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The sacred office space
Church architecture describes visually the idea of the sacred, which is a fundamental need of man.
– Mario Botta, Swiss architect
My parents are visiting the Holy See today – prima volta in Italia! My mom waited years for this. She isn’t meeting the Pope or attending Mass. Yet, in the Whatsapp pics they sent me, you can see tears well up as she experiences St. Peter’s Basilica. It’s a visceral response to what is just a building and a poignant example of the significance of spaces.
More than just appreciating an edifice’s grandeur or exquisiteness, we are wired to connect with spaces emotionally. Beautiful or significant buildings move us, they make us feel something. Churches, synagogues, or mosques are good examples. They combine spiritual and aesthetic allure. But so too do gorgeous hotels, Apple stores, and posh restaurants. We crave the richness of an environment experienced through our five senses. The glory of sunlight through stained glass, the smell of luxurious scent pumped into a lobby, the weight of a silky new iPhone in your hand. We also have a sixth sense, that feeling we get from knowing that we are standing in a sacred place. A physical space that connects us with something wider and deeper than ourselves.
Virtual may be the peak of convenience, but in-real-life is the pinnacle of experience. Patients will be inconvenienced and pay higher costs to experience their appointment in person. This should not be surprising. Contemplate this: Every year, millions of people will travel across the globe to stand before a wall or walk seven times around a stone building. And millions everyday will perambulate around an Apple Store, willingly paying a higher price for the same product they can buy for less elsewhere. The willingness to pay for certain experiences is remarkably high.
Every day when I cover patient messages, I offer some patients an immediate, free solution to their problem. Just today I exchanged emails with a patient thinking I had addressed her concern by reassuring her that it was a benign seborrheic keratosis. Done. She then replied, “Thanks so much, Dr. Benabio! I still would like to schedule an appointment to come in person.” So much for the efficiency of digital medicine.
Before dismissing these patients as Luddites, understand what they want is the doctor’s office experience. The sights, the smells, the sacredness of what happens here. It is no coincidence that the first clinics were temples. In ancient Greece and Rome, the sick and the gashed made pilgrimages to one of at least 300 Asclepieia, temples of healing. During the medieval period, monasteries doubled as housing for the sick until the church began constructing stand-alone hospitals, often in cross-shaped design with an altar in the middle (eventually that became the nurses station, but without the wine).
Patients entrust us with their lives and their loved ones’ lives and a visit takes on far more significance than a simple service transaction. Forty years on, I can recall visits to Dr. Bellin’s office. He saw pediatric patients out of his Victorian home office with broad, creaky hardwood floors, stained glass, and cast iron radiators. The scent of isopropyl soaked cotton balls and typewriter ink is unforgettable. Far from sterile, it was warm, safe. It was a sacred place, one for which we still sometimes drive by when doing the tour of where I grew up.
We shall forge ahead and continue to offer virtual channels to serve our patients just as any service industry. But don’t force them there. At the same time Starbucks has been building its digital app, it is also building Starbucks Reserve Roasteries. Immense cathedral edifices with warm woods and luxurious brass, the smell of roasting coffee and warm leather perfuming the air. It is where patrons will travel long distances and endure long waits to pay a lot more for a cup of coffee.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Church architecture describes visually the idea of the sacred, which is a fundamental need of man.
– Mario Botta, Swiss architect
My parents are visiting the Holy See today – prima volta in Italia! My mom waited years for this. She isn’t meeting the Pope or attending Mass. Yet, in the Whatsapp pics they sent me, you can see tears well up as she experiences St. Peter’s Basilica. It’s a visceral response to what is just a building and a poignant example of the significance of spaces.
More than just appreciating an edifice’s grandeur or exquisiteness, we are wired to connect with spaces emotionally. Beautiful or significant buildings move us, they make us feel something. Churches, synagogues, or mosques are good examples. They combine spiritual and aesthetic allure. But so too do gorgeous hotels, Apple stores, and posh restaurants. We crave the richness of an environment experienced through our five senses. The glory of sunlight through stained glass, the smell of luxurious scent pumped into a lobby, the weight of a silky new iPhone in your hand. We also have a sixth sense, that feeling we get from knowing that we are standing in a sacred place. A physical space that connects us with something wider and deeper than ourselves.
Virtual may be the peak of convenience, but in-real-life is the pinnacle of experience. Patients will be inconvenienced and pay higher costs to experience their appointment in person. This should not be surprising. Contemplate this: Every year, millions of people will travel across the globe to stand before a wall or walk seven times around a stone building. And millions everyday will perambulate around an Apple Store, willingly paying a higher price for the same product they can buy for less elsewhere. The willingness to pay for certain experiences is remarkably high.
Every day when I cover patient messages, I offer some patients an immediate, free solution to their problem. Just today I exchanged emails with a patient thinking I had addressed her concern by reassuring her that it was a benign seborrheic keratosis. Done. She then replied, “Thanks so much, Dr. Benabio! I still would like to schedule an appointment to come in person.” So much for the efficiency of digital medicine.
Before dismissing these patients as Luddites, understand what they want is the doctor’s office experience. The sights, the smells, the sacredness of what happens here. It is no coincidence that the first clinics were temples. In ancient Greece and Rome, the sick and the gashed made pilgrimages to one of at least 300 Asclepieia, temples of healing. During the medieval period, monasteries doubled as housing for the sick until the church began constructing stand-alone hospitals, often in cross-shaped design with an altar in the middle (eventually that became the nurses station, but without the wine).
Patients entrust us with their lives and their loved ones’ lives and a visit takes on far more significance than a simple service transaction. Forty years on, I can recall visits to Dr. Bellin’s office. He saw pediatric patients out of his Victorian home office with broad, creaky hardwood floors, stained glass, and cast iron radiators. The scent of isopropyl soaked cotton balls and typewriter ink is unforgettable. Far from sterile, it was warm, safe. It was a sacred place, one for which we still sometimes drive by when doing the tour of where I grew up.
We shall forge ahead and continue to offer virtual channels to serve our patients just as any service industry. But don’t force them there. At the same time Starbucks has been building its digital app, it is also building Starbucks Reserve Roasteries. Immense cathedral edifices with warm woods and luxurious brass, the smell of roasting coffee and warm leather perfuming the air. It is where patrons will travel long distances and endure long waits to pay a lot more for a cup of coffee.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Church architecture describes visually the idea of the sacred, which is a fundamental need of man.
– Mario Botta, Swiss architect
My parents are visiting the Holy See today – prima volta in Italia! My mom waited years for this. She isn’t meeting the Pope or attending Mass. Yet, in the Whatsapp pics they sent me, you can see tears well up as she experiences St. Peter’s Basilica. It’s a visceral response to what is just a building and a poignant example of the significance of spaces.
More than just appreciating an edifice’s grandeur or exquisiteness, we are wired to connect with spaces emotionally. Beautiful or significant buildings move us, they make us feel something. Churches, synagogues, or mosques are good examples. They combine spiritual and aesthetic allure. But so too do gorgeous hotels, Apple stores, and posh restaurants. We crave the richness of an environment experienced through our five senses. The glory of sunlight through stained glass, the smell of luxurious scent pumped into a lobby, the weight of a silky new iPhone in your hand. We also have a sixth sense, that feeling we get from knowing that we are standing in a sacred place. A physical space that connects us with something wider and deeper than ourselves.
Virtual may be the peak of convenience, but in-real-life is the pinnacle of experience. Patients will be inconvenienced and pay higher costs to experience their appointment in person. This should not be surprising. Contemplate this: Every year, millions of people will travel across the globe to stand before a wall or walk seven times around a stone building. And millions everyday will perambulate around an Apple Store, willingly paying a higher price for the same product they can buy for less elsewhere. The willingness to pay for certain experiences is remarkably high.
Every day when I cover patient messages, I offer some patients an immediate, free solution to their problem. Just today I exchanged emails with a patient thinking I had addressed her concern by reassuring her that it was a benign seborrheic keratosis. Done. She then replied, “Thanks so much, Dr. Benabio! I still would like to schedule an appointment to come in person.” So much for the efficiency of digital medicine.
Before dismissing these patients as Luddites, understand what they want is the doctor’s office experience. The sights, the smells, the sacredness of what happens here. It is no coincidence that the first clinics were temples. In ancient Greece and Rome, the sick and the gashed made pilgrimages to one of at least 300 Asclepieia, temples of healing. During the medieval period, monasteries doubled as housing for the sick until the church began constructing stand-alone hospitals, often in cross-shaped design with an altar in the middle (eventually that became the nurses station, but without the wine).
Patients entrust us with their lives and their loved ones’ lives and a visit takes on far more significance than a simple service transaction. Forty years on, I can recall visits to Dr. Bellin’s office. He saw pediatric patients out of his Victorian home office with broad, creaky hardwood floors, stained glass, and cast iron radiators. The scent of isopropyl soaked cotton balls and typewriter ink is unforgettable. Far from sterile, it was warm, safe. It was a sacred place, one for which we still sometimes drive by when doing the tour of where I grew up.
We shall forge ahead and continue to offer virtual channels to serve our patients just as any service industry. But don’t force them there. At the same time Starbucks has been building its digital app, it is also building Starbucks Reserve Roasteries. Immense cathedral edifices with warm woods and luxurious brass, the smell of roasting coffee and warm leather perfuming the air. It is where patrons will travel long distances and endure long waits to pay a lot more for a cup of coffee.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
No link between PPIs and dementia in new study
TOPLINE:
A new study provides reassurance about the long-term safety of proton pump inhibitors (PPIs) and histamine-2 receptor antagonist (H2RA) use in older adults, finding no increased risk for dementia or cognitive changes.
METHODOLOGY:
- Post hoc observational study within the Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial.
- 18,934 adults aged 65+ from the United States and Australia without dementia at baseline.
- 4,667 (25%) PPI users and 368 (2%) H2RA users at baseline.
