Retinyl palmitate, a storage and ester form of retinol (vitamin A) and the prevailing type of vitamin A found naturally in the skin (Toxicol. Ind. Health 2005;21:167-75), has become increasingly popular during the past 2 decades. It is widely used in more than 600 skin care products, including cosmetics and sunscreens, and, with FDA approval, over-the-counter and prescription drugs (Photodermatol. Photoimmunol. Photomed. 2011;27:58-67). It was also the subject of a controversial summer 2010 report by the Environmental Working Group (EWG) in which the organization warned of possible photocarcinogenicity associated with retinyl palmitate (RP)-containing sunscreens.

Although vitamin A storage in the epidermis takes the form of retinyl esters and retinols, they act differently when exposed to UV light. The retinols display UVB-resistant and UVB-sensitive characteristics not exhibited by retinyl esters such as RP (Dermatology 1999;199:302-7). The EWG used "vitamin A" and "retinyl palmitate" interchangeably in their criticisms and follow-ups, which is misleading. The vitamin A family of drugs includes retinyl esters, retinol, tretinoin, adapalene, tazarotene, and oral isotretinoin (Accutane), in addition to four carotenoids, including beta-carotene, many of which have been shown to prevent or protect against cancer (Br. J. Cancer 1988;57:428-33; Cancer Epidemiol. Biomarkers Prev. 1997;6:949-56; J. Invest. Dermatol. 1981;76:178-80; Arch. Dermatol. Res. 1981;270:453-62). That does not mean that RP prevents cancer just because oral retinol, beta-carotene, or tretinoin have been shown to do so, for example. In fact, the study that the EWG refers to shows evidence that RP may lead to skin tumors in mice.

In response to the EWG report, Wang et al. acknowledged that of the eight in vitro studies published by the Food and Drug Administration from 2002 to 2009, four revealed that reactive oxygen species were produced by RP after UVA exposure (J. Am. Acad. Dermatol. 2010;63:903-6; Photodermatol. Photoimmunol. Photomed. 2011;27:58-67; Toxicol. Ind. Health 2007;23:625-31; Toxicol. Lett. 2006;163:30-43; Int. J. Environ. Res. Public Health 2006;3:185-90; Chem. Res. Toxicol. 2005;18:129-38). However, they questioned the relevance of these results in the context of the convoluted mechanisms of the antioxidant setting in human skin. They also contended that the National Toxicology Program (NTP) study on which the EWG based its report failed to prove that the combination of RP and UV results in photocarcinogenesis and, in fact, was rife with reasons for skepticism (J. Am. Acad. Dermatol. 2010;63:903-6; Photodermatol. Photoimmunol. Photomed. 2011;27:58-67). The EWG offered its own counterarguments and stood by its report. Rather than wade further into the debate that occurred in 2010 and found its way into the pages of the Journal of the American Academy of Dermatology (2010;63:903-6), let’s review what is known about RP.

What else do we know about RP?

In 1997, Duell et al. showed that unoccluded retinol is more effective at penetrating human skin in vivo than RP or retinoic acid (J. Invest. Dermatol. 1997;109:301-5).

In 2003, Antille et al. used an in vitro model to evaluate the photoprotective activity of RP, and then applied topical RP on the back of hairless mice before exposing them to UVB. They also applied topical RP or a sunscreen on the buttocks of human volunteers before exposing them to four minimal erythema doses of UVB. The investigators found that RP was as efficient in vitro as the commercial filter octylmethoxycinnamate in preventing UVB-induced fluorescence or photobleaching of fluorescent markers. Topical RP also significantly suppressed the formation of thymine dimers in mouse epidermis and human skin. In the volunteers, topical RP was as efficient as an SPF (sun protection factor) 20 sunscreen in preventing sunburn erythema (J. Invest. Dermatol. 2003;121:1163-7).

In 2005, Yan et al. studied the phototoxicity of RP, anhydroretinol (AR), and 5,6-epoxyretinyl palmitate (5,6-epoxy-RP) in human skin Jurkat T cells with and without light irradiation. Irradiation of cells in the absence of a retinoid rendered little damage, but the presence of RP, 5,6-epoxy-RP, or AR (50, 100, 150, and 200 micromol/L) yielded DNA fragmentation, with cell death occurring at retinoid concentrations of 100 micromol/L or greater. The investigators concluded that DNA damage and cytotoxicity are engendered by RP and its photodecomposition products in association with UVA and visible light exposure. They also determined that UVA irradiation of these retinoids produces free radicals that spur DNA strand cleavage (Toxicol. Ind. Health 2005;21:167-75).

RP accounts for most of the retinyl esters endogenously formed in skin. In 2006, Yan et al., noting that exogenous RP accumulates via topically applied cosmetic and skin care formulations, investigated the time course for buildup and disappearance of RP and retinol in the stratified layers of skin from female SKH-1 mice singly or repeatedly dosed with topical creams containing 0.5% or 2% RP. The researchers observed that within 24 hours of application, RP quickly diffused into the stratum corneum and epidermal skin layers. RP and retinol levels were lowest in the dermis, intermediate in the stratum corneum, and highest in the epidermis. In separated skin layers and intact skin, RP and retinol levels declined over time, but for 18 days, RP levels remained higher than control values. The investigators concluded that topically applied RP changed the normal physiological levels of RP and retinol in the skin of mice (Toxicol. Ind. Health 2006;22:181-91).

Having previously shown that irradiation of RP with UVA leads to the formation of photodecomposition products, synthesis of reactive oxygen species, and lipid peroxidation induction, Xia et al. demonstrated comparable results, identifying RP as a photosensitizer following irradiation with UVB light (Int. J. Environ. Res. Public Health 2006;3:185-90).

Recommendations

In light of the controversy swirling around RP and the appropriate concern it has engendered, in addition to the weight of evidence as well as experience from personal observation, I advise patients to avoid daytime use of products with RP high on the ingredient list. I add that it poses real risks while offering minimal benefits. Such patients should be using retinol or tretinoin. I recommend the use of retinoids at night, to avoid the photosensitizing action induced by UVA or UVB on retinoids left on the skin.

Conclusion

Retinyl palmitate does not penetrate very well into the skin. Consequently, for over-the-counter topical formulations, I recommend retinol instead. Because of the slow penetration of RP into the skin, the RP that remains on the skin will undergo photoreaction more than a substance that is rapidly absorbed. When exposed to light, RP on the skin may undergo metabolism and/or photoreaction to generate reactive oxygen species. These reactive oxygen species or free radicals can theoretically lead to increased skin cancer. That said, sufficient evidence to establish a causal link between RP and skin cancer has not been produced. Nor, I’m afraid, are there any good reasons to recommend the use of RP. More research on this subject is needed and will likely emerge in a timely fashion.

Dr. Baumann is in private practice in Miami Beach. She did not disclose any conflicts of interest. To respond to this column, or to suggest topics for future columns, write to her at [email protected]. This column, "Cosmeceutical Critique," appears regularly in Skin & Allergy News.

Retinyl palmitate, a storage and ester form of retinol (vitamin A) and the prevailing type of vitamin A found naturally in the skin (Toxicol. Ind. Health 2005;21:167-75), has become increasingly popular during the past 2 decades. It is widely used in more than 600 skin care products, including cosmetics and sunscreens, and, with FDA approval, over-the-counter and prescription drugs (Photodermatol. Photoimmunol. Photomed. 2011;27:58-67). It was also the subject of a controversial summer 2010 report by the Environmental Working Group (EWG) in which the organization warned of possible photocarcinogenicity associated with retinyl palmitate (RP)-containing sunscreens.

Although vitamin A storage in the epidermis takes the form of retinyl esters and retinols, they act differently when exposed to UV light. The retinols display UVB-resistant and UVB-sensitive characteristics not exhibited by retinyl esters such as RP (Dermatology 1999;199:302-7). The EWG used "vitamin A" and "retinyl palmitate" interchangeably in their criticisms and follow-ups, which is misleading. The vitamin A family of drugs includes retinyl esters, retinol, tretinoin, adapalene, tazarotene, and oral isotretinoin (Accutane), in addition to four carotenoids, including beta-carotene, many of which have been shown to prevent or protect against cancer (Br. J. Cancer 1988;57:428-33; Cancer Epidemiol. Biomarkers Prev. 1997;6:949-56; J. Invest. Dermatol. 1981;76:178-80; Arch. Dermatol. Res. 1981;270:453-62). That does not mean that RP prevents cancer just because oral retinol, beta-carotene, or tretinoin have been shown to do so, for example. In fact, the study that the EWG refers to shows evidence that RP may lead to skin tumors in mice.

In response to the EWG report, Wang et al. acknowledged that of the eight in vitro studies published by the Food and Drug Administration from 2002 to 2009, four revealed that reactive oxygen species were produced by RP after UVA exposure (J. Am. Acad. Dermatol. 2010;63:903-6; Photodermatol. Photoimmunol. Photomed. 2011;27:58-67; Toxicol. Ind. Health 2007;23:625-31; Toxicol. Lett. 2006;163:30-43; Int. J. Environ. Res. Public Health 2006;3:185-90; Chem. Res. Toxicol. 2005;18:129-38). However, they questioned the relevance of these results in the context of the convoluted mechanisms of the antioxidant setting in human skin. They also contended that the National Toxicology Program (NTP) study on which the EWG based its report failed to prove that the combination of RP and UV results in photocarcinogenesis and, in fact, was rife with reasons for skepticism (J. Am. Acad. Dermatol. 2010;63:903-6; Photodermatol. Photoimmunol. Photomed. 2011;27:58-67). The EWG offered its own counterarguments and stood by its report. Rather than wade further into the debate that occurred in 2010 and found its way into the pages of the Journal of the American Academy of Dermatology (2010;63:903-6), let’s review what is known about RP.

What else do we know about RP?

