minutes vs. 49 minutes; P less than .0001), and leave the hospital sooner (32 hours vs. 41 hours; P less than .0001). They were also more likely to be transferred from an outside hospital (60% vs. 37%; P less than .001) and less likely to be diagnosed without imaging (2% vs. 26%; P less than .0001). The study found no significant differences in complications.
Among the 31 patients who had perforated appendix, the difference in length of stay was even more pronounced: 4 days in the trauma surgery group (n = 21) versus 7.2 days in the pediatric surgery patients.
The investigators explained the rationale for focusing on the population aged 5-10 years: “We focused on a younger, narrower age range than that in previous studies, allowing comparison of outcomes in children of the same age and with equal rates of perforated appendicitis.” They noted that patients younger than age 5 are “well accepted as the domain of the pediatric surgeon,” while children over than 10 are more frequently managed by general surgeons.
At Evanston Hospital, pediatric surgeons had typically performed appendectomy in the targeted age group. But, “they cannot always quickly get to our hospital because of distance and city traffic,” the study authors noted. Therefore, the trauma surgeons were asked to cover for this population group.
They acknowledged the population size of the study was probably too small to identify any significant difference in complication rates between the two surgery groups, especially for patients who had had perforated appendicitis. Also, because of the study’s retrospective nature, most of the pediatric surgery cases were from an earlier period; therefore, later cases may have reflected advances in minimally invasive technology. “Perhaps surgical practice in a more recent time period contributes more to outcomes than specialty,” investigators wrote.
Dr. Wall and Dr. Ortega reported having no financial relationships.
SOURCE: Wall DB, Ortega C. J Trauma Acute Care Surg. 2018:85;118-21.
But a study of 220 children who had emergency appendectomies found only minor differences in outcomes between those operated on by a trauma surgeon and those by a pediatric surgeon.
“These results may be useful in optimizing the surgical workforce to care for a community,” said Derek B. Wall, MD, FACS, and Carlos Ortega, MD, FACS, of NorthShore University HealthSystem in Skokie, Ill. They noted that trauma surgeons in their group were asked to cover appendicitis in children aged 5-10 years because of the surgeons’ in-house availability and because of the difficulty pediatric surgeons often had in getting to the hospital in a timely fashion.
The study was done at Evanston (Ill.) Hospital, a Level 1 trauma center in the northern suburbs of Chicago. This trauma group were all board certified in general surgery, but none had received formal pediatric surgery fellowship training.
The study, published in the Journal of Trauma and Acute Surgery, evaluated appendectomies in children aged 5-10 years from January 2007 to December 2016. A total of 138 were performed by trauma surgeons, while 82 were done by pediatric surgeons. The patients operated on by trauma surgeons were more likely to be female (47% vs. 32%; P = .03), get to surgery more quickly (214 minutes from diagnosis vs. 318 minutes; P = .01), have a laparoscopic operation (70% vs. 55%; P = .04), have a shorter operation (40 minutes vs. 49 minutes; P less than .0001), and leave the hospital sooner (32 hours vs. 41 hours; P less than .0001). They were also more likely to be transferred from an outside hospital (60% vs. 37%; P less than .001) and less likely to be diagnosed without imaging (2% vs. 26%; P less than .0001). The study found no significant differences in complications.
Among the 31 patients who had perforated appendix, the difference in length of stay was even more pronounced: 4 days in the trauma surgery group (n = 21) versus 7.2 days in the pediatric surgery patients.
The investigators explained the rationale for focusing on the population aged 5-10 years: “We focused on a younger, narrower age range than that in previous studies, allowing comparison of outcomes in children of the same age and with equal rates of perforated appendicitis.” They noted that patients younger than age 5 are “well accepted as the domain of the pediatric surgeon,” while children over than 10 are more frequently managed by general surgeons.
At Evanston Hospital, pediatric surgeons had typically performed appendectomy in the targeted age group. But, “they cannot always quickly get to our hospital because of distance and city traffic,” the study authors noted. Therefore, the trauma surgeons were asked to cover for this population group.
They acknowledged the population size of the study was probably too small to identify any significant difference in complication rates between the two surgery groups, especially for patients who had had perforated appendicitis. Also, because of the study’s retrospective nature, most of the pediatric surgery cases were from an earlier period; therefore, later cases may have reflected advances in minimally invasive technology. “Perhaps surgical practice in a more recent time period contributes more to outcomes than specialty,” investigators wrote.
Dr. Wall and Dr. Ortega reported having no financial relationships.
SOURCE: Wall DB, Ortega C. J Trauma Acute Care Surg. 2018:85;118-21.
But a study of 220 children who had emergency appendectomies found only minor differences in outcomes between those operated on by a trauma surgeon and those by a pediatric surgeon.
“These results may be useful in optimizing the surgical workforce to care for a community,” said Derek B. Wall, MD, FACS, and Carlos Ortega, MD, FACS, of NorthShore University HealthSystem in Skokie, Ill. They noted that trauma surgeons in their group were asked to cover appendicitis in children aged 5-10 years because of the surgeons’ in-house availability and because of the difficulty pediatric surgeons often had in getting to the hospital in a timely fashion.
The study was done at Evanston (Ill.) Hospital, a Level 1 trauma center in the northern suburbs of Chicago. This trauma group were all board certified in general surgery, but none had received formal pediatric surgery fellowship training.
The study, published in the Journal of Trauma and Acute Surgery, evaluated appendectomies in children aged 5-10 years from January 2007 to December 2016. A total of 138 were performed by trauma surgeons, while 82 were done by pediatric surgeons. The patients operated on by trauma surgeons were more likely to be female (47% vs. 32%; P = .03), get to surgery more quickly (214 minutes from diagnosis vs. 318 minutes; P = .01), have a laparoscopic operation (70% vs. 55%; P = .04), have a shorter operation (40 minutes vs. 49 minutes; P less than .0001), and leave the hospital sooner (32 hours vs. 41 hours; P less than .0001). They were also more likely to be transferred from an outside hospital (60% vs. 37%; P less than .001) and less likely to be diagnosed without imaging (2% vs. 26%; P less than .0001). The study found no significant differences in complications.
Among the 31 patients who had perforated appendix, the difference in length of stay was even more pronounced: 4 days in the trauma surgery group (n = 21) versus 7.2 days in the pediatric surgery patients.
The investigators explained the rationale for focusing on the population aged 5-10 years: “We focused on a younger, narrower age range than that in previous studies, allowing comparison of outcomes in children of the same age and with equal rates of perforated appendicitis.” They noted that patients younger than age 5 are “well accepted as the domain of the pediatric surgeon,” while children over than 10 are more frequently managed by general surgeons.
At Evanston Hospital, pediatric surgeons had typically performed appendectomy in the targeted age group. But, “they cannot always quickly get to our hospital because of distance and city traffic,” the study authors noted. Therefore, the trauma surgeons were asked to cover for this population group.
They acknowledged the population size of the study was probably too small to identify any significant difference in complication rates between the two surgery groups, especially for patients who had had perforated appendicitis. Also, because of the study’s retrospective nature, most of the pediatric surgery cases were from an earlier period; therefore, later cases may have reflected advances in minimally invasive technology. “Perhaps surgical practice in a more recent time period contributes more to outcomes than specialty,” investigators wrote.
Dr. Wall and Dr. Ortega reported having no financial relationships.
SOURCE: Wall DB, Ortega C. J Trauma Acute Care Surg. 2018:85;118-21.
FROM THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
Key clinical point: Trauma surgeons performed emergency pediatric appendectomy as well as pediatric surgeons did.
Major finding: Hospital stays averaged 32 and 41 hours for patients treated by trauma surgeons and pediatric surgeons, respectively.
Study details: Retrospective chart review of 220 children aged 5-10 years who had emergency appendectomy at a suburban Level 1 trauma center during 2007-2016.
Disclosures: The investigators reported having no financial relationships.
Source: Wall DB et al. J Trauma Acute Care Surg. 2018:85;118-21.
Study quantifies occupational exposure risks of EDT
For trauma patients who are in extremis, but with the high rates of HIV/hepatitis among trauma patients, one that also carries what had been an unknown exposure risk for emergency staff.
“The most important findings of this prospective, multicenter study are that occupational exposures were reported in 7.2% of EDT resuscitations and 1.6% of EDT resuscitation participants and that occupational exposure risk appears to be further mitigated with strict PPE [personal protective equipment] compliance to universal precautions,” lead author Andrew Nunn, MD, and his colleagues wrote. Dr. Nunn is a trauma surgeon with Wake Forest Baptist Health in Winston-Salem, N.C.
The researchers surveyed 1,360 emergency department (ED) personnel after they performed 305 EDTs at 16 academic and community trauma centers nationwide in 2015 and 2016. The patients who had an EDT were mostly men ranging in age from 24 to 41 years (90.5%) with penetrating injuries (77.4%) and arrived at the ED after prehospital CPR (56.7%). Twenty-two occupational exposures occurred during 22 of the EDT resuscitations, with trainees sustaining most of them (68.2%). The most common source of injury was sharps, accounting for 86.4% (scalpels, 38.9%; fractured bone, 27.8%; needles, 16.7%; and scissors, 3%).
“Occupational exposures correlated with PPE utilization, as universal precautions during EDT were more often observed in providers who did not sustain occupational exposures, compared with those sustaining exposures,” Dr. Nunn and his coauthors wrote. For example, 98% of those reporting no exposure were gloved versus 91% of those who were exposed (P greater than .05).
Dr. Nunn and his coauthors called the risk of HIV or hepatitis C virus (HCV) transmission during EDT “extraordinarily low.” Based on data from their study, they determined the risk of blood-borne pathogen transmission during an EDT resuscitation is 6 in 1 million for HIV and 1 in 10,000 for HCV, and the individual risk is 1 in 1 million and 3 in 100,000, respectively. Compliance with PPE precautions further limited exposure risk, but the study found that more than 10% of surveyed personnel did not utilize one of the four components of PPE besides gloves – eyewear, mask, gown or hat.
Most – but not all – survey responders followed up after the incidence of exposure. “[A total of] 91.7% of providers reporting their exposures also reported following up with their institution specific occupational exposure protocol,” the investigators wrote.
“Our findings have particular implications for trainees,” the study authors noted, citing the high percentage of injuries in this group. The findings emphasized the need for universal PPE compliance and enforcement by resuscitation team leaders. Nonetheless, the study found that the exposure rates during EDT are no greater than other surgical procedures.
“Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with PPE is paramount and would further minimize occupational exposure risks to providers during EDT,” Dr. Nunn and his coauthors said.
Dr. Nunn and his coauthors reported having no financial relationships.
SOURCE: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
For trauma patients who are in extremis, but with the high rates of HIV/hepatitis among trauma patients, one that also carries what had been an unknown exposure risk for emergency staff.
“The most important findings of this prospective, multicenter study are that occupational exposures were reported in 7.2% of EDT resuscitations and 1.6% of EDT resuscitation participants and that occupational exposure risk appears to be further mitigated with strict PPE [personal protective equipment] compliance to universal precautions,” lead author Andrew Nunn, MD, and his colleagues wrote. Dr. Nunn is a trauma surgeon with Wake Forest Baptist Health in Winston-Salem, N.C.
The researchers surveyed 1,360 emergency department (ED) personnel after they performed 305 EDTs at 16 academic and community trauma centers nationwide in 2015 and 2016. The patients who had an EDT were mostly men ranging in age from 24 to 41 years (90.5%) with penetrating injuries (77.4%) and arrived at the ED after prehospital CPR (56.7%). Twenty-two occupational exposures occurred during 22 of the EDT resuscitations, with trainees sustaining most of them (68.2%). The most common source of injury was sharps, accounting for 86.4% (scalpels, 38.9%; fractured bone, 27.8%; needles, 16.7%; and scissors, 3%).
“Occupational exposures correlated with PPE utilization, as universal precautions during EDT were more often observed in providers who did not sustain occupational exposures, compared with those sustaining exposures,” Dr. Nunn and his coauthors wrote. For example, 98% of those reporting no exposure were gloved versus 91% of those who were exposed (P greater than .05).
Dr. Nunn and his coauthors called the risk of HIV or hepatitis C virus (HCV) transmission during EDT “extraordinarily low.” Based on data from their study, they determined the risk of blood-borne pathogen transmission during an EDT resuscitation is 6 in 1 million for HIV and 1 in 10,000 for HCV, and the individual risk is 1 in 1 million and 3 in 100,000, respectively. Compliance with PPE precautions further limited exposure risk, but the study found that more than 10% of surveyed personnel did not utilize one of the four components of PPE besides gloves – eyewear, mask, gown or hat.