- PPI and H2RA use, dementia incidence, and cognitive changes were tracked.
TAKEAWAY:
- In multivariable analysis, baseline PPI use was not associated with incident dementia (hazard ratio, 0.88) or cognitive impairment (HR, 1.00).
- PPI use was not linked to changes in overall cognitive test scores over time (beta –0.002).
- No associations were found between H2RA use and cognitive endpoints.
IN PRACTICE:
“Long-term use of PPIs in older adults is unlikely to have negative effects on cognition,” the study team concludes.
STUDY DETAILS:
The study was led by Raaj Mehta, MD, PhD, with Massachusetts General Hospital and Harvard Medical School in Boston. The study was published online in Gastroenterology. Funding was provided by grants from the National Institute on Aging, the National Cancer Institute, and other institutions.
LIMITATIONS:
Potential for residual confounding and underestimation of PPI and H2RA use, lack of data on medication dose and duration, and the absence of ApoE4 allele status.
DISCLOSURES:
Dr. Mehta has disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
A new study provides reassurance about the long-term safety of proton pump inhibitors (PPIs) and histamine-2 receptor antagonist (H2RA) use in older adults, finding no increased risk for dementia or cognitive changes.
METHODOLOGY:
- Post hoc observational study within the Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial.
- 18,934 adults aged 65+ from the United States and Australia without dementia at baseline.
- 4,667 (25%) PPI users and 368 (2%) H2RA users at baseline.
- PPI and H2RA use, dementia incidence, and cognitive changes were tracked.
TAKEAWAY:
- In multivariable analysis, baseline PPI use was not associated with incident dementia (hazard ratio, 0.88) or cognitive impairment (HR, 1.00).
- PPI use was not linked to changes in overall cognitive test scores over time (beta –0.002).
- No associations were found between H2RA use and cognitive endpoints.
IN PRACTICE:
“Long-term use of PPIs in older adults is unlikely to have negative effects on cognition,” the study team concludes.
STUDY DETAILS:
The study was led by Raaj Mehta, MD, PhD, with Massachusetts General Hospital and Harvard Medical School in Boston. The study was published online in Gastroenterology. Funding was provided by grants from the National Institute on Aging, the National Cancer Institute, and other institutions.
LIMITATIONS:
Potential for residual confounding and underestimation of PPI and H2RA use, lack of data on medication dose and duration, and the absence of ApoE4 allele status.
DISCLOSURES:
Dr. Mehta has disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
A new study provides reassurance about the long-term safety of proton pump inhibitors (PPIs) and histamine-2 receptor antagonist (H2RA) use in older adults, finding no increased risk for dementia or cognitive changes.
METHODOLOGY:
- Post hoc observational study within the Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial.
- 18,934 adults aged 65+ from the United States and Australia without dementia at baseline.
- 4,667 (25%) PPI users and 368 (2%) H2RA users at baseline.
- PPI and H2RA use, dementia incidence, and cognitive changes were tracked.
TAKEAWAY:
- In multivariable analysis, baseline PPI use was not associated with incident dementia (hazard ratio, 0.88) or cognitive impairment (HR, 1.00).
- PPI use was not linked to changes in overall cognitive test scores over time (beta –0.002).
- No associations were found between H2RA use and cognitive endpoints.
IN PRACTICE:
“Long-term use of PPIs in older adults is unlikely to have negative effects on cognition,” the study team concludes.
STUDY DETAILS:
The study was led by Raaj Mehta, MD, PhD, with Massachusetts General Hospital and Harvard Medical School in Boston. The study was published online in Gastroenterology. Funding was provided by grants from the National Institute on Aging, the National Cancer Institute, and other institutions.
LIMITATIONS:
Potential for residual confounding and underestimation of PPI and H2RA use, lack of data on medication dose and duration, and the absence of ApoE4 allele status.
DISCLOSURES:
Dr. Mehta has disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Protecting your practice data
While data protection is important in any industry, it is particularly critical in health care because in addition to the usual financial records, trade secrets, and other valuable data, confidential patient information is also at risk.
You may think that your computer vendor is responsible for safeguarding your data, but third parties can only do so much. And if your data is compromised, the ultimate responsibility is yours – not to mention the financial loss, and the damage to your practice’s reputation.
In addition to the security vulnerabilities inherent in any system, there are external vulnerabilities, such as weak passwords, viruses, and hacking (either externally or internally). And as hardware becomes more and more portable, there is the increasing risk of theft of platforms and storage media containing confidential data.
A close and ongoing relationship with your hardware and software vendors is essential to good data protection. Your office should have a permanent contact at each company, and you should talk to them regularly. Ask them what sort of firewalls, antivirus software, and other safeguards are in place to protect your system. Whenever they identify a bug or other vulnerability, you should know about it. They should tell you about each software update, what improvements it makes, and what defects it fixes. You should also know about any changes to your data encryption.
Encryption has become an essential component of data protection. It is especially important if you use portable devices such as laptops, pads, or smart phones to store and transport patient information. If you lose one of these devices, or a thumb drive or other storage media, HIPAA will probably not consider it a breach if the data it contains is encrypted.
Encryption isn’t perfect, of course. Log-in credentials can be stolen; and data that is stored in house is can be hacked with malware and phishing techniques, especially if the key to decryption is located on that server. And make sure that employees are not putting any medical data on their own private (unencrypted) devices.
Each employee should have his or her own password, and sharing should be strictly prohibited. Multifactor authentication is becoming increasingly popular for an extra level of security.
Your vendor should require you to change your passwords every few months. If it doesn’t, you need to establish a timetable to do it yourself. All passwords should be strong (no birthdays, pet names, etc.), and they shouldn’t be the same or similar to old passwords.
In some offices, I’ve been surprised to see that every employee has unrestricted access to all practice data. The vulnerabilities of such an arrangement are obvious. There is no reason why receptionists, for example, should have access to medical histories, and insurance people don’t need to know what medications a patient is on. Your vendor can help you design partitions that restrict each employee to only the information they need access to.
Ask if your vendor provides security training for employees. If not, look into hiring a security firm to do it. Regular security training can help employees to recognize data security attacks like phishing, and instills a heightened sense of security awareness and vigilance among staff. They will also gain a better understanding of the role they play in maintaining the overall security of your office.
It goes without saying that third parties, such as business vendors, payers, and managed care providers, should never have access to patient records or other personal health information.
Backing up data
I have written many times about the importance of regularly backing up your data. Industry statistics show that fully 10% of hard drives fail in any given year, and 43% of computer users lose one or more files every year in the form of clinical data, financial records, photos, email, documents, and other important information. Recovery of lost data, when it’s possible at all, can be very expensive.
Even if your EHR vendor backs up your data, you should consider making a separate backup of your own. Backup drives have been known to fail too; and if you decide to switch computer vendors, you don’t want to be at the mercy of the old company that might be reluctant to transfer your data without a hefty payment.
The first rule of backing up is to store your backup drives in a different location from your computers. Unfortunately, that’s a pain; and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup. Several companies offer that service, and the cost is very reasonable for individual computers. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it’s still very reasonable and includes other services, such as operating system and network share support.
The procedure is simple: You create an account and tell the service which files you want copied. Your first backup can take a long time, often days, depending on how much data you are sending and how fast your Internet connection runs. After that the program runs in the background, copying only those files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service’s data center, making them HIPAA compliant and, theoretically, only accessible by you.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
While data protection is important in any industry, it is particularly critical in health care because in addition to the usual financial records, trade secrets, and other valuable data, confidential patient information is also at risk.
You may think that your computer vendor is responsible for safeguarding your data, but third parties can only do so much. And if your data is compromised, the ultimate responsibility is yours – not to mention the financial loss, and the damage to your practice’s reputation.
In addition to the security vulnerabilities inherent in any system, there are external vulnerabilities, such as weak passwords, viruses, and hacking (either externally or internally). And as hardware becomes more and more portable, there is the increasing risk of theft of platforms and storage media containing confidential data.
A close and ongoing relationship with your hardware and software vendors is essential to good data protection. Your office should have a permanent contact at each company, and you should talk to them regularly. Ask them what sort of firewalls, antivirus software, and other safeguards are in place to protect your system. Whenever they identify a bug or other vulnerability, you should know about it. They should tell you about each software update, what improvements it makes, and what defects it fixes. You should also know about any changes to your data encryption.
Encryption has become an essential component of data protection. It is especially important if you use portable devices such as laptops, pads, or smart phones to store and transport patient information. If you lose one of these devices, or a thumb drive or other storage media, HIPAA will probably not consider it a breach if the data it contains is encrypted.
Encryption isn’t perfect, of course. Log-in credentials can be stolen; and data that is stored in house is can be hacked with malware and phishing techniques, especially if the key to decryption is located on that server. And make sure that employees are not putting any medical data on their own private (unencrypted) devices.
Each employee should have his or her own password, and sharing should be strictly prohibited. Multifactor authentication is becoming increasingly popular for an extra level of security.
Your vendor should require you to change your passwords every few months. If it doesn’t, you need to establish a timetable to do it yourself. All passwords should be strong (no birthdays, pet names, etc.), and they shouldn’t be the same or similar to old passwords.
In some offices, I’ve been surprised to see that every employee has unrestricted access to all practice data. The vulnerabilities of such an arrangement are obvious. There is no reason why receptionists, for example, should have access to medical histories, and insurance people don’t need to know what medications a patient is on. Your vendor can help you design partitions that restrict each employee to only the information they need access to.
Ask if your vendor provides security training for employees. If not, look into hiring a security firm to do it. Regular security training can help employees to recognize data security attacks like phishing, and instills a heightened sense of security awareness and vigilance among staff. They will also gain a better understanding of the role they play in maintaining the overall security of your office.
It goes without saying that third parties, such as business vendors, payers, and managed care providers, should never have access to patient records or other personal health information.
