Dr. Hospitalist

I would like to know where payment for the service of hospitalists fits into the insurance/Medicare payment system. Are hospitalists considered employees of the hospital and, therefore, billed through the hospital system? Are they considered independent doctors and, therefore, do their own direct billing? Do they, in general, accept assignment of benefits from you for your insurance/Medicare? Do they sign contracts with insurance/Medicare to participate in their plans?

Carole L. Hughes

Dr. Hospitalist responds:

For the sake of argument, let’s say that Carole is on the outside looking in—meaning she’s not a healthcare practitioner, but a consumer. It might seem a bit strange to wonder where all these “hospitalists” come from, and who pays for them. Let’s walk through a few scenarios as outlined here.

Are hospitalists considered employees of the hospital? They certainly could be directly employed by the hospital, but it’s just as likely they could be contracted with the hospital for certain services, such as taking ED call for unassigned patients. It’s also entirely possible that the hospitalist has no direct financial relationship with the hospital at all. In this case, a hospitalist is taking cases that are referred from other physicians and for which there is a coverage agreement. The most common situation is a primary-care physician group that is looking for a hospitalist to care for their patients in the hospital. This is usually a handshake agreement, with no money involved.

Do hospitalists do their own direct billing to the insurers? As for this part of the question, it’s time to separate “hospital services” from “hospitalist services.” Hospital services are billed under Medicare Part A, while physician services are billed under Medicare Part B, meaning that even if a physician is employed directly by the hospital, that physician’s professional services are still billed and paid separate from any hospital charges (for things like the bed, supplies, and nursing). Because Medicare sets the ground rules, other insurances typically follow suit. Payment applies similarly to the contracted hospitalists and independent hospitalists.

Do hospitalists have to be credentialed with the insurers? Yes. Whether it is Medicare or Cigna or United, each individual physician must be credentialed with the payors to receive payment. Medicare credentialing for physicians is pretty universal, given that most of our patients have this as their primary insurance. Without it, there is no payment from Medicare to the physician. Many groups or hospitals won’t even let their physicians begin seeing patients until that paperwork is approved. Due to timely filing rules, you can’t just start to see patients and hope to get paid later. And there’s no negotiating with the government—whatever Medicare pays in a region for a specific service is the payment the physician receives.

For the private insurers, it’s generally easier to receive payment if you are credentialed, but I’ve seen a few physician groups negotiate payments without agreeing to a flat contracted rate. I don’t recommend this setup, as the patient can often get caught in the middle with a rather hefty bill. Still, there is some room for negotiation on the private insurer payment rates.

In summary, whether a hospitalist is employed by the hospital, contracted, or truly independent, they all bill Medicare and the insurers for their professional fees. Medicare payments won’t vary, but private insurance payments can. It’s certainly a challenging payment system to understand, from either the provider or the patient point of view.

Dr. Hospitalist

I would like to know where payment for the service of hospitalists fits into the insurance/Medicare payment system. Are hospitalists considered employees of the hospital and, therefore, billed through the hospital system? Are they considered independent doctors and, therefore, do their own direct billing? Do they, in general, accept assignment of benefits from you for your insurance/Medicare? Do they sign contracts with insurance/Medicare to participate in their plans?

Carole L. Hughes

Dr. Hospitalist responds:

For the sake of argument, let’s say that Carole is on the outside looking in—meaning she’s not a healthcare practitioner, but a consumer. It might seem a bit strange to wonder where all these “hospitalists” come from, and who pays for them. Let’s walk through a few scenarios as outlined here.

Are hospitalists considered employees of the hospital? They certainly could be directly employed by the hospital, but it’s just as likely they could be contracted with the hospital for certain services, such as taking ED call for unassigned patients. It’s also entirely possible that the hospitalist has no direct financial relationship with the hospital at all. In this case, a hospitalist is taking cases that are referred from other physicians and for which there is a coverage agreement. The most common situation is a primary-care physician group that is looking for a hospitalist to care for their patients in the hospital. This is usually a handshake agreement, with no money involved.

Do hospitalists do their own direct billing to the insurers? As for this part of the question, it’s time to separate “hospital services” from “hospitalist services.” Hospital services are billed under Medicare Part A, while physician services are billed under Medicare Part B, meaning that even if a physician is employed directly by the hospital, that physician’s professional services are still billed and paid separate from any hospital charges (for things like the bed, supplies, and nursing). Because Medicare sets the ground rules, other insurances typically follow suit. Payment applies similarly to the contracted hospitalists and independent hospitalists.

Do hospitalists have to be credentialed with the insurers? Yes. Whether it is Medicare or Cigna or United, each individual physician must be credentialed with the payors to receive payment. Medicare credentialing for physicians is pretty universal, given that most of our patients have this as their primary insurance. Without it, there is no payment from Medicare to the physician. Many groups or hospitals won’t even let their physicians begin seeing patients until that paperwork is approved. Due to timely filing rules, you can’t just start to see patients and hope to get paid later. And there’s no negotiating with the government—whatever Medicare pays in a region for a specific service is the payment the physician receives.