Most – but not all – survey responders followed up after the incidence of exposure. “[A total of] 91.7% of providers reporting their exposures also reported following up with their institution specific occupational exposure protocol,” the investigators wrote.
“Our findings have particular implications for trainees,” the study authors noted, citing the high percentage of injuries in this group. The findings emphasized the need for universal PPE compliance and enforcement by resuscitation team leaders. Nonetheless, the study found that the exposure rates during EDT are no greater than other surgical procedures.
“Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with PPE is paramount and would further minimize occupational exposure risks to providers during EDT,” Dr. Nunn and his coauthors said.
Dr. Nunn and his coauthors reported having no financial relationships.
SOURCE: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
For trauma patients who are in extremis, but with the high rates of HIV/hepatitis among trauma patients, one that also carries what had been an unknown exposure risk for emergency staff.
“The most important findings of this prospective, multicenter study are that occupational exposures were reported in 7.2% of EDT resuscitations and 1.6% of EDT resuscitation participants and that occupational exposure risk appears to be further mitigated with strict PPE [personal protective equipment] compliance to universal precautions,” lead author Andrew Nunn, MD, and his colleagues wrote. Dr. Nunn is a trauma surgeon with Wake Forest Baptist Health in Winston-Salem, N.C.
The researchers surveyed 1,360 emergency department (ED) personnel after they performed 305 EDTs at 16 academic and community trauma centers nationwide in 2015 and 2016. The patients who had an EDT were mostly men ranging in age from 24 to 41 years (90.5%) with penetrating injuries (77.4%) and arrived at the ED after prehospital CPR (56.7%). Twenty-two occupational exposures occurred during 22 of the EDT resuscitations, with trainees sustaining most of them (68.2%). The most common source of injury was sharps, accounting for 86.4% (scalpels, 38.9%; fractured bone, 27.8%; needles, 16.7%; and scissors, 3%).
“Occupational exposures correlated with PPE utilization, as universal precautions during EDT were more often observed in providers who did not sustain occupational exposures, compared with those sustaining exposures,” Dr. Nunn and his coauthors wrote. For example, 98% of those reporting no exposure were gloved versus 91% of those who were exposed (P greater than .05).
Dr. Nunn and his coauthors called the risk of HIV or hepatitis C virus (HCV) transmission during EDT “extraordinarily low.” Based on data from their study, they determined the risk of blood-borne pathogen transmission during an EDT resuscitation is 6 in 1 million for HIV and 1 in 10,000 for HCV, and the individual risk is 1 in 1 million and 3 in 100,000, respectively. Compliance with PPE precautions further limited exposure risk, but the study found that more than 10% of surveyed personnel did not utilize one of the four components of PPE besides gloves – eyewear, mask, gown or hat.
Most – but not all – survey responders followed up after the incidence of exposure. “[A total of] 91.7% of providers reporting their exposures also reported following up with their institution specific occupational exposure protocol,” the investigators wrote.
“Our findings have particular implications for trainees,” the study authors noted, citing the high percentage of injuries in this group. The findings emphasized the need for universal PPE compliance and enforcement by resuscitation team leaders. Nonetheless, the study found that the exposure rates during EDT are no greater than other surgical procedures.
“Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with PPE is paramount and would further minimize occupational exposure risks to providers during EDT,” Dr. Nunn and his coauthors said.
Dr. Nunn and his coauthors reported having no financial relationships.
SOURCE: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
FROM THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
Key clinical point: Occupational exposure risk of emergency department thoracotomy (EDT) is low for personnel.
Major finding: Occupational exposure rate to HIV/hepatitis in trauma undergoing EDT is 7.2% for personnel.
Study details: Prospective, observational study that included 1,360 personnel surveyed after they performed 305 EDTs in 2015 and 2016.
Disclosures: Dr. Nunn and his coauthors reported having no financial relationships.
Source: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
Breast cancer patients don’t get the financial counseling they want from their clinicians
About half of medical oncologists – and even fewer surgeons and radiation oncologists – have someone in their practice to discuss the financial implications of treating breast cancer, a physician-patient survey has found.
Patients are feeling that lack of service, too; 73% of women in the survey said their providers didn’t offer much, or even any, help in tackling the potentially devastating financial impact of their cancer. Women reported a variety of these issues, including increased debt, lost time at work, skimping on their food budget, and even losing their homes as the medical bills added up.
“The privations observed in the current study are sobering and consistent with studies published before the widespread awareness of the potential for financial toxicity after the diagnosis and treatment of cancer,” wrote Reshma Jagsi, MD, and coauthors. The report was published in Cancer. 
“… Unfortunately, unmet needs for discussion persist, as does unresolved worry. The percentage of patients who perceive meaningful clinician engagement is low, with far fewer than one-quarter of respondents reporting more than a little discussion of these issues, which is strikingly lower than the percentage of providers who perceive routinely making services available,” they wrote.
Dr. Jagsi, of the University of Michigan, Ann Arbor, and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) database to identify 2,502 women in Georgia and Los Angeles County who were diagnosed with early-stage breast cancer from 2013 to 2015. They contacted these women, who were at least 1 year out from diagnosis, and their oncology providers with a survey designed to determine how both groups communicated about financial issues, and how those issues affected patients’ day-to-day lives.
Most of the clinicians were surgeons (370); the rest were medical oncologists (306) or radiation oncologists (169). About a quarter of each group was in a teaching practice.
Among the medical oncologists, 50.9% reported that someone in their practice often or always discussed financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists. Medical oncologists were also more likely to respond that they were very aware of out-of-pocket costs for patients, as did 27.3% of surgeons and 34.3% of radiation oncologists.
About 57% of medical oncologists thought it was quite or extremely important to save their patients money; 35.3% of surgeons and 55.8% of radiation oncologists also responded so.
Many women reported at least some measure of financial toxicity related to their cancer and its treatment, and this varied widely by ethnicity and race. Debt was common, noted by 58.9% of black patients, 33.5% of Latina patients, and about 28% of both white and Asian patients.
“Many patients also had substantial lost income and out-of-pocket expenses that they attributed to breast cancer,” the authors wrote. “Overall, 14% of patients reported lost income that was [at least] 10% of their household income, 17% of patients reported spending [at least] 10% of household income on out-of-pocket medical expenses, and 7% of patients reported spending [at least] 10% of household income on out-of-pocket nonmedical expenses.
Housing loss attributed to breast cancer was most common among blacks (6%) and Latinas (4.7%), and less so among whites and Asians (about 1% each).
Blacks and Latinas also were more likely to report a utility disconnection due to unpaid bills (5.9% and 3.2%, respectively) compared with whites and Asians (1.7% and 0.5%).
One way women financially coped, the survey found, was to cut the food budget. “One in five whites [21.5%] and Asians [22.5%] cut down spending on food, as did nearly one-half of black individuals [45.2%] and greater than one-third of Latinas [35.8%].”
Worry about finances was most common among blacks and Latinas (about 50%), but about a third of white and Asian women also reported worry. Survey results suggested that clinicians were not addressing these issues.
Women – especially nonwhite women – wanted to have these talks, with 15.2% of whites, 31.1% of blacks, 30.3% of Latinas, and 25.4% of Asians reporting this desire.
“Unmet patient needs for engagement with physicians regarding financial concerns were common. Of the 945 women who expressed worrying at least somewhat, 679 (72.8%) indicated that cancer physicians and their staff did not help at least somewhat,” the authors said.
More than half of the 523 women who expressed a desire to talk to health care providers regarding the impact of breast cancer on employment or finances (55.4%) reported that this discussion never took place, either with the oncologist, primary care provider, social worker, or any other professional involved in their care.
A multivariate analysis examined patient characteristics associated with the desire to discuss financial toxicity with a health care provider. Younger age, nonwhite race, lower income, being employed, receiving chemotherapy, and living in Georgia all showed significant, independent interaction.
“Given these findings, it is clear that thoughtfully designed, prospective interventions are necessary to address the remarkably common experiences of financial burden that patients report even in the modern era,” the investigators wrote. “These interventions might include training for physicians and their staff regarding how to have effective conversations in this context, in ways that are sensitive to cultural differences and needs. Other promising approaches might include the use of advanced technology to engage patients in interactive exercises that elicit their financial concerns and experiences and alert providers to their needs.”
The study was largely funded by a grant from the National Cancer Institute and the University of Michigan. Dr. Jagsi disclosed that she has been a consultant for Amgen but not relative to this study.
SOURCE: Jagsi R et al. Cancer 2018 Jul 23. doi: 10.1002/cncr.31532.
About half of medical oncologists – and even fewer surgeons and radiation oncologists – have someone in their practice to discuss the financial implications of treating breast cancer, a physician-patient survey has found.
Patients are feeling that lack of service, too; 73% of women in the survey said their providers didn’t offer much, or even any, help in tackling the potentially devastating financial impact of their cancer. Women reported a variety of these issues, including increased debt, lost time at work, skimping on their food budget, and even losing their homes as the medical bills added up.
“The privations observed in the current study are sobering and consistent with studies published before the widespread awareness of the potential for financial toxicity after the diagnosis and treatment of cancer,” wrote Reshma Jagsi, MD, and coauthors. The report was published in Cancer.
“… Unfortunately, unmet needs for discussion persist, as does unresolved worry. The percentage of patients who perceive meaningful clinician engagement is low, with far fewer than one-quarter of respondents reporting more than a little discussion of these issues, which is strikingly lower than the percentage of providers who perceive routinely making services available,” they wrote.
Dr. Jagsi, of the University of Michigan, Ann Arbor, and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) database to identify 2,502 women in Georgia and Los Angeles County who were diagnosed with early-stage breast cancer from 2013 to 2015. They contacted these women, who were at least 1 year out from diagnosis, and their oncology providers with a survey designed to determine how both groups communicated about financial issues, and how those issues affected patients’ day-to-day lives.
Most of the clinicians were surgeons (370); the rest were medical oncologists (306) or radiation oncologists (169). About a quarter of each group was in a teaching practice.
Among the medical oncologists, 50.9% reported that someone in their practice often or always discussed financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists. Medical oncologists were also more likely to respond that they were very aware of out-of-pocket costs for patients, as did 27.3% of surgeons and 34.3% of radiation oncologists.
About 57% of medical oncologists thought it was quite or extremely important to save their patients money; 35.3% of surgeons and 55.8% of radiation oncologists also responded so.
Many women reported at least some measure of financial toxicity related to their cancer and its treatment, and this varied widely by ethnicity and race. Debt was common, noted by 58.9% of black patients, 33.5% of Latina patients, and about 28% of both white and Asian patients.
“Many patients also had substantial lost income and out-of-pocket expenses that they attributed to breast cancer,” the authors wrote. “Overall, 14% of patients reported lost income that was [at least] 10% of their household income, 17% of patients reported spending [at least] 10% of household income on out-of-pocket medical expenses, and 7% of patients reported spending [at least] 10% of household income on out-of-pocket nonmedical expenses.
Housing loss attributed to breast cancer was most common among blacks (6%) and Latinas (4.7%), and less so among whites and Asians (about 1% each).
Blacks and Latinas also were more likely to report a utility disconnection due to unpaid bills (5.9% and 3.2%, respectively) compared with whites and Asians (1.7% and 0.5%).
One way women financially coped, the survey found, was to cut the food budget. “One in five whites [21.5%] and Asians [22.5%] cut down spending on food, as did nearly one-half of black individuals [45.2%] and greater than one-third of Latinas [35.8%].”
Worry about finances was most common among blacks and Latinas (about 50%), but about a third of white and Asian women also reported worry. Survey results suggested that clinicians were not addressing these issues.
Women – especially nonwhite women – wanted to have these talks, with 15.2% of whites, 31.1% of blacks, 30.3% of Latinas, and 25.4% of Asians reporting this desire.
“Unmet patient needs for engagement with physicians regarding financial concerns were common. Of the 945 women who expressed worrying at least somewhat, 679 (72.8%) indicated that cancer physicians and their staff did not help at least somewhat,” the authors said.
More than half of the 523 women who expressed a desire to talk to health care providers regarding the impact of breast cancer on employment or finances (55.4%) reported that this discussion never took place, either with the oncologist, primary care provider, social worker, or any other professional involved in their care.