Backing up data
I have written many times about the importance of regularly backing up your data. Industry statistics show that fully 10% of hard drives fail in any given year, and 43% of computer users lose one or more files every year in the form of clinical data, financial records, photos, email, documents, and other important information. Recovery of lost data, when it’s possible at all, can be very expensive.
Even if your EHR vendor backs up your data, you should consider making a separate backup of your own. Backup drives have been known to fail too; and if you decide to switch computer vendors, you don’t want to be at the mercy of the old company that might be reluctant to transfer your data without a hefty payment.
The first rule of backing up is to store your backup drives in a different location from your computers. Unfortunately, that’s a pain; and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup. Several companies offer that service, and the cost is very reasonable for individual computers. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it’s still very reasonable and includes other services, such as operating system and network share support.
The procedure is simple: You create an account and tell the service which files you want copied. Your first backup can take a long time, often days, depending on how much data you are sending and how fast your Internet connection runs. After that the program runs in the background, copying only those files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service’s data center, making them HIPAA compliant and, theoretically, only accessible by you.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
While data protection is important in any industry, it is particularly critical in health care because in addition to the usual financial records, trade secrets, and other valuable data, confidential patient information is also at risk.
You may think that your computer vendor is responsible for safeguarding your data, but third parties can only do so much. And if your data is compromised, the ultimate responsibility is yours – not to mention the financial loss, and the damage to your practice’s reputation.
In addition to the security vulnerabilities inherent in any system, there are external vulnerabilities, such as weak passwords, viruses, and hacking (either externally or internally). And as hardware becomes more and more portable, there is the increasing risk of theft of platforms and storage media containing confidential data.
A close and ongoing relationship with your hardware and software vendors is essential to good data protection. Your office should have a permanent contact at each company, and you should talk to them regularly. Ask them what sort of firewalls, antivirus software, and other safeguards are in place to protect your system. Whenever they identify a bug or other vulnerability, you should know about it. They should tell you about each software update, what improvements it makes, and what defects it fixes. You should also know about any changes to your data encryption.
Encryption has become an essential component of data protection. It is especially important if you use portable devices such as laptops, pads, or smart phones to store and transport patient information. If you lose one of these devices, or a thumb drive or other storage media, HIPAA will probably not consider it a breach if the data it contains is encrypted.
Encryption isn’t perfect, of course. Log-in credentials can be stolen; and data that is stored in house is can be hacked with malware and phishing techniques, especially if the key to decryption is located on that server. And make sure that employees are not putting any medical data on their own private (unencrypted) devices.
Each employee should have his or her own password, and sharing should be strictly prohibited. Multifactor authentication is becoming increasingly popular for an extra level of security.
Your vendor should require you to change your passwords every few months. If it doesn’t, you need to establish a timetable to do it yourself. All passwords should be strong (no birthdays, pet names, etc.), and they shouldn’t be the same or similar to old passwords.
In some offices, I’ve been surprised to see that every employee has unrestricted access to all practice data. The vulnerabilities of such an arrangement are obvious. There is no reason why receptionists, for example, should have access to medical histories, and insurance people don’t need to know what medications a patient is on. Your vendor can help you design partitions that restrict each employee to only the information they need access to.
Ask if your vendor provides security training for employees. If not, look into hiring a security firm to do it. Regular security training can help employees to recognize data security attacks like phishing, and instills a heightened sense of security awareness and vigilance among staff. They will also gain a better understanding of the role they play in maintaining the overall security of your office.
It goes without saying that third parties, such as business vendors, payers, and managed care providers, should never have access to patient records or other personal health information.
Backing up data
I have written many times about the importance of regularly backing up your data. Industry statistics show that fully 10% of hard drives fail in any given year, and 43% of computer users lose one or more files every year in the form of clinical data, financial records, photos, email, documents, and other important information. Recovery of lost data, when it’s possible at all, can be very expensive.
Even if your EHR vendor backs up your data, you should consider making a separate backup of your own. Backup drives have been known to fail too; and if you decide to switch computer vendors, you don’t want to be at the mercy of the old company that might be reluctant to transfer your data without a hefty payment.
The first rule of backing up is to store your backup drives in a different location from your computers. Unfortunately, that’s a pain; and external drives can be lost or stolen, creating a HIPAA nightmare. So an increasingly popular alternative is automatic remote backup. Several companies offer that service, and the cost is very reasonable for individual computers. Backing up an entire office costs more, depending on how many computers and/or servers you have, but it’s still very reasonable and includes other services, such as operating system and network share support.
The procedure is simple: You create an account and tell the service which files you want copied. Your first backup can take a long time, often days, depending on how much data you are sending and how fast your Internet connection runs. After that the program runs in the background, copying only those files that have changed since the previous backup. Files are encrypted before leaving your computer, and they remain encrypted at the service’s data center, making them HIPAA compliant and, theoretically, only accessible by you.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Morning PT
Tuesdays and Fridays are tough. Not so much because of clinic, but rather because of the 32 minutes before clinic that I’m on the Peloton bike. They are the mornings I dedicate to training VO2max.
Training VO2max, or maximal oxygen consumption, is simple. Spin for a leisurely, easy-breathing, 4 minutes, then for 4 minutes push yourself until you see the light of heaven and wish for death to come. Then relax for 4 minutes again. Repeat this cycle four to six times. Done justly, you will dread Tuesdays and Fridays too. The punishing cycle of a 4-minute push, then 4-minute recovery is, however, an excellent way to improve cardiovascular fitness. And no, I’m not training for the Boston Marathon, so why am I working so hard? Because I’m training for marathon clinic days for the next 20 years.
Now more than ever, I feel we have to be physically fit to deal with a physicians’ day’s work. It’s exhausting. The root cause is too much work, yes, but I believe being physically fit could help.
I was talking to an 86-year-old patient about this very topic recently. He was short, with a well-manicured goatee and shiny head. He stuck his arm out to shake my hand. “Glad we’re back to handshakes again, doc.” His grip was that of a 30-year-old. “Buff” you’d likely describe him: He is noticeably muscular, not a skinny old man. He’s an old Navy Master Chief who started a business in wholesale flowers, which distributes all over the United States. And he’s still working full time. Impressed, I asked his secret for such vigor. PT, he replied.
PT, or physical training, is a foundational element of the Navy. Every sailor starts his or her day with morning PT before carrying out their duties. Some 30 years later, this guy is still getting after it. He does push-ups, sit-ups, and pull-ups nearly every morning. Morning PT is what he attributes to his success not only in health, but also business. As he sees it, he has the business savvy and experience of an old guy and the energy and stamina of a college kid. A good combination for a successful life.
I’ve always been pretty fit. Lately, I’ve been trying to take it to the next level, to not just be “physically active,” but rather “high-performance fit.” There are plenty of sources for instruction; how to stay young and healthy isn’t a new idea after all. I mean, Herodotus wrote of finding the Fountain of Youth in the 5th century BCE. A couple thousand years later, it’s still on trend. One of my favorite sages giving health span advice is Peter Attia, MD. I’ve been a fan since I met him at TEDMED in 2013 and I marvel at the astounding body of work he has created since. A Johns Hopkins–trained surgeon, he has spent his career reviewing the scientific literature about longevity and sharing it as actionable content. His book, “Outlive: The Science and Art of Longevity” (New York: Penguin Random House, 2023) is a nice summary of his work. I recommend it.
Right now I’m switching between type 2 muscle fiber work (lots of jumping like my 2-year-old) and cardiovascular training including the aforementioned VO2max work. I cannot say that my patient inbox is any cleaner, or that I’m faster in the office, but I’m not flagging by the end of the day anymore. Master Chief challenged me to match his 10 pull-ups before he returns for his follow up visit. I’ll gladly give up Peloton sprints to work on that.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Tuesdays and Fridays are tough. Not so much because of clinic, but rather because of the 32 minutes before clinic that I’m on the Peloton bike. They are the mornings I dedicate to training VO2max.
Training VO2max, or maximal oxygen consumption, is simple. Spin for a leisurely, easy-breathing, 4 minutes, then for 4 minutes push yourself until you see the light of heaven and wish for death to come. Then relax for 4 minutes again. Repeat this cycle four to six times. Done justly, you will dread Tuesdays and Fridays too. The punishing cycle of a 4-minute push, then 4-minute recovery is, however, an excellent way to improve cardiovascular fitness. And no, I’m not training for the Boston Marathon, so why am I working so hard? Because I’m training for marathon clinic days for the next 20 years.
Now more than ever, I feel we have to be physically fit to deal with a physicians’ day’s work. It’s exhausting. The root cause is too much work, yes, but I believe being physically fit could help.
I was talking to an 86-year-old patient about this very topic recently. He was short, with a well-manicured goatee and shiny head. He stuck his arm out to shake my hand. “Glad we’re back to handshakes again, doc.” His grip was that of a 30-year-old. “Buff” you’d likely describe him: He is noticeably muscular, not a skinny old man. He’s an old Navy Master Chief who started a business in wholesale flowers, which distributes all over the United States. And he’s still working full time. Impressed, I asked his secret for such vigor. PT, he replied.
PT, or physical training, is a foundational element of the Navy. Every sailor starts his or her day with morning PT before carrying out their duties. Some 30 years later, this guy is still getting after it. He does push-ups, sit-ups, and pull-ups nearly every morning. Morning PT is what he attributes to his success not only in health, but also business. As he sees it, he has the business savvy and experience of an old guy and the energy and stamina of a college kid. A good combination for a successful life.
I’ve always been pretty fit. Lately, I’ve been trying to take it to the next level, to not just be “physically active,” but rather “high-performance fit.” There are plenty of sources for instruction; how to stay young and healthy isn’t a new idea after all. I mean, Herodotus wrote of finding the Fountain of Youth in the 5th century BCE. A couple thousand years later, it’s still on trend. One of my favorite sages giving health span advice is Peter Attia, MD. I’ve been a fan since I met him at TEDMED in 2013 and I marvel at the astounding body of work he has created since. A Johns Hopkins–trained surgeon, he has spent his career reviewing the scientific literature about longevity and sharing it as actionable content. His book, “Outlive: The Science and Art of Longevity” (New York: Penguin Random House, 2023) is a nice summary of his work. I recommend it.
