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Weathering this storm and the next
Perspectives on disaster preparedness amid COVID-19
The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.
But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.
Disaster preparedness and assessing ongoing needs
Disaster preparedness cycle and Hazard Vulnerability Assessment
The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.
The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”7
Disaster preparedness staffing considerations
Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.8
To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.
While the COVID-19 pandemic did not significantly affect children, our ride-out and relief teams would have played a significant role in case a surge of pediatric cases had occurred.
Other considerations for disaster staffing include expanding backup coverage and for multisite groups, identifying site leads to help field specific questions or concerns. Lastly, understanding the staffing needs of the hospital during a disaster is vital – bidirectional communication between physicians and hospital leadership optimizes preparedness plans. These measures will help staff feel supported before, during, and after a disaster.
Dynamic disaster response
Supporting patient and hospital needs
The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.
As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.
Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.11 Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.
Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
Unique staffing situations related to COVID-19
Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.12 Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.
We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.
Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.
Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
Preparing for the next disaster during the pandemic
This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.13-15
How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.
Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”9 This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
Conclusion
Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.
Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.
References
1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.
2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.
3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.
4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.
5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.
6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.
7. Hospital Association of Southern California. Hazard and vulnerability analysis.
8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.
9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.
10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.
11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.
12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.
13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.
14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.
15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.
Perspectives on disaster preparedness amid COVID-19
Perspectives on disaster preparedness amid COVID-19
The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.
But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.
Disaster preparedness and assessing ongoing needs
Disaster preparedness cycle and Hazard Vulnerability Assessment
The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.
The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”7
Disaster preparedness staffing considerations
Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.8
To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.
While the COVID-19 pandemic did not significantly affect children, our ride-out and relief teams would have played a significant role in case a surge of pediatric cases had occurred.
Other considerations for disaster staffing include expanding backup coverage and for multisite groups, identifying site leads to help field specific questions or concerns. Lastly, understanding the staffing needs of the hospital during a disaster is vital – bidirectional communication between physicians and hospital leadership optimizes preparedness plans. These measures will help staff feel supported before, during, and after a disaster.
Dynamic disaster response
Supporting patient and hospital needs
The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.
As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.
Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.11 Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.
Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
Unique staffing situations related to COVID-19
Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.12 Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.
We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.
Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.
Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
Preparing for the next disaster during the pandemic
This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.13-15
How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.
Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”9 This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
Conclusion
Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.
Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.
References
1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.
2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.
3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.
4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.
5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.
6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.
7. Hospital Association of Southern California. Hazard and vulnerability analysis.
8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.
9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.
10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.
11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.
12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.
13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.
14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.
15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.
The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.
But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.
Disaster preparedness and assessing ongoing needs
Disaster preparedness cycle and Hazard Vulnerability Assessment
The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.
The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”7
Disaster preparedness staffing considerations
Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.8
To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.
While the COVID-19 pandemic did not significantly affect children, our ride-out and relief teams would have played a significant role in case a surge of pediatric cases had occurred.
Other considerations for disaster staffing include expanding backup coverage and for multisite groups, identifying site leads to help field specific questions or concerns. Lastly, understanding the staffing needs of the hospital during a disaster is vital – bidirectional communication between physicians and hospital leadership optimizes preparedness plans. These measures will help staff feel supported before, during, and after a disaster.
Dynamic disaster response
Supporting patient and hospital needs
The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.
As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.
Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.11 Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.
Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
Unique staffing situations related to COVID-19
Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.12 Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.
We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.
Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.
Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
Preparing for the next disaster during the pandemic
This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.13-15
How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.
Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”9 This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
Conclusion
Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.
Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.
References
1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.
2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.
3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.
4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.
5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.
6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.
7. Hospital Association of Southern California. Hazard and vulnerability analysis.
8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.
9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.
10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.
11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.
12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.
13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.
14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.
15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.
Low depression scores may miss seniors with suicidal intent
Older adults may have a high degree of suicidal intent yet still have low scores on scales measuring psychiatric symptoms, such as depression, new research suggests.
In a cross-sectional cohort study of more than 800 adults who presented with self-harm to psychiatric EDs in Sweden, participants aged 65 years and older scored higher than younger and middle-aged adults on measures of suicidal intent.
However, only half of the older group fulfilled criteria for major depression, compared with three-quarters of both the middle-aged and young adult–aged groups.
“Suicidal older persons show a somewhat different clinical picture with relatively low levels of psychopathology but with high suicide intent compared to younger persons,” lead author Stefan Wiktorsson, PhD, University of Gothenburg (Sweden), said in an interview.
“It is therefore of importance for clinicians to carefully evaluate suicidal thinking in this age group. he said.
The findings were published online Aug. 9, 2021, in the American Journal of Geriatric Psychiatry.
Research by age groups ‘lacking’
“While there are large age differences in the prevalence of suicidal behavior, research studies that compare symptomatology and diagnostics in different age groups are lacking,” Dr. Wiktorsson said.
He and his colleagues “wanted to compare psychopathology in young, middle-aged, and older adults in order to increase knowledge about potential differences in symptomatology related to suicidal behavior over the life span.”
The researchers recruited patients aged 18 years and older who had sought or had been referred to emergency psychiatric services for self-harm at three psychiatric hospitals in Sweden between April 2012 and March 2016.
Among all patients, 821 fit inclusion criteria and agreed to participate. The researchers excluded participants who had engaged in nonsuicidal self-injury (NNSI), as determined on the basis of the Columbia Suicide Severity Rating Scale (C-SSRS). The remaining 683 participants, who had attempted suicide, were included in the analysis.
The participants were then divided into the following three groups: older (n = 96; age, 65-97 years; mean age, 77.2 years; 57% women), middle-aged (n = 164; age, 45-64 years; mean age, 53.4 years; 57% women), and younger (n = 423; age, 18-44 years; mean age, 28.3 years; 64% women)
Mental health staff interviewed participants within 7 days of the index episode. They collected information about sociodemographics, health, and contact with health care professionals. They used the C-SSRS to identify characteristics of the suicide attempts, and they used the Suicide Intent Scale (SIS) to evaluate circumstances surrounding the suicide attempt, such as active preparation.
Investigators also used the Mini International Neuropsychiatric Interview (MINI), the Suicide Assessment Scale (SUAS), and the Karolinska Affective and Borderline Symptoms Scale.
Greater disability, pain
Of the older patients, 75% lived alone; 88% of the middle-aged and 48% of the younger participants lived alone. A higher proportion of older participants had severe physical illness/disability and severe chronic pain compared with younger participants (all comparisons, P < .001).
Older adults had less contact with psychiatric services, but they had more contact than the other age groups with primary care for mental health problems. Older adults were prescribed antidepressants at the time of the suicide attempt at a lower rate, compared with the middle-aged and younger groups (50% vs. 73% and 66%).
Slightly less than half (44%) of the older adults had a previous history of a suicide attempt – a proportion considerably lower than was reported by patients in the middle-aged and young adult groups (63% and 75%, respectively). Few older adults had a history of a previous NNSI (6% vs. 23% and 63%).
Three-quarters of older adults employed poisoning as the single method of suicide attempt at their index episode, compared with 67% and 59% of the middle-aged and younger groups.
Notably, only half of older adults (52%) met criteria for major depression, determined on the basis of the MINI, compared with three quarters of participants in the other groups (73% and 76%, respectively). Fewer members of the older group met criteria for other psychiatric conditions.
Clouded judgment
The mean total SUAS score was “considerably lower” in the older-adult group than in the other groups. This was also the case for the SUAS subscales for affect, bodily states, control, coping, and emotional reactivity.
Importantly, however, older adults scored higher than younger adults on the SIS total score and the subjective subscale, indicating a higher level of suicidal intent.
The mean SIS total score was 17.8 in the older group, 17.4 in the middle-aged group, and 15.9 in the younger group. The SIS subjective suicide intent score was 10.9 versus 10.6 and 9.4.
“While subjective suicidal intent was higher, compared to the young group, older adults were less likely to fulfill criteria for major depression and several other mental disorders and lower scores were observed on all symptom rating scales, compared to both middle-aged and younger adults,” the investigators wrote.
“Low levels of psychopathology may cloud the clinician’s assessment of the serious nature of suicide attempts in older patients,” they added.
‘Silent generation’
Commenting on the findings, Marnin Heisel, PhD, CPsych, associate professor, departments of psychiatry and of epidemiology and biostatistics, University of Western Ontario, London, said an important takeaway from the study is that, if health care professionals look only for depression or only consider suicide risk in individuals who present with depression, “they might miss older adults who are contemplating suicide or engaging in suicidal behavior.”
Dr. Heisel, who was not involved with the study, observed that older adults are sometimes called the “silent generation” because they often tend to downplay or underreport depressive symptoms, partially because of having been socialized to “keep things to themselves and not to air emotional laundry.”
He recommended that, when assessing potentially suicidal older adults, clinicians select tools specifically designed for use in this age group, particularly the Geriatric Suicide Ideation Scale and the Geriatric Depression Scale. Dr. Heisel also recommended the Center for Epidemiological Studies Depression Scale–Revised Version.
“Beyond a specific scale, the question is to walk into a clinical encounter with a much broader viewpoint, understand who the client is, where they come from, their attitudes, life experience, and what in their experience is going on, their reason for coming to see someone and what they’re struggling with,” he said.
“What we’re seeing with this study is that standard clinical tools don’t necessarily identify some of these richer issues that might contribute to emotional pain, so sometimes the best way to go is a broader clinical interview with a humanistic perspective,” Dr. Heisel concluded.
The study was funded by the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, and the Swedish state, Stockholm County Council and Västerbotten County Council. The investigators and Dr. Heisel have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Older adults may have a high degree of suicidal intent yet still have low scores on scales measuring psychiatric symptoms, such as depression, new research suggests.
In a cross-sectional cohort study of more than 800 adults who presented with self-harm to psychiatric EDs in Sweden, participants aged 65 years and older scored higher than younger and middle-aged adults on measures of suicidal intent.
However, only half of the older group fulfilled criteria for major depression, compared with three-quarters of both the middle-aged and young adult–aged groups.
“Suicidal older persons show a somewhat different clinical picture with relatively low levels of psychopathology but with high suicide intent compared to younger persons,” lead author Stefan Wiktorsson, PhD, University of Gothenburg (Sweden), said in an interview.
“It is therefore of importance for clinicians to carefully evaluate suicidal thinking in this age group. he said.
The findings were published online Aug. 9, 2021, in the American Journal of Geriatric Psychiatry.
Research by age groups ‘lacking’
“While there are large age differences in the prevalence of suicidal behavior, research studies that compare symptomatology and diagnostics in different age groups are lacking,” Dr. Wiktorsson said.
He and his colleagues “wanted to compare psychopathology in young, middle-aged, and older adults in order to increase knowledge about potential differences in symptomatology related to suicidal behavior over the life span.”
The researchers recruited patients aged 18 years and older who had sought or had been referred to emergency psychiatric services for self-harm at three psychiatric hospitals in Sweden between April 2012 and March 2016.
Among all patients, 821 fit inclusion criteria and agreed to participate. The researchers excluded participants who had engaged in nonsuicidal self-injury (NNSI), as determined on the basis of the Columbia Suicide Severity Rating Scale (C-SSRS). The remaining 683 participants, who had attempted suicide, were included in the analysis.
The participants were then divided into the following three groups: older (n = 96; age, 65-97 years; mean age, 77.2 years; 57% women), middle-aged (n = 164; age, 45-64 years; mean age, 53.4 years; 57% women), and younger (n = 423; age, 18-44 years; mean age, 28.3 years; 64% women)
Mental health staff interviewed participants within 7 days of the index episode. They collected information about sociodemographics, health, and contact with health care professionals. They used the C-SSRS to identify characteristics of the suicide attempts, and they used the Suicide Intent Scale (SIS) to evaluate circumstances surrounding the suicide attempt, such as active preparation.
Investigators also used the Mini International Neuropsychiatric Interview (MINI), the Suicide Assessment Scale (SUAS), and the Karolinska Affective and Borderline Symptoms Scale.
Greater disability, pain
Of the older patients, 75% lived alone; 88% of the middle-aged and 48% of the younger participants lived alone. A higher proportion of older participants had severe physical illness/disability and severe chronic pain compared with younger participants (all comparisons, P < .001).
Older adults had less contact with psychiatric services, but they had more contact than the other age groups with primary care for mental health problems. Older adults were prescribed antidepressants at the time of the suicide attempt at a lower rate, compared with the middle-aged and younger groups (50% vs. 73% and 66%).
Slightly less than half (44%) of the older adults had a previous history of a suicide attempt – a proportion considerably lower than was reported by patients in the middle-aged and young adult groups (63% and 75%, respectively). Few older adults had a history of a previous NNSI (6% vs. 23% and 63%).
Three-quarters of older adults employed poisoning as the single method of suicide attempt at their index episode, compared with 67% and 59% of the middle-aged and younger groups.
Notably, only half of older adults (52%) met criteria for major depression, determined on the basis of the MINI, compared with three quarters of participants in the other groups (73% and 76%, respectively). Fewer members of the older group met criteria for other psychiatric conditions.
Clouded judgment
The mean total SUAS score was “considerably lower” in the older-adult group than in the other groups. This was also the case for the SUAS subscales for affect, bodily states, control, coping, and emotional reactivity.
Importantly, however, older adults scored higher than younger adults on the SIS total score and the subjective subscale, indicating a higher level of suicidal intent.
The mean SIS total score was 17.8 in the older group, 17.4 in the middle-aged group, and 15.9 in the younger group. The SIS subjective suicide intent score was 10.9 versus 10.6 and 9.4.
“While subjective suicidal intent was higher, compared to the young group, older adults were less likely to fulfill criteria for major depression and several other mental disorders and lower scores were observed on all symptom rating scales, compared to both middle-aged and younger adults,” the investigators wrote.
“Low levels of psychopathology may cloud the clinician’s assessment of the serious nature of suicide attempts in older patients,” they added.
‘Silent generation’
Commenting on the findings, Marnin Heisel, PhD, CPsych, associate professor, departments of psychiatry and of epidemiology and biostatistics, University of Western Ontario, London, said an important takeaway from the study is that, if health care professionals look only for depression or only consider suicide risk in individuals who present with depression, “they might miss older adults who are contemplating suicide or engaging in suicidal behavior.”
Dr. Heisel, who was not involved with the study, observed that older adults are sometimes called the “silent generation” because they often tend to downplay or underreport depressive symptoms, partially because of having been socialized to “keep things to themselves and not to air emotional laundry.”
He recommended that, when assessing potentially suicidal older adults, clinicians select tools specifically designed for use in this age group, particularly the Geriatric Suicide Ideation Scale and the Geriatric Depression Scale. Dr. Heisel also recommended the Center for Epidemiological Studies Depression Scale–Revised Version.
“Beyond a specific scale, the question is to walk into a clinical encounter with a much broader viewpoint, understand who the client is, where they come from, their attitudes, life experience, and what in their experience is going on, their reason for coming to see someone and what they’re struggling with,” he said.
“What we’re seeing with this study is that standard clinical tools don’t necessarily identify some of these richer issues that might contribute to emotional pain, so sometimes the best way to go is a broader clinical interview with a humanistic perspective,” Dr. Heisel concluded.
The study was funded by the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, and the Swedish state, Stockholm County Council and Västerbotten County Council. The investigators and Dr. Heisel have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Older adults may have a high degree of suicidal intent yet still have low scores on scales measuring psychiatric symptoms, such as depression, new research suggests.
In a cross-sectional cohort study of more than 800 adults who presented with self-harm to psychiatric EDs in Sweden, participants aged 65 years and older scored higher than younger and middle-aged adults on measures of suicidal intent.
However, only half of the older group fulfilled criteria for major depression, compared with three-quarters of both the middle-aged and young adult–aged groups.
“Suicidal older persons show a somewhat different clinical picture with relatively low levels of psychopathology but with high suicide intent compared to younger persons,” lead author Stefan Wiktorsson, PhD, University of Gothenburg (Sweden), said in an interview.
“It is therefore of importance for clinicians to carefully evaluate suicidal thinking in this age group. he said.
The findings were published online Aug. 9, 2021, in the American Journal of Geriatric Psychiatry.
Research by age groups ‘lacking’
“While there are large age differences in the prevalence of suicidal behavior, research studies that compare symptomatology and diagnostics in different age groups are lacking,” Dr. Wiktorsson said.
He and his colleagues “wanted to compare psychopathology in young, middle-aged, and older adults in order to increase knowledge about potential differences in symptomatology related to suicidal behavior over the life span.”
The researchers recruited patients aged 18 years and older who had sought or had been referred to emergency psychiatric services for self-harm at three psychiatric hospitals in Sweden between April 2012 and March 2016.
Among all patients, 821 fit inclusion criteria and agreed to participate. The researchers excluded participants who had engaged in nonsuicidal self-injury (NNSI), as determined on the basis of the Columbia Suicide Severity Rating Scale (C-SSRS). The remaining 683 participants, who had attempted suicide, were included in the analysis.
The participants were then divided into the following three groups: older (n = 96; age, 65-97 years; mean age, 77.2 years; 57% women), middle-aged (n = 164; age, 45-64 years; mean age, 53.4 years; 57% women), and younger (n = 423; age, 18-44 years; mean age, 28.3 years; 64% women)
Mental health staff interviewed participants within 7 days of the index episode. They collected information about sociodemographics, health, and contact with health care professionals. They used the C-SSRS to identify characteristics of the suicide attempts, and they used the Suicide Intent Scale (SIS) to evaluate circumstances surrounding the suicide attempt, such as active preparation.
Investigators also used the Mini International Neuropsychiatric Interview (MINI), the Suicide Assessment Scale (SUAS), and the Karolinska Affective and Borderline Symptoms Scale.
Greater disability, pain
Of the older patients, 75% lived alone; 88% of the middle-aged and 48% of the younger participants lived alone. A higher proportion of older participants had severe physical illness/disability and severe chronic pain compared with younger participants (all comparisons, P < .001).
Older adults had less contact with psychiatric services, but they had more contact than the other age groups with primary care for mental health problems. Older adults were prescribed antidepressants at the time of the suicide attempt at a lower rate, compared with the middle-aged and younger groups (50% vs. 73% and 66%).
Slightly less than half (44%) of the older adults had a previous history of a suicide attempt – a proportion considerably lower than was reported by patients in the middle-aged and young adult groups (63% and 75%, respectively). Few older adults had a history of a previous NNSI (6% vs. 23% and 63%).
Three-quarters of older adults employed poisoning as the single method of suicide attempt at their index episode, compared with 67% and 59% of the middle-aged and younger groups.
Notably, only half of older adults (52%) met criteria for major depression, determined on the basis of the MINI, compared with three quarters of participants in the other groups (73% and 76%, respectively). Fewer members of the older group met criteria for other psychiatric conditions.
Clouded judgment
The mean total SUAS score was “considerably lower” in the older-adult group than in the other groups. This was also the case for the SUAS subscales for affect, bodily states, control, coping, and emotional reactivity.
