Opinion

Organized labor seems to be experiencing a rebirth of sorts. In October 2022 a strike by railroad workers was averted when a tentative agreement about wages, working conditions, health insurance, and medical leave was hammered out. This past fall, strikes by auto workers that threatened to paralyze the big three manufacturers have now been resolved with agreements that meet many of the workers’ demands. The President even made an appearance on a picket line. Baristas at coffee shops, screenwriters, and actors have all been involved in work actions around the country.

While the health care industry has been relatively immune to threatened work stoppages, there are a growing number of hospitals and clinics where nurses and physicians are exploring the possibility of organizing to give themselves a stronger voice in how health care is being delivered. The realities that come when you transition from owner to employee are finally beginning to sink in for physicians, whether they are specialists or primary care providers.

One of the most significant efforts toward unionization recently occurred in Minnesota and Wisconsin. About 400 physicians and 150 physician’s assistants and nurse practitioners employed at Allina Health System voted to unionize and join the Doctors Council.

In an interview with Jacobin, a publication that offers a socialist perspective, three of the providers involved in the process that led to the vote shared their observations. The physicians claim that the first steps toward unionization came after multiple efforts to work with the Allina’s administration were rebuffed. As primary care physicians, their initial demands focused on getting help with hiring staffing and getting support with paperwork and administrative obligations.

The organizers complained that while Medicare hoped to bolster primary care by paying the providers more, the funds went to the companies, who then distributed them in a way that often did little to help the overworked providers. In addition to achieving a more equitable distribution of the monies, one of the organizers sees unionization as a way to provide a layer of protection when providers feel they must speak out about situations which clearly put quality of care at risk.

The organizers say the idea of unionization has been particularly appealing to the younger providers who are feeling threatened by burnout. When these new physicians look to their older coworkers for advice, they often find that the seasoned employees are as stressed as they are. Realizing that things aren’t going to improve with time, acting now to strengthen their voices sounds appealing.

With the vote for unionization behind them, the organizers are now ready to formulate a prioritized list of demands. Those of you who are regular readers of Letters from Maine know that I have been urging primary care physicians to find their voices. Unfortunately, unionization seems to be becoming a more common fall-back strategy when other avenues have failed to reach a sympathetic ear in the corporate boardrooms.

As more unions form, it will be interesting to see how the organizers structure their demands and job actions. While walkouts and strikes can certainly be effective in gaining attention, that attention can carry a risk of counter productivity sometimes by alienating patients, who should become allies.

Since an unsustainable burden of paperwork and administrative demands seems to be at the top of everyone’s priority list, it might make sense to adopt this message as a scaffolding on which to built a work action. Instead of walking off the job or marching on a picket line, why not stay in the hospital and continue to see patients but only for part of the work day. The remainder of the day would be spent doing all the clerical work that has become so onerous.

Providers would agree to see patients in the mornings, saving up the clerical work and administrative obligations for the afternoon. The definition of “morning” could vary depending on local conditions.

The important message to the public and the patients would be that the providers were not abandoning them by walking out. The patients’ access to face-to-face care was being limited not because the doctors didn’t want to see them but because the providers were being forced to accept other responsibilities by the administration. The physicians would always be on site in case of a crisis, but until reasonable demands for support from the company were met, a certain portion of the providers’ day would be spent doing things not directly related to face-to-face patient care. This burden of meaningless work is the reality as it stands already. Why not organize it in a way that makes it startlingly visible to the patients and the public.

There would be no video clips of physicians walking the picket lines carrying signs. Any images released to the media would be of empty waiting rooms while providers sat hunched over their computers or talking on the phone to insurance companies.

The strategy needs a catchy phrase like “a paperwork-in” but I’m still struggling with a name. Let me know if you have a better one or even a better strategy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Organized labor seems to be experiencing a rebirth of sorts. In October 2022 a strike by railroad workers was averted when a tentative agreement about wages, working conditions, health insurance, and medical leave was hammered out. This past fall, strikes by auto workers that threatened to paralyze the big three manufacturers have now been resolved with agreements that meet many of the workers’ demands. The President even made an appearance on a picket line. Baristas at coffee shops, screenwriters, and actors have all been involved in work actions around the country.

While the health care industry has been relatively immune to threatened work stoppages, there are a growing number of hospitals and clinics where nurses and physicians are exploring the possibility of organizing to give themselves a stronger voice in how health care is being delivered. The realities that come when you transition from owner to employee are finally beginning to sink in for physicians, whether they are specialists or primary care providers.

One of the most significant efforts toward unionization recently occurred in Minnesota and Wisconsin. About 400 physicians and 150 physician’s assistants and nurse practitioners employed at Allina Health System voted to unionize and join the Doctors Council.

In an interview with Jacobin, a publication that offers a socialist perspective, three of the providers involved in the process that led to the vote shared their observations. The physicians claim that the first steps toward unionization came after multiple efforts to work with the Allina’s administration were rebuffed. As primary care physicians, their initial demands focused on getting help with hiring staffing and getting support with paperwork and administrative obligations.

The organizers complained that while Medicare hoped to bolster primary care by paying the providers more, the funds went to the companies, who then distributed them in a way that often did little to help the overworked providers. In addition to achieving a more equitable distribution of the monies, one of the organizers sees unionization as a way to provide a layer of protection when providers feel they must speak out about situations which clearly put quality of care at risk.

The organizers say the idea of unionization has been particularly appealing to the younger providers who are feeling threatened by burnout. When these new physicians look to their older coworkers for advice, they often find that the seasoned employees are as stressed as they are. Realizing that things aren’t going to improve with time, acting now to strengthen their voices sounds appealing.

With the vote for unionization behind them, the organizers are now ready to formulate a prioritized list of demands. Those of you who are regular readers of Letters from Maine know that I have been urging primary care physicians to find their voices. Unfortunately, unionization seems to be becoming a more common fall-back strategy when other avenues have failed to reach a sympathetic ear in the corporate boardrooms.

As more unions form, it will be interesting to see how the organizers structure their demands and job actions. While walkouts and strikes can certainly be effective in gaining attention, that attention can carry a risk of counter productivity sometimes by alienating patients, who should become allies.

Since an unsustainable burden of paperwork and administrative demands seems to be at the top of everyone’s priority list, it might make sense to adopt this message as a scaffolding on which to built a work action. Instead of walking off the job or marching on a picket line, why not stay in the hospital and continue to see patients but only for part of the work day. The remainder of the day would be spent doing all the clerical work that has become so onerous.

Providers would agree to see patients in the mornings, saving up the clerical work and administrative obligations for the afternoon. The definition of “morning” could vary depending on local conditions.

The important message to the public and the patients would be that the providers were not abandoning them by walking out. The patients’ access to face-to-face care was being limited not because the doctors didn’t want to see them but because the providers were being forced to accept other responsibilities by the administration. The physicians would always be on site in case of a crisis, but until reasonable demands for support from the company were met, a certain portion of the providers’ day would be spent doing things not directly related to face-to-face patient care. This burden of meaningless work is the reality as it stands already. Why not organize it in a way that makes it startlingly visible to the patients and the public.

There would be no video clips of physicians walking the picket lines carrying signs. Any images released to the media would be of empty waiting rooms while providers sat hunched over their computers or talking on the phone to insurance companies.

The strategy needs a catchy phrase like “a paperwork-in” but I’m still struggling with a name. Let me know if you have a better one or even a better strategy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Organized labor seems to be experiencing a rebirth of sorts. In October 2022 a strike by railroad workers was averted when a tentative agreement about wages, working conditions, health insurance, and medical leave was hammered out. This past fall, strikes by auto workers that threatened to paralyze the big three manufacturers have now been resolved with agreements that meet many of the workers’ demands. The President even made an appearance on a picket line. Baristas at coffee shops, screenwriters, and actors have all been involved in work actions around the country.

While the health care industry has been relatively immune to threatened work stoppages, there are a growing number of hospitals and clinics where nurses and physicians are exploring the possibility of organizing to give themselves a stronger voice in how health care is being delivered. The realities that come when you transition from owner to employee are finally beginning to sink in for physicians, whether they are specialists or primary care providers.

One of the most significant efforts toward unionization recently occurred in Minnesota and Wisconsin. About 400 physicians and 150 physician’s assistants and nurse practitioners employed at Allina Health System voted to unionize and join the Doctors Council.

In an interview with Jacobin, a publication that offers a socialist perspective, three of the providers involved in the process that led to the vote shared their observations. The physicians claim that the first steps toward unionization came after multiple efforts to work with the Allina’s administration were rebuffed. As primary care physicians, their initial demands focused on getting help with hiring staffing and getting support with paperwork and administrative obligations.

The organizers complained that while Medicare hoped to bolster primary care by paying the providers more, the funds went to the companies, who then distributed them in a way that often did little to help the overworked providers. In addition to achieving a more equitable distribution of the monies, one of the organizers sees unionization as a way to provide a layer of protection when providers feel they must speak out about situations which clearly put quality of care at risk.

The organizers say the idea of unionization has been particularly appealing to the younger providers who are feeling threatened by burnout. When these new physicians look to their older coworkers for advice, they often find that the seasoned employees are as stressed as they are. Realizing that things aren’t going to improve with time, acting now to strengthen their voices sounds appealing.

With the vote for unionization behind them, the organizers are now ready to formulate a prioritized list of demands. Those of you who are regular readers of Letters from Maine know that I have been urging primary care physicians to find their voices. Unfortunately, unionization seems to be becoming a more common fall-back strategy when other avenues have failed to reach a sympathetic ear in the corporate boardrooms.

As more unions form, it will be interesting to see how the organizers structure their demands and job actions. While walkouts and strikes can certainly be effective in gaining attention, that attention can carry a risk of counter productivity sometimes by alienating patients, who should become allies.