Right now I’m switching between type 2 muscle fiber work (lots of jumping like my 2-year-old) and cardiovascular training including the aforementioned VO2max work. I cannot say that my patient inbox is any cleaner, or that I’m faster in the office, but I’m not flagging by the end of the day anymore. Master Chief challenged me to match his 10 pull-ups before he returns for his follow up visit. I’ll gladly give up Peloton sprints to work on that.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Tuesdays and Fridays are tough. Not so much because of clinic, but rather because of the 32 minutes before clinic that I’m on the Peloton bike. They are the mornings I dedicate to training VO2max.
Training VO2max, or maximal oxygen consumption, is simple. Spin for a leisurely, easy-breathing, 4 minutes, then for 4 minutes push yourself until you see the light of heaven and wish for death to come. Then relax for 4 minutes again. Repeat this cycle four to six times. Done justly, you will dread Tuesdays and Fridays too. The punishing cycle of a 4-minute push, then 4-minute recovery is, however, an excellent way to improve cardiovascular fitness. And no, I’m not training for the Boston Marathon, so why am I working so hard? Because I’m training for marathon clinic days for the next 20 years.
Now more than ever, I feel we have to be physically fit to deal with a physicians’ day’s work. It’s exhausting. The root cause is too much work, yes, but I believe being physically fit could help.
I was talking to an 86-year-old patient about this very topic recently. He was short, with a well-manicured goatee and shiny head. He stuck his arm out to shake my hand. “Glad we’re back to handshakes again, doc.” His grip was that of a 30-year-old. “Buff” you’d likely describe him: He is noticeably muscular, not a skinny old man. He’s an old Navy Master Chief who started a business in wholesale flowers, which distributes all over the United States. And he’s still working full time. Impressed, I asked his secret for such vigor. PT, he replied.
PT, or physical training, is a foundational element of the Navy. Every sailor starts his or her day with morning PT before carrying out their duties. Some 30 years later, this guy is still getting after it. He does push-ups, sit-ups, and pull-ups nearly every morning. Morning PT is what he attributes to his success not only in health, but also business. As he sees it, he has the business savvy and experience of an old guy and the energy and stamina of a college kid. A good combination for a successful life.
I’ve always been pretty fit. Lately, I’ve been trying to take it to the next level, to not just be “physically active,” but rather “high-performance fit.” There are plenty of sources for instruction; how to stay young and healthy isn’t a new idea after all. I mean, Herodotus wrote of finding the Fountain of Youth in the 5th century BCE. A couple thousand years later, it’s still on trend. One of my favorite sages giving health span advice is Peter Attia, MD. I’ve been a fan since I met him at TEDMED in 2013 and I marvel at the astounding body of work he has created since. A Johns Hopkins–trained surgeon, he has spent his career reviewing the scientific literature about longevity and sharing it as actionable content. His book, “Outlive: The Science and Art of Longevity” (New York: Penguin Random House, 2023) is a nice summary of his work. I recommend it.
Right now I’m switching between type 2 muscle fiber work (lots of jumping like my 2-year-old) and cardiovascular training including the aforementioned VO2max work. I cannot say that my patient inbox is any cleaner, or that I’m faster in the office, but I’m not flagging by the end of the day anymore. Master Chief challenged me to match his 10 pull-ups before he returns for his follow up visit. I’ll gladly give up Peloton sprints to work on that.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Evolve your website
The past few years have seen major transformations in the way health care websites operate and interact with patients. .
In mid-2018, a major Google algorithm change, known to the IT community as the “Medic Update,” significantly changed search criteria for most health and wellness websites. Another big update went live in late 2021. Websites that have not evolved with these changes have dropped in search rankings and provide a poorer user experience all around.
Many potential patients are searching for your services online, so your website cannot be an afterthought. Not only does it need to be designed with your target audience in mind, but it is also important to consider the metrics Google and other search engines now use when assessing the quality of your website so that patients will find it in the first place.
Here are some features that you (or your website company) need to prioritize to keep your site current and atop search results in 2023 and beyond.
Begin with an understandable URL. Search engines use URLs to determine how well your site, or a portion of it, matches search criteria. URLs also need to make sense to searchers, especially when they link specific areas of expertise (more on that in a minute). For example, a URL like “jonesdermatology.com/?p=89021” is meaningless to anyone except programmers; but “jonesdermatology.com/psoriasistreatments” obviously leads to a page about psoriasis treatments. Search engines look for not only the most relevant, but also the most helpful and user-friendly answers to a user’s query.
Incidentally, if the URL for your site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.
Continue with a good meta description. That’s the grayish text that follows the title and URL in search results. Searchers will read it to confirm that your site is what they seek, so make sure it describes exactly what you do, including any areas of special expertise.
Make your practice approachable with photos. New patients are more comfortable when they know what you look like, so real photos of you and your staff are always more effective than stock photos of models. Photos or a video tour of your office will reassure prospective patients that they will be visiting a clean, modern, professional facility.
Describe your principal services in detail. You never know which specific service a prospective patient is searching for, so describe everything you offer. Don’t try to summarize everything on a single page; relevance is determined by how deeply a topic is covered, so each principal service should have a detailed description on its own page. Not only will your skills become more visible to search engines, but you can also use the space to enumerate your qualifications and expertise in each area. Whenever possible, write your descriptions in question-and-answer form. Searchers tend to ask questions (“what is the best ... ?”), particularly in voice searches. Search engines increasingly value sites that ask and answer common questions.
Make your site interactive. “Interactivity” is a major buzzword in modern search engine parlance. Once searchers make an appointment, they stop searching. If they have to wait until the next day to call your office, they may keep looking – and might find a competitor with online scheduling. HIPAA-compliant chatbots, secure messaging, and online patient portals to access medical records, lab results, and other important information will also set your site apart.
Testimonials are essential. Amazon.com taught us that candid reviews from customers go a long way toward building the trust necessary to buy products and services, and nowhere is that truer than for medical services. According to one study, when it comes to finding a doctor, 88% of people trust online reviews as much as a personal recommendation. Loyal patients will be happy to write you glowing reviews; feature them prominently.
How does your site look on small screens? More than half of all searches are now made on smartphones, so the more mobile-friendly your site is, the higher it will be ranked. Prospective patients who are forced to scroll forever, or zoom in to tap a link, are likely to become frustrated and move on. Mobile searchers prefer sites that provide the best experience for the least amount of effort, and rankings tend to reflect that preference. You can test how easily a visitor can use your website on a mobile device with Google’s free Mobile-Friendly Test..
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The past few years have seen major transformations in the way health care websites operate and interact with patients. .
In mid-2018, a major Google algorithm change, known to the IT community as the “Medic Update,” significantly changed search criteria for most health and wellness websites. Another big update went live in late 2021. Websites that have not evolved with these changes have dropped in search rankings and provide a poorer user experience all around.
Many potential patients are searching for your services online, so your website cannot be an afterthought. Not only does it need to be designed with your target audience in mind, but it is also important to consider the metrics Google and other search engines now use when assessing the quality of your website so that patients will find it in the first place.
Here are some features that you (or your website company) need to prioritize to keep your site current and atop search results in 2023 and beyond.
Begin with an understandable URL. Search engines use URLs to determine how well your site, or a portion of it, matches search criteria. URLs also need to make sense to searchers, especially when they link specific areas of expertise (more on that in a minute). For example, a URL like “jonesdermatology.com/?p=89021” is meaningless to anyone except programmers; but “jonesdermatology.com/psoriasistreatments” obviously leads to a page about psoriasis treatments. Search engines look for not only the most relevant, but also the most helpful and user-friendly answers to a user’s query.
Incidentally, if the URL for your site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.
Continue with a good meta description. That’s the grayish text that follows the title and URL in search results. Searchers will read it to confirm that your site is what they seek, so make sure it describes exactly what you do, including any areas of special expertise.
Make your practice approachable with photos. New patients are more comfortable when they know what you look like, so real photos of you and your staff are always more effective than stock photos of models. Photos or a video tour of your office will reassure prospective patients that they will be visiting a clean, modern, professional facility.
Describe your principal services in detail. You never know which specific service a prospective patient is searching for, so describe everything you offer. Don’t try to summarize everything on a single page; relevance is determined by how deeply a topic is covered, so each principal service should have a detailed description on its own page. Not only will your skills become more visible to search engines, but you can also use the space to enumerate your qualifications and expertise in each area. Whenever possible, write your descriptions in question-and-answer form. Searchers tend to ask questions (“what is the best ... ?”), particularly in voice searches. Search engines increasingly value sites that ask and answer common questions.
Make your site interactive. “Interactivity” is a major buzzword in modern search engine parlance. Once searchers make an appointment, they stop searching. If they have to wait until the next day to call your office, they may keep looking – and might find a competitor with online scheduling. HIPAA-compliant chatbots, secure messaging, and online patient portals to access medical records, lab results, and other important information will also set your site apart.
Testimonials are essential. Amazon.com taught us that candid reviews from customers go a long way toward building the trust necessary to buy products and services, and nowhere is that truer than for medical services. According to one study, when it comes to finding a doctor, 88% of people trust online reviews as much as a personal recommendation. Loyal patients will be happy to write you glowing reviews; feature them prominently.
How does your site look on small screens? More than half of all searches are now made on smartphones, so the more mobile-friendly your site is, the higher it will be ranked. Prospective patients who are forced to scroll forever, or zoom in to tap a link, are likely to become frustrated and move on. Mobile searchers prefer sites that provide the best experience for the least amount of effort, and rankings tend to reflect that preference. You can test how easily a visitor can use your website on a mobile device with Google’s free Mobile-Friendly Test..