Importantly, however, older adults scored higher than younger adults on the SIS total score and the subjective subscale, indicating a higher level of suicidal intent.
The mean SIS total score was 17.8 in the older group, 17.4 in the middle-aged group, and 15.9 in the younger group. The SIS subjective suicide intent score was 10.9 versus 10.6 and 9.4.
“While subjective suicidal intent was higher, compared to the young group, older adults were less likely to fulfill criteria for major depression and several other mental disorders and lower scores were observed on all symptom rating scales, compared to both middle-aged and younger adults,” the investigators wrote.
“Low levels of psychopathology may cloud the clinician’s assessment of the serious nature of suicide attempts in older patients,” they added.
‘Silent generation’
Commenting on the findings, Marnin Heisel, PhD, CPsych, associate professor, departments of psychiatry and of epidemiology and biostatistics, University of Western Ontario, London, said an important takeaway from the study is that, if health care professionals look only for depression or only consider suicide risk in individuals who present with depression, “they might miss older adults who are contemplating suicide or engaging in suicidal behavior.”
Dr. Heisel, who was not involved with the study, observed that older adults are sometimes called the “silent generation” because they often tend to downplay or underreport depressive symptoms, partially because of having been socialized to “keep things to themselves and not to air emotional laundry.”
He recommended that, when assessing potentially suicidal older adults, clinicians select tools specifically designed for use in this age group, particularly the Geriatric Suicide Ideation Scale and the Geriatric Depression Scale. Dr. Heisel also recommended the Center for Epidemiological Studies Depression Scale–Revised Version.
“Beyond a specific scale, the question is to walk into a clinical encounter with a much broader viewpoint, understand who the client is, where they come from, their attitudes, life experience, and what in their experience is going on, their reason for coming to see someone and what they’re struggling with,” he said.
“What we’re seeing with this study is that standard clinical tools don’t necessarily identify some of these richer issues that might contribute to emotional pain, so sometimes the best way to go is a broader clinical interview with a humanistic perspective,” Dr. Heisel concluded.
The study was funded by the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, and the Swedish state, Stockholm County Council and Västerbotten County Council. The investigators and Dr. Heisel have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Managing sleep in the elderly
Sleep problems are prevalent in older adults, and overmedication is a common cause. Insomnia is a concern, and it might not look the same in older adults as it does in younger populations, especially when neurodegenerative disorders may be present. “There’s often not only the inability to get to sleep and stay asleep in older adults but also changes in their biological rhythms, which is why treatments really need to be focused on both,” Ruth M. Benca, MD, PhD, said in an interview.
Dr. Benca spoke on the topic of insomnia in the elderly at a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists. She is chair of psychiatry at Wake Forest Baptist Health, Winston-Salem, N.C.
Sleep issues strongly affect quality of life and health outcomes in the elderly, and there isn’t a lot of clear guidance for physicians to manage these issues. who spoke at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.
Behavioral approaches are important, because quality of sleep is often affected by daytime activities, such as exercise and light exposure, according to Dr. Benca, who said that those factors can and should be addressed by behavioral interventions. Medications should be used as an adjunct to those treatments. “When we do need to use medications, we need to use ones that have been tested and found to be more helpful than harmful in older adults,” Dr. Benca said.
Many Food and Drug Administration–approved drugs should be used with caution or avoided in the elderly. The Beers criteria provide a useful list of potentially problematic drugs, and removing those drugs from consideration leaves just a few options, including the melatonin receptor agonist ramelteon, low doses of the tricyclic antidepressant doxepin, and dual orexin receptor antagonists, which are being tested in older adults, including some with dementia, Dr. Benca said.
Other drugs like benzodiazepines and related “Z” drugs can cause problems like amnesia, confusion, and psychomotor issues. “They’re advised against because there are some concerns about those side effects,” Dr. Benca said.
Sleep disturbance itself can be the result of polypharmacy. Even something as simple as a diuretic can interrupt slumber because of nocturnal bathroom visits. Antihypertensives and drugs that affect the central nervous system, including antidepressants, can affect sleep. “I’ve had patients get horrible dreams and nightmares from antihypertensive drugs. So there’s a very long laundry list of drugs that can affect sleep in a negative way,” said Dr. Benca.
Physicians have a tendency to prescribe more drugs to a patient without eliminating any, which can result in complex situations. “We see this sort of chasing the tail: You give a drug, it may have a positive effect on the primary thing you want to treat, but it has a side effect. When you give another drug to treat that side effect, it in turn has its own side effect. We keep piling on drugs,” Dr. Benca said.
“So if [a patient is] on medications for an indication, and particularly for sleep or other things, and the patient isn’t getting better, what we might want to do is slowly to withdraw things. Even for older adults who are on sleeping medications and maybe are doing better, sometimes we can decrease the dose [of the other drugs], or get them off those drugs or put them on something that might be less likely to have side effects,” Dr. Benca said.
To do that, she suggests taking a history to determine when the sleep problem began, and whether it coincided with adding or changing a medication. Another approach is to look at the list of current medications, and look for drugs that are prescribed for a problem and where the problem still persists. “You might want to take that away first, before you start adding something else,” said Dr. Benca.
Another challenge is that physicians are often unwilling to investigate sleep disorders, which are more common in older adults. Physicians can be reluctant to prescribe sleep medications, and may also be unfamiliar with behavioral interventions. “For a lot of providers, getting into sleep issues is like opening a Pandora’s Box. I think mostly physicians are taught: Don’t do this, and don’t do that. They’re not as well versed in the things that they can and should do,” said Dr. Benca.
If attempts to treat insomnia don’t succeed, or if the physician suspects a movement disorder or primary sleep disorder like sleep apnea, then the patients should be referred to a sleep specialist, according to Dr. Benca.
During the question-and-answer period following her talk, a questioner brought up the increasingly common use of cannabis to improve sleep. That can be tricky because it can be difficult to stop cannabis use, because of the rebound insomnia that may persist. She noted that there are ongoing studies on the potential impact of cannabidiol oil.
Dr. Benca was also asked about patients who take sedatives chronically and seem to be doing well. She emphasized the need for finding the lowest effective dose of a short-acting medication. “Patients should be monitored frequently, at least every 6 months. Just monitor your patient carefully.”
Dr. Benca is a consultant for Eisai, Genomind, Idorsia, Jazz, Merck, Sage, and Sunovion.
Sleep problems are prevalent in older adults, and overmedication is a common cause. Insomnia is a concern, and it might not look the same in older adults as it does in younger populations, especially when neurodegenerative disorders may be present. “There’s often not only the inability to get to sleep and stay asleep in older adults but also changes in their biological rhythms, which is why treatments really need to be focused on both,” Ruth M. Benca, MD, PhD, said in an interview.
Dr. Benca spoke on the topic of insomnia in the elderly at a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists. She is chair of psychiatry at Wake Forest Baptist Health, Winston-Salem, N.C.
Sleep issues strongly affect quality of life and health outcomes in the elderly, and there isn’t a lot of clear guidance for physicians to manage these issues. who spoke at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.
Behavioral approaches are important, because quality of sleep is often affected by daytime activities, such as exercise and light exposure, according to Dr. Benca, who said that those factors can and should be addressed by behavioral interventions. Medications should be used as an adjunct to those treatments. “When we do need to use medications, we need to use ones that have been tested and found to be more helpful than harmful in older adults,” Dr. Benca said.
Many Food and Drug Administration–approved drugs should be used with caution or avoided in the elderly. The Beers criteria provide a useful list of potentially problematic drugs, and removing those drugs from consideration leaves just a few options, including the melatonin receptor agonist ramelteon, low doses of the tricyclic antidepressant doxepin, and dual orexin receptor antagonists, which are being tested in older adults, including some with dementia, Dr. Benca said.
Other drugs like benzodiazepines and related “Z” drugs can cause problems like amnesia, confusion, and psychomotor issues. “They’re advised against because there are some concerns about those side effects,” Dr. Benca said.
Sleep disturbance itself can be the result of polypharmacy. Even something as simple as a diuretic can interrupt slumber because of nocturnal bathroom visits. Antihypertensives and drugs that affect the central nervous system, including antidepressants, can affect sleep. “I’ve had patients get horrible dreams and nightmares from antihypertensive drugs. So there’s a very long laundry list of drugs that can affect sleep in a negative way,” said Dr. Benca.
Physicians have a tendency to prescribe more drugs to a patient without eliminating any, which can result in complex situations. “We see this sort of chasing the tail: You give a drug, it may have a positive effect on the primary thing you want to treat, but it has a side effect. When you give another drug to treat that side effect, it in turn has its own side effect. We keep piling on drugs,” Dr. Benca said.
“So if [a patient is] on medications for an indication, and particularly for sleep or other things, and the patient isn’t getting better, what we might want to do is slowly to withdraw things. Even for older adults who are on sleeping medications and maybe are doing better, sometimes we can decrease the dose [of the other drugs], or get them off those drugs or put them on something that might be less likely to have side effects,” Dr. Benca said.
To do that, she suggests taking a history to determine when the sleep problem began, and whether it coincided with adding or changing a medication. Another approach is to look at the list of current medications, and look for drugs that are prescribed for a problem and where the problem still persists. “You might want to take that away first, before you start adding something else,” said Dr. Benca.
Another challenge is that physicians are often unwilling to investigate sleep disorders, which are more common in older adults. Physicians can be reluctant to prescribe sleep medications, and may also be unfamiliar with behavioral interventions. “For a lot of providers, getting into sleep issues is like opening a Pandora’s Box. I think mostly physicians are taught: Don’t do this, and don’t do that. They’re not as well versed in the things that they can and should do,” said Dr. Benca.
If attempts to treat insomnia don’t succeed, or if the physician suspects a movement disorder or primary sleep disorder like sleep apnea, then the patients should be referred to a sleep specialist, according to Dr. Benca.
During the question-and-answer period following her talk, a questioner brought up the increasingly common use of cannabis to improve sleep. That can be tricky because it can be difficult to stop cannabis use, because of the rebound insomnia that may persist. She noted that there are ongoing studies on the potential impact of cannabidiol oil.
Dr. Benca was also asked about patients who take sedatives chronically and seem to be doing well. She emphasized the need for finding the lowest effective dose of a short-acting medication. “Patients should be monitored frequently, at least every 6 months. Just monitor your patient carefully.”
Dr. Benca is a consultant for Eisai, Genomind, Idorsia, Jazz, Merck, Sage, and Sunovion.
Sleep problems are prevalent in older adults, and overmedication is a common cause. Insomnia is a concern, and it might not look the same in older adults as it does in younger populations, especially when neurodegenerative disorders may be present. “There’s often not only the inability to get to sleep and stay asleep in older adults but also changes in their biological rhythms, which is why treatments really need to be focused on both,” Ruth M. Benca, MD, PhD, said in an interview.
Dr. Benca spoke on the topic of insomnia in the elderly at a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists. She is chair of psychiatry at Wake Forest Baptist Health, Winston-Salem, N.C.
Sleep issues strongly affect quality of life and health outcomes in the elderly, and there isn’t a lot of clear guidance for physicians to manage these issues. who spoke at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.
Behavioral approaches are important, because quality of sleep is often affected by daytime activities, such as exercise and light exposure, according to Dr. Benca, who said that those factors can and should be addressed by behavioral interventions. Medications should be used as an adjunct to those treatments. “When we do need to use medications, we need to use ones that have been tested and found to be more helpful than harmful in older adults,” Dr. Benca said.
Many Food and Drug Administration–approved drugs should be used with caution or avoided in the elderly. The Beers criteria provide a useful list of potentially problematic drugs, and removing those drugs from consideration leaves just a few options, including the melatonin receptor agonist ramelteon, low doses of the tricyclic antidepressant doxepin, and dual orexin receptor antagonists, which are being tested in older adults, including some with dementia, Dr. Benca said.
Other drugs like benzodiazepines and related “Z” drugs can cause problems like amnesia, confusion, and psychomotor issues. “They’re advised against because there are some concerns about those side effects,” Dr. Benca said.
Sleep disturbance itself can be the result of polypharmacy. Even something as simple as a diuretic can interrupt slumber because of nocturnal bathroom visits. Antihypertensives and drugs that affect the central nervous system, including antidepressants, can affect sleep. “I’ve had patients get horrible dreams and nightmares from antihypertensive drugs. So there’s a very long laundry list of drugs that can affect sleep in a negative way,” said Dr. Benca.
Physicians have a tendency to prescribe more drugs to a patient without eliminating any, which can result in complex situations. “We see this sort of chasing the tail: You give a drug, it may have a positive effect on the primary thing you want to treat, but it has a side effect. When you give another drug to treat that side effect, it in turn has its own side effect. We keep piling on drugs,” Dr. Benca said.
“So if [a patient is] on medications for an indication, and particularly for sleep or other things, and the patient isn’t getting better, what we might want to do is slowly to withdraw things. Even for older adults who are on sleeping medications and maybe are doing better, sometimes we can decrease the dose [of the other drugs], or get them off those drugs or put them on something that might be less likely to have side effects,” Dr. Benca said.
To do that, she suggests taking a history to determine when the sleep problem began, and whether it coincided with adding or changing a medication. Another approach is to look at the list of current medications, and look for drugs that are prescribed for a problem and where the problem still persists. “You might want to take that away first, before you start adding something else,” said Dr. Benca.
Another challenge is that physicians are often unwilling to investigate sleep disorders, which are more common in older adults. Physicians can be reluctant to prescribe sleep medications, and may also be unfamiliar with behavioral interventions. “For a lot of providers, getting into sleep issues is like opening a Pandora’s Box. I think mostly physicians are taught: Don’t do this, and don’t do that. They’re not as well versed in the things that they can and should do,” said Dr. Benca.
If attempts to treat insomnia don’t succeed, or if the physician suspects a movement disorder or primary sleep disorder like sleep apnea, then the patients should be referred to a sleep specialist, according to Dr. Benca.
During the question-and-answer period following her talk, a questioner brought up the increasingly common use of cannabis to improve sleep. That can be tricky because it can be difficult to stop cannabis use, because of the rebound insomnia that may persist. She noted that there are ongoing studies on the potential impact of cannabidiol oil.
Dr. Benca was also asked about patients who take sedatives chronically and seem to be doing well. She emphasized the need for finding the lowest effective dose of a short-acting medication. “Patients should be monitored frequently, at least every 6 months. Just monitor your patient carefully.”
Dr. Benca is a consultant for Eisai, Genomind, Idorsia, Jazz, Merck, Sage, and Sunovion.
FROM FOCUS ON NEUROPSYCHIATRY 2021
Inflation will be the end of medicine
Inflation is the senility of democracies.
–Sylvia Townsend Warner
Electronic medical records? No, all of these are minor annoyances in the face of the practice killer, inflation.
Physicians live in a closed box where medical reimbursements are fixed, directly or by contract proxy to the government (Medicare) pay rate. Inflation is projected to be between 5% and 10% this year. We cannot increase our rates to increase the salaries of our employees, cover our increased medical disposable costs, and pay more for our state licensures and DEA registrations. No, we must try to find savings in our budget, which we have been squeezing for years.
Currently, medicine is facing a 9.75% cut in Medicare reimbursements, which will reset most private insurance rates, based on a percentage of Medicare. The temporary 3.75% conversion factor (CF) increase for all services is expiring. Also expiring is the 2% sequester from the Budget Control Act of 2011 (BCA), signed into law in August 2011. This was originally scheduled to sunset in 2021, but is going to continue to 2030.
A 4% statutory pay-as-you-go (PAYGO) sequester resulting from passage of the American Rescue Plan Act is being imposed. Statutory PAYGO is a policy written into law (it can be changed only through new legislation) that requires deficit neutrality overall in the laws (other than annual appropriations) enacted by Congress and imposes automatic spending reductions at the end of the year if such laws increase the deficit when they are added together.
There is a statutory freeze on Medicare Physician Fee Schedule (PFS) updates until 2026, at which time an annual increase of 0.25%, which is lower than inflation, will be enacted. This adds up to a 9.75% cut in Medicare pay until at least 2026. Recall that almost all of your private insurance contracts are tied to Medicare (some more, some less) and that this cut to the physician is doubled if your overhead is fixed at the typical 50% for most practices. This means an almost 20% cut in take-home pay for most physicians.
Now, when considering the most recent inflation number, which projects 5%-10% inflation for this year and at least 2% annually in the future, which compounds yearly (the Fed target), you are looking at catastrophic numbers.
The conversion factor – the pool of money doled out to physicians – has failed to keep pace with inflation – even at 2%-3% a year – and reimbursement is only 50% of what it was when created in 1998, despite small increases by Congress along the way. A recent Wall Street Journal guest editorial claimed that Medicare payments benefited from cost of living adjustments, same as Social Security. I do not agree, hence the 50% pay gap since 1998.
In addition, the costs of running a practice have increased by 37% between 2001 and 2020, 1.7% per year, according to the Medicare Economic Index.
Some of this may include general inflation, but certainly new OSHA rules, electronic medical records, Medicare quality improvement measures, and assorted other costs do not. So based on my own conservative estimate, on top of the 50% decline in the payment pool, physicians’ noninflationary operating costs increased by at least another 10% over the last 20 odd years. This is a 60% decline in reimbursements!
Medicare payments have been under pressure from the Centers for Medicare & Medicaid Services (CMS) anti-inflationary payment policies for more than 20 years. While physician services represent a very modest portion of the overall growth in health care costs, they are an easy target for cuts when policymakers seek to limit spending. Although we avoided direct cuts to reimbursements caused by the Medicare sustainable growth rate formula (SGR) – which was enacted in 1997 and repealed in 2015 – Medicare provider payments have remained constrained by a budget-neutral financing system.
There used to be ways out of the box. Physicians could go to work for hospitals or have their practices acquired by them, resulting in much better hospital-based reimbursement. This has been eliminated by site-neutral payments, which while instituted by President Trump, are unopposed by President Biden. You could also join larger groups with some loss of autonomy, which could presumably negotiate better rates with private insurers as another way out, but these rates are almost always based on a percentage of Medicare as noted above.
There may be a bit of good news, with price transparency being instituted, which again is unopposed by the Biden administration. At least private practice physicians may be able to show their services are a bargain compared to hospitals.
One could also take the low road, and sell out to private equity, but I suspect these deals will become much less attractive since some of these entities are going broke and all will feel the bite of lower reimbursements.
Physicians and patients should rise up and demand better reimbursements for physicians, or there will be no physicians to see. This is not greed, a bigger house, or a newer car, this is becoming a matter of practice survival. And seniors are not greedy, they have paid hundreds of thousands of dollars into Medicare in taxes for health insurance in retirement.
Physicians and retirees should contact their federal legislators and let them know a 9.75% cut is untenable and ask for Medicare rates to be fixed to the cost of living, just as Social Security is. Before we fund trillions of dollars in new government programs, perhaps we should look to the solvency of the existing ones we have.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Inflation is the senility of democracies.