In 1997, Duell et al. showed that unoccluded retinol is more effective at penetrating human skin in vivo than RP or retinoic acid (J. Invest. Dermatol. 1997;109:301-5).

In 2003, Antille et al. used an in vitro model to evaluate the photoprotective activity of RP, and then applied topical RP on the back of hairless mice before exposing them to UVB. They also applied topical RP or a sunscreen on the buttocks of human volunteers before exposing them to four minimal erythema doses of UVB. The investigators found that RP was as efficient in vitro as the commercial filter octylmethoxycinnamate in preventing UVB-induced fluorescence or photobleaching of fluorescent markers. Topical RP also significantly suppressed the formation of thymine dimers in mouse epidermis and human skin. In the volunteers, topical RP was as efficient as an SPF (sun protection factor) 20 sunscreen in preventing sunburn erythema (J. Invest. Dermatol. 2003;121:1163-7).

In 2005, Yan et al. studied the phototoxicity of RP, anhydroretinol (AR), and 5,6-epoxyretinyl palmitate (5,6-epoxy-RP) in human skin Jurkat T cells with and without light irradiation. Irradiation of cells in the absence of a retinoid rendered little damage, but the presence of RP, 5,6-epoxy-RP, or AR (50, 100, 150, and 200 micromol/L) yielded DNA fragmentation, with cell death occurring at retinoid concentrations of 100 micromol/L or greater. The investigators concluded that DNA damage and cytotoxicity are engendered by RP and its photodecomposition products in association with UVA and visible light exposure. They also determined that UVA irradiation of these retinoids produces free radicals that spur DNA strand cleavage (Toxicol. Ind. Health 2005;21:167-75).

RP accounts for most of the retinyl esters endogenously formed in skin. In 2006, Yan et al., noting that exogenous RP accumulates via topically applied cosmetic and skin care formulations, investigated the time course for buildup and disappearance of RP and retinol in the stratified layers of skin from female SKH-1 mice singly or repeatedly dosed with topical creams containing 0.5% or 2% RP. The researchers observed that within 24 hours of application, RP quickly diffused into the stratum corneum and epidermal skin layers. RP and retinol levels were lowest in the dermis, intermediate in the stratum corneum, and highest in the epidermis. In separated skin layers and intact skin, RP and retinol levels declined over time, but for 18 days, RP levels remained higher than control values. The investigators concluded that topically applied RP changed the normal physiological levels of RP and retinol in the skin of mice (Toxicol. Ind. Health 2006;22:181-91).

Having previously shown that irradiation of RP with UVA leads to the formation of photodecomposition products, synthesis of reactive oxygen species, and lipid peroxidation induction, Xia et al. demonstrated comparable results, identifying RP as a photosensitizer following irradiation with UVB light (Int. J. Environ. Res. Public Health 2006;3:185-90).

Recommendations

In light of the controversy swirling around RP and the appropriate concern it has engendered, in addition to the weight of evidence as well as experience from personal observation, I advise patients to avoid daytime use of products with RP high on the ingredient list. I add that it poses real risks while offering minimal benefits. Such patients should be using retinol or tretinoin. I recommend the use of retinoids at night, to avoid the photosensitizing action induced by UVA or UVB on retinoids left on the skin.

Conclusion

Retinyl palmitate does not penetrate very well into the skin. Consequently, for over-the-counter topical formulations, I recommend retinol instead. Because of the slow penetration of RP into the skin, the RP that remains on the skin will undergo photoreaction more than a substance that is rapidly absorbed. When exposed to light, RP on the skin may undergo metabolism and/or photoreaction to generate reactive oxygen species. These reactive oxygen species or free radicals can theoretically lead to increased skin cancer. That said, sufficient evidence to establish a causal link between RP and skin cancer has not been produced. Nor, I’m afraid, are there any good reasons to recommend the use of RP. More research on this subject is needed and will likely emerge in a timely fashion.

Dr. Baumann is in private practice in Miami Beach. She did not disclose any conflicts of interest. To respond to this column, or to suggest topics for future columns, write to her at [email protected]. This column, "Cosmeceutical Critique," appears regularly in Skin & Allergy News.

Retinyl palmitate, a storage and ester form of retinol (vitamin A) and the prevailing type of vitamin A found naturally in the skin (Toxicol. Ind. Health 2005;21:167-75), has become increasingly popular during the past 2 decades. It is widely used in more than 600 skin care products, including cosmetics and sunscreens, and, with FDA approval, over-the-counter and prescription drugs (Photodermatol. Photoimmunol. Photomed. 2011;27:58-67). It was also the subject of a controversial summer 2010 report by the Environmental Working Group (EWG) in which the organization warned of possible photocarcinogenicity associated with retinyl palmitate (RP)-containing sunscreens.

Although vitamin A storage in the epidermis takes the form of retinyl esters and retinols, they act differently when exposed to UV light. The retinols display UVB-resistant and UVB-sensitive characteristics not exhibited by retinyl esters such as RP (Dermatology 1999;199:302-7). The EWG used "vitamin A" and "retinyl palmitate" interchangeably in their criticisms and follow-ups, which is misleading. The vitamin A family of drugs includes retinyl esters, retinol, tretinoin, adapalene, tazarotene, and oral isotretinoin (Accutane), in addition to four carotenoids, including beta-carotene, many of which have been shown to prevent or protect against cancer (Br. J. Cancer 1988;57:428-33; Cancer Epidemiol. Biomarkers Prev. 1997;6:949-56; J. Invest. Dermatol. 1981;76:178-80; Arch. Dermatol. Res. 1981;270:453-62). That does not mean that RP prevents cancer just because oral retinol, beta-carotene, or tretinoin have been shown to do so, for example. In fact, the study that the EWG refers to shows evidence that RP may lead to skin tumors in mice.

In response to the EWG report, Wang et al. acknowledged that of the eight in vitro studies published by the Food and Drug Administration from 2002 to 2009, four revealed that reactive oxygen species were produced by RP after UVA exposure (J. Am. Acad. Dermatol. 2010;63:903-6; Photodermatol. Photoimmunol. Photomed. 2011;27:58-67; Toxicol. Ind. Health 2007;23:625-31; Toxicol. Lett. 2006;163:30-43; Int. J. Environ. Res. Public Health 2006;3:185-90; Chem. Res. Toxicol. 2005;18:129-38). However, they questioned the relevance of these results in the context of the convoluted mechanisms of the antioxidant setting in human skin. They also contended that the National Toxicology Program (NTP) study on which the EWG based its report failed to prove that the combination of RP and UV results in photocarcinogenesis and, in fact, was rife with reasons for skepticism (J. Am. Acad. Dermatol. 2010;63:903-6; Photodermatol. Photoimmunol. Photomed. 2011;27:58-67). The EWG offered its own counterarguments and stood by its report. Rather than wade further into the debate that occurred in 2010 and found its way into the pages of the Journal of the American Academy of Dermatology (2010;63:903-6), let’s review what is known about RP.

What else do we know about RP?

In 1997, Duell et al. showed that unoccluded retinol is more effective at penetrating human skin in vivo than RP or retinoic acid (J. Invest. Dermatol. 1997;109:301-5).

In 2003, Antille et al. used an in vitro model to evaluate the photoprotective activity of RP, and then applied topical RP on the back of hairless mice before exposing them to UVB. They also applied topical RP or a sunscreen on the buttocks of human volunteers before exposing them to four minimal erythema doses of UVB. The investigators found that RP was as efficient in vitro as the commercial filter octylmethoxycinnamate in preventing UVB-induced fluorescence or photobleaching of fluorescent markers. Topical RP also significantly suppressed the formation of thymine dimers in mouse epidermis and human skin. In the volunteers, topical RP was as efficient as an SPF (sun protection factor) 20 sunscreen in preventing sunburn erythema (J. Invest. Dermatol. 2003;121:1163-7).

In 2005, Yan et al. studied the phototoxicity of RP, anhydroretinol (AR), and 5,6-epoxyretinyl palmitate (5,6-epoxy-RP) in human skin Jurkat T cells with and without light irradiation. Irradiation of cells in the absence of a retinoid rendered little damage, but the presence of RP, 5,6-epoxy-RP, or AR (50, 100, 150, and 200 micromol/L) yielded DNA fragmentation, with cell death occurring at retinoid concentrations of 100 micromol/L or greater. The investigators concluded that DNA damage and cytotoxicity are engendered by RP and its photodecomposition products in association with UVA and visible light exposure. They also determined that UVA irradiation of these retinoids produces free radicals that spur DNA strand cleavage (Toxicol. Ind. Health 2005;21:167-75).

RP accounts for most of the retinyl esters endogenously formed in skin. In 2006, Yan et al., noting that exogenous RP accumulates via topically applied cosmetic and skin care formulations, investigated the time course for buildup and disappearance of RP and retinol in the stratified layers of skin from female SKH-1 mice singly or repeatedly dosed with topical creams containing 0.5% or 2% RP. The researchers observed that within 24 hours of application, RP quickly diffused into the stratum corneum and epidermal skin layers. RP and retinol levels were lowest in the dermis, intermediate in the stratum corneum, and highest in the epidermis. In separated skin layers and intact skin, RP and retinol levels declined over time, but for 18 days, RP levels remained higher than control values. The investigators concluded that topically applied RP changed the normal physiological levels of RP and retinol in the skin of mice (Toxicol. Ind. Health 2006;22:181-91).

Having previously shown that irradiation of RP with UVA leads to the formation of photodecomposition products, synthesis of reactive oxygen species, and lipid peroxidation induction, Xia et al. demonstrated comparable results, identifying RP as a photosensitizer following irradiation with UVB light (Int. J. Environ. Res. Public Health 2006;3:185-90).