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The past few years have seen major transformations in the way health care websites operate and interact with patients. .
In mid-2018, a major Google algorithm change, known to the IT community as the “Medic Update,” significantly changed search criteria for most health and wellness websites. Another big update went live in late 2021. Websites that have not evolved with these changes have dropped in search rankings and provide a poorer user experience all around.
Many potential patients are searching for your services online, so your website cannot be an afterthought. Not only does it need to be designed with your target audience in mind, but it is also important to consider the metrics Google and other search engines now use when assessing the quality of your website so that patients will find it in the first place.
Here are some features that you (or your website company) need to prioritize to keep your site current and atop search results in 2023 and beyond.
Begin with an understandable URL. Search engines use URLs to determine how well your site, or a portion of it, matches search criteria. URLs also need to make sense to searchers, especially when they link specific areas of expertise (more on that in a minute). For example, a URL like “jonesdermatology.com/?p=89021” is meaningless to anyone except programmers; but “jonesdermatology.com/psoriasistreatments” obviously leads to a page about psoriasis treatments. Search engines look for not only the most relevant, but also the most helpful and user-friendly answers to a user’s query.
Incidentally, if the URL for your site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.
Continue with a good meta description. That’s the grayish text that follows the title and URL in search results. Searchers will read it to confirm that your site is what they seek, so make sure it describes exactly what you do, including any areas of special expertise.
Make your practice approachable with photos. New patients are more comfortable when they know what you look like, so real photos of you and your staff are always more effective than stock photos of models. Photos or a video tour of your office will reassure prospective patients that they will be visiting a clean, modern, professional facility.
Describe your principal services in detail. You never know which specific service a prospective patient is searching for, so describe everything you offer. Don’t try to summarize everything on a single page; relevance is determined by how deeply a topic is covered, so each principal service should have a detailed description on its own page. Not only will your skills become more visible to search engines, but you can also use the space to enumerate your qualifications and expertise in each area. Whenever possible, write your descriptions in question-and-answer form. Searchers tend to ask questions (“what is the best ... ?”), particularly in voice searches. Search engines increasingly value sites that ask and answer common questions.
Make your site interactive. “Interactivity” is a major buzzword in modern search engine parlance. Once searchers make an appointment, they stop searching. If they have to wait until the next day to call your office, they may keep looking – and might find a competitor with online scheduling. HIPAA-compliant chatbots, secure messaging, and online patient portals to access medical records, lab results, and other important information will also set your site apart.
Testimonials are essential. Amazon.com taught us that candid reviews from customers go a long way toward building the trust necessary to buy products and services, and nowhere is that truer than for medical services. According to one study, when it comes to finding a doctor, 88% of people trust online reviews as much as a personal recommendation. Loyal patients will be happy to write you glowing reviews; feature them prominently.
How does your site look on small screens? More than half of all searches are now made on smartphones, so the more mobile-friendly your site is, the higher it will be ranked. Prospective patients who are forced to scroll forever, or zoom in to tap a link, are likely to become frustrated and move on. Mobile searchers prefer sites that provide the best experience for the least amount of effort, and rankings tend to reflect that preference. You can test how easily a visitor can use your website on a mobile device with Google’s free Mobile-Friendly Test..
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Early menopause, delayed HT tied to Alzheimer’s pathology
Investigators found elevated levels of tau protein in the brains of women who initiated HT more than 5 years after menopause onset, while those who started the therapy earlier had normal levels.
Tau levels were also higher in women who started menopause before age 45, either naturally or following surgery, but only in those who already had high levels of beta-amyloid.
The findings were published online in JAMA Neurology.
Hotly debated
Previous research has suggested the timing of menopause and HT initiation may be associated with AD. However, the current research is the first to suggest tau deposition may explain that link.
“There have been a lot of conflicting findings around whether HT induces risk for Alzheimer’s disease dementia or not, and – at least in our hands – our observational evidence suggests that any risk is fairly limited to those rarer cases when women might delay their initiation of HT considerably,” senior investigator Rachel Buckley, PhD, assistant investigator in neurology at Massachusetts General Hospital and assistant professor of neurology at Harvard Medical School, Boston, told this news organization.
The link between HT, dementia, and cognitive decline has been hotly debated since the initial release of findings from the Women’s Health Initiative Memory Study, reported 20 years ago.
Since then, dozens of studies have yielded conflicting evidence about HT and AD risk, with some showing a protective effect and others showing the treatment may increase AD risk.
For this study, researchers analyzed data from 292 cognitively unimpaired participants (66.1% female) in the Wisconsin Registry for Alzheimer Prevention. About half of the women had received HT.
Women had higher levels of tau measured on PET imaging than age-matched males, even after adjustment for APOE status and other potential confounders.
Higher tau levels were found in those with an earlier age at menopause (P < .001) and HT use (P = .008) compared with male sex; later menopause onset; or HT nonuse – but only in patients who also had a higher beta-amyloid burden.
Late initiation of HT (> 5 years following age at menopause) was associated with higher tau compared with early initiation (P = .001), regardless of amyloid levels.
Surprising finding
Although researchers expected to find that surgical history (specifically oophorectomy) might have a greater impact on risk, that wasn’t the case.
“Given that bilateral oophorectomy involves the removal of both ovaries, and the immediate ceasing of estrogen production, I had expected this to be the primary driver of higher tau levels,” Dr. Buckley said. “But early age at menopause – regardless of whether the genesis was natural or surgical – seemed to have similar impacts.”
These findings are the latest from Dr. Buckley’s group that indicate that women tend to have higher levels of tau than men, regardless of preexisting amyloid burden in the brain.
“We see this in healthy older women, women with dementia, and even in postmortem cases,” Dr. Buckley said. “It really remains to be seen whether women tend to accumulate tau faster in the brain than men, or whether this is simply a one-shot phenomenon that we see in observational studies at the baseline.”
“One could really flip this finding on its head and suggest that women are truly resilient to the disease,” she continued. “That is, they can hold much more tau in their brain and remain well enough to be studied, unlike men.”
Among the study’s limitations is that the data were collected at a single time point and did not include information on subsequent Alzheimer’s diagnosis or cognitive decline.
“It is important to remember that the participants in this study were not as representative of the general population in the United States, so we cannot extrapolate our findings to women from a range of socioeconomic, racial and ethnic backgrounds or education levels,” she said.
The study’s observational design left researchers unable to demonstrate causation. What’s more, the findings don’t support the assertion that hormone therapy may protect against AD, Dr. Buckley added.
“I would more confidently say that evidence from our work, and that of many others, seems to suggest that HT initiated around the time of menopause may be benign – not providing benefit or risk, at least in the context of Alzheimer’s disease risk,” she said.
Another important takeaway from the study, Dr. Buckley said, is that not all women are at high risk for AD.
“Often the headlines might make you think that most women are destined to progress to dementia, but this simply is not the case,” Dr. Buckley said. “We are now starting to really drill down on what might elevate risk for AD in women and use this information to better inform clinical trials and doctors on how best to think about treating these higher-risk groups.”
New mechanism?
Commenting on the findings, Pauline Maki, PhD, professor of psychiatry, psychology and obstetrics & gynecology at the University of Illinois at Chicago, called the study “interesting.”
“It identifies a new mechanism in humans that could underlie a possible link between sex hormones and dementia,” Dr. Maki said.
However, Dr. Maki noted that the study wasn’t randomized and information about menopause onset was self-reported.
“We must remember that many of the hypotheses about hormone therapy and brain health that came from observational studies were not validated in randomized trials, including the hypothesis that hormone therapy prevents dementia,” she said.
The findings don’t resolve the debate over hormone therapy and AD risk and point to the need for randomized, prospective studies on the topic, Dr. Maki added. Still, she said, they underscore the gender disparity in AD risk.
“It’s a good reminder to clinicians that women have a higher lifetime risk of Alzheimer’s disease and should be advised on factors that might lower their risk,” she said.
The study was funded by the National Institutes of Health. Dr. Buckley reports no relevant financial conflicts. Dr. Maki serves on the advisory boards for Astellas, Bayer, Johnson & Johnson, consults for Pfizer and Mithra, and has equity in Estrigenix, Midi-Health, and Alloy.
A version of this article originally appeared on Medscape.com.
Investigators found elevated levels of tau protein in the brains of women who initiated HT more than 5 years after menopause onset, while those who started the therapy earlier had normal levels.
Tau levels were also higher in women who started menopause before age 45, either naturally or following surgery, but only in those who already had high levels of beta-amyloid.
The findings were published online in JAMA Neurology.
Hotly debated
Previous research has suggested the timing of menopause and HT initiation may be associated with AD. However, the current research is the first to suggest tau deposition may explain that link.
“There have been a lot of conflicting findings around whether HT induces risk for Alzheimer’s disease dementia or not, and – at least in our hands – our observational evidence suggests that any risk is fairly limited to those rarer cases when women might delay their initiation of HT considerably,” senior investigator Rachel Buckley, PhD, assistant investigator in neurology at Massachusetts General Hospital and assistant professor of neurology at Harvard Medical School, Boston, told this news organization.
The link between HT, dementia, and cognitive decline has been hotly debated since the initial release of findings from the Women’s Health Initiative Memory Study, reported 20 years ago.
Since then, dozens of studies have yielded conflicting evidence about HT and AD risk, with some showing a protective effect and others showing the treatment may increase AD risk.
For this study, researchers analyzed data from 292 cognitively unimpaired participants (66.1% female) in the Wisconsin Registry for Alzheimer Prevention. About half of the women had received HT.
Women had higher levels of tau measured on PET imaging than age-matched males, even after adjustment for APOE status and other potential confounders.
Higher tau levels were found in those with an earlier age at menopause (P < .001) and HT use (P = .008) compared with male sex; later menopause onset; or HT nonuse – but only in patients who also had a higher beta-amyloid burden.