A multivariate analysis examined patient characteristics associated with the desire to discuss financial toxicity with a health care provider. Younger age, nonwhite race, lower income, being employed, receiving chemotherapy, and living in Georgia all showed significant, independent interaction.
“Given these findings, it is clear that thoughtfully designed, prospective interventions are necessary to address the remarkably common experiences of financial burden that patients report even in the modern era,” the investigators wrote. “These interventions might include training for physicians and their staff regarding how to have effective conversations in this context, in ways that are sensitive to cultural differences and needs. Other promising approaches might include the use of advanced technology to engage patients in interactive exercises that elicit their financial concerns and experiences and alert providers to their needs.”
The study was largely funded by a grant from the National Cancer Institute and the University of Michigan. Dr. Jagsi disclosed that she has been a consultant for Amgen but not relative to this study.
SOURCE: Jagsi R et al. Cancer 2018 Jul 23. doi: 10.1002/cncr.31532.
About half of medical oncologists – and even fewer surgeons and radiation oncologists – have someone in their practice to discuss the financial implications of treating breast cancer, a physician-patient survey has found.
Patients are feeling that lack of service, too; 73% of women in the survey said their providers didn’t offer much, or even any, help in tackling the potentially devastating financial impact of their cancer. Women reported a variety of these issues, including increased debt, lost time at work, skimping on their food budget, and even losing their homes as the medical bills added up.
“The privations observed in the current study are sobering and consistent with studies published before the widespread awareness of the potential for financial toxicity after the diagnosis and treatment of cancer,” wrote Reshma Jagsi, MD, and coauthors. The report was published in Cancer.
“… Unfortunately, unmet needs for discussion persist, as does unresolved worry. The percentage of patients who perceive meaningful clinician engagement is low, with far fewer than one-quarter of respondents reporting more than a little discussion of these issues, which is strikingly lower than the percentage of providers who perceive routinely making services available,” they wrote.
Dr. Jagsi, of the University of Michigan, Ann Arbor, and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) database to identify 2,502 women in Georgia and Los Angeles County who were diagnosed with early-stage breast cancer from 2013 to 2015. They contacted these women, who were at least 1 year out from diagnosis, and their oncology providers with a survey designed to determine how both groups communicated about financial issues, and how those issues affected patients’ day-to-day lives.
Most of the clinicians were surgeons (370); the rest were medical oncologists (306) or radiation oncologists (169). About a quarter of each group was in a teaching practice.
Among the medical oncologists, 50.9% reported that someone in their practice often or always discussed financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists. Medical oncologists were also more likely to respond that they were very aware of out-of-pocket costs for patients, as did 27.3% of surgeons and 34.3% of radiation oncologists.
About 57% of medical oncologists thought it was quite or extremely important to save their patients money; 35.3% of surgeons and 55.8% of radiation oncologists also responded so.
Many women reported at least some measure of financial toxicity related to their cancer and its treatment, and this varied widely by ethnicity and race. Debt was common, noted by 58.9% of black patients, 33.5% of Latina patients, and about 28% of both white and Asian patients.
“Many patients also had substantial lost income and out-of-pocket expenses that they attributed to breast cancer,” the authors wrote. “Overall, 14% of patients reported lost income that was [at least] 10% of their household income, 17% of patients reported spending [at least] 10% of household income on out-of-pocket medical expenses, and 7% of patients reported spending [at least] 10% of household income on out-of-pocket nonmedical expenses.
Housing loss attributed to breast cancer was most common among blacks (6%) and Latinas (4.7%), and less so among whites and Asians (about 1% each).
Blacks and Latinas also were more likely to report a utility disconnection due to unpaid bills (5.9% and 3.2%, respectively) compared with whites and Asians (1.7% and 0.5%).
One way women financially coped, the survey found, was to cut the food budget. “One in five whites [21.5%] and Asians [22.5%] cut down spending on food, as did nearly one-half of black individuals [45.2%] and greater than one-third of Latinas [35.8%].”
Worry about finances was most common among blacks and Latinas (about 50%), but about a third of white and Asian women also reported worry. Survey results suggested that clinicians were not addressing these issues.
Women – especially nonwhite women – wanted to have these talks, with 15.2% of whites, 31.1% of blacks, 30.3% of Latinas, and 25.4% of Asians reporting this desire.
“Unmet patient needs for engagement with physicians regarding financial concerns were common. Of the 945 women who expressed worrying at least somewhat, 679 (72.8%) indicated that cancer physicians and their staff did not help at least somewhat,” the authors said.
More than half of the 523 women who expressed a desire to talk to health care providers regarding the impact of breast cancer on employment or finances (55.4%) reported that this discussion never took place, either with the oncologist, primary care provider, social worker, or any other professional involved in their care.
A multivariate analysis examined patient characteristics associated with the desire to discuss financial toxicity with a health care provider. Younger age, nonwhite race, lower income, being employed, receiving chemotherapy, and living in Georgia all showed significant, independent interaction.
“Given these findings, it is clear that thoughtfully designed, prospective interventions are necessary to address the remarkably common experiences of financial burden that patients report even in the modern era,” the investigators wrote. “These interventions might include training for physicians and their staff regarding how to have effective conversations in this context, in ways that are sensitive to cultural differences and needs. Other promising approaches might include the use of advanced technology to engage patients in interactive exercises that elicit their financial concerns and experiences and alert providers to their needs.”
The study was largely funded by a grant from the National Cancer Institute and the University of Michigan. Dr. Jagsi disclosed that she has been a consultant for Amgen but not relative to this study.
SOURCE: Jagsi R et al. Cancer 2018 Jul 23. doi: 10.1002/cncr.31532.
FROM CANCER
Key clinical point: Oncology care providers aren’t providing adequate financial counseling for patients with breast cancer.
Major finding: Half of medical oncologists say they don’t have a staff member routinely discuss the financial impact of breast cancer, and 73% of patients say they’ve never had this discussion with their doctor.
Study details: The survey comprised 2,502 patients and 845 physicians.
Disclosures: The study was largely funded by a grant from the National Cancer Institute and the University of Michigan. Dr. Jagsi disclosed that she has been a consultant for Amgen but not relative to this study.
Source: Jagsi R et al. Cancer 2018 Jul 23. doi: 10.1002/cncr.31532.
Nearly one-quarter of presurgery patients already using opioids
at a large academic medical center, a cross-sectional observational study has determined.
Prescription or illegal opioid use can have profound implications for surgical outcomes and continued postoperative medication abuse. “Preoperative opioid use was associated with a greater burden of comorbid disease and multiple risk factors for poor recovery. ... Opioid-tolerant patients are at risk for opioid-associated adverse events and are less likely to discontinue opioid-based therapy after their surgery,” wrote Paul E. Hilliard, MD, and a team of researchers at the University of Michigan Health System. Although the question of preoperative opioid use has been examined and the Michigan findings are consistent with earlier estimates of prevalence (Ann Surg. 2017;265[4]:695-701), this study sought a more detailed profile of both the characteristics of these patients and the types of procedures correlated with opioid use.
Patient data were derived primarily from two ongoing institutional registries, the Michigan Genomics Initiative and the Analgesic Outcomes Study. Each of these projects involved recruiting nonemergency surgery patients to participate and self-report on pain and affect issues. Opioid use data were extracted from the preop anesthesia history and from physical examination. A total of 34,186 patients were recruited for this study; 54.2% were women, 89.1% were white, and the mean age was 53.1 years. Overall, 23.1% of these patients were taking opioids of various kinds, mostly by prescription along with nonprescription opioids and illegal drugs of other kinds.
The most common opioids found in this patient sample were hydrocodone bitartrate (59.4%), tramadol hydrochloride (21.2%) and oxycodone hydrochloride (18.5%), although the duration or frequency of use was not determined.
“In our experience, in surveys like this patients are pretty honest. [The data do not] track to their medical record, but was done privately for research. That having been said, I am sure there is significant underreporting,” study coauthor Michael J. Englesbe, MD, FACS, said in an interview. In addition to some nondisclosure by study participants, the exclusion of patients admitted to surgery from the ED could mean that 23.1% is a conservative estimate, he noted.
Patient characteristics included in the study (tobacco use, alcohol use, sleep apnea, pain, life satisfaction, depression, anxiety) were self-reported and validated using tools such as the Brief Pain Inventory, the Fibromyalgia Survey, and the Hospital Anxiety and Depression Scale. Procedural data were derived from patient records and ICD-10 data and rated via the ASA score and Charlson Comorbidity Index.
A multivariate analysis of patient characteristics found that age between 31 and 40, tobacco use, heavy alcohol use, pain score, depression, comorbidities reflected in a higher ASA score, and Charlson Comorbidity Score were all significant risk factors for presurgical opiate use.
Patients who were scheduled for surgical procedures involving lower extremities (adjusted odds ratio 3.61, 95% confidence interval, 2.81-4.64) were at the highest risk for opioid use, followed by pelvis surgery, excluding hip (aOR, 3.09, 95% CI, 1.88-5.08), upper arm or elbow (aOR, 3.07, 95% CI, 2.12-4.45), and spine surgery (aOR, 2.68, 95% CI, 2.15-3.32).
The study also broke out the data by presurgery opioid usage and surgery service. Of patients having spine neurosurgery, 55.1% were already taking opioids, and among those having orthopedic spine surgery, 65.1% were taking opioids. General surgery patients were not among those mostly likely to be using opioids (gastrointestinal surgery, 19.3% and endocrine surgery 14.3%). “Certain surgical services may be more likely to encounter patients with high comorbidities for opioid use, and more targeted opioid education strategies aimed at those services may help to mitigate risk in the postoperative period,” the authors wrote.
“All surgeons should take a preop pain history. They should ask about current pain and previous pain experiences. They should also ask about a history of substance use disorder. This should lead into a discussion of the pain expectations from the procedure. Patients should expect to be in pain, that is normal. Pain-free surgery is rare. If a patient has a complex pain history or takes chronic opioids, the surgeon should consider referring them to anesthesia for formal preop pain management planning and potentially weaning of opioid dose prior to elective surgery,” noted Dr. Englesbe, the Cyrenus G. Darling Sr., MD and Cyrenus G Darling Jr., MD Professor of Surgery, and faculty at the Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
Surgeons are likely to see patients with a past history of opioid dependence or who are recovering from substance abuse. “Every effort should be made to avoid opioids in these patients. We have developed a Pain Optimization Pathway which facilitates no postoperative opioids for these and other patients. These patients are at high risk to relapse and surgeons must know who these patients are so they can provide optimal care,” Dr. Englesbe added.The limitations of this study as reported by the authors include the single-center design, the nondiverse racial makeup of the sample, and the difficulty of ascertaining the dosing and duration of opioid use, both prescription and illegal.
The investigators reported no disclosures relevant to this study. This study was supported by the National Institute on Drug Abuse, National Institutes of Health, the American College of Surgeons, and other noncommercial sources.
SOURCE: Hilliard PE et al. JAMA Surg. 2018 Jul 11. doi: 10.1001/jamasurg.2018.2102.
at a large academic medical center, a cross-sectional observational study has determined.
Prescription or illegal opioid use can have profound implications for surgical outcomes and continued postoperative medication abuse. “Preoperative opioid use was associated with a greater burden of comorbid disease and multiple risk factors for poor recovery. ... Opioid-tolerant patients are at risk for opioid-associated adverse events and are less likely to discontinue opioid-based therapy after their surgery,” wrote Paul E. Hilliard, MD, and a team of researchers at the University of Michigan Health System. Although the question of preoperative opioid use has been examined and the Michigan findings are consistent with earlier estimates of prevalence (Ann Surg. 2017;265[4]:695-701), this study sought a more detailed profile of both the characteristics of these patients and the types of procedures correlated with opioid use.
Patient data were derived primarily from two ongoing institutional registries, the Michigan Genomics Initiative and the Analgesic Outcomes Study. Each of these projects involved recruiting nonemergency surgery patients to participate and self-report on pain and affect issues. Opioid use data were extracted from the preop anesthesia history and from physical examination. A total of 34,186 patients were recruited for this study; 54.2% were women, 89.1% were white, and the mean age was 53.1 years. Overall, 23.1% of these patients were taking opioids of various kinds, mostly by prescription along with nonprescription opioids and illegal drugs of other kinds.