–Sylvia Townsend Warner
Electronic medical records? No, all of these are minor annoyances in the face of the practice killer, inflation.
Physicians live in a closed box where medical reimbursements are fixed, directly or by contract proxy to the government (Medicare) pay rate. Inflation is projected to be between 5% and 10% this year. We cannot increase our rates to increase the salaries of our employees, cover our increased medical disposable costs, and pay more for our state licensures and DEA registrations. No, we must try to find savings in our budget, which we have been squeezing for years.
Currently, medicine is facing a 9.75% cut in Medicare reimbursements, which will reset most private insurance rates, based on a percentage of Medicare. The temporary 3.75% conversion factor (CF) increase for all services is expiring. Also expiring is the 2% sequester from the Budget Control Act of 2011 (BCA), signed into law in August 2011. This was originally scheduled to sunset in 2021, but is going to continue to 2030.
A 4% statutory pay-as-you-go (PAYGO) sequester resulting from passage of the American Rescue Plan Act is being imposed. Statutory PAYGO is a policy written into law (it can be changed only through new legislation) that requires deficit neutrality overall in the laws (other than annual appropriations) enacted by Congress and imposes automatic spending reductions at the end of the year if such laws increase the deficit when they are added together.
There is a statutory freeze on Medicare Physician Fee Schedule (PFS) updates until 2026, at which time an annual increase of 0.25%, which is lower than inflation, will be enacted. This adds up to a 9.75% cut in Medicare pay until at least 2026. Recall that almost all of your private insurance contracts are tied to Medicare (some more, some less) and that this cut to the physician is doubled if your overhead is fixed at the typical 50% for most practices. This means an almost 20% cut in take-home pay for most physicians.
Now, when considering the most recent inflation number, which projects 5%-10% inflation for this year and at least 2% annually in the future, which compounds yearly (the Fed target), you are looking at catastrophic numbers.
The conversion factor – the pool of money doled out to physicians – has failed to keep pace with inflation – even at 2%-3% a year – and reimbursement is only 50% of what it was when created in 1998, despite small increases by Congress along the way. A recent Wall Street Journal guest editorial claimed that Medicare payments benefited from cost of living adjustments, same as Social Security. I do not agree, hence the 50% pay gap since 1998.
In addition, the costs of running a practice have increased by 37% between 2001 and 2020, 1.7% per year, according to the Medicare Economic Index.
Some of this may include general inflation, but certainly new OSHA rules, electronic medical records, Medicare quality improvement measures, and assorted other costs do not. So based on my own conservative estimate, on top of the 50% decline in the payment pool, physicians’ noninflationary operating costs increased by at least another 10% over the last 20 odd years. This is a 60% decline in reimbursements!
Medicare payments have been under pressure from the Centers for Medicare & Medicaid Services (CMS) anti-inflationary payment policies for more than 20 years. While physician services represent a very modest portion of the overall growth in health care costs, they are an easy target for cuts when policymakers seek to limit spending. Although we avoided direct cuts to reimbursements caused by the Medicare sustainable growth rate formula (SGR) – which was enacted in 1997 and repealed in 2015 – Medicare provider payments have remained constrained by a budget-neutral financing system.
There used to be ways out of the box. Physicians could go to work for hospitals or have their practices acquired by them, resulting in much better hospital-based reimbursement. This has been eliminated by site-neutral payments, which while instituted by President Trump, are unopposed by President Biden. You could also join larger groups with some loss of autonomy, which could presumably negotiate better rates with private insurers as another way out, but these rates are almost always based on a percentage of Medicare as noted above.
There may be a bit of good news, with price transparency being instituted, which again is unopposed by the Biden administration. At least private practice physicians may be able to show their services are a bargain compared to hospitals.
One could also take the low road, and sell out to private equity, but I suspect these deals will become much less attractive since some of these entities are going broke and all will feel the bite of lower reimbursements.
Physicians and patients should rise up and demand better reimbursements for physicians, or there will be no physicians to see. This is not greed, a bigger house, or a newer car, this is becoming a matter of practice survival. And seniors are not greedy, they have paid hundreds of thousands of dollars into Medicare in taxes for health insurance in retirement.
Physicians and retirees should contact their federal legislators and let them know a 9.75% cut is untenable and ask for Medicare rates to be fixed to the cost of living, just as Social Security is. Before we fund trillions of dollars in new government programs, perhaps we should look to the solvency of the existing ones we have.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Inflation is the senility of democracies.
–Sylvia Townsend Warner
Electronic medical records? No, all of these are minor annoyances in the face of the practice killer, inflation.
Physicians live in a closed box where medical reimbursements are fixed, directly or by contract proxy to the government (Medicare) pay rate. Inflation is projected to be between 5% and 10% this year. We cannot increase our rates to increase the salaries of our employees, cover our increased medical disposable costs, and pay more for our state licensures and DEA registrations. No, we must try to find savings in our budget, which we have been squeezing for years.
Currently, medicine is facing a 9.75% cut in Medicare reimbursements, which will reset most private insurance rates, based on a percentage of Medicare. The temporary 3.75% conversion factor (CF) increase for all services is expiring. Also expiring is the 2% sequester from the Budget Control Act of 2011 (BCA), signed into law in August 2011. This was originally scheduled to sunset in 2021, but is going to continue to 2030.
A 4% statutory pay-as-you-go (PAYGO) sequester resulting from passage of the American Rescue Plan Act is being imposed. Statutory PAYGO is a policy written into law (it can be changed only through new legislation) that requires deficit neutrality overall in the laws (other than annual appropriations) enacted by Congress and imposes automatic spending reductions at the end of the year if such laws increase the deficit when they are added together.
There is a statutory freeze on Medicare Physician Fee Schedule (PFS) updates until 2026, at which time an annual increase of 0.25%, which is lower than inflation, will be enacted. This adds up to a 9.75% cut in Medicare pay until at least 2026. Recall that almost all of your private insurance contracts are tied to Medicare (some more, some less) and that this cut to the physician is doubled if your overhead is fixed at the typical 50% for most practices. This means an almost 20% cut in take-home pay for most physicians.
Now, when considering the most recent inflation number, which projects 5%-10% inflation for this year and at least 2% annually in the future, which compounds yearly (the Fed target), you are looking at catastrophic numbers.
The conversion factor – the pool of money doled out to physicians – has failed to keep pace with inflation – even at 2%-3% a year – and reimbursement is only 50% of what it was when created in 1998, despite small increases by Congress along the way. A recent Wall Street Journal guest editorial claimed that Medicare payments benefited from cost of living adjustments, same as Social Security. I do not agree, hence the 50% pay gap since 1998.
In addition, the costs of running a practice have increased by 37% between 2001 and 2020, 1.7% per year, according to the Medicare Economic Index.
Some of this may include general inflation, but certainly new OSHA rules, electronic medical records, Medicare quality improvement measures, and assorted other costs do not. So based on my own conservative estimate, on top of the 50% decline in the payment pool, physicians’ noninflationary operating costs increased by at least another 10% over the last 20 odd years. This is a 60% decline in reimbursements!
Medicare payments have been under pressure from the Centers for Medicare & Medicaid Services (CMS) anti-inflationary payment policies for more than 20 years. While physician services represent a very modest portion of the overall growth in health care costs, they are an easy target for cuts when policymakers seek to limit spending. Although we avoided direct cuts to reimbursements caused by the Medicare sustainable growth rate formula (SGR) – which was enacted in 1997 and repealed in 2015 – Medicare provider payments have remained constrained by a budget-neutral financing system.
There used to be ways out of the box. Physicians could go to work for hospitals or have their practices acquired by them, resulting in much better hospital-based reimbursement. This has been eliminated by site-neutral payments, which while instituted by President Trump, are unopposed by President Biden. You could also join larger groups with some loss of autonomy, which could presumably negotiate better rates with private insurers as another way out, but these rates are almost always based on a percentage of Medicare as noted above.
There may be a bit of good news, with price transparency being instituted, which again is unopposed by the Biden administration. At least private practice physicians may be able to show their services are a bargain compared to hospitals.
One could also take the low road, and sell out to private equity, but I suspect these deals will become much less attractive since some of these entities are going broke and all will feel the bite of lower reimbursements.
Physicians and patients should rise up and demand better reimbursements for physicians, or there will be no physicians to see. This is not greed, a bigger house, or a newer car, this is becoming a matter of practice survival. And seniors are not greedy, they have paid hundreds of thousands of dollars into Medicare in taxes for health insurance in retirement.
Physicians and retirees should contact their federal legislators and let them know a 9.75% cut is untenable and ask for Medicare rates to be fixed to the cost of living, just as Social Security is. Before we fund trillions of dollars in new government programs, perhaps we should look to the solvency of the existing ones we have.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Connecticut chapter of ACC at center of Twitter dustup
Tweets from a black female medical student about the perils of being on call after lengthy hospital shifts was met with a stinging rebuke from the Twitter account of the Connecticut chapter of the American College of Cardiology – prompting an apology and some high-octane exchanges on medical Twitter.
In a series of Tweets, “queen of anonymous medicine” @QueenMD202X describes one friend “working 87 hours this week and 13 days straight” and a second, a third-year medical student working a 15-hour surgical shift. “That is cruel,” she writes, “15-hour shift? For what?????”
In response to a Tweet suggesting that being on call can be a valuable experience for students to know what they’re facing once they get to residency, @QueenMD202X pointed out the 15-hour shifts aren’t just a one-off.
In a now-deleted Tweet that nevertheless appears in several additional tweets as a screenshot, @ConnecticutACC replied: “You might be in the wrong field. You sound very angry probably unsuitable for patient care when your mental state is as you describe it. Emotions are contagious.”
The response from the medical and broader Twitter community was swift, with several tweets calling the chapter’s reply insensitive and racist.
In another Tweet, @BrittGratreak responded by stating: “I think institutions need to be more transparent how they basically weigh the costs & benefits of writing a memorial statement for students who die by suicide rather than investing in changing the toxic culture of medical education to prevent deaths & producing harmed physicians.”
Within hours, Connecticut-ACC issued an apology from their now-deleted account and questioned the origins of the Tweet. “We sincerely apologize for the earlier post as the views do not represent the values or beliefs of the Chapter or broader ACC. We are working to ID its origins. Burnout & well-being are critical issues [that] ACC/CCACC is working to address on behalf of members at all career stages.”
Speaking to this news organization, Connecticut-ACC president and governor Craig McPherson, MD, Yale University, New Haven, Conn., said the chapter believes its account was hacked.
“We provide limited password access to our Twitter account, and we assume, since we’ve contacted most of the individuals who had access to the current password and all of the them deny any knowledge, the account got hacked … it’s just one of those unfortunate aspects of social media,” he said.
The password was quickly changed after the chapter learned of the Tweet on Wednesday and the account has since been closed, at Dr. McPherson’s request.
“We don’t condone that kind of language, that kind of remark. It’s highly inappropriate, and I certainly agree with anyone that voiced that opinion in the Twitterstorm that followed,” he said. “But as I said at the outset, I have no control over what people say on social media once it’s out there. All we can do is apologize for the fact our Twitter feed was used as a vehicle for those comments, which we consider inappropriate.”
Asked whether he considered the remarks racist, Dr. McPherson replied: “That’s not for me to judge.”
ACC president Dipti Itchhaporia, MD, however, weighed in this afternoon with a Tweet citing the need to address clinician well-being and an inclusive workplace.
Some on Twitter recalled their own long hours as a medical student or defended the need to inculcate students in the long hours they’ll face as physicians. Others observed that neither ACC nor its Connecticut chapter addressed the issue of medical student hours in their response. Although fellow and resident hours are regulated, Dr. McPherson pointed out that it’s up to each individual medical school to set the hours for their students.
A version of this article first appeared on Medscape.com.
Tweets from a black female medical student about the perils of being on call after lengthy hospital shifts was met with a stinging rebuke from the Twitter account of the Connecticut chapter of the American College of Cardiology – prompting an apology and some high-octane exchanges on medical Twitter.
In a series of Tweets, “queen of anonymous medicine” @QueenMD202X describes one friend “working 87 hours this week and 13 days straight” and a second, a third-year medical student working a 15-hour surgical shift. “That is cruel,” she writes, “15-hour shift? For what?????”
In response to a Tweet suggesting that being on call can be a valuable experience for students to know what they’re facing once they get to residency, @QueenMD202X pointed out the 15-hour shifts aren’t just a one-off.
In a now-deleted Tweet that nevertheless appears in several additional tweets as a screenshot, @ConnecticutACC replied: “You might be in the wrong field. You sound very angry probably unsuitable for patient care when your mental state is as you describe it. Emotions are contagious.”
The response from the medical and broader Twitter community was swift, with several tweets calling the chapter’s reply insensitive and racist.
In another Tweet, @BrittGratreak responded by stating: “I think institutions need to be more transparent how they basically weigh the costs & benefits of writing a memorial statement for students who die by suicide rather than investing in changing the toxic culture of medical education to prevent deaths & producing harmed physicians.”
Within hours, Connecticut-ACC issued an apology from their now-deleted account and questioned the origins of the Tweet. “We sincerely apologize for the earlier post as the views do not represent the values or beliefs of the Chapter or broader ACC. We are working to ID its origins. Burnout & well-being are critical issues [that] ACC/CCACC is working to address on behalf of members at all career stages.”
Speaking to this news organization, Connecticut-ACC president and governor Craig McPherson, MD, Yale University, New Haven, Conn., said the chapter believes its account was hacked.
“We provide limited password access to our Twitter account, and we assume, since we’ve contacted most of the individuals who had access to the current password and all of the them deny any knowledge, the account got hacked … it’s just one of those unfortunate aspects of social media,” he said.
The password was quickly changed after the chapter learned of the Tweet on Wednesday and the account has since been closed, at Dr. McPherson’s request.
“We don’t condone that kind of language, that kind of remark. It’s highly inappropriate, and I certainly agree with anyone that voiced that opinion in the Twitterstorm that followed,” he said. “But as I said at the outset, I have no control over what people say on social media once it’s out there. All we can do is apologize for the fact our Twitter feed was used as a vehicle for those comments, which we consider inappropriate.”
Asked whether he considered the remarks racist, Dr. McPherson replied: “That’s not for me to judge.”
ACC president Dipti Itchhaporia, MD, however, weighed in this afternoon with a Tweet citing the need to address clinician well-being and an inclusive workplace.
Some on Twitter recalled their own long hours as a medical student or defended the need to inculcate students in the long hours they’ll face as physicians. Others observed that neither ACC nor its Connecticut chapter addressed the issue of medical student hours in their response. Although fellow and resident hours are regulated, Dr. McPherson pointed out that it’s up to each individual medical school to set the hours for their students.
A version of this article first appeared on Medscape.com.
Tweets from a black female medical student about the perils of being on call after lengthy hospital shifts was met with a stinging rebuke from the Twitter account of the Connecticut chapter of the American College of Cardiology – prompting an apology and some high-octane exchanges on medical Twitter.
In a series of Tweets, “queen of anonymous medicine” @QueenMD202X describes one friend “working 87 hours this week and 13 days straight” and a second, a third-year medical student working a 15-hour surgical shift. “That is cruel,” she writes, “15-hour shift? For what?????”
In response to a Tweet suggesting that being on call can be a valuable experience for students to know what they’re facing once they get to residency, @QueenMD202X pointed out the 15-hour shifts aren’t just a one-off.
In a now-deleted Tweet that nevertheless appears in several additional tweets as a screenshot, @ConnecticutACC replied: “You might be in the wrong field. You sound very angry probably unsuitable for patient care when your mental state is as you describe it. Emotions are contagious.”
The response from the medical and broader Twitter community was swift, with several tweets calling the chapter’s reply insensitive and racist.
In another Tweet, @BrittGratreak responded by stating: “I think institutions need to be more transparent how they basically weigh the costs & benefits of writing a memorial statement for students who die by suicide rather than investing in changing the toxic culture of medical education to prevent deaths & producing harmed physicians.”
Within hours, Connecticut-ACC issued an apology from their now-deleted account and questioned the origins of the Tweet. “We sincerely apologize for the earlier post as the views do not represent the values or beliefs of the Chapter or broader ACC. We are working to ID its origins. Burnout & well-being are critical issues [that] ACC/CCACC is working to address on behalf of members at all career stages.”
Speaking to this news organization, Connecticut-ACC president and governor Craig McPherson, MD, Yale University, New Haven, Conn., said the chapter believes its account was hacked.
“We provide limited password access to our Twitter account, and we assume, since we’ve contacted most of the individuals who had access to the current password and all of the them deny any knowledge, the account got hacked … it’s just one of those unfortunate aspects of social media,” he said.
The password was quickly changed after the chapter learned of the Tweet on Wednesday and the account has since been closed, at Dr. McPherson’s request.
“We don’t condone that kind of language, that kind of remark. It’s highly inappropriate, and I certainly agree with anyone that voiced that opinion in the Twitterstorm that followed,” he said. “But as I said at the outset, I have no control over what people say on social media once it’s out there. All we can do is apologize for the fact our Twitter feed was used as a vehicle for those comments, which we consider inappropriate.”
Asked whether he considered the remarks racist, Dr. McPherson replied: “That’s not for me to judge.”
ACC president Dipti Itchhaporia, MD, however, weighed in this afternoon with a Tweet citing the need to address clinician well-being and an inclusive workplace.
Some on Twitter recalled their own long hours as a medical student or defended the need to inculcate students in the long hours they’ll face as physicians. Others observed that neither ACC nor its Connecticut chapter addressed the issue of medical student hours in their response. Although fellow and resident hours are regulated, Dr. McPherson pointed out that it’s up to each individual medical school to set the hours for their students.
A version of this article first appeared on Medscape.com.
Doctor wins restraining order against CVS after prescription ban
In an Aug. 11 decision, District Court Judge William Bertelsman ordered CVS to stop refusing prescriptions written by Kendall E. Hansen, MD. Judge Bertelsman ruled that Dr. Hansen is likely to succeed in his claim that CVS barred his prescriptions without evidence that he violated any law or professional protocol. The restraining order will remain in place while Dr. Hansen’s lawsuit against CVS Pharmacy proceeds.
Ronald W. Chapman II, an attorney representing Dr. Hansen, said the order is groundbreaking and that, to his knowledge, it’s the first time a federal court has overturned a pharmacy’s decision to block a prescriber.
“We believe that CVS’ decision was based solely on algorithms they use to analyze prescriber practices and not an any individual review of patient records,” Mr. Chapman said. “In fact, we invited CVS to come out to Dr. Hansen’s practice and look at how he was treating patients and ensure things were compliant, but they refused. Instead, they had a phone call with him then cut his patients off.”
Michael DeAngelis, a spokesman for CVS, said the court’s order illustrates the proverbial rock and hard place that pharmacies are placed between in the country’s fight against the misuse of prescription opioids.