Late initiation of HT (> 5 years following age at menopause) was associated with higher tau compared with early initiation (P = .001), regardless of amyloid levels.
Surprising finding
Although researchers expected to find that surgical history (specifically oophorectomy) might have a greater impact on risk, that wasn’t the case.
“Given that bilateral oophorectomy involves the removal of both ovaries, and the immediate ceasing of estrogen production, I had expected this to be the primary driver of higher tau levels,” Dr. Buckley said. “But early age at menopause – regardless of whether the genesis was natural or surgical – seemed to have similar impacts.”
These findings are the latest from Dr. Buckley’s group that indicate that women tend to have higher levels of tau than men, regardless of preexisting amyloid burden in the brain.
“We see this in healthy older women, women with dementia, and even in postmortem cases,” Dr. Buckley said. “It really remains to be seen whether women tend to accumulate tau faster in the brain than men, or whether this is simply a one-shot phenomenon that we see in observational studies at the baseline.”
“One could really flip this finding on its head and suggest that women are truly resilient to the disease,” she continued. “That is, they can hold much more tau in their brain and remain well enough to be studied, unlike men.”
Among the study’s limitations is that the data were collected at a single time point and did not include information on subsequent Alzheimer’s diagnosis or cognitive decline.
“It is important to remember that the participants in this study were not as representative of the general population in the United States, so we cannot extrapolate our findings to women from a range of socioeconomic, racial and ethnic backgrounds or education levels,” she said.
The study’s observational design left researchers unable to demonstrate causation. What’s more, the findings don’t support the assertion that hormone therapy may protect against AD, Dr. Buckley added.
“I would more confidently say that evidence from our work, and that of many others, seems to suggest that HT initiated around the time of menopause may be benign – not providing benefit or risk, at least in the context of Alzheimer’s disease risk,” she said.
Another important takeaway from the study, Dr. Buckley said, is that not all women are at high risk for AD.
“Often the headlines might make you think that most women are destined to progress to dementia, but this simply is not the case,” Dr. Buckley said. “We are now starting to really drill down on what might elevate risk for AD in women and use this information to better inform clinical trials and doctors on how best to think about treating these higher-risk groups.”
New mechanism?
Commenting on the findings, Pauline Maki, PhD, professor of psychiatry, psychology and obstetrics & gynecology at the University of Illinois at Chicago, called the study “interesting.”
“It identifies a new mechanism in humans that could underlie a possible link between sex hormones and dementia,” Dr. Maki said.
However, Dr. Maki noted that the study wasn’t randomized and information about menopause onset was self-reported.
“We must remember that many of the hypotheses about hormone therapy and brain health that came from observational studies were not validated in randomized trials, including the hypothesis that hormone therapy prevents dementia,” she said.
The findings don’t resolve the debate over hormone therapy and AD risk and point to the need for randomized, prospective studies on the topic, Dr. Maki added. Still, she said, they underscore the gender disparity in AD risk.
“It’s a good reminder to clinicians that women have a higher lifetime risk of Alzheimer’s disease and should be advised on factors that might lower their risk,” she said.
The study was funded by the National Institutes of Health. Dr. Buckley reports no relevant financial conflicts. Dr. Maki serves on the advisory boards for Astellas, Bayer, Johnson & Johnson, consults for Pfizer and Mithra, and has equity in Estrigenix, Midi-Health, and Alloy.
A version of this article originally appeared on Medscape.com.
Investigators found elevated levels of tau protein in the brains of women who initiated HT more than 5 years after menopause onset, while those who started the therapy earlier had normal levels.
Tau levels were also higher in women who started menopause before age 45, either naturally or following surgery, but only in those who already had high levels of beta-amyloid.
The findings were published online in JAMA Neurology.
Hotly debated
Previous research has suggested the timing of menopause and HT initiation may be associated with AD. However, the current research is the first to suggest tau deposition may explain that link.
“There have been a lot of conflicting findings around whether HT induces risk for Alzheimer’s disease dementia or not, and – at least in our hands – our observational evidence suggests that any risk is fairly limited to those rarer cases when women might delay their initiation of HT considerably,” senior investigator Rachel Buckley, PhD, assistant investigator in neurology at Massachusetts General Hospital and assistant professor of neurology at Harvard Medical School, Boston, told this news organization.
The link between HT, dementia, and cognitive decline has been hotly debated since the initial release of findings from the Women’s Health Initiative Memory Study, reported 20 years ago.
Since then, dozens of studies have yielded conflicting evidence about HT and AD risk, with some showing a protective effect and others showing the treatment may increase AD risk.
For this study, researchers analyzed data from 292 cognitively unimpaired participants (66.1% female) in the Wisconsin Registry for Alzheimer Prevention. About half of the women had received HT.
Women had higher levels of tau measured on PET imaging than age-matched males, even after adjustment for APOE status and other potential confounders.
Higher tau levels were found in those with an earlier age at menopause (P < .001) and HT use (P = .008) compared with male sex; later menopause onset; or HT nonuse – but only in patients who also had a higher beta-amyloid burden.
Late initiation of HT (> 5 years following age at menopause) was associated with higher tau compared with early initiation (P = .001), regardless of amyloid levels.
Surprising finding
Although researchers expected to find that surgical history (specifically oophorectomy) might have a greater impact on risk, that wasn’t the case.
“Given that bilateral oophorectomy involves the removal of both ovaries, and the immediate ceasing of estrogen production, I had expected this to be the primary driver of higher tau levels,” Dr. Buckley said. “But early age at menopause – regardless of whether the genesis was natural or surgical – seemed to have similar impacts.”
These findings are the latest from Dr. Buckley’s group that indicate that women tend to have higher levels of tau than men, regardless of preexisting amyloid burden in the brain.
“We see this in healthy older women, women with dementia, and even in postmortem cases,” Dr. Buckley said. “It really remains to be seen whether women tend to accumulate tau faster in the brain than men, or whether this is simply a one-shot phenomenon that we see in observational studies at the baseline.”
“One could really flip this finding on its head and suggest that women are truly resilient to the disease,” she continued. “That is, they can hold much more tau in their brain and remain well enough to be studied, unlike men.”
Among the study’s limitations is that the data were collected at a single time point and did not include information on subsequent Alzheimer’s diagnosis or cognitive decline.
“It is important to remember that the participants in this study were not as representative of the general population in the United States, so we cannot extrapolate our findings to women from a range of socioeconomic, racial and ethnic backgrounds or education levels,” she said.
The study’s observational design left researchers unable to demonstrate causation. What’s more, the findings don’t support the assertion that hormone therapy may protect against AD, Dr. Buckley added.
“I would more confidently say that evidence from our work, and that of many others, seems to suggest that HT initiated around the time of menopause may be benign – not providing benefit or risk, at least in the context of Alzheimer’s disease risk,” she said.
Another important takeaway from the study, Dr. Buckley said, is that not all women are at high risk for AD.
“Often the headlines might make you think that most women are destined to progress to dementia, but this simply is not the case,” Dr. Buckley said. “We are now starting to really drill down on what might elevate risk for AD in women and use this information to better inform clinical trials and doctors on how best to think about treating these higher-risk groups.”
New mechanism?
Commenting on the findings, Pauline Maki, PhD, professor of psychiatry, psychology and obstetrics & gynecology at the University of Illinois at Chicago, called the study “interesting.”
“It identifies a new mechanism in humans that could underlie a possible link between sex hormones and dementia,” Dr. Maki said.
However, Dr. Maki noted that the study wasn’t randomized and information about menopause onset was self-reported.
“We must remember that many of the hypotheses about hormone therapy and brain health that came from observational studies were not validated in randomized trials, including the hypothesis that hormone therapy prevents dementia,” she said.
The findings don’t resolve the debate over hormone therapy and AD risk and point to the need for randomized, prospective studies on the topic, Dr. Maki added. Still, she said, they underscore the gender disparity in AD risk.
“It’s a good reminder to clinicians that women have a higher lifetime risk of Alzheimer’s disease and should be advised on factors that might lower their risk,” she said.
The study was funded by the National Institutes of Health. Dr. Buckley reports no relevant financial conflicts. Dr. Maki serves on the advisory boards for Astellas, Bayer, Johnson & Johnson, consults for Pfizer and Mithra, and has equity in Estrigenix, Midi-Health, and Alloy.
A version of this article originally appeared on Medscape.com.
FROM JAMA NEUROLOGY
Get action! – Teddy Roosevelt
“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!
No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.
Yes, for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”
Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.
Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”
Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.
Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.
Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!
No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.
Yes, for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”
Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.
Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”
Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.
Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.
Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!
No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.
Yes, for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”
Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.
Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”
Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.
Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.
Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
OSHA revisited
Time for my periodic reminder about your Occupational Health and Safety Administration (OSHA) obligations. The health care field still has the most work-related illness and injury reports of any industry in the United States, and OSHA standards are in place to minimize potential workplace incidents.
Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain sight, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s website or order one at no charge by calling 800-321-OSHA.
The poster discusses the “general standards” that all workplaces must comply with to avoid work-related illnesses and injuries. The standards most applicable to medical offices are those dealing with personal protective equipment (PPE), bloodborne pathogens, hazard communication, and – increasingly, of late – ionizing radiation.
Physicians have become all too familiar with the PPE standard as a result of the COVID pandemic. Ironically, OSHA considers PPE a less acceptable means of employee protection than the other standards, as safe work practices should always supersede safety equipment. Nevertheless, employers must have a PPE program in place to train employees on what equipment is necessary, and under which conditions.
You also need a written exposure control plan for bloodborne pathogens. It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology. You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at that decision, and why you feel that your current protocol is as good or better.
The hazard communication (or right-to-know) standard involves compiling a list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
If your office has x-ray equipment, or you are considering one of the new image-guided superficial radiotherapy machines, you must be in compliance with the ionizing radiation standard, which entails shielding, radiation monitors, and clear labeling of equipment.