Recommendations

In light of the controversy swirling around RP and the appropriate concern it has engendered, in addition to the weight of evidence as well as experience from personal observation, I advise patients to avoid daytime use of products with RP high on the ingredient list. I add that it poses real risks while offering minimal benefits. Such patients should be using retinol or tretinoin. I recommend the use of retinoids at night, to avoid the photosensitizing action induced by UVA or UVB on retinoids left on the skin.

Conclusion

Retinyl palmitate does not penetrate very well into the skin. Consequently, for over-the-counter topical formulations, I recommend retinol instead. Because of the slow penetration of RP into the skin, the RP that remains on the skin will undergo photoreaction more than a substance that is rapidly absorbed. When exposed to light, RP on the skin may undergo metabolism and/or photoreaction to generate reactive oxygen species. These reactive oxygen species or free radicals can theoretically lead to increased skin cancer. That said, sufficient evidence to establish a causal link between RP and skin cancer has not been produced. Nor, I’m afraid, are there any good reasons to recommend the use of RP. More research on this subject is needed and will likely emerge in a timely fashion.

Dr. Baumann is in private practice in Miami Beach. She did not disclose any conflicts of interest. To respond to this column, or to suggest topics for future columns, write to her at [email protected]. This column, "Cosmeceutical Critique," appears regularly in Skin & Allergy News.

Doctor ratings websites can be biased, clinically insignificant, and statistically unreliable. They’re also growing rapidly. In 2011, Inc. Magazine listed vitals.com, a popular doctor rating site, as No. 47 out of the top 100 fasting growing private companies; it grew an impressive 4,637% between 2008 and 2011.

Similarly, a study by Guodong Gordon Gao and colleagues, published in The Journal of Medical Internet Research in February 2012, found a 100-fold increase in the number of ratings on ratemds.com over the last 5 years (J. Med. Internet Res. 2012;14:e38 [doi:10.2196/jmir.2003]). Healthgrades.com, another well known doctor rating site, has 15 million visitors every month, and continues to grow.

As physicians, we have a responsibility to educate ourselves about such rating sites and to use them to our advantage. Start by thinking of them more as directories than rating sites and using them to promote you and your practice.

Most physicians, policy leaders, and consumers believe that transparency will ultimately improve the quality of health care. However, in their current state, doctor rating sites suffer from significant drawbacks, including a limited number of reviews, which skews results either positive or negative, a dearth of reviews about physician quality, and inaccurate information about physicians and practices.

According to a May 2011 report by the Pew Research Center (pewinternet.org) only 4% of Internet users have posted a review online of a doctor. In fact, many physicians have only one patient review.

New York Times columnist Ron Leiber wrote in a March 2012 article that there is a supply and demand problem with doctor rating sites: Most consumers want the information and would trust sites that had more reviews, yet the vast majority of patients are not posting them.

Many physicians lament that online doctor reviews skew heavily toward nonclinical issues, such as office decor, rather than the quality of care delivered. This is not likely to change anytime soon. That’s because patients equate service with quality. This isn’t their fault. As humans, we all make this mistake. When asked a difficult question, rather than do the work required to answer it, we tend to substitute an easier question and answer that instead.

To answer the difficult question, Is he or she a high quality physician? a patient would have to research your training and experience and be able to critique your diagnostic skills and treatment outcomes. Of course, they don’t do this.

Instead, they ask the question, Did I like him or her? and base their answer on the service they received, something they can easily access and understand. Hence, the overwhelming number of doctor reviews that mention wait times, office tidiness, support staff interactions, and bedside manner.

Physicians can still learn a lot from such feedback, so don’t dismiss it. We all spend tremendous time and effort on continuing education to ensure that we deliver high quality health care. We need to be sure we spend adequate time and effort on service delivery as well. Otherwise, much of that value will be lost on our patients.

Whether you like them or not, doctor rating sites are here to stay. You won’t knock them completely off the front page of a Google search on you or your practice, and a vaccine against them has not yet been developed.

But realize this: Several studies show that the average rating for doctors is quite good. For example, a study led by Bassam Kadry and colleagues, published in The Journal of Medical Internet Research in November 2011, found that, depending on the scale, the average doctor rating was 77 out of 100, 3.84 out of 5, and 3.1 out of 4 (J. Med. Internet Res. 2011;13:e95 [doi:10.2196/jmir.1960]).

So, here’s my advice to you: Visit the most used doctor rating sites such as healthgrades.com, ratemds.com, vitals.com, and zocdoc.com as well as angieslist.com and yelp.com, and make your profile as patient friendly as possible. Upload a good picture of yourself or consider doing a short video bio. Provide an accurate professional bio as well as personal information, such as your favorite sports teams, pets, hobbies, or anything else that makes you unique and approachable. Include all medical degrees, academic affiliations, and clinical interests, as well as current office information and links to practice websites, blogs, and social networks you frequent such as Twitter. Check in every month or so to provide updates and read user comments.

In the meantime, keep being the caring, qualified doctor you are. That’s the best defense against worrying about doctor rating sites.

This column, Digital Dermatology, appears in Dermatology News. Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter@Dermdoc, and on Facebook (DermDoc).

Doctor ratings websites can be biased, clinically insignificant, and statistically unreliable. They’re also growing rapidly. In 2011, Inc. Magazine listed vitals.com, a popular doctor rating site, as No. 47 out of the top 100 fasting growing private companies; it grew an impressive 4,637% between 2008 and 2011.

Similarly, a study by Guodong Gordon Gao and colleagues, published in The Journal of Medical Internet Research in February 2012, found a 100-fold increase in the number of ratings on ratemds.com over the last 5 years (J. Med. Internet Res. 2012;14:e38 [doi:10.2196/jmir.2003]). Healthgrades.com, another well known doctor rating site, has 15 million visitors every month, and continues to grow.

As physicians, we have a responsibility to educate ourselves about such rating sites and to use them to our advantage. Start by thinking of them more as directories than rating sites and using them to promote you and your practice.

Most physicians, policy leaders, and consumers believe that transparency will ultimately improve the quality of health care. However, in their current state, doctor rating sites suffer from significant drawbacks, including a limited number of reviews, which skews results either positive or negative, a dearth of reviews about physician quality, and inaccurate information about physicians and practices.

According to a May 2011 report by the Pew Research Center (pewinternet.org) only 4% of Internet users have posted a review online of a doctor. In fact, many physicians have only one patient review.

New York Times columnist Ron Leiber wrote in a March 2012 article that there is a supply and demand problem with doctor rating sites: Most consumers want the information and would trust sites that had more reviews, yet the vast majority of patients are not posting them.

Many physicians lament that online doctor reviews skew heavily toward nonclinical issues, such as office decor, rather than the quality of care delivered. This is not likely to change anytime soon. That’s because patients equate service with quality. This isn’t their fault. As humans, we all make this mistake. When asked a difficult question, rather than do the work required to answer it, we tend to substitute an easier question and answer that instead.

To answer the difficult question, Is he or she a high quality physician? a patient would have to research your training and experience and be able to critique your diagnostic skills and treatment outcomes. Of course, they don’t do this.

Instead, they ask the question, Did I like him or her? and base their answer on the service they received, something they can easily access and understand. Hence, the overwhelming number of doctor reviews that mention wait times, office tidiness, support staff interactions, and bedside manner.

Physicians can still learn a lot from such feedback, so don’t dismiss it. We all spend tremendous time and effort on continuing education to ensure that we deliver high quality health care. We need to be sure we spend adequate time and effort on service delivery as well. Otherwise, much of that value will be lost on our patients.

Whether you like them or not, doctor rating sites are here to stay. You won’t knock them completely off the front page of a Google search on you or your practice, and a vaccine against them has not yet been developed.

But realize this: Several studies show that the average rating for doctors is quite good. For example, a study led by Bassam Kadry and colleagues, published in The Journal of Medical Internet Research in November 2011, found that, depending on the scale, the average doctor rating was 77 out of 100, 3.84 out of 5, and 3.1 out of 4 (J. Med. Internet Res. 2011;13:e95 [doi:10.2196/jmir.1960]).

So, here’s my advice to you: Visit the most used doctor rating sites such as healthgrades.com, ratemds.com, vitals.com, and zocdoc.com as well as angieslist.com and yelp.com, and make your profile as patient friendly as possible. Upload a good picture of yourself or consider doing a short video bio. Provide an accurate professional bio as well as personal information, such as your favorite sports teams, pets, hobbies, or anything else that makes you unique and approachable. Include all medical degrees, academic affiliations, and clinical interests, as well as current office information and links to practice websites, blogs, and social networks you frequent such as Twitter. Check in every month or so to provide updates and read user comments.

In the meantime, keep being the caring, qualified doctor you are. That’s the best defense against worrying about doctor rating sites.

This column, Digital Dermatology, appears in Dermatology News. Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter@Dermdoc, and on Facebook (DermDoc).

Doctor ratings websites can be biased, clinically insignificant, and statistically unreliable. They’re also growing rapidly. In 2011, Inc. Magazine listed vitals.com, a popular doctor rating site, as No. 47 out of the top 100 fasting growing private companies; it grew an impressive 4,637% between 2008 and 2011.

Similarly, a study by Guodong Gordon Gao and colleagues, published in The Journal of Medical Internet Research in February 2012, found a 100-fold increase in the number of ratings on ratemds.com over the last 5 years (J. Med. Internet Res. 2012;14:e38 [doi:10.2196/jmir.2003]). Healthgrades.com, another well known doctor rating site, has 15 million visitors every month, and continues to grow.

As physicians, we have a responsibility to educate ourselves about such rating sites and to use them to our advantage. Start by thinking of them more as directories than rating sites and using them to promote you and your practice.

Most physicians, policy leaders, and consumers believe that transparency will ultimately improve the quality of health care. However, in their current state, doctor rating sites suffer from significant drawbacks, including a limited number of reviews, which skews results either positive or negative, a dearth of reviews about physician quality, and inaccurate information about physicians and practices.