“It is alleged in many lawsuits that pharmacies fill too many opioid prescriptions and should operate programs that use data to block prescriptions written by some doctors,” Mr. DeAngelis told this news organization. “And yet other lawsuits, including this one, argue that we should not operate programs that may block prescriptions. Such contradictions are grossly unfair to the pharmacy profession.”
Mr. DeAngelis declined to comment about Dr. Hansen’s claims or specify what led CVS to refuse his prescriptions.
Dr. Hansen declined to comment for this story through his attorney.
Dr. Hansen is no stranger to the spotlight. The Northern Kentucky pain doctor made headlines in 2012 when two of his horses, Fast and Accurate, and Hansen, ran in the Kentucky Derby. In February 2019, he drew media attention when his practice, Interventional Pain Specialists in Crestview Hills, Ky., was raided by federal agents. Dr. Hansen owns and operates the facility, which serves patients in Kentucky, Ohio, and Indiana.
The search yielded no findings, and no charges were filed, according to Mr. Chapman. Scott Hardcorn, director of the Northern Kentucky Drug Strike Force, confirmed that his agency assisted in the operation but said he was unaware of the outcome and that his officers generated no reports from the investigation. A spokesperson for the Drug Enforcement Administration would not comment about the investigation and directed a reporter for this news organization to the DEA website where enforcement actions are listed. No records or actions against Dr. Hansen can be found.
The CVS complaint stems from actions taken by the pharmacy against Dr. Hansen earlier this year. In June, a pharmacy representative allegedly contacted Dr. Hansen by phone and asked him questions about his practice and his prescribing practices, according to his lawsuit filed in U.S. District Court for the Eastern District of Kentucky. During the call, the representative did not inform Dr. Hansen that any of his prescriptions were in question or were suspected of being medically unnecessary, the complaint alleges.
On July 28, 2021, CVS sent Dr. Hansen a letter announcing that its pharmacies would no longer be honoring his prescriptions. The letter, entered as an exhibit in the lawsuit, states that CVS contacted Dr. Hansen twice in 2021 about his prescribing practices, once in May and again in June.
“Despite our attempts to resolve the concerns with your controlled substance prescribing patterns, these concerns persist,” Kahra Lutkiewicz, director of CVS’ retail pharmacy professional practice, wrote in the letter. “Thus, we are writing to inform you that effective Aug. 5, 2021, CVS/pharmacy stores will no longer be able to fill prescriptions that you write for controlled substances. We take our compliance obligations very seriously, and after careful consideration, find it necessary to take this action.”
The letter does not explain the details behind CVS’ concerns.
Dr. Hansen sued CVS on Aug. 4 for tortious interference with a business relationship and defamation, among other claims. His complaint alleges that Dr. Hansen and his patients will suffer irreparable injury if the prescription decision stands. More than 250 of Dr. Hansen’s patients use CVS pharmacies for their prescriptions, and some are locked into using the pharmacy because of insurance contracts, Mr. Chapman said.
“There really is nowhere else for these patients to go,” Mr. Chapman said. “They would have to go to a new doctor and establish a new relationship, and obviously that has devastating consequences when we’re talking about people who need their medication.”
CVS has not yet issued a written response to the lawsuit. In his order, Judge Bertelsman stated that a preliminary conference was held in which all parties were represented and stated their positions to the judge.
“Plaintiffs are likely to succeed on the merits of their claims that defendant has interfered with plaintiffs’ relationships with their patients by refusing to fill prescriptions written by plaintiffs, and defendant has done so without evidence that plaintiffs have violated any law or professional protocol related to such prescriptions,” Judge Bertelsman wrote. “The balance of the hardships between the parties weighs in favor of issuing a temporary restraining order inasmuch as defendant’s actions pose a threat to plaintiffs’ professional reputation and livelihood and ... because plaintiffs’ patients’ medical care is implicated by defendant’s actions, the public interest weighs in favor of issuance of the temporary restraining order.”
Dr. Hansen is currently embroiled in several other legal battles as both a plaintiff and a defendant.
In 2019, a patient sued him for negligence and fraud for allegedly performing medically unnecessary and excessive injection therapy. The suit claims the patient was required to undergo injection therapy on a continuing basis in order to receive her narcotic pain medication, according to the lawsuit filed in Kenton Circuit Court. The complaint alleges that Dr. Hansen made false representations to the patient and to her insurers that the injections were necessary for the treatment of the patient’s chronic pain.
The federal government is not involved in the case.
The negligence lawsuit is in the discovery stage, and attorneys plan to collect Dr. Hansen’s deposition soon, said Eric Deters, a spokesman for Deters Law, a law firm based in Independence, Ky., that is representing the patient.
“The crux is that he performs unnecessary pain procedures and forces you to get an unnecessary procedure before giving you your medication,” Mr. Deters said.
However, Dr. Hansen’s and Mr. Deters’ history together includes a recent riff, according to an August 2021 lawsuit filed by Dr. Hansen against the law firm. Dr. Hansen was a former medical expert in cases for Deters and Associates, but the relationship turned sour when attorneys believed Dr. Hansen was retained as an expert in a case against their clients, according to Dr. Hansen’s suit. Dr. Hansen claims that as retribution, Deters and Associates issued a medical malpractice lawsuit against him in 2020, even though attorneys allegedly knew the statute of limitations had run out. A trial court dismissed the 2020 lawsuit against Dr. Hansen as being untimely filed. Dr. Hansen’s lawsuit alleges wrongful use of civil proceedings and requests compensatory, punitive damages and court costs from the law firm.
The law firm has faced trouble in the past. In August 2021, the Ohio Supreme Court ordered that Mr. Deters pay a $6,500 fine for engaging in the unauthorized practice of law. Mr. Deters’ Kentucky law license has been suspended since 2013 for ethics infractions, according to court records. He retired from law in 2014 and now acts as a spokesperson and office manager for the law firm. The fine resulted from legal advice given by Mr. Deters to two clients at the law firm, according to the Ohio Supreme Court decision.
As for the CVS lawsuit, an upcoming hearing will determine whether the federal court issues a permanent injunction against CVS’s actions. CVS officials have not said whether they will fight the temporary restraining order or the withdrawal of their prescription ban against Dr. Hansen.
A version of this article first appeared on Medscape.com.
In an Aug. 11 decision, District Court Judge William Bertelsman ordered CVS to stop refusing prescriptions written by Kendall E. Hansen, MD. Judge Bertelsman ruled that Dr. Hansen is likely to succeed in his claim that CVS barred his prescriptions without evidence that he violated any law or professional protocol. The restraining order will remain in place while Dr. Hansen’s lawsuit against CVS Pharmacy proceeds.
Ronald W. Chapman II, an attorney representing Dr. Hansen, said the order is groundbreaking and that, to his knowledge, it’s the first time a federal court has overturned a pharmacy’s decision to block a prescriber.
“We believe that CVS’ decision was based solely on algorithms they use to analyze prescriber practices and not an any individual review of patient records,” Mr. Chapman said. “In fact, we invited CVS to come out to Dr. Hansen’s practice and look at how he was treating patients and ensure things were compliant, but they refused. Instead, they had a phone call with him then cut his patients off.”
Michael DeAngelis, a spokesman for CVS, said the court’s order illustrates the proverbial rock and hard place that pharmacies are placed between in the country’s fight against the misuse of prescription opioids.
“It is alleged in many lawsuits that pharmacies fill too many opioid prescriptions and should operate programs that use data to block prescriptions written by some doctors,” Mr. DeAngelis told this news organization. “And yet other lawsuits, including this one, argue that we should not operate programs that may block prescriptions. Such contradictions are grossly unfair to the pharmacy profession.”
Mr. DeAngelis declined to comment about Dr. Hansen’s claims or specify what led CVS to refuse his prescriptions.
Dr. Hansen declined to comment for this story through his attorney.
Dr. Hansen is no stranger to the spotlight. The Northern Kentucky pain doctor made headlines in 2012 when two of his horses, Fast and Accurate, and Hansen, ran in the Kentucky Derby. In February 2019, he drew media attention when his practice, Interventional Pain Specialists in Crestview Hills, Ky., was raided by federal agents. Dr. Hansen owns and operates the facility, which serves patients in Kentucky, Ohio, and Indiana.
The search yielded no findings, and no charges were filed, according to Mr. Chapman. Scott Hardcorn, director of the Northern Kentucky Drug Strike Force, confirmed that his agency assisted in the operation but said he was unaware of the outcome and that his officers generated no reports from the investigation. A spokesperson for the Drug Enforcement Administration would not comment about the investigation and directed a reporter for this news organization to the DEA website where enforcement actions are listed. No records or actions against Dr. Hansen can be found.
The CVS complaint stems from actions taken by the pharmacy against Dr. Hansen earlier this year. In June, a pharmacy representative allegedly contacted Dr. Hansen by phone and asked him questions about his practice and his prescribing practices, according to his lawsuit filed in U.S. District Court for the Eastern District of Kentucky. During the call, the representative did not inform Dr. Hansen that any of his prescriptions were in question or were suspected of being medically unnecessary, the complaint alleges.
On July 28, 2021, CVS sent Dr. Hansen a letter announcing that its pharmacies would no longer be honoring his prescriptions. The letter, entered as an exhibit in the lawsuit, states that CVS contacted Dr. Hansen twice in 2021 about his prescribing practices, once in May and again in June.
“Despite our attempts to resolve the concerns with your controlled substance prescribing patterns, these concerns persist,” Kahra Lutkiewicz, director of CVS’ retail pharmacy professional practice, wrote in the letter. “Thus, we are writing to inform you that effective Aug. 5, 2021, CVS/pharmacy stores will no longer be able to fill prescriptions that you write for controlled substances. We take our compliance obligations very seriously, and after careful consideration, find it necessary to take this action.”
The letter does not explain the details behind CVS’ concerns.
Dr. Hansen sued CVS on Aug. 4 for tortious interference with a business relationship and defamation, among other claims. His complaint alleges that Dr. Hansen and his patients will suffer irreparable injury if the prescription decision stands. More than 250 of Dr. Hansen’s patients use CVS pharmacies for their prescriptions, and some are locked into using the pharmacy because of insurance contracts, Mr. Chapman said.
“There really is nowhere else for these patients to go,” Mr. Chapman said. “They would have to go to a new doctor and establish a new relationship, and obviously that has devastating consequences when we’re talking about people who need their medication.”
CVS has not yet issued a written response to the lawsuit. In his order, Judge Bertelsman stated that a preliminary conference was held in which all parties were represented and stated their positions to the judge.
“Plaintiffs are likely to succeed on the merits of their claims that defendant has interfered with plaintiffs’ relationships with their patients by refusing to fill prescriptions written by plaintiffs, and defendant has done so without evidence that plaintiffs have violated any law or professional protocol related to such prescriptions,” Judge Bertelsman wrote. “The balance of the hardships between the parties weighs in favor of issuing a temporary restraining order inasmuch as defendant’s actions pose a threat to plaintiffs’ professional reputation and livelihood and ... because plaintiffs’ patients’ medical care is implicated by defendant’s actions, the public interest weighs in favor of issuance of the temporary restraining order.”
Dr. Hansen is currently embroiled in several other legal battles as both a plaintiff and a defendant.
In 2019, a patient sued him for negligence and fraud for allegedly performing medically unnecessary and excessive injection therapy. The suit claims the patient was required to undergo injection therapy on a continuing basis in order to receive her narcotic pain medication, according to the lawsuit filed in Kenton Circuit Court. The complaint alleges that Dr. Hansen made false representations to the patient and to her insurers that the injections were necessary for the treatment of the patient’s chronic pain.
The federal government is not involved in the case.
The negligence lawsuit is in the discovery stage, and attorneys plan to collect Dr. Hansen’s deposition soon, said Eric Deters, a spokesman for Deters Law, a law firm based in Independence, Ky., that is representing the patient.
“The crux is that he performs unnecessary pain procedures and forces you to get an unnecessary procedure before giving you your medication,” Mr. Deters said.
However, Dr. Hansen’s and Mr. Deters’ history together includes a recent riff, according to an August 2021 lawsuit filed by Dr. Hansen against the law firm. Dr. Hansen was a former medical expert in cases for Deters and Associates, but the relationship turned sour when attorneys believed Dr. Hansen was retained as an expert in a case against their clients, according to Dr. Hansen’s suit. Dr. Hansen claims that as retribution, Deters and Associates issued a medical malpractice lawsuit against him in 2020, even though attorneys allegedly knew the statute of limitations had run out. A trial court dismissed the 2020 lawsuit against Dr. Hansen as being untimely filed. Dr. Hansen’s lawsuit alleges wrongful use of civil proceedings and requests compensatory, punitive damages and court costs from the law firm.
The law firm has faced trouble in the past. In August 2021, the Ohio Supreme Court ordered that Mr. Deters pay a $6,500 fine for engaging in the unauthorized practice of law. Mr. Deters’ Kentucky law license has been suspended since 2013 for ethics infractions, according to court records. He retired from law in 2014 and now acts as a spokesperson and office manager for the law firm. The fine resulted from legal advice given by Mr. Deters to two clients at the law firm, according to the Ohio Supreme Court decision.
As for the CVS lawsuit, an upcoming hearing will determine whether the federal court issues a permanent injunction against CVS’s actions. CVS officials have not said whether they will fight the temporary restraining order or the withdrawal of their prescription ban against Dr. Hansen.
A version of this article first appeared on Medscape.com.
In an Aug. 11 decision, District Court Judge William Bertelsman ordered CVS to stop refusing prescriptions written by Kendall E. Hansen, MD. Judge Bertelsman ruled that Dr. Hansen is likely to succeed in his claim that CVS barred his prescriptions without evidence that he violated any law or professional protocol. The restraining order will remain in place while Dr. Hansen’s lawsuit against CVS Pharmacy proceeds.
Ronald W. Chapman II, an attorney representing Dr. Hansen, said the order is groundbreaking and that, to his knowledge, it’s the first time a federal court has overturned a pharmacy’s decision to block a prescriber.
“We believe that CVS’ decision was based solely on algorithms they use to analyze prescriber practices and not an any individual review of patient records,” Mr. Chapman said. “In fact, we invited CVS to come out to Dr. Hansen’s practice and look at how he was treating patients and ensure things were compliant, but they refused. Instead, they had a phone call with him then cut his patients off.”
Michael DeAngelis, a spokesman for CVS, said the court’s order illustrates the proverbial rock and hard place that pharmacies are placed between in the country’s fight against the misuse of prescription opioids.
“It is alleged in many lawsuits that pharmacies fill too many opioid prescriptions and should operate programs that use data to block prescriptions written by some doctors,” Mr. DeAngelis told this news organization. “And yet other lawsuits, including this one, argue that we should not operate programs that may block prescriptions. Such contradictions are grossly unfair to the pharmacy profession.”
Mr. DeAngelis declined to comment about Dr. Hansen’s claims or specify what led CVS to refuse his prescriptions.
Dr. Hansen declined to comment for this story through his attorney.
Dr. Hansen is no stranger to the spotlight. The Northern Kentucky pain doctor made headlines in 2012 when two of his horses, Fast and Accurate, and Hansen, ran in the Kentucky Derby. In February 2019, he drew media attention when his practice, Interventional Pain Specialists in Crestview Hills, Ky., was raided by federal agents. Dr. Hansen owns and operates the facility, which serves patients in Kentucky, Ohio, and Indiana.
The search yielded no findings, and no charges were filed, according to Mr. Chapman. Scott Hardcorn, director of the Northern Kentucky Drug Strike Force, confirmed that his agency assisted in the operation but said he was unaware of the outcome and that his officers generated no reports from the investigation. A spokesperson for the Drug Enforcement Administration would not comment about the investigation and directed a reporter for this news organization to the DEA website where enforcement actions are listed. No records or actions against Dr. Hansen can be found.
The CVS complaint stems from actions taken by the pharmacy against Dr. Hansen earlier this year. In June, a pharmacy representative allegedly contacted Dr. Hansen by phone and asked him questions about his practice and his prescribing practices, according to his lawsuit filed in U.S. District Court for the Eastern District of Kentucky. During the call, the representative did not inform Dr. Hansen that any of his prescriptions were in question or were suspected of being medically unnecessary, the complaint alleges.
On July 28, 2021, CVS sent Dr. Hansen a letter announcing that its pharmacies would no longer be honoring his prescriptions. The letter, entered as an exhibit in the lawsuit, states that CVS contacted Dr. Hansen twice in 2021 about his prescribing practices, once in May and again in June.
“Despite our attempts to resolve the concerns with your controlled substance prescribing patterns, these concerns persist,” Kahra Lutkiewicz, director of CVS’ retail pharmacy professional practice, wrote in the letter. “Thus, we are writing to inform you that effective Aug. 5, 2021, CVS/pharmacy stores will no longer be able to fill prescriptions that you write for controlled substances. We take our compliance obligations very seriously, and after careful consideration, find it necessary to take this action.”
The letter does not explain the details behind CVS’ concerns.
Dr. Hansen sued CVS on Aug. 4 for tortious interference with a business relationship and defamation, among other claims. His complaint alleges that Dr. Hansen and his patients will suffer irreparable injury if the prescription decision stands. More than 250 of Dr. Hansen’s patients use CVS pharmacies for their prescriptions, and some are locked into using the pharmacy because of insurance contracts, Mr. Chapman said.
“There really is nowhere else for these patients to go,” Mr. Chapman said. “They would have to go to a new doctor and establish a new relationship, and obviously that has devastating consequences when we’re talking about people who need their medication.”
CVS has not yet issued a written response to the lawsuit. In his order, Judge Bertelsman stated that a preliminary conference was held in which all parties were represented and stated their positions to the judge.
“Plaintiffs are likely to succeed on the merits of their claims that defendant has interfered with plaintiffs’ relationships with their patients by refusing to fill prescriptions written by plaintiffs, and defendant has done so without evidence that plaintiffs have violated any law or professional protocol related to such prescriptions,” Judge Bertelsman wrote. “The balance of the hardships between the parties weighs in favor of issuing a temporary restraining order inasmuch as defendant’s actions pose a threat to plaintiffs’ professional reputation and livelihood and ... because plaintiffs’ patients’ medical care is implicated by defendant’s actions, the public interest weighs in favor of issuance of the temporary restraining order.”
Dr. Hansen is currently embroiled in several other legal battles as both a plaintiff and a defendant.
In 2019, a patient sued him for negligence and fraud for allegedly performing medically unnecessary and excessive injection therapy. The suit claims the patient was required to undergo injection therapy on a continuing basis in order to receive her narcotic pain medication, according to the lawsuit filed in Kenton Circuit Court. The complaint alleges that Dr. Hansen made false representations to the patient and to her insurers that the injections were necessary for the treatment of the patient’s chronic pain.
The federal government is not involved in the case.
The negligence lawsuit is in the discovery stage, and attorneys plan to collect Dr. Hansen’s deposition soon, said Eric Deters, a spokesman for Deters Law, a law firm based in Independence, Ky., that is representing the patient.
“The crux is that he performs unnecessary pain procedures and forces you to get an unnecessary procedure before giving you your medication,” Mr. Deters said.