The most common opioids found in this patient sample were hydrocodone bitartrate (59.4%), tramadol hydrochloride (21.2%) and oxycodone hydrochloride (18.5%), although the duration or frequency of use was not determined.
“In our experience, in surveys like this patients are pretty honest. [The data do not] track to their medical record, but was done privately for research. That having been said, I am sure there is significant underreporting,” study coauthor Michael J. Englesbe, MD, FACS, said in an interview. In addition to some nondisclosure by study participants, the exclusion of patients admitted to surgery from the ED could mean that 23.1% is a conservative estimate, he noted.
Patient characteristics included in the study (tobacco use, alcohol use, sleep apnea, pain, life satisfaction, depression, anxiety) were self-reported and validated using tools such as the Brief Pain Inventory, the Fibromyalgia Survey, and the Hospital Anxiety and Depression Scale. Procedural data were derived from patient records and ICD-10 data and rated via the ASA score and Charlson Comorbidity Index.
A multivariate analysis of patient characteristics found that age between 31 and 40, tobacco use, heavy alcohol use, pain score, depression, comorbidities reflected in a higher ASA score, and Charlson Comorbidity Score were all significant risk factors for presurgical opiate use.
Patients who were scheduled for surgical procedures involving lower extremities (adjusted odds ratio 3.61, 95% confidence interval, 2.81-4.64) were at the highest risk for opioid use, followed by pelvis surgery, excluding hip (aOR, 3.09, 95% CI, 1.88-5.08), upper arm or elbow (aOR, 3.07, 95% CI, 2.12-4.45), and spine surgery (aOR, 2.68, 95% CI, 2.15-3.32).
The study also broke out the data by presurgery opioid usage and surgery service. Of patients having spine neurosurgery, 55.1% were already taking opioids, and among those having orthopedic spine surgery, 65.1% were taking opioids. General surgery patients were not among those mostly likely to be using opioids (gastrointestinal surgery, 19.3% and endocrine surgery 14.3%). “Certain surgical services may be more likely to encounter patients with high comorbidities for opioid use, and more targeted opioid education strategies aimed at those services may help to mitigate risk in the postoperative period,” the authors wrote.
“All surgeons should take a preop pain history. They should ask about current pain and previous pain experiences. They should also ask about a history of substance use disorder. This should lead into a discussion of the pain expectations from the procedure. Patients should expect to be in pain, that is normal. Pain-free surgery is rare. If a patient has a complex pain history or takes chronic opioids, the surgeon should consider referring them to anesthesia for formal preop pain management planning and potentially weaning of opioid dose prior to elective surgery,” noted Dr. Englesbe, the Cyrenus G. Darling Sr., MD and Cyrenus G Darling Jr., MD Professor of Surgery, and faculty at the Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
Surgeons are likely to see patients with a past history of opioid dependence or who are recovering from substance abuse. “Every effort should be made to avoid opioids in these patients. We have developed a Pain Optimization Pathway which facilitates no postoperative opioids for these and other patients. These patients are at high risk to relapse and surgeons must know who these patients are so they can provide optimal care,” Dr. Englesbe added.The limitations of this study as reported by the authors include the single-center design, the nondiverse racial makeup of the sample, and the difficulty of ascertaining the dosing and duration of opioid use, both prescription and illegal.
The investigators reported no disclosures relevant to this study. This study was supported by the National Institute on Drug Abuse, National Institutes of Health, the American College of Surgeons, and other noncommercial sources.
SOURCE: Hilliard PE et al. JAMA Surg. 2018 Jul 11. doi: 10.1001/jamasurg.2018.2102.
at a large academic medical center, a cross-sectional observational study has determined.
Prescription or illegal opioid use can have profound implications for surgical outcomes and continued postoperative medication abuse. “Preoperative opioid use was associated with a greater burden of comorbid disease and multiple risk factors for poor recovery. ... Opioid-tolerant patients are at risk for opioid-associated adverse events and are less likely to discontinue opioid-based therapy after their surgery,” wrote Paul E. Hilliard, MD, and a team of researchers at the University of Michigan Health System. Although the question of preoperative opioid use has been examined and the Michigan findings are consistent with earlier estimates of prevalence (Ann Surg. 2017;265[4]:695-701), this study sought a more detailed profile of both the characteristics of these patients and the types of procedures correlated with opioid use.
Patient data were derived primarily from two ongoing institutional registries, the Michigan Genomics Initiative and the Analgesic Outcomes Study. Each of these projects involved recruiting nonemergency surgery patients to participate and self-report on pain and affect issues. Opioid use data were extracted from the preop anesthesia history and from physical examination. A total of 34,186 patients were recruited for this study; 54.2% were women, 89.1% were white, and the mean age was 53.1 years. Overall, 23.1% of these patients were taking opioids of various kinds, mostly by prescription along with nonprescription opioids and illegal drugs of other kinds.
The most common opioids found in this patient sample were hydrocodone bitartrate (59.4%), tramadol hydrochloride (21.2%) and oxycodone hydrochloride (18.5%), although the duration or frequency of use was not determined.
“In our experience, in surveys like this patients are pretty honest. [The data do not] track to their medical record, but was done privately for research. That having been said, I am sure there is significant underreporting,” study coauthor Michael J. Englesbe, MD, FACS, said in an interview. In addition to some nondisclosure by study participants, the exclusion of patients admitted to surgery from the ED could mean that 23.1% is a conservative estimate, he noted.
Patient characteristics included in the study (tobacco use, alcohol use, sleep apnea, pain, life satisfaction, depression, anxiety) were self-reported and validated using tools such as the Brief Pain Inventory, the Fibromyalgia Survey, and the Hospital Anxiety and Depression Scale. Procedural data were derived from patient records and ICD-10 data and rated via the ASA score and Charlson Comorbidity Index.
A multivariate analysis of patient characteristics found that age between 31 and 40, tobacco use, heavy alcohol use, pain score, depression, comorbidities reflected in a higher ASA score, and Charlson Comorbidity Score were all significant risk factors for presurgical opiate use.
Patients who were scheduled for surgical procedures involving lower extremities (adjusted odds ratio 3.61, 95% confidence interval, 2.81-4.64) were at the highest risk for opioid use, followed by pelvis surgery, excluding hip (aOR, 3.09, 95% CI, 1.88-5.08), upper arm or elbow (aOR, 3.07, 95% CI, 2.12-4.45), and spine surgery (aOR, 2.68, 95% CI, 2.15-3.32).
The study also broke out the data by presurgery opioid usage and surgery service. Of patients having spine neurosurgery, 55.1% were already taking opioids, and among those having orthopedic spine surgery, 65.1% were taking opioids. General surgery patients were not among those mostly likely to be using opioids (gastrointestinal surgery, 19.3% and endocrine surgery 14.3%). “Certain surgical services may be more likely to encounter patients with high comorbidities for opioid use, and more targeted opioid education strategies aimed at those services may help to mitigate risk in the postoperative period,” the authors wrote.
“All surgeons should take a preop pain history. They should ask about current pain and previous pain experiences. They should also ask about a history of substance use disorder. This should lead into a discussion of the pain expectations from the procedure. Patients should expect to be in pain, that is normal. Pain-free surgery is rare. If a patient has a complex pain history or takes chronic opioids, the surgeon should consider referring them to anesthesia for formal preop pain management planning and potentially weaning of opioid dose prior to elective surgery,” noted Dr. Englesbe, the Cyrenus G. Darling Sr., MD and Cyrenus G Darling Jr., MD Professor of Surgery, and faculty at the Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.
Surgeons are likely to see patients with a past history of opioid dependence or who are recovering from substance abuse. “Every effort should be made to avoid opioids in these patients. We have developed a Pain Optimization Pathway which facilitates no postoperative opioids for these and other patients. These patients are at high risk to relapse and surgeons must know who these patients are so they can provide optimal care,” Dr. Englesbe added.The limitations of this study as reported by the authors include the single-center design, the nondiverse racial makeup of the sample, and the difficulty of ascertaining the dosing and duration of opioid use, both prescription and illegal.
The investigators reported no disclosures relevant to this study. This study was supported by the National Institute on Drug Abuse, National Institutes of Health, the American College of Surgeons, and other noncommercial sources.
SOURCE: Hilliard PE et al. JAMA Surg. 2018 Jul 11. doi: 10.1001/jamasurg.2018.2102.
FROM JAMA SURGERY
Key clinical point: Preoperative opioid use is prevalent in patients who are having spinal surgery and have depression.
Major finding:
Study details: An observational study of 34,186 surgical patients in the University of Michigan Health system.
Disclosures: The investigators reported no disclosures relevant to this study. This study was supported by the National Institute on Drug Abuse, National Institutes of Health, the American College of Surgeons, and other noncommercial sources.
Source: Hilliard P E et al. JAMA Surg. 2018 Jul 11;. doi:10.1001/jamasurg.2018.2102.
Malpractice and pain management
Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.
In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.
B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.
C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.
D. The elevated blood levels indicate that the cause of death was an opioid overdose.
E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.
Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.
Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).
We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.
In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.1 In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.
The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.
A recent article in the Washington Post draws attention to this situation.2 It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.
Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.
Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.3 William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.
After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.
At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.
For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.4 The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.
Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.
The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”
Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.
A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.5 In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.6
While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.
It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”7
To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.
2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.
3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).
4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).
5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.
6. N Engl J Med. 2016 Apr 21;374(16):1501-4.
7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.
Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.
In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.
B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.
C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.
D. The elevated blood levels indicate that the cause of death was an opioid overdose.
E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.
Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.
Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).
We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.
In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.1 In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.
The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.
A recent article in the Washington Post draws attention to this situation.2 It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.
Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.
Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.3 William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.
After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.
At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.
For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.4 The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.
Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.
The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”
Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.
A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.5 In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.6
While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.
It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”7
To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.
2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.
3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).
4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).
5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.
6. N Engl J Med. 2016 Apr 21;374(16):1501-4.
7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.
Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.
In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.
B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.
C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.
D. The elevated blood levels indicate that the cause of death was an opioid overdose.
E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.
Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.
Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).
We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.
In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.1 In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.
The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.
A recent article in the Washington Post draws attention to this situation.2 It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.
Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.
Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.3 William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.
After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.
At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.
For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.4 The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.
Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.
The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”
Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.
A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.5 In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.6
While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.
It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”7
To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.
2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.
3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).
4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).
5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.
6. N Engl J Med. 2016 Apr 21;374(16):1501-4.
7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.
CMS considers expanding telemedicine payments
Payment for more telemedicine services could be in store for physicians and other health providers if new proposals in the latest fee schedule from the Centers for Medicare & Medicaid Services are finalized.
Under the proposed physician fee schedule, announced July 12, the CMS would expand services that qualify for telemedicine payments and add reimbursement for virtual check-ins by phone or other technologies, such as Skype. Telemedicine clinicians would also be paid for time spent reviewing patient photos sent by text or e-mail under the suggested changes.
Such telehealth services would aid patients who have transportation difficulties by creating more opportunities for them to access personalized care, said CMS Administrator Seema Verma.
“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Ms. Verma said in a statement.
Under the proposal, physicians could bill separately for brief, non–face-to-face patient check-ins with patients via communication technology beginning January 2019. In addition, the proposed rule carves out payments for the remote professional evaluation of patient-transmitted information conducted via prerecorded “store and forward” video or image technology. Doctors could use both services to determine whether an office visit or other service is warranted, according to the proposed rule.
The services would have limitations on when they could be separately billed. In cases where the brief communication technology–based service originated from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered “bundled” into that previous E/M service and could not be billed separately. Similarly, a photo evaluation could not be separately billed if it stemmed from a related E/M service provided within the previous 7 days by the same physician, or if the evaluation results in an in-person E/M office visit with the same doctor.
Under the proposal, health providers could perform the newly covered telehealth services only with established patients, but the CMS is seeking comments as to whether in certain cases, such as dermatological or ophthalmological instances, it might be appropriate for a new patient to receive the services. Agency officials also want to know what types of communication technology are used by physicians in furnishing check-in services, including whether audio-only telephone interactions are sufficient, compared with interactions that are enhanced with video. The CMS is asking physicians whether it would be clinically appropriate to apply a frequency limitation on the use of the proposed telehealth services by the same physician.
Latoya Thomas, director of the American Telemedicine Association’s State Policy Resource Center, said the proposal is exciting because it acknowledges the pervasive growth, accessibility, and acceptance of technology advances.