Other, more general regulations include the physical setup of your office. Everyone must be able to evacuate quickly in case of fire or other emergencies. At a minimum, you (or the owner of the office building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it, and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars. How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Time for my periodic reminder about your Occupational Health and Safety Administration (OSHA) obligations. The health care field still has the most work-related illness and injury reports of any industry in the United States, and OSHA standards are in place to minimize potential workplace incidents.
Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain sight, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s website or order one at no charge by calling 800-321-OSHA.
The poster discusses the “general standards” that all workplaces must comply with to avoid work-related illnesses and injuries. The standards most applicable to medical offices are those dealing with personal protective equipment (PPE), bloodborne pathogens, hazard communication, and – increasingly, of late – ionizing radiation.
Physicians have become all too familiar with the PPE standard as a result of the COVID pandemic. Ironically, OSHA considers PPE a less acceptable means of employee protection than the other standards, as safe work practices should always supersede safety equipment. Nevertheless, employers must have a PPE program in place to train employees on what equipment is necessary, and under which conditions.
You also need a written exposure control plan for bloodborne pathogens. It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology. You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at that decision, and why you feel that your current protocol is as good or better.
The hazard communication (or right-to-know) standard involves compiling a list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
If your office has x-ray equipment, or you are considering one of the new image-guided superficial radiotherapy machines, you must be in compliance with the ionizing radiation standard, which entails shielding, radiation monitors, and clear labeling of equipment.
Other, more general regulations include the physical setup of your office. Everyone must be able to evacuate quickly in case of fire or other emergencies. At a minimum, you (or the owner of the office building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it, and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars. How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Time for my periodic reminder about your Occupational Health and Safety Administration (OSHA) obligations. The health care field still has the most work-related illness and injury reports of any industry in the United States, and OSHA standards are in place to minimize potential workplace incidents.
Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain sight, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s website or order one at no charge by calling 800-321-OSHA.
The poster discusses the “general standards” that all workplaces must comply with to avoid work-related illnesses and injuries. The standards most applicable to medical offices are those dealing with personal protective equipment (PPE), bloodborne pathogens, hazard communication, and – increasingly, of late – ionizing radiation.
Physicians have become all too familiar with the PPE standard as a result of the COVID pandemic. Ironically, OSHA considers PPE a less acceptable means of employee protection than the other standards, as safe work practices should always supersede safety equipment. Nevertheless, employers must have a PPE program in place to train employees on what equipment is necessary, and under which conditions.
You also need a written exposure control plan for bloodborne pathogens. It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology. You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at that decision, and why you feel that your current protocol is as good or better.
The hazard communication (or right-to-know) standard involves compiling a list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
If your office has x-ray equipment, or you are considering one of the new image-guided superficial radiotherapy machines, you must be in compliance with the ionizing radiation standard, which entails shielding, radiation monitors, and clear labeling of equipment.
Other, more general regulations include the physical setup of your office. Everyone must be able to evacuate quickly in case of fire or other emergencies. At a minimum, you (or the owner of the office building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it, and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars. How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
How to become wise
The only true wisdom is in knowing you know nothing. – Socrates
At what age is one supposed to be wise? I feel like I’m falling behind. I’ve crossed the middle of life and can check the prerequisite experiences: Joy, tragedy, love, adventure, love again. I lived a jetsetter life with an overnight bag always packed. I’ve sported the “Dad AF” tee with a fully loaded dad-pack. I’ve seen the 50 states and had my picture wrapped on a city bus (super-weird when you pull up next to one). Yet, when a moment arrives to pop in pithy advice for a resident or drop a few reassuring lines for a grieving friend, I’m often unable to find the words. If life were a video game, I’ve not earned the wisdom level yet.
Who are the wise men and women in your life? It’s difficult to list them. This is because it’s a complex attribute and hard to explain. It’s also because the wise who walk among us are rare. Wise is more than being brilliant at bullous diseases or knowing how to sleep train a baby. Nor is wise the buddy who purchased $1,000 of Bitcoin in 2010 (although stay close with him, he probably owns a jet). Neither content experts nor lucky friends rise to the appellation. Both experience and empathy.
The ancients considered wisdom to be one of the vital virtues. It was personified in high-profile gods like Apollo and Athena. It’s rare and important enough to be seen as spiritual. It features heavily in the Bible, the Bhagavad Gita, the Meditations of Marcus Aurelius. In some cultures the wise are called elders or sages. In all cultures they are helpful, respected, sought after, appreciated. We need more wise people in this game of life. I want to be one. But there’s no Coursera for it.
To become wise you have to pass through many levels, put in a lot of reps, suffer through many sleepless nights. Like the third molar, also known as the wisdom tooth, it takes years. You also have to emerge stronger and smarter through those experiences. FDR would not have become one of the wisest presidents in history had it not been for his trials, and victories, over polio. Osler missed Cushing syndrome multiple times before he got it right. It seems you have to go to the mountain, like Batman, and fight a few battles to realize your full wisdom potential.
You must also reflect on your experiences and hone your insight. The management sage Peter Drucker would write what he expected to happen after a decision. Then he’d return to it to hone his intuition and judgment.
Lastly, you have to use your powers for good. Using insight to win your NCAA bracket pool isn’t wisdom. Helping a friend whose marriage is falling apart or colleague whose patient is suing them or a resident whose excision hit an arteriole surely is.
I’ve got a ways to go before anyone puts me on their wise friend list. I’m working on it though. Perhaps you will too – we are desperately short-staffed in this area. For now, I can start with writing better condolences.
“Who maintains that it is not a heavy blow? But it is part of being human.” – Seneca
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
The only true wisdom is in knowing you know nothing. – Socrates
At what age is one supposed to be wise? I feel like I’m falling behind. I’ve crossed the middle of life and can check the prerequisite experiences: Joy, tragedy, love, adventure, love again. I lived a jetsetter life with an overnight bag always packed. I’ve sported the “Dad AF” tee with a fully loaded dad-pack. I’ve seen the 50 states and had my picture wrapped on a city bus (super-weird when you pull up next to one). Yet, when a moment arrives to pop in pithy advice for a resident or drop a few reassuring lines for a grieving friend, I’m often unable to find the words. If life were a video game, I’ve not earned the wisdom level yet.
Who are the wise men and women in your life? It’s difficult to list them. This is because it’s a complex attribute and hard to explain. It’s also because the wise who walk among us are rare. Wise is more than being brilliant at bullous diseases or knowing how to sleep train a baby. Nor is wise the buddy who purchased $1,000 of Bitcoin in 2010 (although stay close with him, he probably owns a jet). Neither content experts nor lucky friends rise to the appellation. Both experience and empathy.
The ancients considered wisdom to be one of the vital virtues. It was personified in high-profile gods like Apollo and Athena. It’s rare and important enough to be seen as spiritual. It features heavily in the Bible, the Bhagavad Gita, the Meditations of Marcus Aurelius. In some cultures the wise are called elders or sages. In all cultures they are helpful, respected, sought after, appreciated. We need more wise people in this game of life. I want to be one. But there’s no Coursera for it.
To become wise you have to pass through many levels, put in a lot of reps, suffer through many sleepless nights. Like the third molar, also known as the wisdom tooth, it takes years. You also have to emerge stronger and smarter through those experiences. FDR would not have become one of the wisest presidents in history had it not been for his trials, and victories, over polio. Osler missed Cushing syndrome multiple times before he got it right. It seems you have to go to the mountain, like Batman, and fight a few battles to realize your full wisdom potential.
You must also reflect on your experiences and hone your insight. The management sage Peter Drucker would write what he expected to happen after a decision. Then he’d return to it to hone his intuition and judgment.
Lastly, you have to use your powers for good. Using insight to win your NCAA bracket pool isn’t wisdom. Helping a friend whose marriage is falling apart or colleague whose patient is suing them or a resident whose excision hit an arteriole surely is.
I’ve got a ways to go before anyone puts me on their wise friend list. I’m working on it though. Perhaps you will too – we are desperately short-staffed in this area. For now, I can start with writing better condolences.
“Who maintains that it is not a heavy blow? But it is part of being human.” – Seneca
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
The only true wisdom is in knowing you know nothing. – Socrates
At what age is one supposed to be wise? I feel like I’m falling behind. I’ve crossed the middle of life and can check the prerequisite experiences: Joy, tragedy, love, adventure, love again. I lived a jetsetter life with an overnight bag always packed. I’ve sported the “Dad AF” tee with a fully loaded dad-pack. I’ve seen the 50 states and had my picture wrapped on a city bus (super-weird when you pull up next to one). Yet, when a moment arrives to pop in pithy advice for a resident or drop a few reassuring lines for a grieving friend, I’m often unable to find the words. If life were a video game, I’ve not earned the wisdom level yet.
Who are the wise men and women in your life? It’s difficult to list them. This is because it’s a complex attribute and hard to explain. It’s also because the wise who walk among us are rare. Wise is more than being brilliant at bullous diseases or knowing how to sleep train a baby. Nor is wise the buddy who purchased $1,000 of Bitcoin in 2010 (although stay close with him, he probably owns a jet). Neither content experts nor lucky friends rise to the appellation. Both experience and empathy.
The ancients considered wisdom to be one of the vital virtues. It was personified in high-profile gods like Apollo and Athena. It’s rare and important enough to be seen as spiritual. It features heavily in the Bible, the Bhagavad Gita, the Meditations of Marcus Aurelius. In some cultures the wise are called elders or sages. In all cultures they are helpful, respected, sought after, appreciated. We need more wise people in this game of life. I want to be one. But there’s no Coursera for it.
To become wise you have to pass through many levels, put in a lot of reps, suffer through many sleepless nights. Like the third molar, also known as the wisdom tooth, it takes years. You also have to emerge stronger and smarter through those experiences. FDR would not have become one of the wisest presidents in history had it not been for his trials, and victories, over polio. Osler missed Cushing syndrome multiple times before he got it right. It seems you have to go to the mountain, like Batman, and fight a few battles to realize your full wisdom potential.