However, Dr. Hansen’s and Mr. Deters’ history together includes a recent riff, according to an August 2021 lawsuit filed by Dr. Hansen against the law firm. Dr. Hansen was a former medical expert in cases for Deters and Associates, but the relationship turned sour when attorneys believed Dr. Hansen was retained as an expert in a case against their clients, according to Dr. Hansen’s suit. Dr. Hansen claims that as retribution, Deters and Associates issued a medical malpractice lawsuit against him in 2020, even though attorneys allegedly knew the statute of limitations had run out. A trial court dismissed the 2020 lawsuit against Dr. Hansen as being untimely filed. Dr. Hansen’s lawsuit alleges wrongful use of civil proceedings and requests compensatory, punitive damages and court costs from the law firm.
The law firm has faced trouble in the past. In August 2021, the Ohio Supreme Court ordered that Mr. Deters pay a $6,500 fine for engaging in the unauthorized practice of law. Mr. Deters’ Kentucky law license has been suspended since 2013 for ethics infractions, according to court records. He retired from law in 2014 and now acts as a spokesperson and office manager for the law firm. The fine resulted from legal advice given by Mr. Deters to two clients at the law firm, according to the Ohio Supreme Court decision.
As for the CVS lawsuit, an upcoming hearing will determine whether the federal court issues a permanent injunction against CVS’s actions. CVS officials have not said whether they will fight the temporary restraining order or the withdrawal of their prescription ban against Dr. Hansen.
A version of this article first appeared on Medscape.com.
Mediterranean diet slows progression of atherosclerosis in CHD
For patients with coronary heart disease (CHD), following a Mediterranean diet is more effective in reducing progression of atherosclerosis than following a low-fat diet, according to new data from the CORDIOPREV randomized, controlled trial.
“The current study is, to our knowledge, the first to establish an effective dietary strategy for secondary cardiovascular prevention, reinforcing the fact that the Mediterranean diet rich in extra virgin olive oil (EVOO) could prevent the progression of atherosclerosis,” the study team said.
The data also show that patients with a higher atherosclerotic burden might benefit the most from the Mediterranean diet.
The study was published online Aug. 10, 2021, in Stroke.
Mediterranean or low fat?
“It is well established that lifestyle and dietary habits powerfully affect cardiovascular risk,” study investigator Elena M. Yubero-Serrano, PhD, with Reina Sofia University Hospital/University of Cordoba (Spain), told this news organization.
“The effectiveness of the Mediterranean diet in reducing cardiovascular risk has been seen in primary prevention. However, currently there is no consensus about a recommended dietary model for the secondary prevention of cardiovascular disease,” she said.
The Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study is an ongoing prospective study comparing the effects of two healthy diets for secondary prevention of cardiovascular disease (CVD) in 1002 patients.
The comparative effect of the diets in reducing CVD risk, assessed by quantification of intima-media thickness of the common carotid arteries (IMT-CC), is a key secondary endpoint of the study.
During the study, half of the patients follow a Mediterranean diet rich in EVOO, fruit and vegetables, whole grains, fish, and nuts. The other half follow a diet low in fat and rich in complex carbohydrates.
A total of 939 participants (459 in the low-fat diet group and 480 in the Mediterranean diet group) completed IMT-CC evaluation at baseline, and 809 (377 and 432, respectively) completed the IMT-CC evaluation at 5 years; 731 (335 and 396, respectively) did so at 7 years.
The Mediterranean diet significantly decreased IMT-CC both after 5 years (–0.027; P < .001) and after 7 years (–0.031 mm; P < .001), relative to baseline. In contrast, the low-fat diet did not exert any change on IMT-CC after 5 or 7 years, the researchers report.
The higher the IMT-CC at baseline, the greater the reduction in this parameter.
The Mediterranean diet also produced a greater decrease in IMT-CC and carotid plaque maximum height, compared with the low-fat diet throughout follow-up.
There were no between-group differences in carotid plaque numbers during follow-up.
“Our findings, in addition to reinforcing the clinical benefits of the Mediterranean diet, provide a beneficial dietary strategy as a clinical and therapeutic tool that could reduce the high cardiovascular recurrence in the context of secondary prevention,” Dr. Yubero-Serrano said in an interview.
Earlier data from CORDIOPREV showed that, after 1 year of eating a Mediterranean diet, compared with the low-fat diet, endothelial function was improved among patients with CHD, even those with type 2 diabetes, which was associated with a better balance of vascular homeostasis.
The Mediterranean diet may also modulate the lipid profile, particularly by increasing HDL cholesterol levels. The anti-inflammatory capacity of the Mediterranean diet could be another factor that contributes to reducing the progression of atherosclerosis, the researchers say.
Important study
Reached for comment, Alan Rozanski, MD, professor of medicine, Icahn School of Medicine at Mount Sinai and cardiologist at Mount Sinai Morningside, New York, said: “We know very well that lifestyle factors, diet, and exercise in particular are extremely important in promoting health, vitality, and decreasing risk for chronic diseases, including heart attack and stroke.
“But a lot of the studies depend on epidemiological work. Until now, we haven’t had important prospective studies evaluating different kinds of dietary approaches and how they affect carotid intimal thickening assessments that we can do by ultrasound. So having this kind of imaging study which shows that diet can halt progression of atherosclerosis is important,” said Dr. Rozanski.
“Changing one’s diet is extremely important and potentially beneficial in many ways, and being able to say to a patient with atherosclerosis that we have data that shows you can halt the progression of the disease can be extraordinarily encouraging to many patients,” he noted.
“When people have disease, they very often gravitate toward drugs, but continuing to emphasize lifestyle changes in these people is extremely important,” he added.
The CORDIOPREV study was supported by the Fundación Patrimonio Comunal Olivarero. Dr. Yubero-Serrano and Dr. Rozanski disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
For patients with coronary heart disease (CHD), following a Mediterranean diet is more effective in reducing progression of atherosclerosis than following a low-fat diet, according to new data from the CORDIOPREV randomized, controlled trial.
“The current study is, to our knowledge, the first to establish an effective dietary strategy for secondary cardiovascular prevention, reinforcing the fact that the Mediterranean diet rich in extra virgin olive oil (EVOO) could prevent the progression of atherosclerosis,” the study team said.
The data also show that patients with a higher atherosclerotic burden might benefit the most from the Mediterranean diet.
The study was published online Aug. 10, 2021, in Stroke.
Mediterranean or low fat?
“It is well established that lifestyle and dietary habits powerfully affect cardiovascular risk,” study investigator Elena M. Yubero-Serrano, PhD, with Reina Sofia University Hospital/University of Cordoba (Spain), told this news organization.
“The effectiveness of the Mediterranean diet in reducing cardiovascular risk has been seen in primary prevention. However, currently there is no consensus about a recommended dietary model for the secondary prevention of cardiovascular disease,” she said.
The Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study is an ongoing prospective study comparing the effects of two healthy diets for secondary prevention of cardiovascular disease (CVD) in 1002 patients.
The comparative effect of the diets in reducing CVD risk, assessed by quantification of intima-media thickness of the common carotid arteries (IMT-CC), is a key secondary endpoint of the study.
During the study, half of the patients follow a Mediterranean diet rich in EVOO, fruit and vegetables, whole grains, fish, and nuts. The other half follow a diet low in fat and rich in complex carbohydrates.
A total of 939 participants (459 in the low-fat diet group and 480 in the Mediterranean diet group) completed IMT-CC evaluation at baseline, and 809 (377 and 432, respectively) completed the IMT-CC evaluation at 5 years; 731 (335 and 396, respectively) did so at 7 years.
The Mediterranean diet significantly decreased IMT-CC both after 5 years (–0.027; P < .001) and after 7 years (–0.031 mm; P < .001), relative to baseline. In contrast, the low-fat diet did not exert any change on IMT-CC after 5 or 7 years, the researchers report.
The higher the IMT-CC at baseline, the greater the reduction in this parameter.
The Mediterranean diet also produced a greater decrease in IMT-CC and carotid plaque maximum height, compared with the low-fat diet throughout follow-up.
There were no between-group differences in carotid plaque numbers during follow-up.
“Our findings, in addition to reinforcing the clinical benefits of the Mediterranean diet, provide a beneficial dietary strategy as a clinical and therapeutic tool that could reduce the high cardiovascular recurrence in the context of secondary prevention,” Dr. Yubero-Serrano said in an interview.
Earlier data from CORDIOPREV showed that, after 1 year of eating a Mediterranean diet, compared with the low-fat diet, endothelial function was improved among patients with CHD, even those with type 2 diabetes, which was associated with a better balance of vascular homeostasis.
The Mediterranean diet may also modulate the lipid profile, particularly by increasing HDL cholesterol levels. The anti-inflammatory capacity of the Mediterranean diet could be another factor that contributes to reducing the progression of atherosclerosis, the researchers say.
Important study
Reached for comment, Alan Rozanski, MD, professor of medicine, Icahn School of Medicine at Mount Sinai and cardiologist at Mount Sinai Morningside, New York, said: “We know very well that lifestyle factors, diet, and exercise in particular are extremely important in promoting health, vitality, and decreasing risk for chronic diseases, including heart attack and stroke.
“But a lot of the studies depend on epidemiological work. Until now, we haven’t had important prospective studies evaluating different kinds of dietary approaches and how they affect carotid intimal thickening assessments that we can do by ultrasound. So having this kind of imaging study which shows that diet can halt progression of atherosclerosis is important,” said Dr. Rozanski.
“Changing one’s diet is extremely important and potentially beneficial in many ways, and being able to say to a patient with atherosclerosis that we have data that shows you can halt the progression of the disease can be extraordinarily encouraging to many patients,” he noted.
“When people have disease, they very often gravitate toward drugs, but continuing to emphasize lifestyle changes in these people is extremely important,” he added.
The CORDIOPREV study was supported by the Fundación Patrimonio Comunal Olivarero. Dr. Yubero-Serrano and Dr. Rozanski disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
For patients with coronary heart disease (CHD), following a Mediterranean diet is more effective in reducing progression of atherosclerosis than following a low-fat diet, according to new data from the CORDIOPREV randomized, controlled trial.
“The current study is, to our knowledge, the first to establish an effective dietary strategy for secondary cardiovascular prevention, reinforcing the fact that the Mediterranean diet rich in extra virgin olive oil (EVOO) could prevent the progression of atherosclerosis,” the study team said.
The data also show that patients with a higher atherosclerotic burden might benefit the most from the Mediterranean diet.
The study was published online Aug. 10, 2021, in Stroke.
Mediterranean or low fat?
“It is well established that lifestyle and dietary habits powerfully affect cardiovascular risk,” study investigator Elena M. Yubero-Serrano, PhD, with Reina Sofia University Hospital/University of Cordoba (Spain), told this news organization.
“The effectiveness of the Mediterranean diet in reducing cardiovascular risk has been seen in primary prevention. However, currently there is no consensus about a recommended dietary model for the secondary prevention of cardiovascular disease,” she said.
The Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study is an ongoing prospective study comparing the effects of two healthy diets for secondary prevention of cardiovascular disease (CVD) in 1002 patients.
The comparative effect of the diets in reducing CVD risk, assessed by quantification of intima-media thickness of the common carotid arteries (IMT-CC), is a key secondary endpoint of the study.
During the study, half of the patients follow a Mediterranean diet rich in EVOO, fruit and vegetables, whole grains, fish, and nuts. The other half follow a diet low in fat and rich in complex carbohydrates.
A total of 939 participants (459 in the low-fat diet group and 480 in the Mediterranean diet group) completed IMT-CC evaluation at baseline, and 809 (377 and 432, respectively) completed the IMT-CC evaluation at 5 years; 731 (335 and 396, respectively) did so at 7 years.
The Mediterranean diet significantly decreased IMT-CC both after 5 years (–0.027; P < .001) and after 7 years (–0.031 mm; P < .001), relative to baseline. In contrast, the low-fat diet did not exert any change on IMT-CC after 5 or 7 years, the researchers report.
The higher the IMT-CC at baseline, the greater the reduction in this parameter.
The Mediterranean diet also produced a greater decrease in IMT-CC and carotid plaque maximum height, compared with the low-fat diet throughout follow-up.
There were no between-group differences in carotid plaque numbers during follow-up.
“Our findings, in addition to reinforcing the clinical benefits of the Mediterranean diet, provide a beneficial dietary strategy as a clinical and therapeutic tool that could reduce the high cardiovascular recurrence in the context of secondary prevention,” Dr. Yubero-Serrano said in an interview.
Earlier data from CORDIOPREV showed that, after 1 year of eating a Mediterranean diet, compared with the low-fat diet, endothelial function was improved among patients with CHD, even those with type 2 diabetes, which was associated with a better balance of vascular homeostasis.
The Mediterranean diet may also modulate the lipid profile, particularly by increasing HDL cholesterol levels. The anti-inflammatory capacity of the Mediterranean diet could be another factor that contributes to reducing the progression of atherosclerosis, the researchers say.
Important study
Reached for comment, Alan Rozanski, MD, professor of medicine, Icahn School of Medicine at Mount Sinai and cardiologist at Mount Sinai Morningside, New York, said: “We know very well that lifestyle factors, diet, and exercise in particular are extremely important in promoting health, vitality, and decreasing risk for chronic diseases, including heart attack and stroke.
“But a lot of the studies depend on epidemiological work. Until now, we haven’t had important prospective studies evaluating different kinds of dietary approaches and how they affect carotid intimal thickening assessments that we can do by ultrasound. So having this kind of imaging study which shows that diet can halt progression of atherosclerosis is important,” said Dr. Rozanski.
“Changing one’s diet is extremely important and potentially beneficial in many ways, and being able to say to a patient with atherosclerosis that we have data that shows you can halt the progression of the disease can be extraordinarily encouraging to many patients,” he noted.
“When people have disease, they very often gravitate toward drugs, but continuing to emphasize lifestyle changes in these people is extremely important,” he added.
The CORDIOPREV study was supported by the Fundación Patrimonio Comunal Olivarero. Dr. Yubero-Serrano and Dr. Rozanski disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Cutaneous Chaetomium globosum Infection in a Vedolizumab-Treated Patient
To the Editor:
Broader availability and utilization of novel biologic treatments has heralded the emergence of unusual infections, including skin and soft tissue infections. These unusual infections may not be seen in clinical trials due to their overall rare incidence. In modern society, exposure to unusual pathogens can occur in locations far from their natural habitat.1 Tissue culture remains the gold standard, as histopathology and smears may not identify the organisms. Tissue culture of these less-common pathogens is challenging and may require multiple samples and specialized laboratory evaluations.2 In some cases, a skin biopsy with histopathologic examination is an efficient means to confirm or exclude a dermatologic manifestation of an inflammatory disease. This information can quickly change the course of treatment, especially for those on immunosuppressive medications.3 We report a case of unusual cutaneous infection with Chaetomium globosum in a patient concomitantly treated with vedolizumab, a gut-specific integrin inhibitor, alongside traditional immunosuppressive therapy.
A 33-year-old woman with Crohn disease on vedolizumab and mercaptopurine was referred to the dermatology clinic with firm, tender, erythematous lesions on the legs of 1 month’s duration (Figure, A). She had a history of inflammatory bowel disease with perianal fistula, sacroiliitis, uveitis, guttate psoriasis, and erythema nodosum. She denied recent medication changes, foreign travel, swimming in freshwater or a hot tub, chills, fever, malaise, night sweats, and weight loss. Physical examination revealed several tender, indurated, erythematous plaques across the legs, ranging in size from 4 to 12 cm. The plaques had central hyperpigmentation, atrophy, and scant scale without ulceration, drainage, or pustules. The largest plaque demonstrated a well-defined area of central fluctuance. Prednisone (60 mg) with taper was initiated for presumed recurrence of erythema nodosum with close follow-up.
Five weeks later, most indurated plaques healed, leaving depressed scars; however, at 10 mg of prednisone she developed 2 additional nodules on the shin that, unlike earlier plaques, developed a central pustule and drained. The prednisone dose was increased to control the new areas and tapered thereafter to 20 mg daily. Despite the overall improvement, 2 plaques remained on the left side of the shin. Initially, erythema nodosum recurrence was considered, given the setting of inflammatory bowel disease and recent more classic presentation4; however, the disease progression and lack of response to standard treatment suggested an alternate pathology. Further history revealed that the patient had a pedicure 3 weeks prior to initial symptom onset. A swab was sent for routine bacterial culture at an outside clinic; no infectious agents were identified.
Three weeks later, the patient's condition had worsened again with increased edema, pain with standing, and more drainage (Figure, B). She did not report fevers or joint swelling. A punch biopsy was performed for tissue culture and histopathologic evaluation, which revealed granulomatous and suppurative inflammation and excluded erythema nodosum. Special stains for organisms were negative (Figure, C and D). Two weeks later, tissue culture began growing an unspecified mold. Mercaptopurine and prednisone were immediately discontinued. The patient remained on vedolizumab, started itraconazole (200 mg), and was referred to an infectious disease (ID) specialist. The sample was eventually identified as C globosum (Figure, E) at a specialized facility (University of Texas, San Antonio). Despite several weeks of itraconazole therapy, the patient developed edema surrounding the knee. Upon evaluation by orthopedics, the patient was diagnosed with reactive arthritis in the left knee and ankle. The knee fluid was drained, and cultures were negative. At recommendation of the ID physician, the itraconazole dosage was doubled given the limited clinical response. After several weeks at the increased dosage, she began to experience slow improvement (Figure, F). Because Chaetomium species infections are rare and have limited response to many antifungal agents,5 no standard treatment protocol was available. Initial recommendations for treatment were for 1 year, based on the experience and expertise of the ID physician. Treatment with itraconazole was continued for 10 months, at which point the patient chose to discontinue therapy prior to her follow-up appointments. The patient had no evidence of infection recurrence 2 months after discontinuing therapy.
In the expanding landscape of targeted biologic therapies for chronic inflammatory disease, physicians of various specialties are increasingly encountering unanticipated cutaneous eruptions and infections. Chaetomium is a dematiaceous mold found primarily in soil, water, decaying plants, paper, or dung. Based on its habitat, populations at risk for infection with Chaetomium species include farmers (plant and animal husbandry), children who play on the ground, and people with inadequate foot protection.1,2Chaetomium globosum has been identified in indoor environments, such as moldy rugs and mattresses. In one report, it was cultured from the environmental air in a bone marrow transplant patient’s room after the patient presented with delayed infection.6 Although human infection is uncommon, clinical isolation of Chaetomium species has occurred mainly in superficial samples from the skin, hair, nails, eyes, and respiratory tract.1 It been reported as a causative agent of onychomycosis in several immunocompetent patients7,8 but rarely is a cause of deep-skin infection. Chaetomium is thought to cause superficial infections, as it uses extracellular keratinases1 to degrade protective keratin structures, such as human nails. Infections in the brain, blood, and lymph nodes also have been noted but are quite rare. Deep skin infections present as painful papules and nodules to nonhealing ulcers that develop into inflammatory granulomas on the extremities.3 Local edema and yellow-brown crust often is present and fevers have been reported. Hyphae may be identified in skin biopsy.8 We posit that our patient may have been exposed to Chaetomium during her pedicure, as recirculating baths in nail salons have been a reported site of other infectious organisms, such as atypical mycobacteria.9
Vedolizumab is a humanized IgG1 monoclonal antibody used in the treatment of ulcerative colitis and Crohn disease. It targets the α4β7 integrin, a specific modulator of gut-trafficking lymphocytes. In vedolizumab’s clinical trial for Crohn disease, there was no increased incidence of life-threatening, severe infection.10,11 Often, new biologic treatments are used with known immunosuppressive medications. Mercaptopurine and prednisone are implicated in infections; however, recovery from the immune suppression usually is seen at 1 month after discontinuation.12 Our patient continued to worsen for several weeks and required increased dosing of itraconazole, despite stopping both prednisone and mercaptopurine. It opens the question as to whether vedolizumab played a role in the recalcitrant disease.