According to a May 2011 report by the Pew Research Center (pewinternet.org) only 4% of Internet users have posted a review online of a doctor. In fact, many physicians have only one patient review.

New York Times columnist Ron Leiber wrote in a March 2012 article that there is a supply and demand problem with doctor rating sites: Most consumers want the information and would trust sites that had more reviews, yet the vast majority of patients are not posting them.

Many physicians lament that online doctor reviews skew heavily toward nonclinical issues, such as office decor, rather than the quality of care delivered. This is not likely to change anytime soon. That’s because patients equate service with quality. This isn’t their fault. As humans, we all make this mistake. When asked a difficult question, rather than do the work required to answer it, we tend to substitute an easier question and answer that instead.

To answer the difficult question, Is he or she a high quality physician? a patient would have to research your training and experience and be able to critique your diagnostic skills and treatment outcomes. Of course, they don’t do this.

Instead, they ask the question, Did I like him or her? and base their answer on the service they received, something they can easily access and understand. Hence, the overwhelming number of doctor reviews that mention wait times, office tidiness, support staff interactions, and bedside manner.

Physicians can still learn a lot from such feedback, so don’t dismiss it. We all spend tremendous time and effort on continuing education to ensure that we deliver high quality health care. We need to be sure we spend adequate time and effort on service delivery as well. Otherwise, much of that value will be lost on our patients.

Whether you like them or not, doctor rating sites are here to stay. You won’t knock them completely off the front page of a Google search on you or your practice, and a vaccine against them has not yet been developed.

But realize this: Several studies show that the average rating for doctors is quite good. For example, a study led by Bassam Kadry and colleagues, published in The Journal of Medical Internet Research in November 2011, found that, depending on the scale, the average doctor rating was 77 out of 100, 3.84 out of 5, and 3.1 out of 4 (J. Med. Internet Res. 2011;13:e95 [doi:10.2196/jmir.1960]).

So, here’s my advice to you: Visit the most used doctor rating sites such as healthgrades.com, ratemds.com, vitals.com, and zocdoc.com as well as angieslist.com and yelp.com, and make your profile as patient friendly as possible. Upload a good picture of yourself or consider doing a short video bio. Provide an accurate professional bio as well as personal information, such as your favorite sports teams, pets, hobbies, or anything else that makes you unique and approachable. Include all medical degrees, academic affiliations, and clinical interests, as well as current office information and links to practice websites, blogs, and social networks you frequent such as Twitter. Check in every month or so to provide updates and read user comments.

In the meantime, keep being the caring, qualified doctor you are. That’s the best defense against worrying about doctor rating sites.

This column, Digital Dermatology, appears in Dermatology News. Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter@Dermdoc, and on Facebook (DermDoc).

Click here to listen to Sherri Dumford

Click here to listen to Sherri Dumford

Click here to listen to Sherri Dumford

Click here to listen to Dr. Wright

Click here to listen to Dr. Wright

Click here to listen to Dr. Wright

Engage

For hospitalists, the first order of business should be ensuring that your group is participating in the Physician Quality Reporting System (PQRS) and receiving the current 0.5% participation bonus (in some cases, that may require an electronic billing system add-on that adds the necessary PQRS codes to claims). If not, you could be leaving an estimated $800 in reporting incentives per hospitalist on the table. Once the PQRS penalty phase begins in 2015, your group could lose 1.5% of CMS reimbursements. Eventually, failure to engage will spur an additional 1% penalty through the Value-Based Payment Modifier (VBPM).

Respond

SHM’s early feedback to CMS was based in part on a problematic Quality and Resource Use Report (QRUR) brought to the society’s attention by a member hospitalist. Dr. Torcson says SHM carefully reviewed that report to register its concerns about proper attribution, fair comparisons, relevant metrics, and other issues. In turn, CMS signaled its appreciation of SHM’s due diligence and has indicated a willingness to work with SHM to address its concerns. The lesson is that a constructive, collaborative process was eased by the willingness of an SHM member to help the society develop a thoughtful and thorough response—one that is more likely to yield sought-after changes by federal officials. “CMS reacts much better to physician groups that are willing to collaborate with them versus the ones that just want to deny, deny, deny that changes are coming,” Dr. Whitcomb says.

Communicate

CMS has indicated that lack of communication among individual physicians and groups won’t excuse anyone from the PQRS and VBPM programs. Hospitalists clearly have an advantage here, and experts say a continued focus on collaborative teamwork and making sure providers are on the same page could help ensure that everyone is making the necessary improvements in care. To keep the conversation going, initiate and take part in online discussions with fellow HM providers via the advocacy and public policy community of SHM’s Hospital Medical Exchange.

Plan

Which PQRS measures are most applicable to you and your colleagues? Make sure you review the final rules and develop a plan for how to address the performance measures that you can control, either directly or indirectly. For group practices with 100 or more eligible providers, the first performance year for the VBPM program begins Jan. 1.

Engage

For hospitalists, the first order of business should be ensuring that your group is participating in the Physician Quality Reporting System (PQRS) and receiving the current 0.5% participation bonus (in some cases, that may require an electronic billing system add-on that adds the necessary PQRS codes to claims). If not, you could be leaving an estimated $800 in reporting incentives per hospitalist on the table. Once the PQRS penalty phase begins in 2015, your group could lose 1.5% of CMS reimbursements. Eventually, failure to engage will spur an additional 1% penalty through the Value-Based Payment Modifier (VBPM).

Respond

SHM’s early feedback to CMS was based in part on a problematic Quality and Resource Use Report (QRUR) brought to the society’s attention by a member hospitalist. Dr. Torcson says SHM carefully reviewed that report to register its concerns about proper attribution, fair comparisons, relevant metrics, and other issues. In turn, CMS signaled its appreciation of SHM’s due diligence and has indicated a willingness to work with SHM to address its concerns. The lesson is that a constructive, collaborative process was eased by the willingness of an SHM member to help the society develop a thoughtful and thorough response—one that is more likely to yield sought-after changes by federal officials. “CMS reacts much better to physician groups that are willing to collaborate with them versus the ones that just want to deny, deny, deny that changes are coming,” Dr. Whitcomb says.

Communicate

CMS has indicated that lack of communication among individual physicians and groups won’t excuse anyone from the PQRS and VBPM programs. Hospitalists clearly have an advantage here, and experts say a continued focus on collaborative teamwork and making sure providers are on the same page could help ensure that everyone is making the necessary improvements in care. To keep the conversation going, initiate and take part in online discussions with fellow HM providers via the advocacy and public policy community of SHM’s Hospital Medical Exchange.

Plan

Which PQRS measures are most applicable to you and your colleagues? Make sure you review the final rules and develop a plan for how to address the performance measures that you can control, either directly or indirectly. For group practices with 100 or more eligible providers, the first performance year for the VBPM program begins Jan. 1.

Engage

For hospitalists, the first order of business should be ensuring that your group is participating in the Physician Quality Reporting System (PQRS) and receiving the current 0.5% participation bonus (in some cases, that may require an electronic billing system add-on that adds the necessary PQRS codes to claims). If not, you could be leaving an estimated $800 in reporting incentives per hospitalist on the table. Once the PQRS penalty phase begins in 2015, your group could lose 1.5% of CMS reimbursements. Eventually, failure to engage will spur an additional 1% penalty through the Value-Based Payment Modifier (VBPM).

Respond

SHM’s early feedback to CMS was based in part on a problematic Quality and Resource Use Report (QRUR) brought to the society’s attention by a member hospitalist. Dr. Torcson says SHM carefully reviewed that report to register its concerns about proper attribution, fair comparisons, relevant metrics, and other issues. In turn, CMS signaled its appreciation of SHM’s due diligence and has indicated a willingness to work with SHM to address its concerns. The lesson is that a constructive, collaborative process was eased by the willingness of an SHM member to help the society develop a thoughtful and thorough response—one that is more likely to yield sought-after changes by federal officials. “CMS reacts much better to physician groups that are willing to collaborate with them versus the ones that just want to deny, deny, deny that changes are coming,” Dr. Whitcomb says.

Communicate

CMS has indicated that lack of communication among individual physicians and groups won’t excuse anyone from the PQRS and VBPM programs. Hospitalists clearly have an advantage here, and experts say a continued focus on collaborative teamwork and making sure providers are on the same page could help ensure that everyone is making the necessary improvements in care. To keep the conversation going, initiate and take part in online discussions with fellow HM providers via the advocacy and public policy community of SHM’s Hospital Medical Exchange.

Plan

Which PQRS measures are most applicable to you and your colleagues? Make sure you review the final rules and develop a plan for how to address the performance measures that you can control, either directly or indirectly. For group practices with 100 or more eligible providers, the first performance year for the VBPM program begins Jan. 1.

The intricacies of billing and coding typically aren’t taught in physician residency training programs.

“Residents want to learn how to take care of patients. They’re not really focused on learning [Centers for Medicare & Medicaid Services] rules,” says Balazs Zsenits, MD, FACP, SFHM, medical director of the Rochester General Hospitalist Group in Rochester, N.Y. As a result, “there’s a knowledge gap” between newly minted physicians and experienced practitioners when it comes to documenting their work.

To bridge that gap, some hospitalist groups offer training on the business side of medicine during physician orientation, as well as provide constructive reviews of hospitalists’ progress notes on a periodic basis. Some hospitals provide seminars in proper documentation.

“I’ve seen a lot of hospitals do ‘lunch and learn’” sessions on documentation requirements, says Angie Comfort, RHIT, CCS, a director of HIM Solutions at the American Health Information Management Association. The goal is to facilitate reimbursement for the hospital from patients’ insurance providers.

“If more specific documentation is not in the record, the coder must ask the physician for additional clarification,” Comfort says. “Without the clarification, sometimes the conditions are not able to be coded.”