Since an unsustainable burden of paperwork and administrative demands seems to be at the top of everyone’s priority list, it might make sense to adopt this message as a scaffolding on which to built a work action. Instead of walking off the job or marching on a picket line, why not stay in the hospital and continue to see patients but only for part of the work day. The remainder of the day would be spent doing all the clerical work that has become so onerous.

Providers would agree to see patients in the mornings, saving up the clerical work and administrative obligations for the afternoon. The definition of “morning” could vary depending on local conditions.

The important message to the public and the patients would be that the providers were not abandoning them by walking out. The patients’ access to face-to-face care was being limited not because the doctors didn’t want to see them but because the providers were being forced to accept other responsibilities by the administration. The physicians would always be on site in case of a crisis, but until reasonable demands for support from the company were met, a certain portion of the providers’ day would be spent doing things not directly related to face-to-face patient care. This burden of meaningless work is the reality as it stands already. Why not organize it in a way that makes it startlingly visible to the patients and the public.

There would be no video clips of physicians walking the picket lines carrying signs. Any images released to the media would be of empty waiting rooms while providers sat hunched over their computers or talking on the phone to insurance companies.

The strategy needs a catchy phrase like “a paperwork-in” but I’m still struggling with a name. Let me know if you have a better one or even a better strategy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

This transcript has been edited for clarity.

Much of my research focuses on what is known as clinical decision support — prompts and messages to providers to help them make good decisions for their patients. I know that these things can be annoying, which is exactly why I study them — to figure out which ones actually help.

When I got started on this about 10 years ago, we were learning a lot about how best to message providers about their patients. My team had developed a simple alert for acute kidney injury (AKI). We knew that providers often missed the diagnosis, so maybe letting them know would improve patient outcomes.

As we tested the alert, we got feedback, and I have kept an email from an ICU doctor from those early days. It read:

Dear Dr. Wilson: Thank you for the automated alert informing me that my patient had AKI. Regrettably, the alert fired about an hour after the patient had died. I feel that the information is less than actionable at this time.

Our early system had neglected to add a conditional flag ensuring that the patient was still alive at the time it sent the alert message. A small oversight, but one that had very large implications. Future studies would show that “false positive” alerts like this seriously degrade physician confidence in the system. And why wouldn’t they?

Knowing whether a patient is alive or dead seems like it should be trivial. But, as it turns out, in our modern balkanized health care system, it can be quite difficult. Not knowing the vital status of a patient can have major consequences.

Health systems send messages to their patients all the time: reminders of appointments, reminders for preventive care, reminders for vaccinations, and so on.

But what if the patient being reminded has died? It’s a waste of resources, of course, but more than that, it can be painful for their families and reflects poorly on the health care system. Of all the people who should know whether someone is alive or dead, shouldn’t their doctor be at the top of the list?

A new study in JAMA Internal Medicine quantifies this very phenomenon.

Researchers examined 11,658 primary care patients in their health system who met the criteria of being “seriously ill” and followed them for 2 years. During that period of time, 25% were recorded as deceased in the electronic health record. But 30.8% had died. That left 676 patients who had died, but were not known to have died, left in the system.

Courtesy Dr. F. Perry Wilson

Courtesy Dr. F. Perry Wilson

Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Connecticut. He has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com .

This transcript has been edited for clarity.

Much of my research focuses on what is known as clinical decision support — prompts and messages to providers to help them make good decisions for their patients. I know that these things can be annoying, which is exactly why I study them — to figure out which ones actually help.

When I got started on this about 10 years ago, we were learning a lot about how best to message providers about their patients. My team had developed a simple alert for acute kidney injury (AKI). We knew that providers often missed the diagnosis, so maybe letting them know would improve patient outcomes.

As we tested the alert, we got feedback, and I have kept an email from an ICU doctor from those early days. It read:

Dear Dr. Wilson: Thank you for the automated alert informing me that my patient had AKI. Regrettably, the alert fired about an hour after the patient had died. I feel that the information is less than actionable at this time.

Our early system had neglected to add a conditional flag ensuring that the patient was still alive at the time it sent the alert message. A small oversight, but one that had very large implications. Future studies would show that “false positive” alerts like this seriously degrade physician confidence in the system. And why wouldn’t they?

Knowing whether a patient is alive or dead seems like it should be trivial. But, as it turns out, in our modern balkanized health care system, it can be quite difficult. Not knowing the vital status of a patient can have major consequences.

Health systems send messages to their patients all the time: reminders of appointments, reminders for preventive care, reminders for vaccinations, and so on.

But what if the patient being reminded has died? It’s a waste of resources, of course, but more than that, it can be painful for their families and reflects poorly on the health care system. Of all the people who should know whether someone is alive or dead, shouldn’t their doctor be at the top of the list?

A new study in JAMA Internal Medicine quantifies this very phenomenon.

Researchers examined 11,658 primary care patients in their health system who met the criteria of being “seriously ill” and followed them for 2 years. During that period of time, 25% were recorded as deceased in the electronic health record. But 30.8% had died. That left 676 patients who had died, but were not known to have died, left in the system.

Courtesy Dr. F. Perry Wilson

Courtesy Dr. F. Perry Wilson

Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Connecticut. He has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com .

This transcript has been edited for clarity.

Much of my research focuses on what is known as clinical decision support — prompts and messages to providers to help them make good decisions for their patients. I know that these things can be annoying, which is exactly why I study them — to figure out which ones actually help.

When I got started on this about 10 years ago, we were learning a lot about how best to message providers about their patients. My team had developed a simple alert for acute kidney injury (AKI). We knew that providers often missed the diagnosis, so maybe letting them know would improve patient outcomes.

As we tested the alert, we got feedback, and I have kept an email from an ICU doctor from those early days. It read:

Dear Dr. Wilson: Thank you for the automated alert informing me that my patient had AKI. Regrettably, the alert fired about an hour after the patient had died. I feel that the information is less than actionable at this time.

Our early system had neglected to add a conditional flag ensuring that the patient was still alive at the time it sent the alert message. A small oversight, but one that had very large implications. Future studies would show that “false positive” alerts like this seriously degrade physician confidence in the system. And why wouldn’t they?

Knowing whether a patient is alive or dead seems like it should be trivial. But, as it turns out, in our modern balkanized health care system, it can be quite difficult. Not knowing the vital status of a patient can have major consequences.

Health systems send messages to their patients all the time: reminders of appointments, reminders for preventive care, reminders for vaccinations, and so on.

But what if the patient being reminded has died? It’s a waste of resources, of course, but more than that, it can be painful for their families and reflects poorly on the health care system. Of all the people who should know whether someone is alive or dead, shouldn’t their doctor be at the top of the list?

A new study in JAMA Internal Medicine quantifies this very phenomenon.

Researchers examined 11,658 primary care patients in their health system who met the criteria of being “seriously ill” and followed them for 2 years. During that period of time, 25% were recorded as deceased in the electronic health record. But 30.8% had died. That left 676 patients who had died, but were not known to have died, left in the system.

Courtesy Dr. F. Perry Wilson

Courtesy Dr. F. Perry Wilson

Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Connecticut. He has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com .

Nonalcoholic fatty liver disease is a manifestation of the metabolic syndrome, and effective management requires weight reduction and mitigation of other risk factors, including glucose intolerance and hyperlipidemia. A lingering concern about potential hepatotoxicity has resulted in widespread reluctance to prescribe statins to treat hyperlipidemia in patients with liver disease; however, their safety in this setting has been documented in the literature as well as in clinical practice. Therefore, statins should not be withheld in patients with liver disease when indicated — with a few caveats. Baseline liver chemistries should be obtained. After initiation of statin therapy, a modest rise in serum aminotransferase levels may occur but is not an indication to discontinue the drug. In fact, monitoring of liver biochemical tests more frequently than is appropriate for any patient with chronic liver disease is unnecessary. The role of statins in cirrhosis may even expand, as recent reports suggest that statin use in patients with cirrhosis may slow the progression of liver disease and reduce the frequency of complications, such as hepatocellular carcinoma. These observations, however, require confirmation before statins can be suggested for any indication other than treating hyperlipidemia in patients with chronic liver disease, and statins are generally not appropriate in patients with decompensated cirrhosis.

(Mass General)

Pearls from the Pros was published in Gastro Hep Advances .

Dr. Friedman is the Anton R. Fried, MD, Chair of the Department of Medicine at Newton-Wellesley Hospital in Newton, Mass., and assistant chief of medicine at Massachusetts General Hospital, and a professor of medicine at Harvard Medical School and Tufts University, Boston. Dr. Martin is chief of the division of digestive health and liver diseases at the University of Miami, where he is the Mandel Chair of Gastroenterology. The authors disclose no conflicts.

Nonalcoholic fatty liver disease is a manifestation of the metabolic syndrome, and effective management requires weight reduction and mitigation of other risk factors, including glucose intolerance and hyperlipidemia. A lingering concern about potential hepatotoxicity has resulted in widespread reluctance to prescribe statins to treat hyperlipidemia in patients with liver disease; however, their safety in this setting has been documented in the literature as well as in clinical practice. Therefore, statins should not be withheld in patients with liver disease when indicated — with a few caveats. Baseline liver chemistries should be obtained. After initiation of statin therapy, a modest rise in serum aminotransferase levels may occur but is not an indication to discontinue the drug. In fact, monitoring of liver biochemical tests more frequently than is appropriate for any patient with chronic liver disease is unnecessary. The role of statins in cirrhosis may even expand, as recent reports suggest that statin use in patients with cirrhosis may slow the progression of liver disease and reduce the frequency of complications, such as hepatocellular carcinoma. These observations, however, require confirmation before statins can be suggested for any indication other than treating hyperlipidemia in patients with chronic liver disease, and statins are generally not appropriate in patients with decompensated cirrhosis.

(Mass General)

Pearls from the Pros was published in Gastro Hep Advances .