This case illustrates the importance of a high index of suspicion for unusual infections in the setting of biologic therapy. An infectious etiology of a cutaneous eruption in an immunosuppressed patient should always be included in the differential diagnosis and actively pursued early on; tissue culture may shorten the treatment course and decrease severity of the disease. Although a direct link between the mechanism of action of vedolizumab and cutaneous infection is not clear, given the rare incidence of this infection, a report of such a case is important to the practicing clinician.
- de Hoog GS, Ahmed SA, Najafzadeh MJ, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumycetoma. PLoS Negl Trop Dis. 2013;7:e2229. doi:10.1371/journal.pntd.0002229
- Zhang H, Ran Y, Li D, et al. Clavispora lusitaniae and Chaetomium atrobrunneum as rare agents of cutaneous infection. Mycopathologia. 2010;169:373-380. doi:10.1007/s11046-009-9266-9
- Schieffelin JS, Garcia-Diaz JB, Loss GE, et al. Phaeohyphomycosis fungal infections in solid organ transplant recipients: clinical presentation, pathology, and treatment. Transpl Infect Dis Off J Transplant Soc. 2014;16:270-278. doi:10.1111/tid.12197
- Farhi D, Cosnes J, Zizi N, et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine (Baltimore). 2008;87:281-293. doi:10.1097/MD.0b013e318187cc9c
- Guarro J, Soler L, Rinaldi MG. Pathogenicity and antifungal susceptibility of Chaetomium species. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol. 1995;14:613-618.
- Teixeira ABA, Trabasso P, Moretti-Branchini ML, et al. Phaeohyphomycosis caused by Chaetomium globosum in an allogeneic bone marrow transplant recipient. Mycopathologia. 2003;156:309-312.
- Falcón CS, Falcón MDMS, Ceballos JD, et al. Onychomycosis by Chaetomium spp. Mycoses. 2009;52:77-79. doi:10.1111/j.14390507.2008.01519.x
- Kim DM, Lee MH, Suh MK, et al. Onychomycosis caused by Chaetomium globosum. Ann Dermatol. 2013;25:232-236. doi:10.5021/ad.2013.25.2.232
- Vugia DJ, Jang Y, Zizek C, et al. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11:616-618. doi:10.3201/eid1104.040936
- Luthra P, Peyrin-Biroulet L, Ford AC. Systematic review and meta-analysis: opportunistic infections and malignancies during treatment with anti-integrin antibodies in inflammatory bowel disease. Aliment Pharmacol Ther. 2015;41:1227-1236. doi:10.1111/apt.13215
- Colombel J-F, Sands BE, Rutgeerts P, et al. The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut. 2017;66:839-851. doi:10.1136/gutjnl-2015-311079
- Connell WR, Kamm MA, Ritchie JK, et al. Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience. Gut. 1993;34:1081-1085.
To the Editor:
Broader availability and utilization of novel biologic treatments has heralded the emergence of unusual infections, including skin and soft tissue infections. These unusual infections may not be seen in clinical trials due to their overall rare incidence. In modern society, exposure to unusual pathogens can occur in locations far from their natural habitat.1 Tissue culture remains the gold standard, as histopathology and smears may not identify the organisms. Tissue culture of these less-common pathogens is challenging and may require multiple samples and specialized laboratory evaluations.2 In some cases, a skin biopsy with histopathologic examination is an efficient means to confirm or exclude a dermatologic manifestation of an inflammatory disease. This information can quickly change the course of treatment, especially for those on immunosuppressive medications.3 We report a case of unusual cutaneous infection with Chaetomium globosum in a patient concomitantly treated with vedolizumab, a gut-specific integrin inhibitor, alongside traditional immunosuppressive therapy.
A 33-year-old woman with Crohn disease on vedolizumab and mercaptopurine was referred to the dermatology clinic with firm, tender, erythematous lesions on the legs of 1 month’s duration (Figure, A). She had a history of inflammatory bowel disease with perianal fistula, sacroiliitis, uveitis, guttate psoriasis, and erythema nodosum. She denied recent medication changes, foreign travel, swimming in freshwater or a hot tub, chills, fever, malaise, night sweats, and weight loss. Physical examination revealed several tender, indurated, erythematous plaques across the legs, ranging in size from 4 to 12 cm. The plaques had central hyperpigmentation, atrophy, and scant scale without ulceration, drainage, or pustules. The largest plaque demonstrated a well-defined area of central fluctuance. Prednisone (60 mg) with taper was initiated for presumed recurrence of erythema nodosum with close follow-up.
Five weeks later, most indurated plaques healed, leaving depressed scars; however, at 10 mg of prednisone she developed 2 additional nodules on the shin that, unlike earlier plaques, developed a central pustule and drained. The prednisone dose was increased to control the new areas and tapered thereafter to 20 mg daily. Despite the overall improvement, 2 plaques remained on the left side of the shin. Initially, erythema nodosum recurrence was considered, given the setting of inflammatory bowel disease and recent more classic presentation4; however, the disease progression and lack of response to standard treatment suggested an alternate pathology. Further history revealed that the patient had a pedicure 3 weeks prior to initial symptom onset. A swab was sent for routine bacterial culture at an outside clinic; no infectious agents were identified.
Three weeks later, the patient's condition had worsened again with increased edema, pain with standing, and more drainage (Figure, B). She did not report fevers or joint swelling. A punch biopsy was performed for tissue culture and histopathologic evaluation, which revealed granulomatous and suppurative inflammation and excluded erythema nodosum. Special stains for organisms were negative (Figure, C and D). Two weeks later, tissue culture began growing an unspecified mold. Mercaptopurine and prednisone were immediately discontinued. The patient remained on vedolizumab, started itraconazole (200 mg), and was referred to an infectious disease (ID) specialist. The sample was eventually identified as C globosum (Figure, E) at a specialized facility (University of Texas, San Antonio). Despite several weeks of itraconazole therapy, the patient developed edema surrounding the knee. Upon evaluation by orthopedics, the patient was diagnosed with reactive arthritis in the left knee and ankle. The knee fluid was drained, and cultures were negative. At recommendation of the ID physician, the itraconazole dosage was doubled given the limited clinical response. After several weeks at the increased dosage, she began to experience slow improvement (Figure, F). Because Chaetomium species infections are rare and have limited response to many antifungal agents,5 no standard treatment protocol was available. Initial recommendations for treatment were for 1 year, based on the experience and expertise of the ID physician. Treatment with itraconazole was continued for 10 months, at which point the patient chose to discontinue therapy prior to her follow-up appointments. The patient had no evidence of infection recurrence 2 months after discontinuing therapy.
In the expanding landscape of targeted biologic therapies for chronic inflammatory disease, physicians of various specialties are increasingly encountering unanticipated cutaneous eruptions and infections. Chaetomium is a dematiaceous mold found primarily in soil, water, decaying plants, paper, or dung. Based on its habitat, populations at risk for infection with Chaetomium species include farmers (plant and animal husbandry), children who play on the ground, and people with inadequate foot protection.1,2Chaetomium globosum has been identified in indoor environments, such as moldy rugs and mattresses. In one report, it was cultured from the environmental air in a bone marrow transplant patient’s room after the patient presented with delayed infection.6 Although human infection is uncommon, clinical isolation of Chaetomium species has occurred mainly in superficial samples from the skin, hair, nails, eyes, and respiratory tract.1 It been reported as a causative agent of onychomycosis in several immunocompetent patients7,8 but rarely is a cause of deep-skin infection. Chaetomium is thought to cause superficial infections, as it uses extracellular keratinases1 to degrade protective keratin structures, such as human nails. Infections in the brain, blood, and lymph nodes also have been noted but are quite rare. Deep skin infections present as painful papules and nodules to nonhealing ulcers that develop into inflammatory granulomas on the extremities.3 Local edema and yellow-brown crust often is present and fevers have been reported. Hyphae may be identified in skin biopsy.8 We posit that our patient may have been exposed to Chaetomium during her pedicure, as recirculating baths in nail salons have been a reported site of other infectious organisms, such as atypical mycobacteria.9
Vedolizumab is a humanized IgG1 monoclonal antibody used in the treatment of ulcerative colitis and Crohn disease. It targets the α4β7 integrin, a specific modulator of gut-trafficking lymphocytes. In vedolizumab’s clinical trial for Crohn disease, there was no increased incidence of life-threatening, severe infection.10,11 Often, new biologic treatments are used with known immunosuppressive medications. Mercaptopurine and prednisone are implicated in infections; however, recovery from the immune suppression usually is seen at 1 month after discontinuation.12 Our patient continued to worsen for several weeks and required increased dosing of itraconazole, despite stopping both prednisone and mercaptopurine. It opens the question as to whether vedolizumab played a role in the recalcitrant disease.
This case illustrates the importance of a high index of suspicion for unusual infections in the setting of biologic therapy. An infectious etiology of a cutaneous eruption in an immunosuppressed patient should always be included in the differential diagnosis and actively pursued early on; tissue culture may shorten the treatment course and decrease severity of the disease. Although a direct link between the mechanism of action of vedolizumab and cutaneous infection is not clear, given the rare incidence of this infection, a report of such a case is important to the practicing clinician.
To the Editor:
Broader availability and utilization of novel biologic treatments has heralded the emergence of unusual infections, including skin and soft tissue infections. These unusual infections may not be seen in clinical trials due to their overall rare incidence. In modern society, exposure to unusual pathogens can occur in locations far from their natural habitat.1 Tissue culture remains the gold standard, as histopathology and smears may not identify the organisms. Tissue culture of these less-common pathogens is challenging and may require multiple samples and specialized laboratory evaluations.2 In some cases, a skin biopsy with histopathologic examination is an efficient means to confirm or exclude a dermatologic manifestation of an inflammatory disease. This information can quickly change the course of treatment, especially for those on immunosuppressive medications.3 We report a case of unusual cutaneous infection with Chaetomium globosum in a patient concomitantly treated with vedolizumab, a gut-specific integrin inhibitor, alongside traditional immunosuppressive therapy.
A 33-year-old woman with Crohn disease on vedolizumab and mercaptopurine was referred to the dermatology clinic with firm, tender, erythematous lesions on the legs of 1 month’s duration (Figure, A). She had a history of inflammatory bowel disease with perianal fistula, sacroiliitis, uveitis, guttate psoriasis, and erythema nodosum. She denied recent medication changes, foreign travel, swimming in freshwater or a hot tub, chills, fever, malaise, night sweats, and weight loss. Physical examination revealed several tender, indurated, erythematous plaques across the legs, ranging in size from 4 to 12 cm. The plaques had central hyperpigmentation, atrophy, and scant scale without ulceration, drainage, or pustules. The largest plaque demonstrated a well-defined area of central fluctuance. Prednisone (60 mg) with taper was initiated for presumed recurrence of erythema nodosum with close follow-up.
Five weeks later, most indurated plaques healed, leaving depressed scars; however, at 10 mg of prednisone she developed 2 additional nodules on the shin that, unlike earlier plaques, developed a central pustule and drained. The prednisone dose was increased to control the new areas and tapered thereafter to 20 mg daily. Despite the overall improvement, 2 plaques remained on the left side of the shin. Initially, erythema nodosum recurrence was considered, given the setting of inflammatory bowel disease and recent more classic presentation4; however, the disease progression and lack of response to standard treatment suggested an alternate pathology. Further history revealed that the patient had a pedicure 3 weeks prior to initial symptom onset. A swab was sent for routine bacterial culture at an outside clinic; no infectious agents were identified.
Three weeks later, the patient's condition had worsened again with increased edema, pain with standing, and more drainage (Figure, B). She did not report fevers or joint swelling. A punch biopsy was performed for tissue culture and histopathologic evaluation, which revealed granulomatous and suppurative inflammation and excluded erythema nodosum. Special stains for organisms were negative (Figure, C and D). Two weeks later, tissue culture began growing an unspecified mold. Mercaptopurine and prednisone were immediately discontinued. The patient remained on vedolizumab, started itraconazole (200 mg), and was referred to an infectious disease (ID) specialist. The sample was eventually identified as C globosum (Figure, E) at a specialized facility (University of Texas, San Antonio). Despite several weeks of itraconazole therapy, the patient developed edema surrounding the knee. Upon evaluation by orthopedics, the patient was diagnosed with reactive arthritis in the left knee and ankle. The knee fluid was drained, and cultures were negative. At recommendation of the ID physician, the itraconazole dosage was doubled given the limited clinical response. After several weeks at the increased dosage, she began to experience slow improvement (Figure, F). Because Chaetomium species infections are rare and have limited response to many antifungal agents,5 no standard treatment protocol was available. Initial recommendations for treatment were for 1 year, based on the experience and expertise of the ID physician. Treatment with itraconazole was continued for 10 months, at which point the patient chose to discontinue therapy prior to her follow-up appointments. The patient had no evidence of infection recurrence 2 months after discontinuing therapy.
In the expanding landscape of targeted biologic therapies for chronic inflammatory disease, physicians of various specialties are increasingly encountering unanticipated cutaneous eruptions and infections. Chaetomium is a dematiaceous mold found primarily in soil, water, decaying plants, paper, or dung. Based on its habitat, populations at risk for infection with Chaetomium species include farmers (plant and animal husbandry), children who play on the ground, and people with inadequate foot protection.1,2Chaetomium globosum has been identified in indoor environments, such as moldy rugs and mattresses. In one report, it was cultured from the environmental air in a bone marrow transplant patient’s room after the patient presented with delayed infection.6 Although human infection is uncommon, clinical isolation of Chaetomium species has occurred mainly in superficial samples from the skin, hair, nails, eyes, and respiratory tract.1 It been reported as a causative agent of onychomycosis in several immunocompetent patients7,8 but rarely is a cause of deep-skin infection. Chaetomium is thought to cause superficial infections, as it uses extracellular keratinases1 to degrade protective keratin structures, such as human nails. Infections in the brain, blood, and lymph nodes also have been noted but are quite rare. Deep skin infections present as painful papules and nodules to nonhealing ulcers that develop into inflammatory granulomas on the extremities.3 Local edema and yellow-brown crust often is present and fevers have been reported. Hyphae may be identified in skin biopsy.8 We posit that our patient may have been exposed to Chaetomium during her pedicure, as recirculating baths in nail salons have been a reported site of other infectious organisms, such as atypical mycobacteria.9
Vedolizumab is a humanized IgG1 monoclonal antibody used in the treatment of ulcerative colitis and Crohn disease. It targets the α4β7 integrin, a specific modulator of gut-trafficking lymphocytes. In vedolizumab’s clinical trial for Crohn disease, there was no increased incidence of life-threatening, severe infection.10,11 Often, new biologic treatments are used with known immunosuppressive medications. Mercaptopurine and prednisone are implicated in infections; however, recovery from the immune suppression usually is seen at 1 month after discontinuation.12 Our patient continued to worsen for several weeks and required increased dosing of itraconazole, despite stopping both prednisone and mercaptopurine. It opens the question as to whether vedolizumab played a role in the recalcitrant disease.
This case illustrates the importance of a high index of suspicion for unusual infections in the setting of biologic therapy. An infectious etiology of a cutaneous eruption in an immunosuppressed patient should always be included in the differential diagnosis and actively pursued early on; tissue culture may shorten the treatment course and decrease severity of the disease. Although a direct link between the mechanism of action of vedolizumab and cutaneous infection is not clear, given the rare incidence of this infection, a report of such a case is important to the practicing clinician.
- de Hoog GS, Ahmed SA, Najafzadeh MJ, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumycetoma. PLoS Negl Trop Dis. 2013;7:e2229. doi:10.1371/journal.pntd.0002229
- Zhang H, Ran Y, Li D, et al. Clavispora lusitaniae and Chaetomium atrobrunneum as rare agents of cutaneous infection. Mycopathologia. 2010;169:373-380. doi:10.1007/s11046-009-9266-9
- Schieffelin JS, Garcia-Diaz JB, Loss GE, et al. Phaeohyphomycosis fungal infections in solid organ transplant recipients: clinical presentation, pathology, and treatment. Transpl Infect Dis Off J Transplant Soc. 2014;16:270-278. doi:10.1111/tid.12197
- Farhi D, Cosnes J, Zizi N, et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine (Baltimore). 2008;87:281-293. doi:10.1097/MD.0b013e318187cc9c
- Guarro J, Soler L, Rinaldi MG. Pathogenicity and antifungal susceptibility of Chaetomium species. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol. 1995;14:613-618.
- Teixeira ABA, Trabasso P, Moretti-Branchini ML, et al. Phaeohyphomycosis caused by Chaetomium globosum in an allogeneic bone marrow transplant recipient. Mycopathologia. 2003;156:309-312.
- Falcón CS, Falcón MDMS, Ceballos JD, et al. Onychomycosis by Chaetomium spp. Mycoses. 2009;52:77-79. doi:10.1111/j.14390507.2008.01519.x
- Kim DM, Lee MH, Suh MK, et al. Onychomycosis caused by Chaetomium globosum. Ann Dermatol. 2013;25:232-236. doi:10.5021/ad.2013.25.2.232
- Vugia DJ, Jang Y, Zizek C, et al. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11:616-618. doi:10.3201/eid1104.040936
- Luthra P, Peyrin-Biroulet L, Ford AC. Systematic review and meta-analysis: opportunistic infections and malignancies during treatment with anti-integrin antibodies in inflammatory bowel disease. Aliment Pharmacol Ther. 2015;41:1227-1236. doi:10.1111/apt.13215
- Colombel J-F, Sands BE, Rutgeerts P, et al. The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut. 2017;66:839-851. doi:10.1136/gutjnl-2015-311079
- Connell WR, Kamm MA, Ritchie JK, et al. Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience. Gut. 1993;34:1081-1085.