“In expanding reimbursement to providers for more modality-neutral and site-neutral virtual care, such as store-and-forward and remote patient monitoring, [the rules] address longstanding barriers to broader dissemination of telehealth,” Ms. Thomas said in an interview. “By making available ‘virtual check ins’ to every Medicare beneficiary, it can improve patient engagement and reduce unnecessary trips back to their provider’s office.”
James P. Marcin, MD, a telemedicine physician and director of the Center for Health and Technology at UC Davis Children’s Hospital in Sacramento, Calif., said he was pleased with the proposed telehealth changes, but he noted that more work remains to address further telemedicine challenges.
“The needle is finally moving, albeit too slowly for some of us,” Dr. Marcin said in an interview. “There are still some areas users of telemedicine and organizations supporting the use of telemedicine want to address, including the need for verbal informed consent, the requirements for established relationships with patients, and of course, rate valuations for the remote patient monitoring and professional codes. But again, this is good news for patients.”
Public comments on the proposed rule are due by Sept. 10, 2018. Comments can be submitted to regulations.gov.
Payment for more telemedicine services could be in store for physicians and other health providers if new proposals in the latest fee schedule from the Centers for Medicare & Medicaid Services are finalized.
Under the proposed physician fee schedule, announced July 12, the CMS would expand services that qualify for telemedicine payments and add reimbursement for virtual check-ins by phone or other technologies, such as Skype. Telemedicine clinicians would also be paid for time spent reviewing patient photos sent by text or e-mail under the suggested changes.
Such telehealth services would aid patients who have transportation difficulties by creating more opportunities for them to access personalized care, said CMS Administrator Seema Verma.
“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Ms. Verma said in a statement.
Under the proposal, physicians could bill separately for brief, non–face-to-face patient check-ins with patients via communication technology beginning January 2019. In addition, the proposed rule carves out payments for the remote professional evaluation of patient-transmitted information conducted via prerecorded “store and forward” video or image technology. Doctors could use both services to determine whether an office visit or other service is warranted, according to the proposed rule.
The services would have limitations on when they could be separately billed. In cases where the brief communication technology–based service originated from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered “bundled” into that previous E/M service and could not be billed separately. Similarly, a photo evaluation could not be separately billed if it stemmed from a related E/M service provided within the previous 7 days by the same physician, or if the evaluation results in an in-person E/M office visit with the same doctor.
Under the proposal, health providers could perform the newly covered telehealth services only with established patients, but the CMS is seeking comments as to whether in certain cases, such as dermatological or ophthalmological instances, it might be appropriate for a new patient to receive the services. Agency officials also want to know what types of communication technology are used by physicians in furnishing check-in services, including whether audio-only telephone interactions are sufficient, compared with interactions that are enhanced with video. The CMS is asking physicians whether it would be clinically appropriate to apply a frequency limitation on the use of the proposed telehealth services by the same physician.
Latoya Thomas, director of the American Telemedicine Association’s State Policy Resource Center, said the proposal is exciting because it acknowledges the pervasive growth, accessibility, and acceptance of technology advances.
“In expanding reimbursement to providers for more modality-neutral and site-neutral virtual care, such as store-and-forward and remote patient monitoring, [the rules] address longstanding barriers to broader dissemination of telehealth,” Ms. Thomas said in an interview. “By making available ‘virtual check ins’ to every Medicare beneficiary, it can improve patient engagement and reduce unnecessary trips back to their provider’s office.”
James P. Marcin, MD, a telemedicine physician and director of the Center for Health and Technology at UC Davis Children’s Hospital in Sacramento, Calif., said he was pleased with the proposed telehealth changes, but he noted that more work remains to address further telemedicine challenges.
“The needle is finally moving, albeit too slowly for some of us,” Dr. Marcin said in an interview. “There are still some areas users of telemedicine and organizations supporting the use of telemedicine want to address, including the need for verbal informed consent, the requirements for established relationships with patients, and of course, rate valuations for the remote patient monitoring and professional codes. But again, this is good news for patients.”
Public comments on the proposed rule are due by Sept. 10, 2018. Comments can be submitted to regulations.gov.
Payment for more telemedicine services could be in store for physicians and other health providers if new proposals in the latest fee schedule from the Centers for Medicare & Medicaid Services are finalized.
Under the proposed physician fee schedule, announced July 12, the CMS would expand services that qualify for telemedicine payments and add reimbursement for virtual check-ins by phone or other technologies, such as Skype. Telemedicine clinicians would also be paid for time spent reviewing patient photos sent by text or e-mail under the suggested changes.
Such telehealth services would aid patients who have transportation difficulties by creating more opportunities for them to access personalized care, said CMS Administrator Seema Verma.
“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Ms. Verma said in a statement.
Under the proposal, physicians could bill separately for brief, non–face-to-face patient check-ins with patients via communication technology beginning January 2019. In addition, the proposed rule carves out payments for the remote professional evaluation of patient-transmitted information conducted via prerecorded “store and forward” video or image technology. Doctors could use both services to determine whether an office visit or other service is warranted, according to the proposed rule.
The services would have limitations on when they could be separately billed. In cases where the brief communication technology–based service originated from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered “bundled” into that previous E/M service and could not be billed separately. Similarly, a photo evaluation could not be separately billed if it stemmed from a related E/M service provided within the previous 7 days by the same physician, or if the evaluation results in an in-person E/M office visit with the same doctor.
Under the proposal, health providers could perform the newly covered telehealth services only with established patients, but the CMS is seeking comments as to whether in certain cases, such as dermatological or ophthalmological instances, it might be appropriate for a new patient to receive the services. Agency officials also want to know what types of communication technology are used by physicians in furnishing check-in services, including whether audio-only telephone interactions are sufficient, compared with interactions that are enhanced with video. The CMS is asking physicians whether it would be clinically appropriate to apply a frequency limitation on the use of the proposed telehealth services by the same physician.
Latoya Thomas, director of the American Telemedicine Association’s State Policy Resource Center, said the proposal is exciting because it acknowledges the pervasive growth, accessibility, and acceptance of technology advances.
“In expanding reimbursement to providers for more modality-neutral and site-neutral virtual care, such as store-and-forward and remote patient monitoring, [the rules] address longstanding barriers to broader dissemination of telehealth,” Ms. Thomas said in an interview. “By making available ‘virtual check ins’ to every Medicare beneficiary, it can improve patient engagement and reduce unnecessary trips back to their provider’s office.”
James P. Marcin, MD, a telemedicine physician and director of the Center for Health and Technology at UC Davis Children’s Hospital in Sacramento, Calif., said he was pleased with the proposed telehealth changes, but he noted that more work remains to address further telemedicine challenges.
“The needle is finally moving, albeit too slowly for some of us,” Dr. Marcin said in an interview. “There are still some areas users of telemedicine and organizations supporting the use of telemedicine want to address, including the need for verbal informed consent, the requirements for established relationships with patients, and of course, rate valuations for the remote patient monitoring and professional codes. But again, this is good news for patients.”
Public comments on the proposed rule are due by Sept. 10, 2018. Comments can be submitted to regulations.gov.
Better ICU staff communication with family may improve end-of-life choices
A nurse-led support intervention for the families of critically ill patients did little to ease families’ psychological symptoms, but it did improve their perception of staff communication and family-centered care in the intensive care unit.
The length of ICU stay was also significantly shorter and the in-unit death rate higher among patients whose families received the intervention – a finding that suggests difficult end-of-life choices may have been eased, reported Douglas B. White, MD, and his colleagues (N Engl J Med. 2018;378:2365-75).
“The intervention resulted in significant improvements in markers of the quality of decision making, including the patient- and family-centeredness of care and the quality of clinician-family communication. Taken together, these findings suggest that the intervention allowed surrogates to transition a patient’s treatment to comfort-focused care when doing so aligned with the patient’s values,” wrote Dr. White of the University of Pittsburgh. “A previous study that was conducted in the context of advanced illness suggested that treatment that accords with the patient’s preferences may lead to shorter survival among those who prioritize comfort over longevity.”
The trial randomized 1,420 patients and their family surrogates in five ICUs to usual care, or to the multicomponent family-support intervention. The primary outcome was change in the surrogates’ scores on the Hospital Anxiety Depression Scale (HADS) at 6 months. The secondary outcomes were changes in Impact of Event Scale (IES; a measure of posttraumatic stress) the Quality of Communication (QOC) scale, quality of clinician-family communication measured by the Patient Perception of Patient Centeredness (PPPC) scale and the mean length of ICU stay.
The intervention was delivered by nurses who received special training on communication and other skills needed to support the families of critically ill patients. Nurses met with families every day and arranged regular meetings with ICU clinicians. A quality improvement specialist incorporated the family support into daily work flow.
In a fully adjusted model, there was no significant between-group difference in the 6-month HADS scores (11.7 vs. 12 points). Likewise, there was no significant difference between the groups in the mean IES score at 6 months.
Family members in the active group did rate the quality of clinician-family communication as significantly better, and they also gave significantly higher ratings to the quality of patient- and family-centered care during the ICU stay.
The shorter length of stay was reflected in the time to death among patients who died during the stay (4.4 days in the intervention group vs. 6.8 days in the control group), although there was no significant difference in length of stay among patients who survived to discharge. Significantly more patients in the intervention group died in the ICU as well (36% vs. 28.5%); however, there was no significant difference in 6-month mortality (60.4% vs. 55.4%).
The study was supported by an Innovation Award from the University of Pittsburgh Medical Center Health System and by the Greenwell Foundation. Dr. White reported having no financial disclosures
Although the results by White and colleagues “cannot be interpreted as clinically directive,” the study offers a glimpse of the path forward in improving the experience of families with critically ill loved ones, Daniela Lamas, MD, wrote in an accompanying editorial (N Engl J Med. 2018; 378:2431-2).
The study didn’t meet its primary endpoint of reducing surrogates’ psychological symptoms at 6 months, but it did lead to an improved ICU experience, with better clinician communication. There was another finding that deserves a close look: In the intervention group, ICU length of stay was shorter and in-hospital mortality greater, although mortality among those who survived to discharge was similar at 6 months.
These findings suggest that the intervention did not lead to the premature death of patients who would have otherwise done well, but rather was associated with a shorter dying process for those who faced a dismal prognosis, according to Dr. Lamas.
“As we increasingly look beyond mortality as the primary outcome that matters, seeking to maximize quality of life and minimize suffering, this work represents an ‘end of the beginning’ by suggesting the next steps in moving closer to achieving these goals.”
Dr. Lamas is a pulmonary and critical care doctor at Brigham & Women’s Hospital and on the faculty at Harvard Medical School, Boston.
Although the results by White and colleagues “cannot be interpreted as clinically directive,” the study offers a glimpse of the path forward in improving the experience of families with critically ill loved ones, Daniela Lamas, MD, wrote in an accompanying editorial (N Engl J Med. 2018; 378:2431-2).
The study didn’t meet its primary endpoint of reducing surrogates’ psychological symptoms at 6 months, but it did lead to an improved ICU experience, with better clinician communication. There was another finding that deserves a close look: In the intervention group, ICU length of stay was shorter and in-hospital mortality greater, although mortality among those who survived to discharge was similar at 6 months.
These findings suggest that the intervention did not lead to the premature death of patients who would have otherwise done well, but rather was associated with a shorter dying process for those who faced a dismal prognosis, according to Dr. Lamas.
“As we increasingly look beyond mortality as the primary outcome that matters, seeking to maximize quality of life and minimize suffering, this work represents an ‘end of the beginning’ by suggesting the next steps in moving closer to achieving these goals.”
Dr. Lamas is a pulmonary and critical care doctor at Brigham & Women’s Hospital and on the faculty at Harvard Medical School, Boston.
Although the results by White and colleagues “cannot be interpreted as clinically directive,” the study offers a glimpse of the path forward in improving the experience of families with critically ill loved ones, Daniela Lamas, MD, wrote in an accompanying editorial (N Engl J Med. 2018; 378:2431-2).
The study didn’t meet its primary endpoint of reducing surrogates’ psychological symptoms at 6 months, but it did lead to an improved ICU experience, with better clinician communication. There was another finding that deserves a close look: In the intervention group, ICU length of stay was shorter and in-hospital mortality greater, although mortality among those who survived to discharge was similar at 6 months.
These findings suggest that the intervention did not lead to the premature death of patients who would have otherwise done well, but rather was associated with a shorter dying process for those who faced a dismal prognosis, according to Dr. Lamas.