Dr. Friedman is the Anton R. Fried, MD, Chair of the Department of Medicine at Newton-Wellesley Hospital in Newton, Mass., and assistant chief of medicine at Massachusetts General Hospital, and a professor of medicine at Harvard Medical School and Tufts University, Boston. Dr. Martin is chief of the division of digestive health and liver diseases at the University of Miami, where he is the Mandel Chair of Gastroenterology. The authors disclose no conflicts.

Nonalcoholic fatty liver disease is a manifestation of the metabolic syndrome, and effective management requires weight reduction and mitigation of other risk factors, including glucose intolerance and hyperlipidemia. A lingering concern about potential hepatotoxicity has resulted in widespread reluctance to prescribe statins to treat hyperlipidemia in patients with liver disease; however, their safety in this setting has been documented in the literature as well as in clinical practice. Therefore, statins should not be withheld in patients with liver disease when indicated — with a few caveats. Baseline liver chemistries should be obtained. After initiation of statin therapy, a modest rise in serum aminotransferase levels may occur but is not an indication to discontinue the drug. In fact, monitoring of liver biochemical tests more frequently than is appropriate for any patient with chronic liver disease is unnecessary. The role of statins in cirrhosis may even expand, as recent reports suggest that statin use in patients with cirrhosis may slow the progression of liver disease and reduce the frequency of complications, such as hepatocellular carcinoma. These observations, however, require confirmation before statins can be suggested for any indication other than treating hyperlipidemia in patients with chronic liver disease, and statins are generally not appropriate in patients with decompensated cirrhosis.

(Mass General)

Pearls from the Pros was published in Gastro Hep Advances .

Dr. Friedman is the Anton R. Fried, MD, Chair of the Department of Medicine at Newton-Wellesley Hospital in Newton, Mass., and assistant chief of medicine at Massachusetts General Hospital, and a professor of medicine at Harvard Medical School and Tufts University, Boston. Dr. Martin is chief of the division of digestive health and liver diseases at the University of Miami, where he is the Mandel Chair of Gastroenterology. The authors disclose no conflicts.

Our psychiatric research, which found a high incidence of undiagnosed mental illness in mass shooters, was recently awarded the esteemed Psychodynamic Psychiatry Journal Prize for best paper published in the last 2 years (2022-2023). The editors noted our integrity in using quantitative data to argue against the common, careless assumption that mass shooters are not mentally ill.

Some of the mass shooters we studied were motivated by religious or political ideologies that were considered forms of terrorism. Given the current tragically violent landscape both at home and in Israel/Palestine, the “desire for destruction” is vital to understand.

Although there have been a limited number of psychiatric studies of perpetrators of mass shootings, our team took the first step to lay the groundwork by conducting a systematic, quantitative study. Our psychiatric research team’s research findings were published in the Journal of Clinical Psychopharmacology and then in greater detail in Psychodynamic Psychiatry,^1,2 which provided important context to the complicated backgrounds of these mass shooters who suffer from abuse, marginalization, and severe undiagnosed brain illness.³

Dr. Cerfolio

The Mother Jones database of 115 mass shootings from 1982 to 2019 was used to study retrospectively 55 shooters in the United States. We developed a uniform, comprehensive, 62-item questionnaire to compile the data collection from multiple sources and record our psychiatric assessments of the assailants, using DSM-5 criteria. After developing this detailed psychiatric assessment questionnaire, psychiatric researchers evaluated the weight and quality of clinical evidence by (1) interviewing forensic psychiatrists who had assessed the assailant following the crime, and/or (2) reviewing court records of psychiatric evaluations conducted during the postcrime judicial proceedings to determine the prevalence of psychiatric illness. Rather than accepting diagnoses from forensic psychiatrists and/or court records, our team independently reviewed the clinical data gathered from multiple sources to apply the DSM-5 criteria to diagnose mental illness.

In most incidents in the database, the perpetrator died either during or shortly after the crime. We examined every case (n=35) in which the assailant survived, and criminal proceedings were instituted.

Of the 35 cases in which the assailant survived and criminal proceedings were instituted, there was insufficient information to make a diagnosis in 3 cases. Of the remaining 32 cases in which we had sufficient information, we determined that 87.5% had the following psychiatric diagnosis: 18 assailants (56%) had schizophrenia, while 10 assailants (31%) had other psychiatric diagnoses: 3 had bipolar I disorder, 2 had delusional disorders (persecutory), 2 had personality disorders (1 paranoid, 1 borderline), 2 had substance-related disorders without other psychiatric diagnosis, and 1 had post-traumatic stress disorder (PTSD).

Out of the 32 surviving assailants for whom we have sufficient evidence, 87.5% of perpetrators of mass shootings were diagnosed with major psychiatric illness, and none were treated appropriately with medication at the time of the crime. Four assailants (12.5%) had no psychiatric diagnosis that we could discern. Of the 18 surviving assailants with schizophrenia, no assailant was on antipsychotic medication for the treatment of schizophrenia prior to the crime. Of the 10 surviving assailants with other psychiatric illnesses, no assailant was on antipsychotic and/or appropriate medication.

In addition, we found that the clinical misdiagnosis of early-onset schizophrenia was associated with the worsening of many of these assailants’ psychotic symptoms. Many of our adolescent shooters prior to the massacre had been misdiagnosed with attention-deficit disorder (ADD), major depression disorder (MDD), or autism spectrum disorder.

Though the vast majority of those suffering from psychiatric illnesses who are appropriately treated are not violent, there is a growing body of scientific research that indicates a strong association of untreated brain illness with those who commit mass shootings.^4,5,6 This research demonstrates that such untreated illness combined with access to firearms poses a lethal threat to society.

Stanford University

Most of the assailants also experienced profound estrangement, not only from families and friends, but most importantly from themselves. Being marginalized rendered them more vulnerable to their untreated psychiatric illness and to radicalization online, which fostered their violence. While there are complex reasons that a person is not diagnosed, there remains a vital need to decrease the stigma of mental illness to enable those with psychiatric illness to be more respected, less marginalized, and encouraged to receive effective psychiatric treatments.

Dr. Cerfolio is author of “Psychoanalytic and Spiritual Perspectives on Terrorism: Desire for Destruction.” She is clinical assistant professor at the Icahn School of Medicine at Mount Sinai, New York. Dr. Glick is Professor Emeritus, Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, Stanford, Calif.

References

1. Glick ID, et al. Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness. J Clin Psychopharmacol. 2021 Jul-Aug;41(4):366-369. doi: 10.1097/JCP.0000000000001417.

2. Cerfolio NE, et al. A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States. Psychodyn Psychiatry. 2022 Fall;50(3):1-16. doi: 10.1521/pdps.2022.50.5.001.

3. Cerfolio NE. The Parkland gunman, a horrific crime, and mental illness. The New York Times. 2022 Oct 14. www.nytimes.com/2022/10/14/opinion/letters/jan-6-panel-trump.html#link-5e2ccc1.

4. Corner E, et al. Mental Health Disorders and the Terrorist: A Research Note Probing Selection Effects and Disorder Prevalence. Stud Confl Terror. 2016 Jan;39(6):560–568. doi: 10.1080/1057610X.2015.1120099.

5. Gruenewald J, et al. Distinguishing “Loner” Attacks from Other Domestic Extremist Violence. Criminol Public Policy. 2013 Feb;12(1):65–91. doi: 10.1111/1745-9133.12008.

6. Lankford A. Detecting mental health problems and suicidal motives among terrorists and mass shooters. Crim Behav Ment Health. 2016 Dec;26(5):315-321. doi: 10.1002/cbm.2020.

Our psychiatric research, which found a high incidence of undiagnosed mental illness in mass shooters, was recently awarded the esteemed Psychodynamic Psychiatry Journal Prize for best paper published in the last 2 years (2022-2023). The editors noted our integrity in using quantitative data to argue against the common, careless assumption that mass shooters are not mentally ill.

Some of the mass shooters we studied were motivated by religious or political ideologies that were considered forms of terrorism. Given the current tragically violent landscape both at home and in Israel/Palestine, the “desire for destruction” is vital to understand.

Although there have been a limited number of psychiatric studies of perpetrators of mass shootings, our team took the first step to lay the groundwork by conducting a systematic, quantitative study. Our psychiatric research team’s research findings were published in the Journal of Clinical Psychopharmacology and then in greater detail in Psychodynamic Psychiatry,^1,2 which provided important context to the complicated backgrounds of these mass shooters who suffer from abuse, marginalization, and severe undiagnosed brain illness.³

Dr. Cerfolio

The Mother Jones database of 115 mass shootings from 1982 to 2019 was used to study retrospectively 55 shooters in the United States. We developed a uniform, comprehensive, 62-item questionnaire to compile the data collection from multiple sources and record our psychiatric assessments of the assailants, using DSM-5 criteria. After developing this detailed psychiatric assessment questionnaire, psychiatric researchers evaluated the weight and quality of clinical evidence by (1) interviewing forensic psychiatrists who had assessed the assailant following the crime, and/or (2) reviewing court records of psychiatric evaluations conducted during the postcrime judicial proceedings to determine the prevalence of psychiatric illness. Rather than accepting diagnoses from forensic psychiatrists and/or court records, our team independently reviewed the clinical data gathered from multiple sources to apply the DSM-5 criteria to diagnose mental illness.

In most incidents in the database, the perpetrator died either during or shortly after the crime. We examined every case (n=35) in which the assailant survived, and criminal proceedings were instituted.

Of the 35 cases in which the assailant survived and criminal proceedings were instituted, there was insufficient information to make a diagnosis in 3 cases. Of the remaining 32 cases in which we had sufficient information, we determined that 87.5% had the following psychiatric diagnosis: 18 assailants (56%) had schizophrenia, while 10 assailants (31%) had other psychiatric diagnoses: 3 had bipolar I disorder, 2 had delusional disorders (persecutory), 2 had personality disorders (1 paranoid, 1 borderline), 2 had substance-related disorders without other psychiatric diagnosis, and 1 had post-traumatic stress disorder (PTSD).