The HM group in Rochester, which employs 46 hospitalists, provides about six hours of billing compliance education for new hires during orientation and holds regular, topic-based presentations at weekly staff meetings.

Physicians “need timely information as we submit our own charges, and we set up our productivity bonus so that it depends on our billing accuracy, not just volume,” Dr. Zsenits says. Using an internal Web portal, physicians can look up billing codes and explanations. “They realize the risks involved if they don’t do it right,” she says, so they also accept feedback from reviews of their patient charts.

Easy-to-access information is key to helping hospitalists learn coding requirements. “We have a Web-based documentation education module, so the provider is able to log on from home,” says David Grace, MD, FHM, senior medical officer at The Schumacher Group’s hospital medicine division in Lafayette, La. The practice management company employs hospitalists in 12 states.

Its initial module takes about an hour to review. For those who are already proficient in billing and coding, a test-out option lasting 10 to 15 minutes is available online as well. Pocket cards are provided as a reference thereafter.

“Documentation and coding is a complex entity, and certainly we don’t expect them to remember all the details after one educational module,” Dr. Grace says. “They do have access to be able to go back to it for a refresher whenever they want.”

Internal coding experts audit about 20% of the hospitalists’ work, and audited physicians are provided feedback on compliance. The Schumacher Group also uses a proprietary template to help hospitalists capture the important data points in their patient progress notes.

“Physicians are under a lot of scrutiny by regulatory agencies,” says Peter Thompson, MD, chief of clinical operations at Apogee Physicians, a national hospitalist management company based in Phoenix.

At new hospitalist orientation, called Apogee University, providers spend several hours learning the rules for documentation. The group follows up with regular reviews of hospitalists’ notes through an audit system. A program director “breaks down the components that make it a compliant note or not,” Dr. Thompson says. Audits are performed monthly on every physician.

“It takes a commitment to knowing what the requirements are,” he adds. “And it takes repetition and it takes practice to make something a habit.”

Susan Kreimer is a freelance medical writer in New York.

The intricacies of billing and coding typically aren’t taught in physician residency training programs.

“Residents want to learn how to take care of patients. They’re not really focused on learning [Centers for Medicare & Medicaid Services] rules,” says Balazs Zsenits, MD, FACP, SFHM, medical director of the Rochester General Hospitalist Group in Rochester, N.Y. As a result, “there’s a knowledge gap” between newly minted physicians and experienced practitioners when it comes to documenting their work.

To bridge that gap, some hospitalist groups offer training on the business side of medicine during physician orientation, as well as provide constructive reviews of hospitalists’ progress notes on a periodic basis. Some hospitals provide seminars in proper documentation.

“I’ve seen a lot of hospitals do ‘lunch and learn’” sessions on documentation requirements, says Angie Comfort, RHIT, CCS, a director of HIM Solutions at the American Health Information Management Association. The goal is to facilitate reimbursement for the hospital from patients’ insurance providers.

“If more specific documentation is not in the record, the coder must ask the physician for additional clarification,” Comfort says. “Without the clarification, sometimes the conditions are not able to be coded.”

The HM group in Rochester, which employs 46 hospitalists, provides about six hours of billing compliance education for new hires during orientation and holds regular, topic-based presentations at weekly staff meetings.

Physicians “need timely information as we submit our own charges, and we set up our productivity bonus so that it depends on our billing accuracy, not just volume,” Dr. Zsenits says. Using an internal Web portal, physicians can look up billing codes and explanations. “They realize the risks involved if they don’t do it right,” she says, so they also accept feedback from reviews of their patient charts.

Easy-to-access information is key to helping hospitalists learn coding requirements. “We have a Web-based documentation education module, so the provider is able to log on from home,” says David Grace, MD, FHM, senior medical officer at The Schumacher Group’s hospital medicine division in Lafayette, La. The practice management company employs hospitalists in 12 states.

Its initial module takes about an hour to review. For those who are already proficient in billing and coding, a test-out option lasting 10 to 15 minutes is available online as well. Pocket cards are provided as a reference thereafter.

“Documentation and coding is a complex entity, and certainly we don’t expect them to remember all the details after one educational module,” Dr. Grace says. “They do have access to be able to go back to it for a refresher whenever they want.”

Internal coding experts audit about 20% of the hospitalists’ work, and audited physicians are provided feedback on compliance. The Schumacher Group also uses a proprietary template to help hospitalists capture the important data points in their patient progress notes.

“Physicians are under a lot of scrutiny by regulatory agencies,” says Peter Thompson, MD, chief of clinical operations at Apogee Physicians, a national hospitalist management company based in Phoenix.

At new hospitalist orientation, called Apogee University, providers spend several hours learning the rules for documentation. The group follows up with regular reviews of hospitalists’ notes through an audit system. A program director “breaks down the components that make it a compliant note or not,” Dr. Thompson says. Audits are performed monthly on every physician.

“It takes a commitment to knowing what the requirements are,” he adds. “And it takes repetition and it takes practice to make something a habit.”

Susan Kreimer is a freelance medical writer in New York.

The intricacies of billing and coding typically aren’t taught in physician residency training programs.

“Residents want to learn how to take care of patients. They’re not really focused on learning [Centers for Medicare & Medicaid Services] rules,” says Balazs Zsenits, MD, FACP, SFHM, medical director of the Rochester General Hospitalist Group in Rochester, N.Y. As a result, “there’s a knowledge gap” between newly minted physicians and experienced practitioners when it comes to documenting their work.

To bridge that gap, some hospitalist groups offer training on the business side of medicine during physician orientation, as well as provide constructive reviews of hospitalists’ progress notes on a periodic basis. Some hospitals provide seminars in proper documentation.

“I’ve seen a lot of hospitals do ‘lunch and learn’” sessions on documentation requirements, says Angie Comfort, RHIT, CCS, a director of HIM Solutions at the American Health Information Management Association. The goal is to facilitate reimbursement for the hospital from patients’ insurance providers.

“If more specific documentation is not in the record, the coder must ask the physician for additional clarification,” Comfort says. “Without the clarification, sometimes the conditions are not able to be coded.”

The HM group in Rochester, which employs 46 hospitalists, provides about six hours of billing compliance education for new hires during orientation and holds regular, topic-based presentations at weekly staff meetings.

Physicians “need timely information as we submit our own charges, and we set up our productivity bonus so that it depends on our billing accuracy, not just volume,” Dr. Zsenits says. Using an internal Web portal, physicians can look up billing codes and explanations. “They realize the risks involved if they don’t do it right,” she says, so they also accept feedback from reviews of their patient charts.

Easy-to-access information is key to helping hospitalists learn coding requirements. “We have a Web-based documentation education module, so the provider is able to log on from home,” says David Grace, MD, FHM, senior medical officer at The Schumacher Group’s hospital medicine division in Lafayette, La. The practice management company employs hospitalists in 12 states.

Its initial module takes about an hour to review. For those who are already proficient in billing and coding, a test-out option lasting 10 to 15 minutes is available online as well. Pocket cards are provided as a reference thereafter.

“Documentation and coding is a complex entity, and certainly we don’t expect them to remember all the details after one educational module,” Dr. Grace says. “They do have access to be able to go back to it for a refresher whenever they want.”

Internal coding experts audit about 20% of the hospitalists’ work, and audited physicians are provided feedback on compliance. The Schumacher Group also uses a proprietary template to help hospitalists capture the important data points in their patient progress notes.

“Physicians are under a lot of scrutiny by regulatory agencies,” says Peter Thompson, MD, chief of clinical operations at Apogee Physicians, a national hospitalist management company based in Phoenix.

At new hospitalist orientation, called Apogee University, providers spend several hours learning the rules for documentation. The group follows up with regular reviews of hospitalists’ notes through an audit system. A program director “breaks down the components that make it a compliant note or not,” Dr. Thompson says. Audits are performed monthly on every physician.

“It takes a commitment to knowing what the requirements are,” he adds. “And it takes repetition and it takes practice to make something a habit.”

Susan Kreimer is a freelance medical writer in New York.

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

It is that time of year when 2013 predictions come your way, with insights into upcoming changes and/or developments in the specialty of pediatric infectious diseases. The theme this year: drugs, bugs, and the new immunization schedule.

Antimicrobial resistance for Gram negative organisms will reach new heights in 2013, new antibiotics will not likely appear on the market, and you will see an increase in emphasis on judicious antibiotic use in other venues such as the animal industry.

Particularly worrisome is the increased rate of hospital acquired carbapenem-resistant Klebsiella pneumoniae infections as few good therapeutic options currently exist for these pathogens. Judicious use of antibiotics in all instances is key, and pediatricians should particularly focus on their practice patterns for common infections (streptococcal pharyngitis, otitis media, and sinusitis), and avoiding antibiotics for upper respiratory infections and bronchitis.

The United States is the fifth greatest user of antibiotics in the world (France, Greece, Italy, and Belgium exceed us), and Kentucky, West Virginia, Tennessee, Mississippi, and Louisiana are the states with the highest use. Check out the map of this data to see antibiotic use for your state.

The winter scourge of rotavirus infection has virtually disappeared following the introduction of rotavirus vaccine but two diarrheal pathogens you’ll likely hear more about in 2013 are norovirus and cryptosporidia.

Norovirus (think cruise ship diarrhea) moves front and center as the most important cause of diarrheal outbreaks in the United States. While foodborne disease occurs, most outbreaks relate to person-to-person transmission, and you are most likely to see disease this time of year (November through April). This might be explained by the fact that infected individuals shed billions of norovirus particles, and it only takes 18 particles to infect another, plus folks are more likely to be closely quartered in winter months.