“As we increasingly look beyond mortality as the primary outcome that matters, seeking to maximize quality of life and minimize suffering, this work represents an ‘end of the beginning’ by suggesting the next steps in moving closer to achieving these goals.”
Dr. Lamas is a pulmonary and critical care doctor at Brigham & Women’s Hospital and on the faculty at Harvard Medical School, Boston.
A nurse-led support intervention for the families of critically ill patients did little to ease families’ psychological symptoms, but it did improve their perception of staff communication and family-centered care in the intensive care unit.
The length of ICU stay was also significantly shorter and the in-unit death rate higher among patients whose families received the intervention – a finding that suggests difficult end-of-life choices may have been eased, reported Douglas B. White, MD, and his colleagues (N Engl J Med. 2018;378:2365-75).
“The intervention resulted in significant improvements in markers of the quality of decision making, including the patient- and family-centeredness of care and the quality of clinician-family communication. Taken together, these findings suggest that the intervention allowed surrogates to transition a patient’s treatment to comfort-focused care when doing so aligned with the patient’s values,” wrote Dr. White of the University of Pittsburgh. “A previous study that was conducted in the context of advanced illness suggested that treatment that accords with the patient’s preferences may lead to shorter survival among those who prioritize comfort over longevity.”
The trial randomized 1,420 patients and their family surrogates in five ICUs to usual care, or to the multicomponent family-support intervention. The primary outcome was change in the surrogates’ scores on the Hospital Anxiety Depression Scale (HADS) at 6 months. The secondary outcomes were changes in Impact of Event Scale (IES; a measure of posttraumatic stress) the Quality of Communication (QOC) scale, quality of clinician-family communication measured by the Patient Perception of Patient Centeredness (PPPC) scale and the mean length of ICU stay.
The intervention was delivered by nurses who received special training on communication and other skills needed to support the families of critically ill patients. Nurses met with families every day and arranged regular meetings with ICU clinicians. A quality improvement specialist incorporated the family support into daily work flow.
In a fully adjusted model, there was no significant between-group difference in the 6-month HADS scores (11.7 vs. 12 points). Likewise, there was no significant difference between the groups in the mean IES score at 6 months.
Family members in the active group did rate the quality of clinician-family communication as significantly better, and they also gave significantly higher ratings to the quality of patient- and family-centered care during the ICU stay.
The shorter length of stay was reflected in the time to death among patients who died during the stay (4.4 days in the intervention group vs. 6.8 days in the control group), although there was no significant difference in length of stay among patients who survived to discharge. Significantly more patients in the intervention group died in the ICU as well (36% vs. 28.5%); however, there was no significant difference in 6-month mortality (60.4% vs. 55.4%).
The study was supported by an Innovation Award from the University of Pittsburgh Medical Center Health System and by the Greenwell Foundation. Dr. White reported having no financial disclosures
A nurse-led support intervention for the families of critically ill patients did little to ease families’ psychological symptoms, but it did improve their perception of staff communication and family-centered care in the intensive care unit.
The length of ICU stay was also significantly shorter and the in-unit death rate higher among patients whose families received the intervention – a finding that suggests difficult end-of-life choices may have been eased, reported Douglas B. White, MD, and his colleagues (N Engl J Med. 2018;378:2365-75).
“The intervention resulted in significant improvements in markers of the quality of decision making, including the patient- and family-centeredness of care and the quality of clinician-family communication. Taken together, these findings suggest that the intervention allowed surrogates to transition a patient’s treatment to comfort-focused care when doing so aligned with the patient’s values,” wrote Dr. White of the University of Pittsburgh. “A previous study that was conducted in the context of advanced illness suggested that treatment that accords with the patient’s preferences may lead to shorter survival among those who prioritize comfort over longevity.”
The trial randomized 1,420 patients and their family surrogates in five ICUs to usual care, or to the multicomponent family-support intervention. The primary outcome was change in the surrogates’ scores on the Hospital Anxiety Depression Scale (HADS) at 6 months. The secondary outcomes were changes in Impact of Event Scale (IES; a measure of posttraumatic stress) the Quality of Communication (QOC) scale, quality of clinician-family communication measured by the Patient Perception of Patient Centeredness (PPPC) scale and the mean length of ICU stay.
The intervention was delivered by nurses who received special training on communication and other skills needed to support the families of critically ill patients. Nurses met with families every day and arranged regular meetings with ICU clinicians. A quality improvement specialist incorporated the family support into daily work flow.
In a fully adjusted model, there was no significant between-group difference in the 6-month HADS scores (11.7 vs. 12 points). Likewise, there was no significant difference between the groups in the mean IES score at 6 months.
Family members in the active group did rate the quality of clinician-family communication as significantly better, and they also gave significantly higher ratings to the quality of patient- and family-centered care during the ICU stay.
The shorter length of stay was reflected in the time to death among patients who died during the stay (4.4 days in the intervention group vs. 6.8 days in the control group), although there was no significant difference in length of stay among patients who survived to discharge. Significantly more patients in the intervention group died in the ICU as well (36% vs. 28.5%); however, there was no significant difference in 6-month mortality (60.4% vs. 55.4%).
The study was supported by an Innovation Award from the University of Pittsburgh Medical Center Health System and by the Greenwell Foundation. Dr. White reported having no financial disclosures
FROM NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: A family communication intervention didn’t improve 6-month psychological symptoms among those with loved ones in intensive care units.
Major finding: There was no significant difference on the Hospital Anxiety and Depression Scale at 6 months (11.7 vs. 12 points).
Study details: The study randomized 1,420 ICU patients and surrogates to the intervention or to usual care.
Disclosures: The study was supported by an Innovation Award from the University of Pittsburgh Medical Center Health System and by the Greenwell Foundation. Dr. White had no financial disclosures.
Source: White et al. N Engl J Med. 2018;378:2365-75.
Assessing adverse events tied to outpatient opioid use in children
Nearly three-quarters of opioid-related adverse events seen in children were related to therapeutic opioid use, based on data from more than a million prescriptions.
Prescription of opioids to children for outpatient conditions may have risen along with the increased opioid prescriptions for adults, but most of the literature focuses on opioid toxicity in children, and “the incidence of adverse opioid effects for children during appropriate medical use for relatively minor conditions is unknown,” wrote Cecilia P. Chung, MD, of Vanderbilt University in Nashville, Tenn., and her colleagues.
In a retrospective study published in Pediatrics, the researchers reviewed data from 401,972 children and adolescents aged 2-17 years with no chronic or severe conditions. The patients filled a total of 1,362,503 prescriptions for opioids, with a mean 15% filling one or more opioid prescriptions a year, and 1 in every 2,611 prescriptions was followed by an emergency department visit, hospitalization, or death related to an adverse event associated with opioid use.
Approximately 20% of the prescriptions were for children aged 2-5 years, 28% for ages 6-11 years, and 52% for ages 12-17 years. The patients were enrolled in Medicaid between Jan. 1, 1999, and Dec. 31, 2014, in Tennessee, and were seen at outpatient centers. Dental procedures were the most common reasons for opioid prescriptions in the study population (31%), followed by outpatient procedures or surgeries (25%), trauma (18%), and infections (16%).
Overall, 437 cases of opioid-related adverse events were confirmed by medical record review; 89% of these were deemed related to the prescription, and 71% were related to proper therapeutic use, the researchers said. The remainder were considered to be related to unintentional overdose, abuse, self-harm, or the circumstances were not indicated.
The opioid-related symptoms most frequently were gastrointestinal, neuropsychiatric, dermatologic, and central nervous system depression.
“The incidence of opioid-related adverse events increased for children and adolescents 12-17 years of age, during current opioid use, and with higher opioid doses,” the researchers said.
The study findings were limited by several factors including the use of Medicaid patients only, the lack of clinical details such as patient weight, and the potential for incomplete medical records, Dr. Chung and her associates noted. However, the results support the need for more comprehensive guidelines in treating acute, self-limited conditions in children to reduce unnecessary opioid exposure, they said.
The researchers had no relevant financial conflicts to disclose. The study was supported by the Eunice Kennedy Shriver National Institute for Child Health and Human Development and funded by the National Institutes of Health. Dr. Chung received grant support from the National Institutes of Health and the Rheumatology Research Foundation Career Development Research K-supplement.
SOURCE: Chung C et al. Pediatrics. 2018 Jul 16. doi: 10.1542/peds.2017-2156.
“We know that opioids are associated with many untoward side effects and are potentially lethal. But we believe there is a reason why opioids have been used to treat pain since the Sumerians 5,000 years ago,” Elliot J. Krane, MD, Steven J. Weisman, MD, and Gary A. Walco, PhD, wrote in an accompanying editorial.
The editorialists noted that they are not blanket advocates of opioid prescriptions for children, but they do believe in the importance of pain management for conditions including postsurgical pain, burns, physical trauma, and medical illnesses. In many cases, opioids are the most effective treatment option.
In addition, data on opioid-related deaths in the United States have been shown inaccurate for various reasons including the coding of deaths as opioid related if opioids were present among a number of other drugs, even if the cause of death was another substance or an act such as suicide, the writers noted. Even the Centers for Disease Control and Prevention has admitted overestimating the prevalence of opioid-related deaths by as much as 100%. Consequently, the opioid epidemic portrayed in the media, “pales in comparison with other public health hazards and causes of deaths in America such as tobacco-related deaths, alcoholic hepatic disease, and even hospital-acquired infections,” Dr. Krane, Dr. Weisman, and Dr. Walco said.
“The data as presented cannot be considered causal for associating opioid prescribing with severe morbidity, more hospital emergency department visits, and even death,” the editorialists concluded. They emphasized the need for good judgment on the part of clinicians when prescribing opioids to children and advocated always making good use of nonopioid alternatives, but Dr. Krane, Dr. Weisman, and Dr. Walco added that the findings of this study should not deter doctors from prescribing an opioid when they think it is the most effective and appropriate option for moderately to severely painful conditions.
“Too often, consideration of the need to prevent and treat pain can be lost in the national discussion,” they said.
Dr. Krane is affiliated with Stanford University in Palo Alto, Calif., Dr. Weisman is affiliated with the Medical College of Milwaukee, Wisc., and Dr. Walco is affiliated with the University of Washington, Seattle. Dr. Krane disclosed consulting for Collegium Pharmaceuticals and honoraria for lecturing on pain and analgesia. Dr. Weisman disclosed consulting for Grünenthal Pharmaceuticals and Pfizer Pharmaceuticals and has conducted clinical trials for Grünenthal Pharmaceuticals, Cadence Pharmaceuticals, and The Medicines Company. Their editorial accompanying the article by Chung et al. appeared in Pediatrics (2018 Jul 16. doi: 10.1542/peds.2018-1623).
“We know that opioids are associated with many untoward side effects and are potentially lethal. But we believe there is a reason why opioids have been used to treat pain since the Sumerians 5,000 years ago,” Elliot J. Krane, MD, Steven J. Weisman, MD, and Gary A. Walco, PhD, wrote in an accompanying editorial.
The editorialists noted that they are not blanket advocates of opioid prescriptions for children, but they do believe in the importance of pain management for conditions including postsurgical pain, burns, physical trauma, and medical illnesses. In many cases, opioids are the most effective treatment option.
In addition, data on opioid-related deaths in the United States have been shown inaccurate for various reasons including the coding of deaths as opioid related if opioids were present among a number of other drugs, even if the cause of death was another substance or an act such as suicide, the writers noted. Even the Centers for Disease Control and Prevention has admitted overestimating the prevalence of opioid-related deaths by as much as 100%. Consequently, the opioid epidemic portrayed in the media, “pales in comparison with other public health hazards and causes of deaths in America such as tobacco-related deaths, alcoholic hepatic disease, and even hospital-acquired infections,” Dr. Krane, Dr. Weisman, and Dr. Walco said.
“The data as presented cannot be considered causal for associating opioid prescribing with severe morbidity, more hospital emergency department visits, and even death,” the editorialists concluded. They emphasized the need for good judgment on the part of clinicians when prescribing opioids to children and advocated always making good use of nonopioid alternatives, but Dr. Krane, Dr. Weisman, and Dr. Walco added that the findings of this study should not deter doctors from prescribing an opioid when they think it is the most effective and appropriate option for moderately to severely painful conditions.
“Too often, consideration of the need to prevent and treat pain can be lost in the national discussion,” they said.