Out of the 32 surviving assailants for whom we have sufficient evidence, 87.5% of perpetrators of mass shootings were diagnosed with major psychiatric illness, and none were treated appropriately with medication at the time of the crime. Four assailants (12.5%) had no psychiatric diagnosis that we could discern. Of the 18 surviving assailants with schizophrenia, no assailant was on antipsychotic medication for the treatment of schizophrenia prior to the crime. Of the 10 surviving assailants with other psychiatric illnesses, no assailant was on antipsychotic and/or appropriate medication.

In addition, we found that the clinical misdiagnosis of early-onset schizophrenia was associated with the worsening of many of these assailants’ psychotic symptoms. Many of our adolescent shooters prior to the massacre had been misdiagnosed with attention-deficit disorder (ADD), major depression disorder (MDD), or autism spectrum disorder.

Though the vast majority of those suffering from psychiatric illnesses who are appropriately treated are not violent, there is a growing body of scientific research that indicates a strong association of untreated brain illness with those who commit mass shootings.^4,5,6 This research demonstrates that such untreated illness combined with access to firearms poses a lethal threat to society.

Stanford University

Most of the assailants also experienced profound estrangement, not only from families and friends, but most importantly from themselves. Being marginalized rendered them more vulnerable to their untreated psychiatric illness and to radicalization online, which fostered their violence. While there are complex reasons that a person is not diagnosed, there remains a vital need to decrease the stigma of mental illness to enable those with psychiatric illness to be more respected, less marginalized, and encouraged to receive effective psychiatric treatments.

Dr. Cerfolio is author of “Psychoanalytic and Spiritual Perspectives on Terrorism: Desire for Destruction.” She is clinical assistant professor at the Icahn School of Medicine at Mount Sinai, New York. Dr. Glick is Professor Emeritus, Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, Stanford, Calif.

References

1. Glick ID, et al. Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness. J Clin Psychopharmacol. 2021 Jul-Aug;41(4):366-369. doi: 10.1097/JCP.0000000000001417.

2. Cerfolio NE, et al. A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States. Psychodyn Psychiatry. 2022 Fall;50(3):1-16. doi: 10.1521/pdps.2022.50.5.001.

3. Cerfolio NE. The Parkland gunman, a horrific crime, and mental illness. The New York Times. 2022 Oct 14. www.nytimes.com/2022/10/14/opinion/letters/jan-6-panel-trump.html#link-5e2ccc1.

4. Corner E, et al. Mental Health Disorders and the Terrorist: A Research Note Probing Selection Effects and Disorder Prevalence. Stud Confl Terror. 2016 Jan;39(6):560–568. doi: 10.1080/1057610X.2015.1120099.

5. Gruenewald J, et al. Distinguishing “Loner” Attacks from Other Domestic Extremist Violence. Criminol Public Policy. 2013 Feb;12(1):65–91. doi: 10.1111/1745-9133.12008.

6. Lankford A. Detecting mental health problems and suicidal motives among terrorists and mass shooters. Crim Behav Ment Health. 2016 Dec;26(5):315-321. doi: 10.1002/cbm.2020.

Our psychiatric research, which found a high incidence of undiagnosed mental illness in mass shooters, was recently awarded the esteemed Psychodynamic Psychiatry Journal Prize for best paper published in the last 2 years (2022-2023). The editors noted our integrity in using quantitative data to argue against the common, careless assumption that mass shooters are not mentally ill.

Some of the mass shooters we studied were motivated by religious or political ideologies that were considered forms of terrorism. Given the current tragically violent landscape both at home and in Israel/Palestine, the “desire for destruction” is vital to understand.

Although there have been a limited number of psychiatric studies of perpetrators of mass shootings, our team took the first step to lay the groundwork by conducting a systematic, quantitative study. Our psychiatric research team’s research findings were published in the Journal of Clinical Psychopharmacology and then in greater detail in Psychodynamic Psychiatry,^1,2 which provided important context to the complicated backgrounds of these mass shooters who suffer from abuse, marginalization, and severe undiagnosed brain illness.³

Dr. Cerfolio

The Mother Jones database of 115 mass shootings from 1982 to 2019 was used to study retrospectively 55 shooters in the United States. We developed a uniform, comprehensive, 62-item questionnaire to compile the data collection from multiple sources and record our psychiatric assessments of the assailants, using DSM-5 criteria. After developing this detailed psychiatric assessment questionnaire, psychiatric researchers evaluated the weight and quality of clinical evidence by (1) interviewing forensic psychiatrists who had assessed the assailant following the crime, and/or (2) reviewing court records of psychiatric evaluations conducted during the postcrime judicial proceedings to determine the prevalence of psychiatric illness. Rather than accepting diagnoses from forensic psychiatrists and/or court records, our team independently reviewed the clinical data gathered from multiple sources to apply the DSM-5 criteria to diagnose mental illness.

In most incidents in the database, the perpetrator died either during or shortly after the crime. We examined every case (n=35) in which the assailant survived, and criminal proceedings were instituted.

Of the 35 cases in which the assailant survived and criminal proceedings were instituted, there was insufficient information to make a diagnosis in 3 cases. Of the remaining 32 cases in which we had sufficient information, we determined that 87.5% had the following psychiatric diagnosis: 18 assailants (56%) had schizophrenia, while 10 assailants (31%) had other psychiatric diagnoses: 3 had bipolar I disorder, 2 had delusional disorders (persecutory), 2 had personality disorders (1 paranoid, 1 borderline), 2 had substance-related disorders without other psychiatric diagnosis, and 1 had post-traumatic stress disorder (PTSD).

Out of the 32 surviving assailants for whom we have sufficient evidence, 87.5% of perpetrators of mass shootings were diagnosed with major psychiatric illness, and none were treated appropriately with medication at the time of the crime. Four assailants (12.5%) had no psychiatric diagnosis that we could discern. Of the 18 surviving assailants with schizophrenia, no assailant was on antipsychotic medication for the treatment of schizophrenia prior to the crime. Of the 10 surviving assailants with other psychiatric illnesses, no assailant was on antipsychotic and/or appropriate medication.

In addition, we found that the clinical misdiagnosis of early-onset schizophrenia was associated with the worsening of many of these assailants’ psychotic symptoms. Many of our adolescent shooters prior to the massacre had been misdiagnosed with attention-deficit disorder (ADD), major depression disorder (MDD), or autism spectrum disorder.

Though the vast majority of those suffering from psychiatric illnesses who are appropriately treated are not violent, there is a growing body of scientific research that indicates a strong association of untreated brain illness with those who commit mass shootings.^4,5,6 This research demonstrates that such untreated illness combined with access to firearms poses a lethal threat to society.

Stanford University

Most of the assailants also experienced profound estrangement, not only from families and friends, but most importantly from themselves. Being marginalized rendered them more vulnerable to their untreated psychiatric illness and to radicalization online, which fostered their violence. While there are complex reasons that a person is not diagnosed, there remains a vital need to decrease the stigma of mental illness to enable those with psychiatric illness to be more respected, less marginalized, and encouraged to receive effective psychiatric treatments.

Dr. Cerfolio is author of “Psychoanalytic and Spiritual Perspectives on Terrorism: Desire for Destruction.” She is clinical assistant professor at the Icahn School of Medicine at Mount Sinai, New York. Dr. Glick is Professor Emeritus, Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, Stanford, Calif.

References

1. Glick ID, et al. Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness. J Clin Psychopharmacol. 2021 Jul-Aug;41(4):366-369. doi: 10.1097/JCP.0000000000001417.

2. Cerfolio NE, et al. A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States. Psychodyn Psychiatry. 2022 Fall;50(3):1-16. doi: 10.1521/pdps.2022.50.5.001.

3. Cerfolio NE. The Parkland gunman, a horrific crime, and mental illness. The New York Times. 2022 Oct 14. www.nytimes.com/2022/10/14/opinion/letters/jan-6-panel-trump.html#link-5e2ccc1.

4. Corner E, et al. Mental Health Disorders and the Terrorist: A Research Note Probing Selection Effects and Disorder Prevalence. Stud Confl Terror. 2016 Jan;39(6):560–568. doi: 10.1080/1057610X.2015.1120099.

5. Gruenewald J, et al. Distinguishing “Loner” Attacks from Other Domestic Extremist Violence. Criminol Public Policy. 2013 Feb;12(1):65–91. doi: 10.1111/1745-9133.12008.

6. Lankford A. Detecting mental health problems and suicidal motives among terrorists and mass shooters. Crim Behav Ment Health. 2016 Dec;26(5):315-321. doi: 10.1002/cbm.2020.

The 2024 updates to the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rules represent a mixed bag for gastroenterologists.

Medicare Physician Fee Schedule (MPFS) Final Rule

Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.

New add-on code for complex care: CMS is finalizing complexity add-on code, G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.

CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”

While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.

CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:

• Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
• Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
• Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
• Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
• Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.

Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule

Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.

Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.

Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.

• 43252 (EGD, flexible transoral with optical microscopy)
• 43263 (ERCP with pressure measurement, sphincter of Oddi)
• 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)

GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.

• CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
• CPT 43252 (EGD, flexible transoral with optical microscopy)

For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.

The Coverage and Reimbursement Subcommittee members have no conflicts of interest.

The 2024 updates to the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rules represent a mixed bag for gastroenterologists.

Medicare Physician Fee Schedule (MPFS) Final Rule

Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.

New add-on code for complex care: CMS is finalizing complexity add-on code, G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.

CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”

While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.

CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:

• Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
• Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
• Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
• Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
• Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.

Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule

Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.

Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.

Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.

• 43252 (EGD, flexible transoral with optical microscopy)
• 43263 (ERCP with pressure measurement, sphincter of Oddi)
• 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)

GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.

• CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
• CPT 43252 (EGD, flexible transoral with optical microscopy)

For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.

The Coverage and Reimbursement Subcommittee members have no conflicts of interest.

The 2024 updates to the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rules represent a mixed bag for gastroenterologists.

Medicare Physician Fee Schedule (MPFS) Final Rule

Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.

New add-on code for complex care: CMS is finalizing complexity add-on code, G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.

CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”

While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.

CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:

• Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
• Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
• Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
• Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
• Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.

Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule

Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.

Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.

Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.

• 43252 (EGD, flexible transoral with optical microscopy)
• 43263 (ERCP with pressure measurement, sphincter of Oddi)
• 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)

GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.

• CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
• CPT 43252 (EGD, flexible transoral with optical microscopy)

For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.

The Coverage and Reimbursement Subcommittee members have no conflicts of interest.

A recent article hypothesized that fructose causes more metabolic disease than does sucrose when overfed in the human diet. Fructose intake as high-fructose corn syrup (HFCS) has risen since its use in soft drinks in the United States and parallels the increase in the prevalence of obesity.

The newest hypothesis regarding fructose invokes a genetic survival of the fittest rationale for how fructose-enhanced fat deposition exacerbates the increased caloric consumption from the Western diet to promote metabolic disease especially in our adolescent and young adult population. This theory suggests that fructose consumption causes low adenosine triphosphate, which stimulates energy intake causing an imbalance of energy regulation.

Ongoing interest in the association between the increased use of HFCS and the prevalence of obesity in the United States continues. The use of HFCS in sugary sweetened beverages (SSBs) has reduced the cost of these beverages because of technology in preparing HFCS from corn and the substitution of the cheaper HFCS for sugar in SSBs. Although SSBs haven’t been proven to cause obesity, there has been an increase in the risk for type 2 diabetes, cardiovascular disease (CVD), nonalcoholic fatty liver disease (NAFLD), and even cancer. Research in HFCS, weight gain, and metabolic disease continues despite little definitive evidence of causation.

The relationship between SSBs consumption and obesity has been attributed to the increase in overall total caloric intake of the diet. These liquid calories do not suppress the intake of other foods to equalize the total amount of calories ingested. This knowledge has been gleaned from work performed by R. Mattes and B. Rolls in the 1990s through the early 2000s.

This research and the current work on HFCS and metabolic disease is important because there are adolescents and young adults in the United States and globally that ingest a large amount of SSBs and therefore are at risk for metabolic disease, type 2 diabetes, NAFLD, and CVD at an early age.

The concern over fructose stems from the association between the advent of increasing HFCS in SSBs and the increase in prevalence of obesity occurring at similar time periods in the United States, around 1970-1980.

Researchers noted the association and began to focus on potential reasons to pinpoint HFCS or fructose itself so we have a mechanism of action specific to fructose. Therefore, the public could be warned about the risk of drinking SSBs due to the HFCS and fructose ingested and the possibility of metabolic disease. Perhaps, there is a method to remove harmful HFCS from the food supply much like what has happened with industrially produced trans fatty acids. In 2018, the World Health Organization called for a total ban on trans fats due to causation of 500 million early deaths per year globally.

Similar to the process of making HFCS, most trans fats are formed through an industrial process that alters vegetable oil and creates a shelf stable inexpensive partially hydrogenated oil. Trans fats have been shown to increase low-density lipoprotein (LDL) cholesterol and decrease high-density lipoprotein (HDL) increasing the risk for myocardial infarction and stroke.

The prevalence of obesity has increased worldwide, even in countries where SSBs do not contain HFCS.

Still, the proof that HFCS can override the satiety pathway and cause excess calorie intake is intriguing and may have teeth if we can pinpoint the increase in prevalence of obesity in children and adolescents on increased ingestion of HFCS in SSBs. There is no reason nutritionally to add sugar or HFCS to liquids. Plus, if HFCS has a metabolic disadvantage then all the more reason to ban it. Then, it becomes like trans fats: a toxin in the food supply.


Dr. Apovian is a Faculty Member, Department of Medicine; Co-Director, Center for Weight Management and Wellness, Section of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. She has disclosed financial relationships with Altimmune, Inc; Cowen and Company, LLC; Currax Pharmaceuticals, LLC; EPG Communication Holdings, Ltd; Gelesis, Srl; L-Nutra, Inc; NeuroBo Pharmaceuticals; and Novo Nordisk, Inc. She has received research grants from the National Institutes of Health; Patient-Centered Outcomes Research Institute; GI Dynamics, Inc.

A version of this article appeared on Medscape.com.

A recent article hypothesized that fructose causes more metabolic disease than does sucrose when overfed in the human diet. Fructose intake as high-fructose corn syrup (HFCS) has risen since its use in soft drinks in the United States and parallels the increase in the prevalence of obesity.

The newest hypothesis regarding fructose invokes a genetic survival of the fittest rationale for how fructose-enhanced fat deposition exacerbates the increased caloric consumption from the Western diet to promote metabolic disease especially in our adolescent and young adult population. This theory suggests that fructose consumption causes low adenosine triphosphate, which stimulates energy intake causing an imbalance of energy regulation.

Ongoing interest in the association between the increased use of HFCS and the prevalence of obesity in the United States continues. The use of HFCS in sugary sweetened beverages (SSBs) has reduced the cost of these beverages because of technology in preparing HFCS from corn and the substitution of the cheaper HFCS for sugar in SSBs. Although SSBs haven’t been proven to cause obesity, there has been an increase in the risk for type 2 diabetes, cardiovascular disease (CVD), nonalcoholic fatty liver disease (NAFLD), and even cancer. Research in HFCS, weight gain, and metabolic disease continues despite little definitive evidence of causation.

The relationship between SSBs consumption and obesity has been attributed to the increase in overall total caloric intake of the diet. These liquid calories do not suppress the intake of other foods to equalize the total amount of calories ingested. This knowledge has been gleaned from work performed by R. Mattes and B. Rolls in the 1990s through the early 2000s.

This research and the current work on HFCS and metabolic disease is important because there are adolescents and young adults in the United States and globally that ingest a large amount of SSBs and therefore are at risk for metabolic disease, type 2 diabetes, NAFLD, and CVD at an early age.

The concern over fructose stems from the association between the advent of increasing HFCS in SSBs and the increase in prevalence of obesity occurring at similar time periods in the United States, around 1970-1980.

Researchers noted the association and began to focus on potential reasons to pinpoint HFCS or fructose itself so we have a mechanism of action specific to fructose. Therefore, the public could be warned about the risk of drinking SSBs due to the HFCS and fructose ingested and the possibility of metabolic disease. Perhaps, there is a method to remove harmful HFCS from the food supply much like what has happened with industrially produced trans fatty acids. In 2018, the World Health Organization called for a total ban on trans fats due to causation of 500 million early deaths per year globally.

Similar to the process of making HFCS, most trans fats are formed through an industrial process that alters vegetable oil and creates a shelf stable inexpensive partially hydrogenated oil. Trans fats have been shown to increase low-density lipoprotein (LDL) cholesterol and decrease high-density lipoprotein (HDL) increasing the risk for myocardial infarction and stroke.

The prevalence of obesity has increased worldwide, even in countries where SSBs do not contain HFCS.

Still, the proof that HFCS can override the satiety pathway and cause excess calorie intake is intriguing and may have teeth if we can pinpoint the increase in prevalence of obesity in children and adolescents on increased ingestion of HFCS in SSBs. There is no reason nutritionally to add sugar or HFCS to liquids. Plus, if HFCS has a metabolic disadvantage then all the more reason to ban it. Then, it becomes like trans fats: a toxin in the food supply.


Dr. Apovian is a Faculty Member, Department of Medicine; Co-Director, Center for Weight Management and Wellness, Section of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. She has disclosed financial relationships with Altimmune, Inc; Cowen and Company, LLC; Currax Pharmaceuticals, LLC; EPG Communication Holdings, Ltd; Gelesis, Srl; L-Nutra, Inc; NeuroBo Pharmaceuticals; and Novo Nordisk, Inc. She has received research grants from the National Institutes of Health; Patient-Centered Outcomes Research Institute; GI Dynamics, Inc.

A version of this article appeared on Medscape.com.

A recent article hypothesized that fructose causes more metabolic disease than does sucrose when overfed in the human diet. Fructose intake as high-fructose corn syrup (HFCS) has risen since its use in soft drinks in the United States and parallels the increase in the prevalence of obesity.

The newest hypothesis regarding fructose invokes a genetic survival of the fittest rationale for how fructose-enhanced fat deposition exacerbates the increased caloric consumption from the Western diet to promote metabolic disease especially in our adolescent and young adult population. This theory suggests that fructose consumption causes low adenosine triphosphate, which stimulates energy intake causing an imbalance of energy regulation.

Ongoing interest in the association between the increased use of HFCS and the prevalence of obesity in the United States continues. The use of HFCS in sugary sweetened beverages (SSBs) has reduced the cost of these beverages because of technology in preparing HFCS from corn and the substitution of the cheaper HFCS for sugar in SSBs. Although SSBs haven’t been proven to cause obesity, there has been an increase in the risk for type 2 diabetes, cardiovascular disease (CVD), nonalcoholic fatty liver disease (NAFLD), and even cancer. Research in HFCS, weight gain, and metabolic disease continues despite little definitive evidence of causation.

The relationship between SSBs consumption and obesity has been attributed to the increase in overall total caloric intake of the diet. These liquid calories do not suppress the intake of other foods to equalize the total amount of calories ingested. This knowledge has been gleaned from work performed by R. Mattes and B. Rolls in the 1990s through the early 2000s.

This research and the current work on HFCS and metabolic disease is important because there are adolescents and young adults in the United States and globally that ingest a large amount of SSBs and therefore are at risk for metabolic disease, type 2 diabetes, NAFLD, and CVD at an early age.