In terms of cryptosporidiosis, famous outbreaks have followed contamination of drinking water, and sporadic cases are often seen in summer following recreational water exposure. While self-limited in the healthy child, cryptosporidiosis is hard to treat and causes significant morbidity in immunocompromised individuals, such as organ transplant patients. Pediatricians should alert parents to the risk related to recreational water exposure for high-risk patients who should avoid ingesting such water, and particularly avoid pools where diapered children may contaminate the water.

Speaking of diarrhea, as rates for Clostridium difficile associated disease (CDAD) in children have been increasing over the last decade, I suspect clinicians will need to gain a better understanding of the specifics regarding newer C. difficile tests. Many institutions have gone to molecular assays. Polymerase chain reaction (PCR) testing, for instance, has been introduced, which is very sensitive, and doubled the rate of positivity (compared with enzyme immunoassay) in some studies. We know that asymptomatic carriage of C. difficile is common in infants younger than 12 months of age, but several studies suggest that 25%-33% of 0- to 36-month control patients had stools that were positive for C. difficile toxin. Take a highly sensitive test, high rates of asymptomatic colonization, and the overall low prevalence CDAD, and you are likely to see diagnosis and treatment instituted inappropriately in some cases. The key to diagnosis of CDAD is to perform testing only on liquid stools and to make sure that other etiologies of diarrhea have been excluded in those less than 3 years of age. Don’t test young infants younger than 1 year (unless they have Hirschsprung’s disease), and do not perform tests to check for cure. See the new guideline published in the January issue of Pediatrics (2013; 131:196-200).

We may still be months away from knowing the full extent of the 2012 national fungal meningitis outbreak; however, based on what we know now, there is a clear need for legislation to ensure safe practices in compounding pharmacies, and I predict this will come in 2013. The first case of fungal meningitis cases was reported Sept. 18, 2012, in a man in Tennessee, and within a week, seven other cases were diagnosed; all had epidural steroid injections at the same center (N. Engl. J. Med. 2012 Dec. 19 [doi: 10.1056/NEJMoa1213978]).

Since then, a Centers for Disease Control and Prevention investigation has found that more than 600 infected patients and 39 patients have died. Three lots of methylprednisolone products from a compounding pharmacy in New England were found to be the source, and the CDC investigation found that more than 14,000 individuals in 70-plus clinics in 22 states were exposed to the products, mostly adult patients with chronic back pain. The organism in all but one case is an unusual environmental fungus (Exserohilum rostratum) that likely was introduced into the products during drug preparation. The Food and Drug Administration has since inspected the company’s processing room and noted a number of different issues that may have resulted in contamination. Products have been recalled from the implicated pharmacy (New England Compounding Center), and a sister pharmacy (Ameridose) has voluntarily recalled its products. This is not the first time that an outbreak has been tracked to contamination at a compounding pharmacies, but the extent of this outbreak emphasizes the need for definitive action to prevent this from ever happening again.

The 2013 Immunization Schedule will be out soon, and I predict practitioners may be happy to see a comprehensive footnote table, a harmonized schedule for those 0-18 years, and separate tables for the high-risk patient and for those requiring catch-up schedules.

In terms of vaccines, an important goal for practitioners may be to increase vaccine coverage in teens. Human papillomavirus (HPV) coverage rates are still dismal; 35% of girls and 1% of boys completed three vaccines in 2011, according to the National Immunization Survey–Teen. Parents who refused HPV vaccines in their daughters more likely cited safety concerns, but those who refused for their sons were more likely not to be aware of the recommendation for vaccination, according to data from the NIS-Teen. Geographic disparities also have been noted, with the southeastern U.S. states having lowest rates for immunization and some of the highest rates for cervical cancer. Recommend HPV vaccine every time another teen platform vaccine is recommended, and use a standing order in your practice so every encounter is an opportunity to immunize.

I wish you blessings in the coming year and hope that at least some of my predictions have utility for those of you in practice.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

It is that time of year when 2013 predictions come your way, with insights into upcoming changes and/or developments in the specialty of pediatric infectious diseases. The theme this year: drugs, bugs, and the new immunization schedule.

Antimicrobial resistance for Gram negative organisms will reach new heights in 2013, new antibiotics will not likely appear on the market, and you will see an increase in emphasis on judicious antibiotic use in other venues such as the animal industry.

Particularly worrisome is the increased rate of hospital acquired carbapenem-resistant Klebsiella pneumoniae infections as few good therapeutic options currently exist for these pathogens. Judicious use of antibiotics in all instances is key, and pediatricians should particularly focus on their practice patterns for common infections (streptococcal pharyngitis, otitis media, and sinusitis), and avoiding antibiotics for upper respiratory infections and bronchitis.

The United States is the fifth greatest user of antibiotics in the world (France, Greece, Italy, and Belgium exceed us), and Kentucky, West Virginia, Tennessee, Mississippi, and Louisiana are the states with the highest use. Check out the map of this data to see antibiotic use for your state.

The winter scourge of rotavirus infection has virtually disappeared following the introduction of rotavirus vaccine but two diarrheal pathogens you’ll likely hear more about in 2013 are norovirus and cryptosporidia.

Norovirus (think cruise ship diarrhea) moves front and center as the most important cause of diarrheal outbreaks in the United States. While foodborne disease occurs, most outbreaks relate to person-to-person transmission, and you are most likely to see disease this time of year (November through April). This might be explained by the fact that infected individuals shed billions of norovirus particles, and it only takes 18 particles to infect another, plus folks are more likely to be closely quartered in winter months.

In terms of cryptosporidiosis, famous outbreaks have followed contamination of drinking water, and sporadic cases are often seen in summer following recreational water exposure. While self-limited in the healthy child, cryptosporidiosis is hard to treat and causes significant morbidity in immunocompromised individuals, such as organ transplant patients. Pediatricians should alert parents to the risk related to recreational water exposure for high-risk patients who should avoid ingesting such water, and particularly avoid pools where diapered children may contaminate the water.

Speaking of diarrhea, as rates for Clostridium difficile associated disease (CDAD) in children have been increasing over the last decade, I suspect clinicians will need to gain a better understanding of the specifics regarding newer C. difficile tests. Many institutions have gone to molecular assays. Polymerase chain reaction (PCR) testing, for instance, has been introduced, which is very sensitive, and doubled the rate of positivity (compared with enzyme immunoassay) in some studies. We know that asymptomatic carriage of C. difficile is common in infants younger than 12 months of age, but several studies suggest that 25%-33% of 0- to 36-month control patients had stools that were positive for C. difficile toxin. Take a highly sensitive test, high rates of asymptomatic colonization, and the overall low prevalence CDAD, and you are likely to see diagnosis and treatment instituted inappropriately in some cases. The key to diagnosis of CDAD is to perform testing only on liquid stools and to make sure that other etiologies of diarrhea have been excluded in those less than 3 years of age. Don’t test young infants younger than 1 year (unless they have Hirschsprung’s disease), and do not perform tests to check for cure. See the new guideline published in the January issue of Pediatrics (2013; 131:196-200).

We may still be months away from knowing the full extent of the 2012 national fungal meningitis outbreak; however, based on what we know now, there is a clear need for legislation to ensure safe practices in compounding pharmacies, and I predict this will come in 2013. The first case of fungal meningitis cases was reported Sept. 18, 2012, in a man in Tennessee, and within a week, seven other cases were diagnosed; all had epidural steroid injections at the same center (N. Engl. J. Med. 2012 Dec. 19 [doi: 10.1056/NEJMoa1213978]).

Since then, a Centers for Disease Control and Prevention investigation has found that more than 600 infected patients and 39 patients have died. Three lots of methylprednisolone products from a compounding pharmacy in New England were found to be the source, and the CDC investigation found that more than 14,000 individuals in 70-plus clinics in 22 states were exposed to the products, mostly adult patients with chronic back pain. The organism in all but one case is an unusual environmental fungus (Exserohilum rostratum) that likely was introduced into the products during drug preparation. The Food and Drug Administration has since inspected the company’s processing room and noted a number of different issues that may have resulted in contamination. Products have been recalled from the implicated pharmacy (New England Compounding Center), and a sister pharmacy (Ameridose) has voluntarily recalled its products. This is not the first time that an outbreak has been tracked to contamination at a compounding pharmacies, but the extent of this outbreak emphasizes the need for definitive action to prevent this from ever happening again.

The 2013 Immunization Schedule will be out soon, and I predict practitioners may be happy to see a comprehensive footnote table, a harmonized schedule for those 0-18 years, and separate tables for the high-risk patient and for those requiring catch-up schedules.

In terms of vaccines, an important goal for practitioners may be to increase vaccine coverage in teens. Human papillomavirus (HPV) coverage rates are still dismal; 35% of girls and 1% of boys completed three vaccines in 2011, according to the National Immunization Survey–Teen. Parents who refused HPV vaccines in their daughters more likely cited safety concerns, but those who refused for their sons were more likely not to be aware of the recommendation for vaccination, according to data from the NIS-Teen. Geographic disparities also have been noted, with the southeastern U.S. states having lowest rates for immunization and some of the highest rates for cervical cancer. Recommend HPV vaccine every time another teen platform vaccine is recommended, and use a standing order in your practice so every encounter is an opportunity to immunize.

I wish you blessings in the coming year and hope that at least some of my predictions have utility for those of you in practice.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

It is that time of year when 2013 predictions come your way, with insights into upcoming changes and/or developments in the specialty of pediatric infectious diseases. The theme this year: drugs, bugs, and the new immunization schedule.

Antimicrobial resistance for Gram negative organisms will reach new heights in 2013, new antibiotics will not likely appear on the market, and you will see an increase in emphasis on judicious antibiotic use in other venues such as the animal industry.

Particularly worrisome is the increased rate of hospital acquired carbapenem-resistant Klebsiella pneumoniae infections as few good therapeutic options currently exist for these pathogens. Judicious use of antibiotics in all instances is key, and pediatricians should particularly focus on their practice patterns for common infections (streptococcal pharyngitis, otitis media, and sinusitis), and avoiding antibiotics for upper respiratory infections and bronchitis.