Dr. Krane is affiliated with Stanford University in Palo Alto, Calif., Dr. Weisman is affiliated with the Medical College of Milwaukee, Wisc., and Dr. Walco is affiliated with the University of Washington, Seattle. Dr. Krane disclosed consulting for Collegium Pharmaceuticals and honoraria for lecturing on pain and analgesia. Dr. Weisman disclosed consulting for Grünenthal Pharmaceuticals and Pfizer Pharmaceuticals and has conducted clinical trials for Grünenthal Pharmaceuticals, Cadence Pharmaceuticals, and The Medicines Company. Their editorial accompanying the article by Chung et al. appeared in Pediatrics (2018 Jul 16. doi: 10.1542/peds.2018-1623).
“We know that opioids are associated with many untoward side effects and are potentially lethal. But we believe there is a reason why opioids have been used to treat pain since the Sumerians 5,000 years ago,” Elliot J. Krane, MD, Steven J. Weisman, MD, and Gary A. Walco, PhD, wrote in an accompanying editorial.
The editorialists noted that they are not blanket advocates of opioid prescriptions for children, but they do believe in the importance of pain management for conditions including postsurgical pain, burns, physical trauma, and medical illnesses. In many cases, opioids are the most effective treatment option.
In addition, data on opioid-related deaths in the United States have been shown inaccurate for various reasons including the coding of deaths as opioid related if opioids were present among a number of other drugs, even if the cause of death was another substance or an act such as suicide, the writers noted. Even the Centers for Disease Control and Prevention has admitted overestimating the prevalence of opioid-related deaths by as much as 100%. Consequently, the opioid epidemic portrayed in the media, “pales in comparison with other public health hazards and causes of deaths in America such as tobacco-related deaths, alcoholic hepatic disease, and even hospital-acquired infections,” Dr. Krane, Dr. Weisman, and Dr. Walco said.
“The data as presented cannot be considered causal for associating opioid prescribing with severe morbidity, more hospital emergency department visits, and even death,” the editorialists concluded. They emphasized the need for good judgment on the part of clinicians when prescribing opioids to children and advocated always making good use of nonopioid alternatives, but Dr. Krane, Dr. Weisman, and Dr. Walco added that the findings of this study should not deter doctors from prescribing an opioid when they think it is the most effective and appropriate option for moderately to severely painful conditions.
“Too often, consideration of the need to prevent and treat pain can be lost in the national discussion,” they said.
Dr. Krane is affiliated with Stanford University in Palo Alto, Calif., Dr. Weisman is affiliated with the Medical College of Milwaukee, Wisc., and Dr. Walco is affiliated with the University of Washington, Seattle. Dr. Krane disclosed consulting for Collegium Pharmaceuticals and honoraria for lecturing on pain and analgesia. Dr. Weisman disclosed consulting for Grünenthal Pharmaceuticals and Pfizer Pharmaceuticals and has conducted clinical trials for Grünenthal Pharmaceuticals, Cadence Pharmaceuticals, and The Medicines Company. Their editorial accompanying the article by Chung et al. appeared in Pediatrics (2018 Jul 16. doi: 10.1542/peds.2018-1623).
Nearly three-quarters of opioid-related adverse events seen in children were related to therapeutic opioid use, based on data from more than a million prescriptions.
Prescription of opioids to children for outpatient conditions may have risen along with the increased opioid prescriptions for adults, but most of the literature focuses on opioid toxicity in children, and “the incidence of adverse opioid effects for children during appropriate medical use for relatively minor conditions is unknown,” wrote Cecilia P. Chung, MD, of Vanderbilt University in Nashville, Tenn., and her colleagues.
In a retrospective study published in Pediatrics, the researchers reviewed data from 401,972 children and adolescents aged 2-17 years with no chronic or severe conditions. The patients filled a total of 1,362,503 prescriptions for opioids, with a mean 15% filling one or more opioid prescriptions a year, and 1 in every 2,611 prescriptions was followed by an emergency department visit, hospitalization, or death related to an adverse event associated with opioid use.
Approximately 20% of the prescriptions were for children aged 2-5 years, 28% for ages 6-11 years, and 52% for ages 12-17 years. The patients were enrolled in Medicaid between Jan. 1, 1999, and Dec. 31, 2014, in Tennessee, and were seen at outpatient centers. Dental procedures were the most common reasons for opioid prescriptions in the study population (31%), followed by outpatient procedures or surgeries (25%), trauma (18%), and infections (16%).
Overall, 437 cases of opioid-related adverse events were confirmed by medical record review; 89% of these were deemed related to the prescription, and 71% were related to proper therapeutic use, the researchers said. The remainder were considered to be related to unintentional overdose, abuse, self-harm, or the circumstances were not indicated.
The opioid-related symptoms most frequently were gastrointestinal, neuropsychiatric, dermatologic, and central nervous system depression.
“The incidence of opioid-related adverse events increased for children and adolescents 12-17 years of age, during current opioid use, and with higher opioid doses,” the researchers said.
The study findings were limited by several factors including the use of Medicaid patients only, the lack of clinical details such as patient weight, and the potential for incomplete medical records, Dr. Chung and her associates noted. However, the results support the need for more comprehensive guidelines in treating acute, self-limited conditions in children to reduce unnecessary opioid exposure, they said.
The researchers had no relevant financial conflicts to disclose. The study was supported by the Eunice Kennedy Shriver National Institute for Child Health and Human Development and funded by the National Institutes of Health. Dr. Chung received grant support from the National Institutes of Health and the Rheumatology Research Foundation Career Development Research K-supplement.
SOURCE: Chung C et al. Pediatrics. 2018 Jul 16. doi: 10.1542/peds.2017-2156.
Nearly three-quarters of opioid-related adverse events seen in children were related to therapeutic opioid use, based on data from more than a million prescriptions.
Prescription of opioids to children for outpatient conditions may have risen along with the increased opioid prescriptions for adults, but most of the literature focuses on opioid toxicity in children, and “the incidence of adverse opioid effects for children during appropriate medical use for relatively minor conditions is unknown,” wrote Cecilia P. Chung, MD, of Vanderbilt University in Nashville, Tenn., and her colleagues.
In a retrospective study published in Pediatrics, the researchers reviewed data from 401,972 children and adolescents aged 2-17 years with no chronic or severe conditions. The patients filled a total of 1,362,503 prescriptions for opioids, with a mean 15% filling one or more opioid prescriptions a year, and 1 in every 2,611 prescriptions was followed by an emergency department visit, hospitalization, or death related to an adverse event associated with opioid use.
Approximately 20% of the prescriptions were for children aged 2-5 years, 28% for ages 6-11 years, and 52% for ages 12-17 years. The patients were enrolled in Medicaid between Jan. 1, 1999, and Dec. 31, 2014, in Tennessee, and were seen at outpatient centers. Dental procedures were the most common reasons for opioid prescriptions in the study population (31%), followed by outpatient procedures or surgeries (25%), trauma (18%), and infections (16%).
Overall, 437 cases of opioid-related adverse events were confirmed by medical record review; 89% of these were deemed related to the prescription, and 71% were related to proper therapeutic use, the researchers said. The remainder were considered to be related to unintentional overdose, abuse, self-harm, or the circumstances were not indicated.
The opioid-related symptoms most frequently were gastrointestinal, neuropsychiatric, dermatologic, and central nervous system depression.
“The incidence of opioid-related adverse events increased for children and adolescents 12-17 years of age, during current opioid use, and with higher opioid doses,” the researchers said.
The study findings were limited by several factors including the use of Medicaid patients only, the lack of clinical details such as patient weight, and the potential for incomplete medical records, Dr. Chung and her associates noted. However, the results support the need for more comprehensive guidelines in treating acute, self-limited conditions in children to reduce unnecessary opioid exposure, they said.
The researchers had no relevant financial conflicts to disclose. The study was supported by the Eunice Kennedy Shriver National Institute for Child Health and Human Development and funded by the National Institutes of Health. Dr. Chung received grant support from the National Institutes of Health and the Rheumatology Research Foundation Career Development Research K-supplement.
SOURCE: Chung C et al. Pediatrics. 2018 Jul 16. doi: 10.1542/peds.2017-2156.
FROM PEDIATRICS
Key clinical point: One in every 2,611 opioid prescriptions in children and teens was followed by an ED visit, hospitalization, or death related to an adverse event associated with opioid use.
Major finding: A total of 437 cases of opioid-related adverse events were confirmed; most were associated with therapeutic medication use.
Study details: The data come from a retrospective cohort study of 401,972 children aged 2-17 years enrolled in Medicaid between Jan. 1, 1999, and Dec. 31, 2014.
Disclosures: The researchers had no relevant financial conflicts to disclose. The study was supported by the Eunice Kennedy Shriver National Institute for Child Health and Human Development, and funded by the National Institutes of Health. Dr. Chung received grant support from the National Institutes of Health and the Rheumatology Research Foundation Career Development Research K-supplement.
Source: Chung C et al. Pediatrics. 2018 Jul 16. doi: 10.1542/peds.2017-2156
No gender bias found in ABS exam
, an analysis found.
Lead author Thai Q. Ong of the James Madison University Center for Assessment and Research Studies, Harrisonburg, Va., and colleagues examined data from the 2016-2017 ABS general surgery certifying exam (CE), which included 1,341 examinees and 216 examiners. Of examinees, 61% were male and of examiners, 82% were male. Investigators used factorial analysis of variance and logistic regression analyses to evaluate the effect of examinee and examiner gender on CE ratings and likelihood of passing the CE.
Results showed that gender was not a factor in rates received, and the gender of examiners had no bearing on the ratings they gave examinees of either gender, according to the study, published in the Journal of Surgical Research. In addition, examiner teams of different gender combinations did not affect their ratings of examinees. The investigators found also that examinee gender was not a significant predictor of session pass rates nor was examiner gender a factor in session pass rates.
The study authors concluded that there is no evidence of gender bias in ABS certifying exam rates or the likelihood of passing the exam. “Although these findings are favorable, the ABS continues to undertake efforts to minimize potential examiner bias in future examinations. All examiners are required to participate in rater training as well as implicit bias training in advance of the general surgery CE. The ABS has also added information on preventing implicit bias in the instructions that examiners receive in preparation for these exams.”
However, they noted, further studies should be conducted to replicate the results and explore other possible sources of examiner bias in CE ratings.
The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
SOURCE: Ong et al. J Surg Res. 2018 June doi: 10.1016/j.jss.2018.06.014.
, an analysis found.
Lead author Thai Q. Ong of the James Madison University Center for Assessment and Research Studies, Harrisonburg, Va., and colleagues examined data from the 2016-2017 ABS general surgery certifying exam (CE), which included 1,341 examinees and 216 examiners. Of examinees, 61% were male and of examiners, 82% were male. Investigators used factorial analysis of variance and logistic regression analyses to evaluate the effect of examinee and examiner gender on CE ratings and likelihood of passing the CE.
Results showed that gender was not a factor in rates received, and the gender of examiners had no bearing on the ratings they gave examinees of either gender, according to the study, published in the Journal of Surgical Research. In addition, examiner teams of different gender combinations did not affect their ratings of examinees. The investigators found also that examinee gender was not a significant predictor of session pass rates nor was examiner gender a factor in session pass rates.
The study authors concluded that there is no evidence of gender bias in ABS certifying exam rates or the likelihood of passing the exam. “Although these findings are favorable, the ABS continues to undertake efforts to minimize potential examiner bias in future examinations. All examiners are required to participate in rater training as well as implicit bias training in advance of the general surgery CE. The ABS has also added information on preventing implicit bias in the instructions that examiners receive in preparation for these exams.”
However, they noted, further studies should be conducted to replicate the results and explore other possible sources of examiner bias in CE ratings.
The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
SOURCE: Ong et al. J Surg Res. 2018 June doi: 10.1016/j.jss.2018.06.014.
, an analysis found.
Lead author Thai Q. Ong of the James Madison University Center for Assessment and Research Studies, Harrisonburg, Va., and colleagues examined data from the 2016-2017 ABS general surgery certifying exam (CE), which included 1,341 examinees and 216 examiners. Of examinees, 61% were male and of examiners, 82% were male. Investigators used factorial analysis of variance and logistic regression analyses to evaluate the effect of examinee and examiner gender on CE ratings and likelihood of passing the CE.