The concern over fructose stems from the association between the advent of increasing HFCS in SSBs and the increase in prevalence of obesity occurring at similar time periods in the United States, around 1970-1980.

Researchers noted the association and began to focus on potential reasons to pinpoint HFCS or fructose itself so we have a mechanism of action specific to fructose. Therefore, the public could be warned about the risk of drinking SSBs due to the HFCS and fructose ingested and the possibility of metabolic disease. Perhaps, there is a method to remove harmful HFCS from the food supply much like what has happened with industrially produced trans fatty acids. In 2018, the World Health Organization called for a total ban on trans fats due to causation of 500 million early deaths per year globally.

Similar to the process of making HFCS, most trans fats are formed through an industrial process that alters vegetable oil and creates a shelf stable inexpensive partially hydrogenated oil. Trans fats have been shown to increase low-density lipoprotein (LDL) cholesterol and decrease high-density lipoprotein (HDL) increasing the risk for myocardial infarction and stroke.

The prevalence of obesity has increased worldwide, even in countries where SSBs do not contain HFCS.

Still, the proof that HFCS can override the satiety pathway and cause excess calorie intake is intriguing and may have teeth if we can pinpoint the increase in prevalence of obesity in children and adolescents on increased ingestion of HFCS in SSBs. There is no reason nutritionally to add sugar or HFCS to liquids. Plus, if HFCS has a metabolic disadvantage then all the more reason to ban it. Then, it becomes like trans fats: a toxin in the food supply.


Dr. Apovian is a Faculty Member, Department of Medicine; Co-Director, Center for Weight Management and Wellness, Section of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. She has disclosed financial relationships with Altimmune, Inc; Cowen and Company, LLC; Currax Pharmaceuticals, LLC; EPG Communication Holdings, Ltd; Gelesis, Srl; L-Nutra, Inc; NeuroBo Pharmaceuticals; and Novo Nordisk, Inc. She has received research grants from the National Institutes of Health; Patient-Centered Outcomes Research Institute; GI Dynamics, Inc.

A version of this article appeared on Medscape.com.

When we launched GIHN’s monthly Member Spotlight column in January of this year, our vision was to provide a platform to recognize AGA members’ unique accomplishments across all career stages and practice settings, highlight the diversity of our membership, and build a sense of community by learning more about one another.

As physicians, we are fortunate to have the opportunity to meaningfully impact the lives of our patients through the practice of clinical medicine, or by spearheading groundbreaking research that improves patient outcomes. However, some physicians arguably make their greatest mark outside of medicine.

To close out the inaugural year of our Member Spotlight feature, we introduce you to gastroenterologist Eric Esrailian, MD, MPH, chair of the division of gastroenterology at UCLA. He is an Emmy-nominated film producer and distinguished human rights advocate. His story is inspirational, and poignantly highlights how one’s impact as a physician can extend far beyond the walls of the hospital. We hope to continue to feature exceptional individuals like Dr. Esrailian who leverage their unique talents for societal good. We appreciate your continued nominations as we plan our 2024 coverage.

Also in the December issue, we summarize the results of a pivotal, head-to-head trial of risankizumab (Skyrizi) and ustekinumab (Stelara) for Crohn’s disease, which was presented in October at United European Gastroenterology (UEG) Week in Copenhagen.

We also highlight the FDA’s recent approval of vonoprazan, a new pharmacologic treatment for erosive esophagitis expected to be available in the U.S. sometime this month. Finally, Dr. Lauren Feld explains how gastroenterologists can advocate for more robust parental leave and return to work policies at their institutions and why it matters.

We wish you all a wonderful holiday season and look forward to seeing you again in the New Year.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

When we launched GIHN’s monthly Member Spotlight column in January of this year, our vision was to provide a platform to recognize AGA members’ unique accomplishments across all career stages and practice settings, highlight the diversity of our membership, and build a sense of community by learning more about one another.

As physicians, we are fortunate to have the opportunity to meaningfully impact the lives of our patients through the practice of clinical medicine, or by spearheading groundbreaking research that improves patient outcomes. However, some physicians arguably make their greatest mark outside of medicine.

To close out the inaugural year of our Member Spotlight feature, we introduce you to gastroenterologist Eric Esrailian, MD, MPH, chair of the division of gastroenterology at UCLA. He is an Emmy-nominated film producer and distinguished human rights advocate. His story is inspirational, and poignantly highlights how one’s impact as a physician can extend far beyond the walls of the hospital. We hope to continue to feature exceptional individuals like Dr. Esrailian who leverage their unique talents for societal good. We appreciate your continued nominations as we plan our 2024 coverage.

Also in the December issue, we summarize the results of a pivotal, head-to-head trial of risankizumab (Skyrizi) and ustekinumab (Stelara) for Crohn’s disease, which was presented in October at United European Gastroenterology (UEG) Week in Copenhagen.

We also highlight the FDA’s recent approval of vonoprazan, a new pharmacologic treatment for erosive esophagitis expected to be available in the U.S. sometime this month. Finally, Dr. Lauren Feld explains how gastroenterologists can advocate for more robust parental leave and return to work policies at their institutions and why it matters.

We wish you all a wonderful holiday season and look forward to seeing you again in the New Year.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

When we launched GIHN’s monthly Member Spotlight column in January of this year, our vision was to provide a platform to recognize AGA members’ unique accomplishments across all career stages and practice settings, highlight the diversity of our membership, and build a sense of community by learning more about one another.

As physicians, we are fortunate to have the opportunity to meaningfully impact the lives of our patients through the practice of clinical medicine, or by spearheading groundbreaking research that improves patient outcomes. However, some physicians arguably make their greatest mark outside of medicine.

To close out the inaugural year of our Member Spotlight feature, we introduce you to gastroenterologist Eric Esrailian, MD, MPH, chair of the division of gastroenterology at UCLA. He is an Emmy-nominated film producer and distinguished human rights advocate. His story is inspirational, and poignantly highlights how one’s impact as a physician can extend far beyond the walls of the hospital. We hope to continue to feature exceptional individuals like Dr. Esrailian who leverage their unique talents for societal good. We appreciate your continued nominations as we plan our 2024 coverage.

Also in the December issue, we summarize the results of a pivotal, head-to-head trial of risankizumab (Skyrizi) and ustekinumab (Stelara) for Crohn’s disease, which was presented in October at United European Gastroenterology (UEG) Week in Copenhagen.

We also highlight the FDA’s recent approval of vonoprazan, a new pharmacologic treatment for erosive esophagitis expected to be available in the U.S. sometime this month. Finally, Dr. Lauren Feld explains how gastroenterologists can advocate for more robust parental leave and return to work policies at their institutions and why it matters.

We wish you all a wonderful holiday season and look forward to seeing you again in the New Year.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

I’m a general neurologist. I consider myself a jack of all (or at least most) trades in my field, and a master of none.

In the April 2023 issue of JAMA Neurology there was an editorial about neurology training, with general neurology being renamed “comprehensive neurology” and a fellowship offered in practicing general neurology.

This seems rather silly to me. If 4 years of residency (1 of internship and 3 of neurology) don’t prepare you to practice general neurology, then what’s the point of residency at all? For that matter, what difference will renaming it do?

Imagine completing a 3-year internal medicine residency, then being told you need to do a fellowship in “comprehensive medicine” in order to practice. Or at least so you can add the word “comprehensive” to your shingle.

The authors bemoan the increasing number of neurology residents wanting to do fellowships and subspecialize, a situation that mirrors the general trend of people away from general medicine toward specialties.

While I agree we do need subspecialists in neurology (and currently there are at least 31 recognized, which is way more than I would have guessed), the fact is that patients, and sometimes their internists, aren’t going to be the best judge of who does or doesn’t need to see one, compared with a general neurologist.

Most of us general people can handle straightforward Parkinson’s disease, epilepsy, migraines, etc. Certainly, there are times where the condition is refractory to our care, or there’s something unusual about the case, that leads us to refer them to someone with more expertise. But isn’t that how it’s supposed to work? Like medicine in general, we need more general people than subspecialists.

Honestly, I can’t claim to be any different. Twenty-six years ago, when I finished residency, I did a clinical neurophysiology fellowship. From a practical view it was an epilepsy fellowship at my program. Some of this was an interest at the time in subspecializing, some of it was me putting off joining the “real world” of having to find a job for a year.

When I hung up my own shingle, my business card listed a subspecialty in epilepsy. Looking back years later, this wasn’t the best move. In solo practice I had no access to an epilepsy monitoring unit, vagus nerve stimulation capabilities, or epilepsy surgery at the hospital I rounded at. Not only that, I discovered it put me at a disadvantage, as internists were referring only epilepsy patients to me, and all the other stuff (which is the majority of patients) to the general (or comprehensive) neurologists around me. Which, financially, wasn’t a good thing when you’re young and starting out.

Not only that, but I discovered that I didn’t like only seeing one thing. I found it boring, and not for me.

So after a year or so, I took the word “epilepsy” off my card, left it at “general neurology,” and sent out letters reminding my referral base that I was willing to see the majority of things in my field (rare diseases, even today, I won’t attempt to handle).

So now my days are a mix of things, which I like. Neurology is enough of a specialty for me without going further up the pyramid. Having sub (and even sub-sub) specialists is important to maintain medical excellence, but we still need people willing to do general neurology, and I’m happy there.

Changing my title to “comprehensive” is unnecessary. I’m happy with what I am.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m a general neurologist. I consider myself a jack of all (or at least most) trades in my field, and a master of none.

In the April 2023 issue of JAMA Neurology there was an editorial about neurology training, with general neurology being renamed “comprehensive neurology” and a fellowship offered in practicing general neurology.

This seems rather silly to me. If 4 years of residency (1 of internship and 3 of neurology) don’t prepare you to practice general neurology, then what’s the point of residency at all? For that matter, what difference will renaming it do?