- de Hoog GS, Ahmed SA, Najafzadeh MJ, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumycetoma. PLoS Negl Trop Dis. 2013;7:e2229. doi:10.1371/journal.pntd.0002229
- Zhang H, Ran Y, Li D, et al. Clavispora lusitaniae and Chaetomium atrobrunneum as rare agents of cutaneous infection. Mycopathologia. 2010;169:373-380. doi:10.1007/s11046-009-9266-9
- Schieffelin JS, Garcia-Diaz JB, Loss GE, et al. Phaeohyphomycosis fungal infections in solid organ transplant recipients: clinical presentation, pathology, and treatment. Transpl Infect Dis Off J Transplant Soc. 2014;16:270-278. doi:10.1111/tid.12197
- Farhi D, Cosnes J, Zizi N, et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine (Baltimore). 2008;87:281-293. doi:10.1097/MD.0b013e318187cc9c
- Guarro J, Soler L, Rinaldi MG. Pathogenicity and antifungal susceptibility of Chaetomium species. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol. 1995;14:613-618.
- Teixeira ABA, Trabasso P, Moretti-Branchini ML, et al. Phaeohyphomycosis caused by Chaetomium globosum in an allogeneic bone marrow transplant recipient. Mycopathologia. 2003;156:309-312.
- Falcón CS, Falcón MDMS, Ceballos JD, et al. Onychomycosis by Chaetomium spp. Mycoses. 2009;52:77-79. doi:10.1111/j.14390507.2008.01519.x
- Kim DM, Lee MH, Suh MK, et al. Onychomycosis caused by Chaetomium globosum. Ann Dermatol. 2013;25:232-236. doi:10.5021/ad.2013.25.2.232
- Vugia DJ, Jang Y, Zizek C, et al. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11:616-618. doi:10.3201/eid1104.040936
- Luthra P, Peyrin-Biroulet L, Ford AC. Systematic review and meta-analysis: opportunistic infections and malignancies during treatment with anti-integrin antibodies in inflammatory bowel disease. Aliment Pharmacol Ther. 2015;41:1227-1236. doi:10.1111/apt.13215
- Colombel J-F, Sands BE, Rutgeerts P, et al. The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut. 2017;66:839-851. doi:10.1136/gutjnl-2015-311079
- Connell WR, Kamm MA, Ritchie JK, et al. Bone marrow toxicity caused by azathioprine in inflammatory bowel disease: 27 years of experience. Gut. 1993;34:1081-1085.
Practice Points
- Tissue culture remains the gold standard for deep fungal infections.
- Physicians must maintain a high index of suspicion for alternate diagnoses when a disease progresses along an unexpected course.
- Biologic medications may have low-incidence side effects that emerge in postmarket use.
Verrucous Carcinoma in a Wounded Military Amputee
To the Editor:
Verrucous carcinoma is a rare, well-differentiated, locally aggressive squamous cell carcinoma first described by Ackerman in 1948.1 There are 4 main clinicopathologic types: oral florid papillomatosis or Ackerman tumor, giant condyloma acuminatum or Buschke-Lowenstein tumor, plantar verrucous carcinoma, and cutaneous verrucous carcinoma.2,3 Historically, most patients are older white men. The lesion commonly occurs in sites of inflammation4 or chronic irritation/trauma. Clinically, patients present with a slowly enlarging, exophytic, verrucous plaque violating the skin, fascia, and occasionally bone. Although these lesions have little tendency to metastasize, substantial morbidity can be seen due to local invasion. Despite surgical excision, recurrence is not uncommon and is associated with a poor prognosis and higher infiltrative potential.5
A 45-year-old male veteran initially presented to our dermatology clinic with a 4-cm, macerated, verrucous plaque on the left lateral ankle in the area of a skin graft placed during a prior limb salvage surgery (Figure 1). The patient experienced a traumatic blast injury while deployed 7 years prior with a subsequent right-sided below-the-knee amputation and left lower limb salvage. The lesion was clinically diagnosed as verruca vulgaris and treated with daily salicylic acid. Six weeks after the initial presentation, the lesion remained largely unchanged. A biopsy subsequently was obtained to confirm the diagnosis. At that time, the histopathology was consistent with verruca vulgaris without evidence of carcinoma. Due to the persistence of the lesion, lack of improvement with topical treatment, and overall size, the patient opted for surgical excision.
A year later, the lesion was excised again by orthopedic surgery, and the tissue was submitted for histopathologic evaluation, which was suggestive of a verrucous neoplasm with some disagreement on whether it was consistent with verrucous hyperplasia or verrucous carcinoma. Following excision, the patient sustained a nonhealing chronic ulcer that required wound care for a total of 6 months. The lesion recurred a year later and was surgically excised a third time. A split-thickness skin graft was utilized to repair the defect. Histopathology again was consistent with verrucous carcinoma. With a fourth and final recurrence of the verrucous plaque 6 months later, the patient elected to undergo a left-sided below-the-knee amputation.
Verrucous carcinoma can represent a diagnostic dilemma, as histologic sections may mimic benign entities. The features of a well-differentiated squamous epithelium with hyperkeratosis, papillomatosis, and acanthosis can be mistaken for verruca vulgaris, keratoacanthoma, and pseudoepitheliomatous hyperplasia,6 which are characteristic of verrucous hyperplasia. Accurate diagnosis can be difficult with a superficial biopsy because of the mature appearance of the epithelium,7 prompting the need for multiple and deeper biopsies8 to include sampling of the base of the hyperplastic epithelium in which the characteristic bulbous pushing growth pattern of the rete ridges is visualized. Precise histologic diagnosis can be further confounded by external mechanical factors, such as pressure, which can distort the classic histopathology.7 The histopathologic features leading to the diagnosis of verrucous carcinoma in our specimen were minimal squamous atypia present in a predominantly exophytic squamous proliferation with human papillomavirus cytopathic effect and focal endophytic pushing borders by rounded bulbous rete ridges into the mid and deep dermis (Figure 2).
Diagnostic uncertainty can delay surgical excision and lead to progression of verrucous carcinoma. Unfortunately, even with appropriate surgical intervention, recurrence has been documented; therefore, close clinical follow-up is recommended. The tumor spreads by local invasion and may follow the path of least resistance.4 In our patient, the frequent tissue manipulation may have facilitated aggressive infiltration of the tumor, ultimately resulting in the loss of his remaining leg. Therefore, it is important for clinicians to recognize that verrucous carcinoma, especially one that develops on a refractory ulcer or scar tissue, may be a complex malignant neoplasm that requires extensive treatment at onset to prevent the amputation of a limb.
- Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery. 1948;23:670-678.
- Yoshitasu S, Takagi T, Ohata C, et al. Plantar verrucous carcinoma: report of a case treated with Boyd amputation followed by reconstruction with a free forearm flap. J Dermatol. 2001;28:226-230.
- Schwartz R. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol. 1995;32:1-14.
- Bernstein SC, Lim KK, Brodland DG, et al. The many faces of squamous cell carcinoma. Dermatol Surg. 1996;22:243-254.
- Costache M, Tatiana D, Mitrache L, et al. Cutaneous verrucous carcinoma—report of three cases with review of literature. Rom J Morphol Embryol. 2014;55:383-388.
- Shenoy A, Waghmare R, Kavishwar V, et al. Carcinoma cuniculatum of foot. Foot. 2011;21:207-208.
- Klima M, Kurtis B, Jordan P. Verrucous carcinoma of skin. J Cutan Pathol.1980;7:88-98.
- Pleat J, Sacks L, Rigby H. Cutaneous verrucous carcinoma. Br J Plast Surg. 2001;54:554-555.
To the Editor:
Verrucous carcinoma is a rare, well-differentiated, locally aggressive squamous cell carcinoma first described by Ackerman in 1948.1 There are 4 main clinicopathologic types: oral florid papillomatosis or Ackerman tumor, giant condyloma acuminatum or Buschke-Lowenstein tumor, plantar verrucous carcinoma, and cutaneous verrucous carcinoma.2,3 Historically, most patients are older white men. The lesion commonly occurs in sites of inflammation4 or chronic irritation/trauma. Clinically, patients present with a slowly enlarging, exophytic, verrucous plaque violating the skin, fascia, and occasionally bone. Although these lesions have little tendency to metastasize, substantial morbidity can be seen due to local invasion. Despite surgical excision, recurrence is not uncommon and is associated with a poor prognosis and higher infiltrative potential.5
A 45-year-old male veteran initially presented to our dermatology clinic with a 4-cm, macerated, verrucous plaque on the left lateral ankle in the area of a skin graft placed during a prior limb salvage surgery (Figure 1). The patient experienced a traumatic blast injury while deployed 7 years prior with a subsequent right-sided below-the-knee amputation and left lower limb salvage. The lesion was clinically diagnosed as verruca vulgaris and treated with daily salicylic acid. Six weeks after the initial presentation, the lesion remained largely unchanged. A biopsy subsequently was obtained to confirm the diagnosis. At that time, the histopathology was consistent with verruca vulgaris without evidence of carcinoma. Due to the persistence of the lesion, lack of improvement with topical treatment, and overall size, the patient opted for surgical excision.
A year later, the lesion was excised again by orthopedic surgery, and the tissue was submitted for histopathologic evaluation, which was suggestive of a verrucous neoplasm with some disagreement on whether it was consistent with verrucous hyperplasia or verrucous carcinoma. Following excision, the patient sustained a nonhealing chronic ulcer that required wound care for a total of 6 months. The lesion recurred a year later and was surgically excised a third time. A split-thickness skin graft was utilized to repair the defect. Histopathology again was consistent with verrucous carcinoma. With a fourth and final recurrence of the verrucous plaque 6 months later, the patient elected to undergo a left-sided below-the-knee amputation.
Verrucous carcinoma can represent a diagnostic dilemma, as histologic sections may mimic benign entities. The features of a well-differentiated squamous epithelium with hyperkeratosis, papillomatosis, and acanthosis can be mistaken for verruca vulgaris, keratoacanthoma, and pseudoepitheliomatous hyperplasia,6 which are characteristic of verrucous hyperplasia. Accurate diagnosis can be difficult with a superficial biopsy because of the mature appearance of the epithelium,7 prompting the need for multiple and deeper biopsies8 to include sampling of the base of the hyperplastic epithelium in which the characteristic bulbous pushing growth pattern of the rete ridges is visualized. Precise histologic diagnosis can be further confounded by external mechanical factors, such as pressure, which can distort the classic histopathology.7 The histopathologic features leading to the diagnosis of verrucous carcinoma in our specimen were minimal squamous atypia present in a predominantly exophytic squamous proliferation with human papillomavirus cytopathic effect and focal endophytic pushing borders by rounded bulbous rete ridges into the mid and deep dermis (Figure 2).
Diagnostic uncertainty can delay surgical excision and lead to progression of verrucous carcinoma. Unfortunately, even with appropriate surgical intervention, recurrence has been documented; therefore, close clinical follow-up is recommended. The tumor spreads by local invasion and may follow the path of least resistance.4 In our patient, the frequent tissue manipulation may have facilitated aggressive infiltration of the tumor, ultimately resulting in the loss of his remaining leg. Therefore, it is important for clinicians to recognize that verrucous carcinoma, especially one that develops on a refractory ulcer or scar tissue, may be a complex malignant neoplasm that requires extensive treatment at onset to prevent the amputation of a limb.
To the Editor:
Verrucous carcinoma is a rare, well-differentiated, locally aggressive squamous cell carcinoma first described by Ackerman in 1948.1 There are 4 main clinicopathologic types: oral florid papillomatosis or Ackerman tumor, giant condyloma acuminatum or Buschke-Lowenstein tumor, plantar verrucous carcinoma, and cutaneous verrucous carcinoma.2,3 Historically, most patients are older white men. The lesion commonly occurs in sites of inflammation4 or chronic irritation/trauma. Clinically, patients present with a slowly enlarging, exophytic, verrucous plaque violating the skin, fascia, and occasionally bone. Although these lesions have little tendency to metastasize, substantial morbidity can be seen due to local invasion. Despite surgical excision, recurrence is not uncommon and is associated with a poor prognosis and higher infiltrative potential.5
A 45-year-old male veteran initially presented to our dermatology clinic with a 4-cm, macerated, verrucous plaque on the left lateral ankle in the area of a skin graft placed during a prior limb salvage surgery (Figure 1). The patient experienced a traumatic blast injury while deployed 7 years prior with a subsequent right-sided below-the-knee amputation and left lower limb salvage. The lesion was clinically diagnosed as verruca vulgaris and treated with daily salicylic acid. Six weeks after the initial presentation, the lesion remained largely unchanged. A biopsy subsequently was obtained to confirm the diagnosis. At that time, the histopathology was consistent with verruca vulgaris without evidence of carcinoma. Due to the persistence of the lesion, lack of improvement with topical treatment, and overall size, the patient opted for surgical excision.
A year later, the lesion was excised again by orthopedic surgery, and the tissue was submitted for histopathologic evaluation, which was suggestive of a verrucous neoplasm with some disagreement on whether it was consistent with verrucous hyperplasia or verrucous carcinoma. Following excision, the patient sustained a nonhealing chronic ulcer that required wound care for a total of 6 months. The lesion recurred a year later and was surgically excised a third time. A split-thickness skin graft was utilized to repair the defect. Histopathology again was consistent with verrucous carcinoma. With a fourth and final recurrence of the verrucous plaque 6 months later, the patient elected to undergo a left-sided below-the-knee amputation.
Verrucous carcinoma can represent a diagnostic dilemma, as histologic sections may mimic benign entities. The features of a well-differentiated squamous epithelium with hyperkeratosis, papillomatosis, and acanthosis can be mistaken for verruca vulgaris, keratoacanthoma, and pseudoepitheliomatous hyperplasia,6 which are characteristic of verrucous hyperplasia. Accurate diagnosis can be difficult with a superficial biopsy because of the mature appearance of the epithelium,7 prompting the need for multiple and deeper biopsies8 to include sampling of the base of the hyperplastic epithelium in which the characteristic bulbous pushing growth pattern of the rete ridges is visualized. Precise histologic diagnosis can be further confounded by external mechanical factors, such as pressure, which can distort the classic histopathology.7 The histopathologic features leading to the diagnosis of verrucous carcinoma in our specimen were minimal squamous atypia present in a predominantly exophytic squamous proliferation with human papillomavirus cytopathic effect and focal endophytic pushing borders by rounded bulbous rete ridges into the mid and deep dermis (Figure 2).
Diagnostic uncertainty can delay surgical excision and lead to progression of verrucous carcinoma. Unfortunately, even with appropriate surgical intervention, recurrence has been documented; therefore, close clinical follow-up is recommended. The tumor spreads by local invasion and may follow the path of least resistance.4 In our patient, the frequent tissue manipulation may have facilitated aggressive infiltration of the tumor, ultimately resulting in the loss of his remaining leg. Therefore, it is important for clinicians to recognize that verrucous carcinoma, especially one that develops on a refractory ulcer or scar tissue, may be a complex malignant neoplasm that requires extensive treatment at onset to prevent the amputation of a limb.
- Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery. 1948;23:670-678.
- Yoshitasu S, Takagi T, Ohata C, et al. Plantar verrucous carcinoma: report of a case treated with Boyd amputation followed by reconstruction with a free forearm flap. J Dermatol. 2001;28:226-230.
- Schwartz R. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol. 1995;32:1-14.
- Bernstein SC, Lim KK, Brodland DG, et al. The many faces of squamous cell carcinoma. Dermatol Surg. 1996;22:243-254.
- Costache M, Tatiana D, Mitrache L, et al. Cutaneous verrucous carcinoma—report of three cases with review of literature. Rom J Morphol Embryol. 2014;55:383-388.
- Shenoy A, Waghmare R, Kavishwar V, et al. Carcinoma cuniculatum of foot. Foot. 2011;21:207-208.
- Klima M, Kurtis B, Jordan P. Verrucous carcinoma of skin. J Cutan Pathol.1980;7:88-98.
- Pleat J, Sacks L, Rigby H. Cutaneous verrucous carcinoma. Br J Plast Surg. 2001;54:554-555.
- Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery. 1948;23:670-678.
- Yoshitasu S, Takagi T, Ohata C, et al. Plantar verrucous carcinoma: report of a case treated with Boyd amputation followed by reconstruction with a free forearm flap. J Dermatol. 2001;28:226-230.
- Schwartz R. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol. 1995;32:1-14.
- Bernstein SC, Lim KK, Brodland DG, et al. The many faces of squamous cell carcinoma. Dermatol Surg. 1996;22:243-254.
- Costache M, Tatiana D, Mitrache L, et al. Cutaneous verrucous carcinoma—report of three cases with review of literature. Rom J Morphol Embryol. 2014;55:383-388.
- Shenoy A, Waghmare R, Kavishwar V, et al. Carcinoma cuniculatum of foot. Foot. 2011;21:207-208.
- Klima M, Kurtis B, Jordan P. Verrucous carcinoma of skin. J Cutan Pathol.1980;7:88-98.
- Pleat J, Sacks L, Rigby H. Cutaneous verrucous carcinoma. Br J Plast Surg. 2001;54:554-555.
Practice Points
- Verrucous carcinoma is a rare, well-differentiated, locally aggressive squamous cell carcinoma that commonly occurs in sites of inflammation or chronic irritation.
- Histologically, verrucous carcinoma can be mistaken for other entities including verruca vulgaris, keratoacanthoma, and pseudoepitheliomatous hyperplasia, often delaying the appropriate diagnosis and treatment.
Business Education in Dermatology Residency: A Survey of Program Directors
Globally, the United States has the highest per-capita cost of health care; total costs are expected to account for approximately 20% of the nation’s gross domestic product by 2025.1 These rising costs have prompted residency programs and medical schools to incorporate business education into their curricula.2-5 Although medical training is demanding—with little room to add curricular components—these business-focused curricula have consistently received positive feedback from residents.5,6
In dermatology, more than 50% of residents opt to join a private practice upon graduation.7 In the United States, there also is an upward trend of practice acquisition and consolidation by private equity firms. Therefore, dermatology trainees are uniquely positioned to benefit from business education to make well-informed decisions about joining or starting a practice.Furthermore, whether in a private or academic setting, knowledge of foundational economics, business strategy, finance, marketing, and health care policy can equip dermatologists to more effectively advocate for local and national policies that benefit their patient population.7
We conducted a survey of dermatology program directors (PDs) to determine the availability of and perceptions regarding business education during residency training.
Materials and Methods
Institutional review board (Vanderbilt University Medical Center, Nashville, Tennessee) approval was obtained. The survey was distributed weekly during a 5-week period from July 2020 to August 2020 through the Research Electronic Data Capture survey application (www.project-redcap.org). Program director email addresses were obtained through the Accreditation Council for Graduate Medical Education (ACGME) program list. A PD was included in the survey if they were employed by an accredited US osteopathic or allopathic program and their email address was provided in the ACGME program list or on their program’s faculty web page; a PD was excluded if an email address was not provided in the ACGME program list or on their program’s faculty web page.