The United States is the fifth greatest user of antibiotics in the world (France, Greece, Italy, and Belgium exceed us), and Kentucky, West Virginia, Tennessee, Mississippi, and Louisiana are the states with the highest use. Check out the map of this data to see antibiotic use for your state.

The winter scourge of rotavirus infection has virtually disappeared following the introduction of rotavirus vaccine but two diarrheal pathogens you’ll likely hear more about in 2013 are norovirus and cryptosporidia.

Norovirus (think cruise ship diarrhea) moves front and center as the most important cause of diarrheal outbreaks in the United States. While foodborne disease occurs, most outbreaks relate to person-to-person transmission, and you are most likely to see disease this time of year (November through April). This might be explained by the fact that infected individuals shed billions of norovirus particles, and it only takes 18 particles to infect another, plus folks are more likely to be closely quartered in winter months.

In terms of cryptosporidiosis, famous outbreaks have followed contamination of drinking water, and sporadic cases are often seen in summer following recreational water exposure. While self-limited in the healthy child, cryptosporidiosis is hard to treat and causes significant morbidity in immunocompromised individuals, such as organ transplant patients. Pediatricians should alert parents to the risk related to recreational water exposure for high-risk patients who should avoid ingesting such water, and particularly avoid pools where diapered children may contaminate the water.

Speaking of diarrhea, as rates for Clostridium difficile associated disease (CDAD) in children have been increasing over the last decade, I suspect clinicians will need to gain a better understanding of the specifics regarding newer C. difficile tests. Many institutions have gone to molecular assays. Polymerase chain reaction (PCR) testing, for instance, has been introduced, which is very sensitive, and doubled the rate of positivity (compared with enzyme immunoassay) in some studies. We know that asymptomatic carriage of C. difficile is common in infants younger than 12 months of age, but several studies suggest that 25%-33% of 0- to 36-month control patients had stools that were positive for C. difficile toxin. Take a highly sensitive test, high rates of asymptomatic colonization, and the overall low prevalence CDAD, and you are likely to see diagnosis and treatment instituted inappropriately in some cases. The key to diagnosis of CDAD is to perform testing only on liquid stools and to make sure that other etiologies of diarrhea have been excluded in those less than 3 years of age. Don’t test young infants younger than 1 year (unless they have Hirschsprung’s disease), and do not perform tests to check for cure. See the new guideline published in the January issue of Pediatrics (2013; 131:196-200).

We may still be months away from knowing the full extent of the 2012 national fungal meningitis outbreak; however, based on what we know now, there is a clear need for legislation to ensure safe practices in compounding pharmacies, and I predict this will come in 2013. The first case of fungal meningitis cases was reported Sept. 18, 2012, in a man in Tennessee, and within a week, seven other cases were diagnosed; all had epidural steroid injections at the same center (N. Engl. J. Med. 2012 Dec. 19 [doi: 10.1056/NEJMoa1213978]).

Since then, a Centers for Disease Control and Prevention investigation has found that more than 600 infected patients and 39 patients have died. Three lots of methylprednisolone products from a compounding pharmacy in New England were found to be the source, and the CDC investigation found that more than 14,000 individuals in 70-plus clinics in 22 states were exposed to the products, mostly adult patients with chronic back pain. The organism in all but one case is an unusual environmental fungus (Exserohilum rostratum) that likely was introduced into the products during drug preparation. The Food and Drug Administration has since inspected the company’s processing room and noted a number of different issues that may have resulted in contamination. Products have been recalled from the implicated pharmacy (New England Compounding Center), and a sister pharmacy (Ameridose) has voluntarily recalled its products. This is not the first time that an outbreak has been tracked to contamination at a compounding pharmacies, but the extent of this outbreak emphasizes the need for definitive action to prevent this from ever happening again.

The 2013 Immunization Schedule will be out soon, and I predict practitioners may be happy to see a comprehensive footnote table, a harmonized schedule for those 0-18 years, and separate tables for the high-risk patient and for those requiring catch-up schedules.

In terms of vaccines, an important goal for practitioners may be to increase vaccine coverage in teens. Human papillomavirus (HPV) coverage rates are still dismal; 35% of girls and 1% of boys completed three vaccines in 2011, according to the National Immunization Survey–Teen. Parents who refused HPV vaccines in their daughters more likely cited safety concerns, but those who refused for their sons were more likely not to be aware of the recommendation for vaccination, according to data from the NIS-Teen. Geographic disparities also have been noted, with the southeastern U.S. states having lowest rates for immunization and some of the highest rates for cervical cancer. Recommend HPV vaccine every time another teen platform vaccine is recommended, and use a standing order in your practice so every encounter is an opportunity to immunize.

I wish you blessings in the coming year and hope that at least some of my predictions have utility for those of you in practice.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

On online review sites, one of the measures doctors are judged by is how long patients are kept waiting in the waiting room before they are seen. But is that a fair measure?

One of my patients is habitually late, always 15-20 minutes late for her 15-minute follow-up visit. And she’s not a straightforward patient. If I am lucky, the person scheduled to come after her arrives early, so I see him or her first and my schedule is thrown off by only a few minutes. But more often I end up running late, and the rest of the patients have to wait longer than they normally would.

The last time I saw her, I politely asked her why she was late again, and after her initial protestations that she was actually on time, she said to me: "I don’t yell at you when you make me wait."

I do my best not to keep patients waiting. Of course, in a busy rheumatology practice, that is not always realistic. I need to take a history, perform a physical exam, monitor labs and x-rays and bone densities, as well as counsel on smoking cessation. Not to mention the elderly man who needs time for a good cry because he still feels guilty about having put his wife in a nursing home, or the lovely gentleman with a bad stutter who takes a very long time to finish his sentences.

Although I am typically quite prompt, sometimes I am a little late. I don’t make a habit of it, and if I am late it is with good reason. Trust me, I was not twiddling my thumbs.

But when patients are habitually late, it implies a certain expectation that they’ll be seen anyway even if they’re late. It signifies complacency toward the doctor and a lack of consideration for the other people who are inconvenienced – all the subsequent patients who are then kept waiting.

The difference between a doctor being late and a patient being late is that the doctor is providing a service, not only to that patient but to all the other patients on their schedule. If I keep you waiting, you know it’s because I was giving the patients before you the same kind of attention and level of care that you can and should expect to get. This is why patients don’t usually yell at their doctors for being late, nor do doctors deserve to be yelled at when they are.

Asking patients if they were kept waiting is not a useful question. How much or how little a doctor keeps a patient waiting is not an indication of the quality of care that the doctor is capable of giving.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at [email protected].

On online review sites, one of the measures doctors are judged by is how long patients are kept waiting in the waiting room before they are seen. But is that a fair measure?

One of my patients is habitually late, always 15-20 minutes late for her 15-minute follow-up visit. And she’s not a straightforward patient. If I am lucky, the person scheduled to come after her arrives early, so I see him or her first and my schedule is thrown off by only a few minutes. But more often I end up running late, and the rest of the patients have to wait longer than they normally would.

The last time I saw her, I politely asked her why she was late again, and after her initial protestations that she was actually on time, she said to me: "I don’t yell at you when you make me wait."

I do my best not to keep patients waiting. Of course, in a busy rheumatology practice, that is not always realistic. I need to take a history, perform a physical exam, monitor labs and x-rays and bone densities, as well as counsel on smoking cessation. Not to mention the elderly man who needs time for a good cry because he still feels guilty about having put his wife in a nursing home, or the lovely gentleman with a bad stutter who takes a very long time to finish his sentences.

Although I am typically quite prompt, sometimes I am a little late. I don’t make a habit of it, and if I am late it is with good reason. Trust me, I was not twiddling my thumbs.

But when patients are habitually late, it implies a certain expectation that they’ll be seen anyway even if they’re late. It signifies complacency toward the doctor and a lack of consideration for the other people who are inconvenienced – all the subsequent patients who are then kept waiting.

The difference between a doctor being late and a patient being late is that the doctor is providing a service, not only to that patient but to all the other patients on their schedule. If I keep you waiting, you know it’s because I was giving the patients before you the same kind of attention and level of care that you can and should expect to get. This is why patients don’t usually yell at their doctors for being late, nor do doctors deserve to be yelled at when they are.

Asking patients if they were kept waiting is not a useful question. How much or how little a doctor keeps a patient waiting is not an indication of the quality of care that the doctor is capable of giving.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at [email protected].

On online review sites, one of the measures doctors are judged by is how long patients are kept waiting in the waiting room before they are seen. But is that a fair measure?

One of my patients is habitually late, always 15-20 minutes late for her 15-minute follow-up visit. And she’s not a straightforward patient. If I am lucky, the person scheduled to come after her arrives early, so I see him or her first and my schedule is thrown off by only a few minutes. But more often I end up running late, and the rest of the patients have to wait longer than they normally would.

The last time I saw her, I politely asked her why she was late again, and after her initial protestations that she was actually on time, she said to me: "I don’t yell at you when you make me wait."

I do my best not to keep patients waiting. Of course, in a busy rheumatology practice, that is not always realistic. I need to take a history, perform a physical exam, monitor labs and x-rays and bone densities, as well as counsel on smoking cessation. Not to mention the elderly man who needs time for a good cry because he still feels guilty about having put his wife in a nursing home, or the lovely gentleman with a bad stutter who takes a very long time to finish his sentences.

Although I am typically quite prompt, sometimes I am a little late. I don’t make a habit of it, and if I am late it is with good reason. Trust me, I was not twiddling my thumbs.

But when patients are habitually late, it implies a certain expectation that they’ll be seen anyway even if they’re late. It signifies complacency toward the doctor and a lack of consideration for the other people who are inconvenienced – all the subsequent patients who are then kept waiting.