You must also reflect on your experiences and hone your insight. The management sage Peter Drucker would write what he expected to happen after a decision. Then he’d return to it to hone his intuition and judgment.
Lastly, you have to use your powers for good. Using insight to win your NCAA bracket pool isn’t wisdom. Helping a friend whose marriage is falling apart or colleague whose patient is suing them or a resident whose excision hit an arteriole surely is.
I’ve got a ways to go before anyone puts me on their wise friend list. I’m working on it though. Perhaps you will too – we are desperately short-staffed in this area. For now, I can start with writing better condolences.
“Who maintains that it is not a heavy blow? But it is part of being human.” – Seneca
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Firing patients
One might assume that, just as patients are free to accept or reject their doctors, physicians have an equal right to reject their patients; to a certain extent, that is true. There are no specific laws prohibiting a provider from terminating a patient relationship for any reason, other than a discriminatory one – race, nationality, religion, age, gender, sexual orientation, and so on. However, the evolution of ever-larger practice environments has raised new questions.
While verbal abuse, inappropriate treatment demands (particularly for controlled substances), refusal to adhere to mutually agreed treatment plans, and failure to keep appointments or pay bills remain the most common reasons for dismissal, evolving practice environments may require us to modify our responses.
What happens, for example, when a patient is banned from a large clinic that employs most of that community’s physicians, or is the only practice in town with the specialists required by that patient? The medical profession does have an obligation to not exclude such patients from care.
In a large cross-specialty system or consolidated specialist practice, firing a patient has a very different level of consequences than in a small office. There must be a balance between separating patients and doctors who don’t get along and seeing that the patient in question receives competent treatment. The physician, as the professional, has a higher standard to live up to with respect to handling this kind of situation.
If the problem is a personality conflict, the solution may be as simple as transferring the patient to another caregiver within the practice. While it does not make sense for a patient to continue seeing a doctor who does not want to see them, it also does not make sense to ban a patient from a large system where there could well be one or more other doctors who would be a good match. If a patient is unable to pay outstanding bills, a large clinic might prohibit them from making new appointments until they have worked out a payment plan rather than firing them outright.
If you are part of a large practice, take the time to research your group’s official policies for dealing with such situations. If there is no written policy, you might want to start that discussion with your colleagues.
The point is that in any practice, large or small, firing a patient should be a last resort. Try to make every effort to resolve the problem amicably. Communicate with the patient in question, explain your concerns, and discuss options for resolution. Take time to listen to the patient, as they may have an explanation (rational or not) for their objectionable behavior.
You can also send a letter, repeating your concerns and proposed solutions, as further documentation of your efforts to achieve an amicable resolution. All verbal and written warnings must, of course, be documented. If the patient has a managed care policy, we review the managed care contract, which sometimes includes specific requirements for dismissal of its patients.
When such efforts fail, we send the patient two letters – one certified with return receipt, the other by conventional first class, in case the patient refuses the certified copy – explaining the reason for dismissal, and that care will be discontinued in 30 days from the letter’s date. (Most attorneys and medical associations agree that 30 days is sufficient reasonable notice.) We offer to provide care during the interim period, include a list of names and contact information for potential alternate providers, and offer to transfer records after receiving written permission.
Following these precautions will usually protect you from charges of “patient abandonment,” which is generally defined as the unilateral severance by the physician of the physician-patient relationship without giving the patient sufficient advance notice to obtain the services of another practitioner, and at a time when the patient still requires medical attention.
Some states have their own unique definitions of patient abandonment. You should check with your state’s health department, and your attorney, for any unusual requirements in your state, because violating them could lead to intervention by your state licensing board. There is also the risk of civil litigation, which is typically not covered by malpractice policies, and may not be covered by your general liability policy either.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
One might assume that, just as patients are free to accept or reject their doctors, physicians have an equal right to reject their patients; to a certain extent, that is true. There are no specific laws prohibiting a provider from terminating a patient relationship for any reason, other than a discriminatory one – race, nationality, religion, age, gender, sexual orientation, and so on. However, the evolution of ever-larger practice environments has raised new questions.
While verbal abuse, inappropriate treatment demands (particularly for controlled substances), refusal to adhere to mutually agreed treatment plans, and failure to keep appointments or pay bills remain the most common reasons for dismissal, evolving practice environments may require us to modify our responses.
What happens, for example, when a patient is banned from a large clinic that employs most of that community’s physicians, or is the only practice in town with the specialists required by that patient? The medical profession does have an obligation to not exclude such patients from care.
In a large cross-specialty system or consolidated specialist practice, firing a patient has a very different level of consequences than in a small office. There must be a balance between separating patients and doctors who don’t get along and seeing that the patient in question receives competent treatment. The physician, as the professional, has a higher standard to live up to with respect to handling this kind of situation.
If the problem is a personality conflict, the solution may be as simple as transferring the patient to another caregiver within the practice. While it does not make sense for a patient to continue seeing a doctor who does not want to see them, it also does not make sense to ban a patient from a large system where there could well be one or more other doctors who would be a good match. If a patient is unable to pay outstanding bills, a large clinic might prohibit them from making new appointments until they have worked out a payment plan rather than firing them outright.
If you are part of a large practice, take the time to research your group’s official policies for dealing with such situations. If there is no written policy, you might want to start that discussion with your colleagues.
The point is that in any practice, large or small, firing a patient should be a last resort. Try to make every effort to resolve the problem amicably. Communicate with the patient in question, explain your concerns, and discuss options for resolution. Take time to listen to the patient, as they may have an explanation (rational or not) for their objectionable behavior.
You can also send a letter, repeating your concerns and proposed solutions, as further documentation of your efforts to achieve an amicable resolution. All verbal and written warnings must, of course, be documented. If the patient has a managed care policy, we review the managed care contract, which sometimes includes specific requirements for dismissal of its patients.
When such efforts fail, we send the patient two letters – one certified with return receipt, the other by conventional first class, in case the patient refuses the certified copy – explaining the reason for dismissal, and that care will be discontinued in 30 days from the letter’s date. (Most attorneys and medical associations agree that 30 days is sufficient reasonable notice.) We offer to provide care during the interim period, include a list of names and contact information for potential alternate providers, and offer to transfer records after receiving written permission.
Following these precautions will usually protect you from charges of “patient abandonment,” which is generally defined as the unilateral severance by the physician of the physician-patient relationship without giving the patient sufficient advance notice to obtain the services of another practitioner, and at a time when the patient still requires medical attention.
Some states have their own unique definitions of patient abandonment. You should check with your state’s health department, and your attorney, for any unusual requirements in your state, because violating them could lead to intervention by your state licensing board. There is also the risk of civil litigation, which is typically not covered by malpractice policies, and may not be covered by your general liability policy either.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
One might assume that, just as patients are free to accept or reject their doctors, physicians have an equal right to reject their patients; to a certain extent, that is true. There are no specific laws prohibiting a provider from terminating a patient relationship for any reason, other than a discriminatory one – race, nationality, religion, age, gender, sexual orientation, and so on. However, the evolution of ever-larger practice environments has raised new questions.
While verbal abuse, inappropriate treatment demands (particularly for controlled substances), refusal to adhere to mutually agreed treatment plans, and failure to keep appointments or pay bills remain the most common reasons for dismissal, evolving practice environments may require us to modify our responses.
What happens, for example, when a patient is banned from a large clinic that employs most of that community’s physicians, or is the only practice in town with the specialists required by that patient? The medical profession does have an obligation to not exclude such patients from care.
In a large cross-specialty system or consolidated specialist practice, firing a patient has a very different level of consequences than in a small office. There must be a balance between separating patients and doctors who don’t get along and seeing that the patient in question receives competent treatment. The physician, as the professional, has a higher standard to live up to with respect to handling this kind of situation.
If the problem is a personality conflict, the solution may be as simple as transferring the patient to another caregiver within the practice. While it does not make sense for a patient to continue seeing a doctor who does not want to see them, it also does not make sense to ban a patient from a large system where there could well be one or more other doctors who would be a good match. If a patient is unable to pay outstanding bills, a large clinic might prohibit them from making new appointments until they have worked out a payment plan rather than firing them outright.
If you are part of a large practice, take the time to research your group’s official policies for dealing with such situations. If there is no written policy, you might want to start that discussion with your colleagues.
The point is that in any practice, large or small, firing a patient should be a last resort. Try to make every effort to resolve the problem amicably. Communicate with the patient in question, explain your concerns, and discuss options for resolution. Take time to listen to the patient, as they may have an explanation (rational or not) for their objectionable behavior.
You can also send a letter, repeating your concerns and proposed solutions, as further documentation of your efforts to achieve an amicable resolution. All verbal and written warnings must, of course, be documented. If the patient has a managed care policy, we review the managed care contract, which sometimes includes specific requirements for dismissal of its patients.
When such efforts fail, we send the patient two letters – one certified with return receipt, the other by conventional first class, in case the patient refuses the certified copy – explaining the reason for dismissal, and that care will be discontinued in 30 days from the letter’s date. (Most attorneys and medical associations agree that 30 days is sufficient reasonable notice.) We offer to provide care during the interim period, include a list of names and contact information for potential alternate providers, and offer to transfer records after receiving written permission.
Following these precautions will usually protect you from charges of “patient abandonment,” which is generally defined as the unilateral severance by the physician of the physician-patient relationship without giving the patient sufficient advance notice to obtain the services of another practitioner, and at a time when the patient still requires medical attention.
Some states have their own unique definitions of patient abandonment. You should check with your state’s health department, and your attorney, for any unusual requirements in your state, because violating them could lead to intervention by your state licensing board. There is also the risk of civil litigation, which is typically not covered by malpractice policies, and may not be covered by your general liability policy either.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].