Imagine completing a 3-year internal medicine residency, then being told you need to do a fellowship in “comprehensive medicine” in order to practice. Or at least so you can add the word “comprehensive” to your shingle.

The authors bemoan the increasing number of neurology residents wanting to do fellowships and subspecialize, a situation that mirrors the general trend of people away from general medicine toward specialties.

While I agree we do need subspecialists in neurology (and currently there are at least 31 recognized, which is way more than I would have guessed), the fact is that patients, and sometimes their internists, aren’t going to be the best judge of who does or doesn’t need to see one, compared with a general neurologist.

Most of us general people can handle straightforward Parkinson’s disease, epilepsy, migraines, etc. Certainly, there are times where the condition is refractory to our care, or there’s something unusual about the case, that leads us to refer them to someone with more expertise. But isn’t that how it’s supposed to work? Like medicine in general, we need more general people than subspecialists.

Honestly, I can’t claim to be any different. Twenty-six years ago, when I finished residency, I did a clinical neurophysiology fellowship. From a practical view it was an epilepsy fellowship at my program. Some of this was an interest at the time in subspecializing, some of it was me putting off joining the “real world” of having to find a job for a year.

When I hung up my own shingle, my business card listed a subspecialty in epilepsy. Looking back years later, this wasn’t the best move. In solo practice I had no access to an epilepsy monitoring unit, vagus nerve stimulation capabilities, or epilepsy surgery at the hospital I rounded at. Not only that, I discovered it put me at a disadvantage, as internists were referring only epilepsy patients to me, and all the other stuff (which is the majority of patients) to the general (or comprehensive) neurologists around me. Which, financially, wasn’t a good thing when you’re young and starting out.

Not only that, but I discovered that I didn’t like only seeing one thing. I found it boring, and not for me.

So after a year or so, I took the word “epilepsy” off my card, left it at “general neurology,” and sent out letters reminding my referral base that I was willing to see the majority of things in my field (rare diseases, even today, I won’t attempt to handle).

So now my days are a mix of things, which I like. Neurology is enough of a specialty for me without going further up the pyramid. Having sub (and even sub-sub) specialists is important to maintain medical excellence, but we still need people willing to do general neurology, and I’m happy there.

Changing my title to “comprehensive” is unnecessary. I’m happy with what I am.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m a general neurologist. I consider myself a jack of all (or at least most) trades in my field, and a master of none.

In the April 2023 issue of JAMA Neurology there was an editorial about neurology training, with general neurology being renamed “comprehensive neurology” and a fellowship offered in practicing general neurology.

This seems rather silly to me. If 4 years of residency (1 of internship and 3 of neurology) don’t prepare you to practice general neurology, then what’s the point of residency at all? For that matter, what difference will renaming it do?

Imagine completing a 3-year internal medicine residency, then being told you need to do a fellowship in “comprehensive medicine” in order to practice. Or at least so you can add the word “comprehensive” to your shingle.

The authors bemoan the increasing number of neurology residents wanting to do fellowships and subspecialize, a situation that mirrors the general trend of people away from general medicine toward specialties.

While I agree we do need subspecialists in neurology (and currently there are at least 31 recognized, which is way more than I would have guessed), the fact is that patients, and sometimes their internists, aren’t going to be the best judge of who does or doesn’t need to see one, compared with a general neurologist.

Most of us general people can handle straightforward Parkinson’s disease, epilepsy, migraines, etc. Certainly, there are times where the condition is refractory to our care, or there’s something unusual about the case, that leads us to refer them to someone with more expertise. But isn’t that how it’s supposed to work? Like medicine in general, we need more general people than subspecialists.

Honestly, I can’t claim to be any different. Twenty-six years ago, when I finished residency, I did a clinical neurophysiology fellowship. From a practical view it was an epilepsy fellowship at my program. Some of this was an interest at the time in subspecializing, some of it was me putting off joining the “real world” of having to find a job for a year.

When I hung up my own shingle, my business card listed a subspecialty in epilepsy. Looking back years later, this wasn’t the best move. In solo practice I had no access to an epilepsy monitoring unit, vagus nerve stimulation capabilities, or epilepsy surgery at the hospital I rounded at. Not only that, I discovered it put me at a disadvantage, as internists were referring only epilepsy patients to me, and all the other stuff (which is the majority of patients) to the general (or comprehensive) neurologists around me. Which, financially, wasn’t a good thing when you’re young and starting out.

Not only that, but I discovered that I didn’t like only seeing one thing. I found it boring, and not for me.

So after a year or so, I took the word “epilepsy” off my card, left it at “general neurology,” and sent out letters reminding my referral base that I was willing to see the majority of things in my field (rare diseases, even today, I won’t attempt to handle).

So now my days are a mix of things, which I like. Neurology is enough of a specialty for me without going further up the pyramid. Having sub (and even sub-sub) specialists is important to maintain medical excellence, but we still need people willing to do general neurology, and I’m happy there.

Changing my title to “comprehensive” is unnecessary. I’m happy with what I am.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A few weeks ago I shared by concerns about the dwindling numbers of primary care physicians. The early exodus of practicing providers and an obvious disinterest by future physicians in what they see as the unpalatable work/life balance of frontline hands-on medicine are among the causes.

A recent study published in the journal Pediatrics highlights personal finance as a contributor to the drain on the primary care workforce. The investigators found “high self-reported educational debt ($200,000 to < $300,000) was positively associated with training in a positive lifetime earnings potential subspecialty.” In other words, why would a physician who was burdened with student loans enter a subspecialty that would limit his or her ability to pay it off? I suspect that money has always been a factor in career selection, but the ballooning cost of college and medical school has certainly not nudged graduates toward the low lifetime earnings potential of primary care pediatrics.

Another recently released survey adds the perspective of current medical school students to the murky future of the primary health care workforce. The Clinician of the Future 2023: Education Edition, published by Elsevier Health, reports on insights of more than 2,000 nursing and medical school student from around the world. The headline shocker was that while across the board a not surprising 12% of medical students were considering quitting their studies, in the United States this number was 25%.

Overall, more than 60% of the students worried about their future income, how workforce shortages would effect them and whether they would join the ranks of those clinicians suffering from burnout. While the students surveyed acknowledged that artificial intelligence could have some negative repercussions, 62% were excited about its use in their education. Similarly, they anticipated the positive contribution of digital technology while acknowledging its potential downsides.

Given the current mental health climate in this country, I was not surprised that almost a quarter of medical students in this country are considering quitting school. I would like to see a larger sample surveyed and repeated over time. But, the discrepancy between the United States and the rest of the world is troubling.

The number that really jumped out at me was that 54% of medical students (nurses, 62%) viewed “ their current studies as a stepping-stone toward a broader career in health care.” As an example, the authors quoted one medical student who plans to “look for other possibilities where I don’t directly treat patients.”

Whether this disinterest in direct patient care is an attitude that preceded their entry into medical school or a change reflecting a major reversal induced by the realty of face-to-face patient encounters in school was not addressed in the survey. I think the general population would be surprised and maybe disappointed to learn that half the students in medical school weren’t planning on seeing patients.

I went off to medical school with a rather naive Norman Rockwellian view of a physician. I was a little surprised that a few of my classmates seemed to be gravitating toward administrative and research careers, but by far most of us were heading toward opportunities that would place us face to face with patients. Some would become specialists but primary care still had an appeal for many of us.

In my last letter about primary care training, I suggested that traditional medical school was probably a poor investment for the person who shares a bit of my old-school image of the primary care physician. In addition to cost and the time invested, the curriculum would likely be overly broad and deep and not terribly applicable to the patient mix he or she would eventually be seeing. This global survey may suggest that medical students have already discovered, or are just now discovering, this mismatch between medical school and the realities of primary care.

Our challenge is to first deal with deterrent of student debt and then to develop a new, affordable and efficient pathway to primary care that attracts those people who are looking for a face to face style of medicine on the front line. The patients know we need specialists and administrators but they also want a bit more of Norman Rockwell.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

A few weeks ago I shared by concerns about the dwindling numbers of primary care physicians. The early exodus of practicing providers and an obvious disinterest by future physicians in what they see as the unpalatable work/life balance of frontline hands-on medicine are among the causes.

A recent study published in the journal Pediatrics highlights personal finance as a contributor to the drain on the primary care workforce. The investigators found “high self-reported educational debt ($200,000 to < $300,000) was positively associated with training in a positive lifetime earnings potential subspecialty.” In other words, why would a physician who was burdened with student loans enter a subspecialty that would limit his or her ability to pay it off? I suspect that money has always been a factor in career selection, but the ballooning cost of college and medical school has certainly not nudged graduates toward the low lifetime earnings potential of primary care pediatrics.

Another recently released survey adds the perspective of current medical school students to the murky future of the primary health care workforce. The Clinician of the Future 2023: Education Edition, published by Elsevier Health, reports on insights of more than 2,000 nursing and medical school student from around the world. The headline shocker was that while across the board a not surprising 12% of medical students were considering quitting their studies, in the United States this number was 25%.

Overall, more than 60% of the students worried about their future income, how workforce shortages would effect them and whether they would join the ranks of those clinicians suffering from burnout. While the students surveyed acknowledged that artificial intelligence could have some negative repercussions, 62% were excited about its use in their education. Similarly, they anticipated the positive contribution of digital technology while acknowledging its potential downsides.

Given the current mental health climate in this country, I was not surprised that almost a quarter of medical students in this country are considering quitting school. I would like to see a larger sample surveyed and repeated over time. But, the discrepancy between the United States and the rest of the world is troubling.

The number that really jumped out at me was that 54% of medical students (nurses, 62%) viewed “ their current studies as a stepping-stone toward a broader career in health care.” As an example, the authors quoted one medical student who plans to “look for other possibilities where I don’t directly treat patients.”