The 8-part questionnaire was designed to assess the following characteristics: details about the respondent’s residency program (institutional affiliation, number of residents), the respondent’s professional background (number of years as a PD, business training experience), resources for business education provided by the program, the respondent’s opinion about business education for residents, and the respondent’s perception of the most important topics to include in a dermatology curriculum’s business education component, which included economics/finance, health care policy/government, management, marketing, negotiation, private equity involvement in health care, business strategy, supply chain/operations, and technology/product development. Responses were kept anonymous. Categorical and continuous variables were analyzed with medians and proportions.
Results
Of the 139 surveys distributed, 35 were completed and returned (response rate, 25.2%). Most programs were university-affiliated (71.4%) or community-affiliated (22.9%). The median number of residents was 12. The respondents had a median of 5 years’ experience in their role. Most respondents (65.7%) had no business training, although 20.0% had completed undergraduate business coursework, and 8.6% had attended formal seminars on business topics; 5.7% were self-taught on business topics.
Business Education Availability
Approximately half (51.4%) of programs offered business training to residents, primarily through seminars or lectures (94.4%) and take-home modules (16.7%). None of the programs offered a formal gap year during which residents could pursue a professional business degree. Most respondents thought business education during residency was important (82.8%) and that programs should implement more training (57.1%). When asked whether residents were competent to handle business aspects of dermatology upon graduation, most respondents disagreed somewhat (22.9%) or were neutral (40.0%).
Topics for Business Education
The most important topics identified for inclusion in a business curriculum were economics or finance (68.6%), management (68.6%), and health care policy or government (57.1%). Other identified topics included negotiation (40.0%), private equity involvement in health care (40.0%), strategy (11.4%), supply chain or operations (11.4%), marketing (2.9%), and technology (2.9%).
Comment
Residency programs and medical schools in the United States have started to integrate formal business training into their curricula; however, the state of business training in dermatology has not been characterized. Overall, this survey revealed largely positive perceptions about business education and identified a demand for more resources.
Whereas most PDs identified business education as important, only one half (51.4%) of the representative programs offered structured training. Notably, most PDs did not agree that graduating residents were competent to handle the business demands of dermatology practice. These responses highlight a gap in the demand and resources available for business training.
Identifying Curricular Resources
During an already demanding residency, additional curricular components need to be beneficial and worthwhile. To avoid significant disruption, business training could take place in the form of online lectures or take-home modules. Most programs represented in the survey responses had an academic affiliation and therefore commonly have access to an affiliated graduate business school and/or hospital administrators who have clinical and business training.
Community dermatologists who own or run their own practice also are uniquely positioned to provide residents with practical, dermatology-specific business education. Programs can utilize their institutional and local colleagues to aid in curricular design and implementation. In addition, a potential long-term solution to obtaining resources for business education is to coordinate with a national dermatology organization to create standardized modules that are available to all residency programs.
Key Curriculum Topics
Our survey identified the most important topics to include in a business curriculum for dermatology residents. Economics and finance, management, and health care policy would be valuable to a trainee regardless of whether they ultimately choose a career in academia or private practice. A thorough understanding of complex health care policy reinforces knowledge about insurance and regional and national regulations, which could ultimately benefit patient care. As an example, the American Academy of Dermatology outlines several advocacy priorities such as Medicare reimbursement policies, access to dermatologic care through public and private insurance, medication access and pricing, and preservation of private practice in the setting of market consolidation. Having a better understanding of health care policy and business could better equip dermatologists to lead these often business-driven advocacy efforts to ultimately improve patient care and advance the specialty.8
Limitations
There were notable limitations to this survey, primarily related to its design. With a 25% response rate, there was the potential for response and selection biases; therefore, these results might not be generalizable to all programs. In addition, views held by PDs might not be consistent with those of other members of the dermatology community; for example, surveying residents, other faculty members, and dermatologists in private practice would have provided a more comprehensive characterization of the topic.
Conclusion
This study assessed residency program directors’ perceptions of business education in dermatology training. There appears to be an imbalance between the perceived importance of such education and the resources that are available to provide it. More attention is needed to address this gap to ensure that dermatologists are prepared to manage a rapidly changing health care environment. Results of this survey should encourage efforts to establish (1) a standardized, dermatology-specific business curriculum and (2) a plan to make that curriculum accessible to trainees and other members of the dermatology community.
- Branning G, Vater M. Healthcare spending: plenty of blame to go around. Am Health Drug Benefits. 2016;9:445-447.
- Bayard M, Peeples CR, Holt J, et al. An interactive approach to teaching practice management to family practice residents. Fam Med. 2003;35:622-624.
- Chan S. Management education during radiology residency: development of an educational practice. Acad Radiol. 2004;11:1308-1317.
- Ninan D, Patel D. Career and leadership education in anesthesia residency training. Cureus. 2018;10:e2546.
- Yu-Chin R. Teaching administration and management within psychiatric residency training. Acad Psychiatry. 2002;26:245-252.
- Winkelman JW, Brugnara C. Management training for pathology residents. II. experience with a focused curriculum. Am J Clin Pathol. 1994;101:564-568.
- Tan S, Seiger K, Renehan P, et al. Trends in private equity acquisition of dermatology practices in the United States. JAMA Dermatol. 2019;155:1013-1021.
- Academy advocacy priorities. American Academy of Dermatology website. Accessed August 11, 2021. www.aad.org/member/advocacy/priorities
Globally, the United States has the highest per-capita cost of health care; total costs are expected to account for approximately 20% of the nation’s gross domestic product by 2025.1 These rising costs have prompted residency programs and medical schools to incorporate business education into their curricula.2-5 Although medical training is demanding—with little room to add curricular components—these business-focused curricula have consistently received positive feedback from residents.5,6
In dermatology, more than 50% of residents opt to join a private practice upon graduation.7 In the United States, there also is an upward trend of practice acquisition and consolidation by private equity firms. Therefore, dermatology trainees are uniquely positioned to benefit from business education to make well-informed decisions about joining or starting a practice.Furthermore, whether in a private or academic setting, knowledge of foundational economics, business strategy, finance, marketing, and health care policy can equip dermatologists to more effectively advocate for local and national policies that benefit their patient population.7
We conducted a survey of dermatology program directors (PDs) to determine the availability of and perceptions regarding business education during residency training.
Materials and Methods
Institutional review board (Vanderbilt University Medical Center, Nashville, Tennessee) approval was obtained. The survey was distributed weekly during a 5-week period from July 2020 to August 2020 through the Research Electronic Data Capture survey application (www.project-redcap.org). Program director email addresses were obtained through the Accreditation Council for Graduate Medical Education (ACGME) program list. A PD was included in the survey if they were employed by an accredited US osteopathic or allopathic program and their email address was provided in the ACGME program list or on their program’s faculty web page; a PD was excluded if an email address was not provided in the ACGME program list or on their program’s faculty web page.
The 8-part questionnaire was designed to assess the following characteristics: details about the respondent’s residency program (institutional affiliation, number of residents), the respondent’s professional background (number of years as a PD, business training experience), resources for business education provided by the program, the respondent’s opinion about business education for residents, and the respondent’s perception of the most important topics to include in a dermatology curriculum’s business education component, which included economics/finance, health care policy/government, management, marketing, negotiation, private equity involvement in health care, business strategy, supply chain/operations, and technology/product development. Responses were kept anonymous. Categorical and continuous variables were analyzed with medians and proportions.
Results
Of the 139 surveys distributed, 35 were completed and returned (response rate, 25.2%). Most programs were university-affiliated (71.4%) or community-affiliated (22.9%). The median number of residents was 12. The respondents had a median of 5 years’ experience in their role. Most respondents (65.7%) had no business training, although 20.0% had completed undergraduate business coursework, and 8.6% had attended formal seminars on business topics; 5.7% were self-taught on business topics.
Business Education Availability
Approximately half (51.4%) of programs offered business training to residents, primarily through seminars or lectures (94.4%) and take-home modules (16.7%). None of the programs offered a formal gap year during which residents could pursue a professional business degree. Most respondents thought business education during residency was important (82.8%) and that programs should implement more training (57.1%). When asked whether residents were competent to handle business aspects of dermatology upon graduation, most respondents disagreed somewhat (22.9%) or were neutral (40.0%).
Topics for Business Education
The most important topics identified for inclusion in a business curriculum were economics or finance (68.6%), management (68.6%), and health care policy or government (57.1%). Other identified topics included negotiation (40.0%), private equity involvement in health care (40.0%), strategy (11.4%), supply chain or operations (11.4%), marketing (2.9%), and technology (2.9%).
Comment
Residency programs and medical schools in the United States have started to integrate formal business training into their curricula; however, the state of business training in dermatology has not been characterized. Overall, this survey revealed largely positive perceptions about business education and identified a demand for more resources.
Whereas most PDs identified business education as important, only one half (51.4%) of the representative programs offered structured training. Notably, most PDs did not agree that graduating residents were competent to handle the business demands of dermatology practice. These responses highlight a gap in the demand and resources available for business training.
Identifying Curricular Resources
During an already demanding residency, additional curricular components need to be beneficial and worthwhile. To avoid significant disruption, business training could take place in the form of online lectures or take-home modules. Most programs represented in the survey responses had an academic affiliation and therefore commonly have access to an affiliated graduate business school and/or hospital administrators who have clinical and business training.
Community dermatologists who own or run their own practice also are uniquely positioned to provide residents with practical, dermatology-specific business education. Programs can utilize their institutional and local colleagues to aid in curricular design and implementation. In addition, a potential long-term solution to obtaining resources for business education is to coordinate with a national dermatology organization to create standardized modules that are available to all residency programs.
Key Curriculum Topics
Our survey identified the most important topics to include in a business curriculum for dermatology residents. Economics and finance, management, and health care policy would be valuable to a trainee regardless of whether they ultimately choose a career in academia or private practice. A thorough understanding of complex health care policy reinforces knowledge about insurance and regional and national regulations, which could ultimately benefit patient care. As an example, the American Academy of Dermatology outlines several advocacy priorities such as Medicare reimbursement policies, access to dermatologic care through public and private insurance, medication access and pricing, and preservation of private practice in the setting of market consolidation. Having a better understanding of health care policy and business could better equip dermatologists to lead these often business-driven advocacy efforts to ultimately improve patient care and advance the specialty.8
Limitations
There were notable limitations to this survey, primarily related to its design. With a 25% response rate, there was the potential for response and selection biases; therefore, these results might not be generalizable to all programs. In addition, views held by PDs might not be consistent with those of other members of the dermatology community; for example, surveying residents, other faculty members, and dermatologists in private practice would have provided a more comprehensive characterization of the topic.
Conclusion
This study assessed residency program directors’ perceptions of business education in dermatology training. There appears to be an imbalance between the perceived importance of such education and the resources that are available to provide it. More attention is needed to address this gap to ensure that dermatologists are prepared to manage a rapidly changing health care environment. Results of this survey should encourage efforts to establish (1) a standardized, dermatology-specific business curriculum and (2) a plan to make that curriculum accessible to trainees and other members of the dermatology community.
Globally, the United States has the highest per-capita cost of health care; total costs are expected to account for approximately 20% of the nation’s gross domestic product by 2025.1 These rising costs have prompted residency programs and medical schools to incorporate business education into their curricula.2-5 Although medical training is demanding—with little room to add curricular components—these business-focused curricula have consistently received positive feedback from residents.5,6
In dermatology, more than 50% of residents opt to join a private practice upon graduation.7 In the United States, there also is an upward trend of practice acquisition and consolidation by private equity firms. Therefore, dermatology trainees are uniquely positioned to benefit from business education to make well-informed decisions about joining or starting a practice.Furthermore, whether in a private or academic setting, knowledge of foundational economics, business strategy, finance, marketing, and health care policy can equip dermatologists to more effectively advocate for local and national policies that benefit their patient population.7
We conducted a survey of dermatology program directors (PDs) to determine the availability of and perceptions regarding business education during residency training.
Materials and Methods
Institutional review board (Vanderbilt University Medical Center, Nashville, Tennessee) approval was obtained. The survey was distributed weekly during a 5-week period from July 2020 to August 2020 through the Research Electronic Data Capture survey application (www.project-redcap.org). Program director email addresses were obtained through the Accreditation Council for Graduate Medical Education (ACGME) program list. A PD was included in the survey if they were employed by an accredited US osteopathic or allopathic program and their email address was provided in the ACGME program list or on their program’s faculty web page; a PD was excluded if an email address was not provided in the ACGME program list or on their program’s faculty web page.
The 8-part questionnaire was designed to assess the following characteristics: details about the respondent’s residency program (institutional affiliation, number of residents), the respondent’s professional background (number of years as a PD, business training experience), resources for business education provided by the program, the respondent’s opinion about business education for residents, and the respondent’s perception of the most important topics to include in a dermatology curriculum’s business education component, which included economics/finance, health care policy/government, management, marketing, negotiation, private equity involvement in health care, business strategy, supply chain/operations, and technology/product development. Responses were kept anonymous. Categorical and continuous variables were analyzed with medians and proportions.
Results
Of the 139 surveys distributed, 35 were completed and returned (response rate, 25.2%). Most programs were university-affiliated (71.4%) or community-affiliated (22.9%). The median number of residents was 12. The respondents had a median of 5 years’ experience in their role. Most respondents (65.7%) had no business training, although 20.0% had completed undergraduate business coursework, and 8.6% had attended formal seminars on business topics; 5.7% were self-taught on business topics.
Business Education Availability
Approximately half (51.4%) of programs offered business training to residents, primarily through seminars or lectures (94.4%) and take-home modules (16.7%). None of the programs offered a formal gap year during which residents could pursue a professional business degree. Most respondents thought business education during residency was important (82.8%) and that programs should implement more training (57.1%). When asked whether residents were competent to handle business aspects of dermatology upon graduation, most respondents disagreed somewhat (22.9%) or were neutral (40.0%).
Topics for Business Education
The most important topics identified for inclusion in a business curriculum were economics or finance (68.6%), management (68.6%), and health care policy or government (57.1%). Other identified topics included negotiation (40.0%), private equity involvement in health care (40.0%), strategy (11.4%), supply chain or operations (11.4%), marketing (2.9%), and technology (2.9%).
Comment
Residency programs and medical schools in the United States have started to integrate formal business training into their curricula; however, the state of business training in dermatology has not been characterized. Overall, this survey revealed largely positive perceptions about business education and identified a demand for more resources.
Whereas most PDs identified business education as important, only one half (51.4%) of the representative programs offered structured training. Notably, most PDs did not agree that graduating residents were competent to handle the business demands of dermatology practice. These responses highlight a gap in the demand and resources available for business training.
Identifying Curricular Resources
During an already demanding residency, additional curricular components need to be beneficial and worthwhile. To avoid significant disruption, business training could take place in the form of online lectures or take-home modules. Most programs represented in the survey responses had an academic affiliation and therefore commonly have access to an affiliated graduate business school and/or hospital administrators who have clinical and business training.
Community dermatologists who own or run their own practice also are uniquely positioned to provide residents with practical, dermatology-specific business education. Programs can utilize their institutional and local colleagues to aid in curricular design and implementation. In addition, a potential long-term solution to obtaining resources for business education is to coordinate with a national dermatology organization to create standardized modules that are available to all residency programs.
Key Curriculum Topics
Our survey identified the most important topics to include in a business curriculum for dermatology residents. Economics and finance, management, and health care policy would be valuable to a trainee regardless of whether they ultimately choose a career in academia or private practice. A thorough understanding of complex health care policy reinforces knowledge about insurance and regional and national regulations, which could ultimately benefit patient care. As an example, the American Academy of Dermatology outlines several advocacy priorities such as Medicare reimbursement policies, access to dermatologic care through public and private insurance, medication access and pricing, and preservation of private practice in the setting of market consolidation. Having a better understanding of health care policy and business could better equip dermatologists to lead these often business-driven advocacy efforts to ultimately improve patient care and advance the specialty.8
Limitations
There were notable limitations to this survey, primarily related to its design. With a 25% response rate, there was the potential for response and selection biases; therefore, these results might not be generalizable to all programs. In addition, views held by PDs might not be consistent with those of other members of the dermatology community; for example, surveying residents, other faculty members, and dermatologists in private practice would have provided a more comprehensive characterization of the topic.
Conclusion
This study assessed residency program directors’ perceptions of business education in dermatology training. There appears to be an imbalance between the perceived importance of such education and the resources that are available to provide it. More attention is needed to address this gap to ensure that dermatologists are prepared to manage a rapidly changing health care environment. Results of this survey should encourage efforts to establish (1) a standardized, dermatology-specific business curriculum and (2) a plan to make that curriculum accessible to trainees and other members of the dermatology community.
- Branning G, Vater M. Healthcare spending: plenty of blame to go around. Am Health Drug Benefits. 2016;9:445-447.
- Bayard M, Peeples CR, Holt J, et al. An interactive approach to teaching practice management to family practice residents. Fam Med. 2003;35:622-624.
- Chan S. Management education during radiology residency: development of an educational practice. Acad Radiol. 2004;11:1308-1317.
- Ninan D, Patel D. Career and leadership education in anesthesia residency training. Cureus. 2018;10:e2546.
- Yu-Chin R. Teaching administration and management within psychiatric residency training. Acad Psychiatry. 2002;26:245-252.
- Winkelman JW, Brugnara C. Management training for pathology residents. II. experience with a focused curriculum. Am J Clin Pathol. 1994;101:564-568.
- Tan S, Seiger K, Renehan P, et al. Trends in private equity acquisition of dermatology practices in the United States. JAMA Dermatol. 2019;155:1013-1021.
- Academy advocacy priorities. American Academy of Dermatology website. Accessed August 11, 2021. www.aad.org/member/advocacy/priorities
- Branning G, Vater M. Healthcare spending: plenty of blame to go around. Am Health Drug Benefits. 2016;9:445-447.
- Bayard M, Peeples CR, Holt J, et al. An interactive approach to teaching practice management to family practice residents. Fam Med. 2003;35:622-624.
- Chan S. Management education during radiology residency: development of an educational practice. Acad Radiol. 2004;11:1308-1317.
- Ninan D, Patel D. Career and leadership education in anesthesia residency training. Cureus. 2018;10:e2546.
- Yu-Chin R. Teaching administration and management within psychiatric residency training. Acad Psychiatry. 2002;26:245-252.
- Winkelman JW, Brugnara C. Management training for pathology residents. II. experience with a focused curriculum. Am J Clin Pathol. 1994;101:564-568.
- Tan S, Seiger K, Renehan P, et al. Trends in private equity acquisition of dermatology practices in the United States. JAMA Dermatol. 2019;155:1013-1021.
- Academy advocacy priorities. American Academy of Dermatology website. Accessed August 11, 2021. www.aad.org/member/advocacy/priorities
Practice Points
- In our survey of dermatology program directors, most felt inclusion of business education in residency training was important.
- Approximately half of the dermatology programs that responded to our survey offer business training to their residents.
- Economics and finance, management, and health care policy were the most important topics identified to include in a business curriculum for dermatology residents