The difference between a doctor being late and a patient being late is that the doctor is providing a service, not only to that patient but to all the other patients on their schedule. If I keep you waiting, you know it’s because I was giving the patients before you the same kind of attention and level of care that you can and should expect to get. This is why patients don’t usually yell at their doctors for being late, nor do doctors deserve to be yelled at when they are.

Asking patients if they were kept waiting is not a useful question. How much or how little a doctor keeps a patient waiting is not an indication of the quality of care that the doctor is capable of giving.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at [email protected].

As Washington hurtled toward the fiscal cliff, I watched with increasing confidence that savvy politicians would announce a last-minute deal. However, I gained even more confidence that it would not actually deal with the problem. Far from forming a grand bargain, Congress just kicked the can a bit further down the road.

The next hurdle the federal government will face and crawl under will be raising the debt ceiling by the end of February 2013. I have no plans to write my next column on that subject. This column is not meant to be a fount for political analysis. But there are two important ways in which the fiscal cliff debacle impacts physicians. One is exemplified by the legend of the sword of Damocles. The other comes from an aphorism attributed to Mahatma Gandhi.

In 1997, Congress created a correction factor, based on a Sustainable Growth Rate (SGR), to control runaway increases in health care spending. Starting in 1999, Medicare fees were to be adjusted so that the rate of growth in Medicare spending was no larger than the growth of the gross domestic product (GDP). In short, if spending increased more than that, physician fees for a given service would be reduced by a proportionate amount. However, each year since then, an act of Congress has postponed, but not repealed, implementation of the correction factor. This has happened so repeatedly that it has acquired the nickname "the doc fix." In total, these accumulated corrections now exceed 27%. Once again, as part of the bill passed by the Senate on Jan. 1, 2013, a postponement was authorized. Physicians will not see a sudden 27% drop in Medicare fees in 2013. But the threat of such a reduction in fees for 2014 remains on the legislative books.

By legend, Damocles temporarily sat upon the throne of Dionysius, but could not enjoy its luxury because over his head was a large sword suspended by a single hair of a horse’s tail. For physicians, the sword of Damocles grows larger annually. As the size of the Medicare SGR correction has accumulated, fewer people believe it will ever be implemented. I am reminded of an adage that "experience allows us to repeat the same mistakes with increasing levels of confidence." The longer the sword remains over our heads, the less worried we become that it will actually fall. That may not be wise in a world of political brinkmanship.

The second take-home message from Washington’s paralysis is more cynical and insidious. Health care in the United States, particularly public health, has been very successful, adding 10 years to the average life expectancy over the past 50 years. But it has created a Faustian bargain with unsustainable cost increases. We’ve gone from 6% of the GDP to 17% spent on health care. Of course, if the average working person gets to live 10 years longer, he might be willing to pay for that with 11% of the GDP. But other countries have obtained the same benefit for half the price. The state of Oregon once tried to prioritize Medicaid spending, creating a list of which medical interventions would be covered and which were too extravagant. The process failed. The fiscal cliff debacle is further demonstration that our current form of government cannot handle these difficult choices over diverse ideals.

The financing of health care in the United States has fostered wasteful and futile care for the elderly while services for children, particularly dental and mental health, remained woefully underfunded. It appears to be irrational to continue to wait for government to create a just framework for allocating medical care. Inaction is collusion with this insanity.

Change is needed before the sword falls. Instead of relying on centralized planning, can we find salvation in the individual choices of physicians? What could you personally do to increase access to the most beneficial types of health care services rather than the most lucrative? As Gandhi suggested, "You must be the change you want to see in the world."

This column, "Beyond the White Coat," regularly appears in Pediatric News. Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at [email protected].

As Washington hurtled toward the fiscal cliff, I watched with increasing confidence that savvy politicians would announce a last-minute deal. However, I gained even more confidence that it would not actually deal with the problem. Far from forming a grand bargain, Congress just kicked the can a bit further down the road.

The next hurdle the federal government will face and crawl under will be raising the debt ceiling by the end of February 2013. I have no plans to write my next column on that subject. This column is not meant to be a fount for political analysis. But there are two important ways in which the fiscal cliff debacle impacts physicians. One is exemplified by the legend of the sword of Damocles. The other comes from an aphorism attributed to Mahatma Gandhi.

In 1997, Congress created a correction factor, based on a Sustainable Growth Rate (SGR), to control runaway increases in health care spending. Starting in 1999, Medicare fees were to be adjusted so that the rate of growth in Medicare spending was no larger than the growth of the gross domestic product (GDP). In short, if spending increased more than that, physician fees for a given service would be reduced by a proportionate amount. However, each year since then, an act of Congress has postponed, but not repealed, implementation of the correction factor. This has happened so repeatedly that it has acquired the nickname "the doc fix." In total, these accumulated corrections now exceed 27%. Once again, as part of the bill passed by the Senate on Jan. 1, 2013, a postponement was authorized. Physicians will not see a sudden 27% drop in Medicare fees in 2013. But the threat of such a reduction in fees for 2014 remains on the legislative books.

By legend, Damocles temporarily sat upon the throne of Dionysius, but could not enjoy its luxury because over his head was a large sword suspended by a single hair of a horse’s tail. For physicians, the sword of Damocles grows larger annually. As the size of the Medicare SGR correction has accumulated, fewer people believe it will ever be implemented. I am reminded of an adage that "experience allows us to repeat the same mistakes with increasing levels of confidence." The longer the sword remains over our heads, the less worried we become that it will actually fall. That may not be wise in a world of political brinkmanship.

The second take-home message from Washington’s paralysis is more cynical and insidious. Health care in the United States, particularly public health, has been very successful, adding 10 years to the average life expectancy over the past 50 years. But it has created a Faustian bargain with unsustainable cost increases. We’ve gone from 6% of the GDP to 17% spent on health care. Of course, if the average working person gets to live 10 years longer, he might be willing to pay for that with 11% of the GDP. But other countries have obtained the same benefit for half the price. The state of Oregon once tried to prioritize Medicaid spending, creating a list of which medical interventions would be covered and which were too extravagant. The process failed. The fiscal cliff debacle is further demonstration that our current form of government cannot handle these difficult choices over diverse ideals.

The financing of health care in the United States has fostered wasteful and futile care for the elderly while services for children, particularly dental and mental health, remained woefully underfunded. It appears to be irrational to continue to wait for government to create a just framework for allocating medical care. Inaction is collusion with this insanity.

Change is needed before the sword falls. Instead of relying on centralized planning, can we find salvation in the individual choices of physicians? What could you personally do to increase access to the most beneficial types of health care services rather than the most lucrative? As Gandhi suggested, "You must be the change you want to see in the world."

This column, "Beyond the White Coat," regularly appears in Pediatric News. Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at [email protected].

As Washington hurtled toward the fiscal cliff, I watched with increasing confidence that savvy politicians would announce a last-minute deal. However, I gained even more confidence that it would not actually deal with the problem. Far from forming a grand bargain, Congress just kicked the can a bit further down the road.

The next hurdle the federal government will face and crawl under will be raising the debt ceiling by the end of February 2013. I have no plans to write my next column on that subject. This column is not meant to be a fount for political analysis. But there are two important ways in which the fiscal cliff debacle impacts physicians. One is exemplified by the legend of the sword of Damocles. The other comes from an aphorism attributed to Mahatma Gandhi.

In 1997, Congress created a correction factor, based on a Sustainable Growth Rate (SGR), to control runaway increases in health care spending. Starting in 1999, Medicare fees were to be adjusted so that the rate of growth in Medicare spending was no larger than the growth of the gross domestic product (GDP). In short, if spending increased more than that, physician fees for a given service would be reduced by a proportionate amount. However, each year since then, an act of Congress has postponed, but not repealed, implementation of the correction factor. This has happened so repeatedly that it has acquired the nickname "the doc fix." In total, these accumulated corrections now exceed 27%. Once again, as part of the bill passed by the Senate on Jan. 1, 2013, a postponement was authorized. Physicians will not see a sudden 27% drop in Medicare fees in 2013. But the threat of such a reduction in fees for 2014 remains on the legislative books.

By legend, Damocles temporarily sat upon the throne of Dionysius, but could not enjoy its luxury because over his head was a large sword suspended by a single hair of a horse’s tail. For physicians, the sword of Damocles grows larger annually. As the size of the Medicare SGR correction has accumulated, fewer people believe it will ever be implemented. I am reminded of an adage that "experience allows us to repeat the same mistakes with increasing levels of confidence." The longer the sword remains over our heads, the less worried we become that it will actually fall. That may not be wise in a world of political brinkmanship.

The second take-home message from Washington’s paralysis is more cynical and insidious. Health care in the United States, particularly public health, has been very successful, adding 10 years to the average life expectancy over the past 50 years. But it has created a Faustian bargain with unsustainable cost increases. We’ve gone from 6% of the GDP to 17% spent on health care. Of course, if the average working person gets to live 10 years longer, he might be willing to pay for that with 11% of the GDP. But other countries have obtained the same benefit for half the price. The state of Oregon once tried to prioritize Medicaid spending, creating a list of which medical interventions would be covered and which were too extravagant. The process failed. The fiscal cliff debacle is further demonstration that our current form of government cannot handle these difficult choices over diverse ideals.

The financing of health care in the United States has fostered wasteful and futile care for the elderly while services for children, particularly dental and mental health, remained woefully underfunded. It appears to be irrational to continue to wait for government to create a just framework for allocating medical care. Inaction is collusion with this insanity.

Change is needed before the sword falls. Instead of relying on centralized planning, can we find salvation in the individual choices of physicians? What could you personally do to increase access to the most beneficial types of health care services rather than the most lucrative? As Gandhi suggested, "You must be the change you want to see in the world."

This column, "Beyond the White Coat," regularly appears in Pediatric News. Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at [email protected].