Whether this disinterest in direct patient care is an attitude that preceded their entry into medical school or a change reflecting a major reversal induced by the realty of face-to-face patient encounters in school was not addressed in the survey. I think the general population would be surprised and maybe disappointed to learn that half the students in medical school weren’t planning on seeing patients.

I went off to medical school with a rather naive Norman Rockwellian view of a physician. I was a little surprised that a few of my classmates seemed to be gravitating toward administrative and research careers, but by far most of us were heading toward opportunities that would place us face to face with patients. Some would become specialists but primary care still had an appeal for many of us.

In my last letter about primary care training, I suggested that traditional medical school was probably a poor investment for the person who shares a bit of my old-school image of the primary care physician. In addition to cost and the time invested, the curriculum would likely be overly broad and deep and not terribly applicable to the patient mix he or she would eventually be seeing. This global survey may suggest that medical students have already discovered, or are just now discovering, this mismatch between medical school and the realities of primary care.

Our challenge is to first deal with deterrent of student debt and then to develop a new, affordable and efficient pathway to primary care that attracts those people who are looking for a face to face style of medicine on the front line. The patients know we need specialists and administrators but they also want a bit more of Norman Rockwell.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

A few weeks ago I shared by concerns about the dwindling numbers of primary care physicians. The early exodus of practicing providers and an obvious disinterest by future physicians in what they see as the unpalatable work/life balance of frontline hands-on medicine are among the causes.

A recent study published in the journal Pediatrics highlights personal finance as a contributor to the drain on the primary care workforce. The investigators found “high self-reported educational debt ($200,000 to < $300,000) was positively associated with training in a positive lifetime earnings potential subspecialty.” In other words, why would a physician who was burdened with student loans enter a subspecialty that would limit his or her ability to pay it off? I suspect that money has always been a factor in career selection, but the ballooning cost of college and medical school has certainly not nudged graduates toward the low lifetime earnings potential of primary care pediatrics.

Another recently released survey adds the perspective of current medical school students to the murky future of the primary health care workforce. The Clinician of the Future 2023: Education Edition, published by Elsevier Health, reports on insights of more than 2,000 nursing and medical school student from around the world. The headline shocker was that while across the board a not surprising 12% of medical students were considering quitting their studies, in the United States this number was 25%.

Overall, more than 60% of the students worried about their future income, how workforce shortages would effect them and whether they would join the ranks of those clinicians suffering from burnout. While the students surveyed acknowledged that artificial intelligence could have some negative repercussions, 62% were excited about its use in their education. Similarly, they anticipated the positive contribution of digital technology while acknowledging its potential downsides.

Given the current mental health climate in this country, I was not surprised that almost a quarter of medical students in this country are considering quitting school. I would like to see a larger sample surveyed and repeated over time. But, the discrepancy between the United States and the rest of the world is troubling.

The number that really jumped out at me was that 54% of medical students (nurses, 62%) viewed “ their current studies as a stepping-stone toward a broader career in health care.” As an example, the authors quoted one medical student who plans to “look for other possibilities where I don’t directly treat patients.”

Whether this disinterest in direct patient care is an attitude that preceded their entry into medical school or a change reflecting a major reversal induced by the realty of face-to-face patient encounters in school was not addressed in the survey. I think the general population would be surprised and maybe disappointed to learn that half the students in medical school weren’t planning on seeing patients.

I went off to medical school with a rather naive Norman Rockwellian view of a physician. I was a little surprised that a few of my classmates seemed to be gravitating toward administrative and research careers, but by far most of us were heading toward opportunities that would place us face to face with patients. Some would become specialists but primary care still had an appeal for many of us.

In my last letter about primary care training, I suggested that traditional medical school was probably a poor investment for the person who shares a bit of my old-school image of the primary care physician. In addition to cost and the time invested, the curriculum would likely be overly broad and deep and not terribly applicable to the patient mix he or she would eventually be seeing. This global survey may suggest that medical students have already discovered, or are just now discovering, this mismatch between medical school and the realities of primary care.

Our challenge is to first deal with deterrent of student debt and then to develop a new, affordable and efficient pathway to primary care that attracts those people who are looking for a face to face style of medicine on the front line. The patients know we need specialists and administrators but they also want a bit more of Norman Rockwell.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

This transcript has been edited for clarity.

When it comes to the public health fight against respiratory viruses – COVID, flu, RSV,  and so on – it has always struck me as strange how staunchly basically any intervention is opposed. Masking was, of course, the prototypical entrenched warfare of opposing ideologies, with advocates pointing to studies suggesting the efficacy of masking to prevent transmission and advocating for broad masking recommendations, and detractors citing studies that suggested masks were ineffective and characterizing masking policies as fascist overreach. I’ll admit that I was always perplexed by this a bit, as that particular intervention seemed so benign – a bit annoying, I guess, but not crazy.

I have come to appreciate what I call status quo bias, which is the tendency to reject any policy, advice, or intervention that would force you, as an individual, to change your usual behavior. We just don’t like to do that. It has made me think that the most successful public health interventions might be the ones that take the individual out of the loop. And air quality control seems an ideal fit here. Here is a potential intervention where you, the individual, have to do precisely nothing. The status quo is preserved. We just, you know, have cleaner indoor air.

But even the suggestion of air treatment systems as a bulwark against respiratory virus transmission has been met with not just skepticism but cynicism, and perhaps even defeatism. It seems that there are those out there who think there really is nothing we can do. Sickness is interpreted in a Calvinistic framework: You become ill because it is your pre-destiny. But maybe air treatment could actually work. It seems like it might, if a new paper from PLOS One is to be believed.

What we’re talking about is a study titled “Bipolar Ionization Rapidly Inactivates Real-World, Airborne Concentrations of Infective Respiratory Viruses” – a highly controlled, laboratory-based analysis of a bipolar ionization system which seems to rapidly reduce viral counts in the air.

The proposed mechanism of action is pretty simple. The ionization system – which, don’t worry, has been shown not to produce ozone – spits out positively and negatively charged particles, which float around the test chamber, designed to look like a pretty standard room that you might find in an office or a school.

courtesy PLOS One

courtesy PLOS One

courtesy PLOS One

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. He reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

When it comes to the public health fight against respiratory viruses – COVID, flu, RSV,  and so on – it has always struck me as strange how staunchly basically any intervention is opposed. Masking was, of course, the prototypical entrenched warfare of opposing ideologies, with advocates pointing to studies suggesting the efficacy of masking to prevent transmission and advocating for broad masking recommendations, and detractors citing studies that suggested masks were ineffective and characterizing masking policies as fascist overreach. I’ll admit that I was always perplexed by this a bit, as that particular intervention seemed so benign – a bit annoying, I guess, but not crazy.

I have come to appreciate what I call status quo bias, which is the tendency to reject any policy, advice, or intervention that would force you, as an individual, to change your usual behavior. We just don’t like to do that. It has made me think that the most successful public health interventions might be the ones that take the individual out of the loop. And air quality control seems an ideal fit here. Here is a potential intervention where you, the individual, have to do precisely nothing. The status quo is preserved. We just, you know, have cleaner indoor air.

But even the suggestion of air treatment systems as a bulwark against respiratory virus transmission has been met with not just skepticism but cynicism, and perhaps even defeatism. It seems that there are those out there who think there really is nothing we can do. Sickness is interpreted in a Calvinistic framework: You become ill because it is your pre-destiny. But maybe air treatment could actually work. It seems like it might, if a new paper from PLOS One is to be believed.

What we’re talking about is a study titled “Bipolar Ionization Rapidly Inactivates Real-World, Airborne Concentrations of Infective Respiratory Viruses” – a highly controlled, laboratory-based analysis of a bipolar ionization system which seems to rapidly reduce viral counts in the air.

The proposed mechanism of action is pretty simple. The ionization system – which, don’t worry, has been shown not to produce ozone – spits out positively and negatively charged particles, which float around the test chamber, designed to look like a pretty standard room that you might find in an office or a school.

courtesy PLOS One

courtesy PLOS One

courtesy PLOS One

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. He reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

When it comes to the public health fight against respiratory viruses – COVID, flu, RSV,  and so on – it has always struck me as strange how staunchly basically any intervention is opposed. Masking was, of course, the prototypical entrenched warfare of opposing ideologies, with advocates pointing to studies suggesting the efficacy of masking to prevent transmission and advocating for broad masking recommendations, and detractors citing studies that suggested masks were ineffective and characterizing masking policies as fascist overreach. I’ll admit that I was always perplexed by this a bit, as that particular intervention seemed so benign – a bit annoying, I guess, but not crazy.

I have come to appreciate what I call status quo bias, which is the tendency to reject any policy, advice, or intervention that would force you, as an individual, to change your usual behavior. We just don’t like to do that. It has made me think that the most successful public health interventions might be the ones that take the individual out of the loop. And air quality control seems an ideal fit here. Here is a potential intervention where you, the individual, have to do precisely nothing. The status quo is preserved. We just, you know, have cleaner indoor air.

But even the suggestion of air treatment systems as a bulwark against respiratory virus transmission has been met with not just skepticism but cynicism, and perhaps even defeatism. It seems that there are those out there who think there really is nothing we can do. Sickness is interpreted in a Calvinistic framework: You become ill because it is your pre-destiny. But maybe air treatment could actually work. It seems like it might, if a new paper from PLOS One is to be believed.

What we’re talking about is a study titled “Bipolar Ionization Rapidly Inactivates Real-World, Airborne Concentrations of Infective Respiratory Viruses” – a highly controlled, laboratory-based analysis of a bipolar ionization system which seems to rapidly reduce viral counts in the air.

The proposed mechanism of action is pretty simple. The ionization system – which, don’t worry, has been shown not to produce ozone – spits out positively and negatively charged particles, which float around the test chamber, designed to look like a pretty standard room that you might find in an office or a school.

courtesy PLOS One

courtesy PLOS One

courtesy PLOS One

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. He reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.