Results showed that gender was not a factor in rates received, and the gender of examiners had no bearing on the ratings they gave examinees of either gender, according to the study, published in the Journal of Surgical Research. In addition, examiner teams of different gender combinations did not affect their ratings of examinees. The investigators found also that examinee gender was not a significant predictor of session pass rates nor was examiner gender a factor in session pass rates.
The study authors concluded that there is no evidence of gender bias in ABS certifying exam rates or the likelihood of passing the exam. “Although these findings are favorable, the ABS continues to undertake efforts to minimize potential examiner bias in future examinations. All examiners are required to participate in rater training as well as implicit bias training in advance of the general surgery CE. The ABS has also added information on preventing implicit bias in the instructions that examiners receive in preparation for these exams.”
However, they noted, further studies should be conducted to replicate the results and explore other possible sources of examiner bias in CE ratings.
The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
SOURCE: Ong et al. J Surg Res. 2018 June doi: 10.1016/j.jss.2018.06.014.
Key clinical point: The gender of examinees and the gender of examiners do not affect ABS exam outcomes.
Major finding: No correlation was found between surgeon gender and CE ratings received.
Study details: Investigators examined data from the 2016-2017 ABS general surgery certifying exam, which consisted of 1,341 examinees and 216 examiners.
Disclosures: The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Source: Ong et al. J Surg Res. 2018 Jun. doi: 10.1016/j.jss.2018.06.014.
From the Editors: The Value of Community
I was recently reminded of the importance of face-to-face meetings to gain understanding and to learn from the experiences of others. In this case, the lesson was delivered in the idyllic setting of Sunriver, Oregon, where the Oregon and Washington chapters of the American College of Surgeons held their annual meeting. I always come away from this meeting energized and inspired by the shared experiences of young and old, urban and rural. This meeting exceeded all expectations in the quality of the presentations but also, more importantly, in the quality of the exchange of ideas and viewpoints among surgeons across the full spectrum of practice types, geographical locations, and generations.
Community and rural surgeons were both well represented at this meeting, perhaps because our Oregon chapter president, Keith Thomas, is a rural surgeon; he had invited rural surgeon extraordinaire Tyler Hughes to be the keynote speaker; and the overarching theme of the meeting was “The Right Care in the Right Place.” The program featured controversial topics that were presented in a way that respected all views and shed more light than heat on the subject: a debate about whether (and which) cancers needed to be referred to tertiary centers, an exploration of how surgical care for all might be improved by regionalization in a matrix that could allow all patients to access timely and appropriate care, and even a discussion of a strategy through which we might build consensus for the prevention of firearm injuries and deaths while avoiding the “demonization of the enemy” that currently occurs whenever the subject is mentioned.
The residents’ and fellows’ presentations have evolved over the past few decades to include a broader range of research topics than those in prior meetings. This year, trainees gave papers not only on the treatment of specific surgical conditions or basic science studies but also on quality improvement, patient safety, ethics, end-of-life care, and cutting-edge technologies. Those who presented their research displayed the very best attributes of the millennial generation: creativity, altruism, and a commitment to make our shared future world a better, safer, more humane place. They fielded questions from the audience like “old pros,” demonstrating an impressive understanding of their subjects as well as a passion for their work.
Although the accelerating demands on our lives have led some to question whether the time required to attend a chapter meeting is worth the money and effort, I would argue that it is crucial to our future to do so. As surgical practice becomes more specialized and “siloed,” it is critical that we reaffirm what unites us rather than focus on what separates us. It is easy to attribute ill motives and malevolent characteristics to someone who sees things differently than you do. Is much more difficult to do so when you spend time with that person and learn about him or her as an individual. Local ACS chapter meetings accomplish that and more. Older surgeons nearing retirement and worried about the future of their communities can meet and mingle with residents and fellows who might become future partners. Former colleagues from medical school or residency who have pursued different practice paths can reacquaint themselves with one another, relive the good (and perhaps bad) old times, and share a chuckle or two. Surgeons who practice in the “ivory tower” can gain appreciation for the challenges of practicing in a resource-limited facility. Those from competing institutions or practices can learn that the “other” is facing the same issues and that common strategies for success might be found. We can all gain a greater understanding that the other person’s problems aren’t that different or less complex than ours.
In addition to providing a stimulating program, a successful chapter meeting requires skillful planning and execution by an experienced chapter manager. Our Oregon chapter is fortunate to have Harvey Gail, an outstanding manager who takes care of those essential tasks that make the meeting run smoothly so that we can focus on the substance of the meeting itself.
Attending a chapter meeting requires a relatively short time commitment of three days away from home – including a weekend – and a tank of gas. Some have suggested that holding the meeting in the largest city in the region would lessen travel time demands for many, but doing so would mean losing the low-key setting that creates the perfect atmosphere for developing professional and personal relationships and building a true community. The future survival of our profession depends on finding better, novel solutions to our common problems; we can accomplish that only by sharing our diverse perspectives and identifying solutions that meet all of our needs and those of our patients.
To those of you who rarely (or never) have attended a chapter meeting, you need to go. You’ll be surprised at how much you can learn from your fellow surgeons, who, I guarantee, are more like you than they are different.
Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
I was recently reminded of the importance of face-to-face meetings to gain understanding and to learn from the experiences of others. In this case, the lesson was delivered in the idyllic setting of Sunriver, Oregon, where the Oregon and Washington chapters of the American College of Surgeons held their annual meeting. I always come away from this meeting energized and inspired by the shared experiences of young and old, urban and rural. This meeting exceeded all expectations in the quality of the presentations but also, more importantly, in the quality of the exchange of ideas and viewpoints among surgeons across the full spectrum of practice types, geographical locations, and generations.
Community and rural surgeons were both well represented at this meeting, perhaps because our Oregon chapter president, Keith Thomas, is a rural surgeon; he had invited rural surgeon extraordinaire Tyler Hughes to be the keynote speaker; and the overarching theme of the meeting was “The Right Care in the Right Place.” The program featured controversial topics that were presented in a way that respected all views and shed more light than heat on the subject: a debate about whether (and which) cancers needed to be referred to tertiary centers, an exploration of how surgical care for all might be improved by regionalization in a matrix that could allow all patients to access timely and appropriate care, and even a discussion of a strategy through which we might build consensus for the prevention of firearm injuries and deaths while avoiding the “demonization of the enemy” that currently occurs whenever the subject is mentioned.
The residents’ and fellows’ presentations have evolved over the past few decades to include a broader range of research topics than those in prior meetings. This year, trainees gave papers not only on the treatment of specific surgical conditions or basic science studies but also on quality improvement, patient safety, ethics, end-of-life care, and cutting-edge technologies. Those who presented their research displayed the very best attributes of the millennial generation: creativity, altruism, and a commitment to make our shared future world a better, safer, more humane place. They fielded questions from the audience like “old pros,” demonstrating an impressive understanding of their subjects as well as a passion for their work.
Although the accelerating demands on our lives have led some to question whether the time required to attend a chapter meeting is worth the money and effort, I would argue that it is crucial to our future to do so. As surgical practice becomes more specialized and “siloed,” it is critical that we reaffirm what unites us rather than focus on what separates us. It is easy to attribute ill motives and malevolent characteristics to someone who sees things differently than you do. Is much more difficult to do so when you spend time with that person and learn about him or her as an individual. Local ACS chapter meetings accomplish that and more. Older surgeons nearing retirement and worried about the future of their communities can meet and mingle with residents and fellows who might become future partners. Former colleagues from medical school or residency who have pursued different practice paths can reacquaint themselves with one another, relive the good (and perhaps bad) old times, and share a chuckle or two. Surgeons who practice in the “ivory tower” can gain appreciation for the challenges of practicing in a resource-limited facility. Those from competing institutions or practices can learn that the “other” is facing the same issues and that common strategies for success might be found. We can all gain a greater understanding that the other person’s problems aren’t that different or less complex than ours.
In addition to providing a stimulating program, a successful chapter meeting requires skillful planning and execution by an experienced chapter manager. Our Oregon chapter is fortunate to have Harvey Gail, an outstanding manager who takes care of those essential tasks that make the meeting run smoothly so that we can focus on the substance of the meeting itself.
Attending a chapter meeting requires a relatively short time commitment of three days away from home – including a weekend – and a tank of gas. Some have suggested that holding the meeting in the largest city in the region would lessen travel time demands for many, but doing so would mean losing the low-key setting that creates the perfect atmosphere for developing professional and personal relationships and building a true community. The future survival of our profession depends on finding better, novel solutions to our common problems; we can accomplish that only by sharing our diverse perspectives and identifying solutions that meet all of our needs and those of our patients.
To those of you who rarely (or never) have attended a chapter meeting, you need to go. You’ll be surprised at how much you can learn from your fellow surgeons, who, I guarantee, are more like you than they are different.
Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
I was recently reminded of the importance of face-to-face meetings to gain understanding and to learn from the experiences of others. In this case, the lesson was delivered in the idyllic setting of Sunriver, Oregon, where the Oregon and Washington chapters of the American College of Surgeons held their annual meeting. I always come away from this meeting energized and inspired by the shared experiences of young and old, urban and rural. This meeting exceeded all expectations in the quality of the presentations but also, more importantly, in the quality of the exchange of ideas and viewpoints among surgeons across the full spectrum of practice types, geographical locations, and generations.
Community and rural surgeons were both well represented at this meeting, perhaps because our Oregon chapter president, Keith Thomas, is a rural surgeon; he had invited rural surgeon extraordinaire Tyler Hughes to be the keynote speaker; and the overarching theme of the meeting was “The Right Care in the Right Place.” The program featured controversial topics that were presented in a way that respected all views and shed more light than heat on the subject: a debate about whether (and which) cancers needed to be referred to tertiary centers, an exploration of how surgical care for all might be improved by regionalization in a matrix that could allow all patients to access timely and appropriate care, and even a discussion of a strategy through which we might build consensus for the prevention of firearm injuries and deaths while avoiding the “demonization of the enemy” that currently occurs whenever the subject is mentioned.
The residents’ and fellows’ presentations have evolved over the past few decades to include a broader range of research topics than those in prior meetings. This year, trainees gave papers not only on the treatment of specific surgical conditions or basic science studies but also on quality improvement, patient safety, ethics, end-of-life care, and cutting-edge technologies. Those who presented their research displayed the very best attributes of the millennial generation: creativity, altruism, and a commitment to make our shared future world a better, safer, more humane place. They fielded questions from the audience like “old pros,” demonstrating an impressive understanding of their subjects as well as a passion for their work.
Although the accelerating demands on our lives have led some to question whether the time required to attend a chapter meeting is worth the money and effort, I would argue that it is crucial to our future to do so. As surgical practice becomes more specialized and “siloed,” it is critical that we reaffirm what unites us rather than focus on what separates us. It is easy to attribute ill motives and malevolent characteristics to someone who sees things differently than you do. Is much more difficult to do so when you spend time with that person and learn about him or her as an individual. Local ACS chapter meetings accomplish that and more. Older surgeons nearing retirement and worried about the future of their communities can meet and mingle with residents and fellows who might become future partners. Former colleagues from medical school or residency who have pursued different practice paths can reacquaint themselves with one another, relive the good (and perhaps bad) old times, and share a chuckle or two. Surgeons who practice in the “ivory tower” can gain appreciation for the challenges of practicing in a resource-limited facility. Those from competing institutions or practices can learn that the “other” is facing the same issues and that common strategies for success might be found. We can all gain a greater understanding that the other person’s problems aren’t that different or less complex than ours.
In addition to providing a stimulating program, a successful chapter meeting requires skillful planning and execution by an experienced chapter manager. Our Oregon chapter is fortunate to have Harvey Gail, an outstanding manager who takes care of those essential tasks that make the meeting run smoothly so that we can focus on the substance of the meeting itself.
Attending a chapter meeting requires a relatively short time commitment of three days away from home – including a weekend – and a tank of gas. Some have suggested that holding the meeting in the largest city in the region would lessen travel time demands for many, but doing so would mean losing the low-key setting that creates the perfect atmosphere for developing professional and personal relationships and building a true community. The future survival of our profession depends on finding better, novel solutions to our common problems; we can accomplish that only by sharing our diverse perspectives and identifying solutions that meet all of our needs and those of our patients.
To those of you who rarely (or never) have attended a chapter meeting, you need to go. You’ll be surprised at how much you can learn from your fellow surgeons, who, I guarantee, are more like you than they are different.
Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.