For the private insurers, it’s generally easier to receive payment if you are credentialed, but I’ve seen a few physician groups negotiate payments without agreeing to a flat contracted rate. I don’t recommend this setup, as the patient can often get caught in the middle with a rather hefty bill. Still, there is some room for negotiation on the private insurer payment rates.

In summary, whether a hospitalist is employed by the hospital, contracted, or truly independent, they all bill Medicare and the insurers for their professional fees. Medicare payments won’t vary, but private insurance payments can. It’s certainly a challenging payment system to understand, from either the provider or the patient point of view.

Dr. Hospitalist

I would like to know where payment for the service of hospitalists fits into the insurance/Medicare payment system. Are hospitalists considered employees of the hospital and, therefore, billed through the hospital system? Are they considered independent doctors and, therefore, do their own direct billing? Do they, in general, accept assignment of benefits from you for your insurance/Medicare? Do they sign contracts with insurance/Medicare to participate in their plans?

Carole L. Hughes

Dr. Hospitalist responds:

For the sake of argument, let’s say that Carole is on the outside looking in—meaning she’s not a healthcare practitioner, but a consumer. It might seem a bit strange to wonder where all these “hospitalists” come from, and who pays for them. Let’s walk through a few scenarios as outlined here.

Are hospitalists considered employees of the hospital? They certainly could be directly employed by the hospital, but it’s just as likely they could be contracted with the hospital for certain services, such as taking ED call for unassigned patients. It’s also entirely possible that the hospitalist has no direct financial relationship with the hospital at all. In this case, a hospitalist is taking cases that are referred from other physicians and for which there is a coverage agreement. The most common situation is a primary-care physician group that is looking for a hospitalist to care for their patients in the hospital. This is usually a handshake agreement, with no money involved.

Do hospitalists do their own direct billing to the insurers? As for this part of the question, it’s time to separate “hospital services” from “hospitalist services.” Hospital services are billed under Medicare Part A, while physician services are billed under Medicare Part B, meaning that even if a physician is employed directly by the hospital, that physician’s professional services are still billed and paid separate from any hospital charges (for things like the bed, supplies, and nursing). Because Medicare sets the ground rules, other insurances typically follow suit. Payment applies similarly to the contracted hospitalists and independent hospitalists.

Do hospitalists have to be credentialed with the insurers? Yes. Whether it is Medicare or Cigna or United, each individual physician must be credentialed with the payors to receive payment. Medicare credentialing for physicians is pretty universal, given that most of our patients have this as their primary insurance. Without it, there is no payment from Medicare to the physician. Many groups or hospitals won’t even let their physicians begin seeing patients until that paperwork is approved. Due to timely filing rules, you can’t just start to see patients and hope to get paid later. And there’s no negotiating with the government—whatever Medicare pays in a region for a specific service is the payment the physician receives.

For the private insurers, it’s generally easier to receive payment if you are credentialed, but I’ve seen a few physician groups negotiate payments without agreeing to a flat contracted rate. I don’t recommend this setup, as the patient can often get caught in the middle with a rather hefty bill. Still, there is some room for negotiation on the private insurer payment rates.

In summary, whether a hospitalist is employed by the hospital, contracted, or truly independent, they all bill Medicare and the insurers for their professional fees. Medicare payments won’t vary, but private insurance payments can. It’s certainly a challenging payment system to understand, from either the provider or the patient point of view.

In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.

The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.

Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.

Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.

Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative.  QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.

To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.

Richard Bankowitz, MD, MBA, FACP,

chief medical officer,

Premier Inc. healthcare alliance

In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.

The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.

Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.

Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.

Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative.  QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.

To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.

Richard Bankowitz, MD, MBA, FACP,

chief medical officer,

Premier Inc. healthcare alliance

In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.

The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.

Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.

Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.

Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative.  QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.

To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.

Richard Bankowitz, MD, MBA, FACP,

chief medical officer,

Premier Inc. healthcare alliance

In response to Dr. Leland Allen and his contention that family medicine hospitalists are less prepared to handle inpatient infectious disease (ID) issues in Birmingham, Ala., I would like to point out the following:

• Family medicine hospitalists do have much more outpatient training than internal medicine (IM) residents, and in the early part of their careers, they will be at a slight disadvantage. After a year or so, the difference will be nil.
• The additional exposure to outpatient care allows family medicine graduates to be in a better position to integrate care of hospitalized patients from Day One.

We have internal medicine and family medicine working together well on our hospitalist teams. Other programs should consider the advantages of benefiting from adding family medicine hospitalists to their teams.

Bob Hollis,

SEP Hospitalists,

Florence, Ky.

In response to Dr. Leland Allen and his contention that family medicine hospitalists are less prepared to handle inpatient infectious disease (ID) issues in Birmingham, Ala., I would like to point out the following:

• Family medicine hospitalists do have much more outpatient training than internal medicine (IM) residents, and in the early part of their careers, they will be at a slight disadvantage. After a year or so, the difference will be nil.
• The additional exposure to outpatient care allows family medicine graduates to be in a better position to integrate care of hospitalized patients from Day One.

We have internal medicine and family medicine working together well on our hospitalist teams. Other programs should consider the advantages of benefiting from adding family medicine hospitalists to their teams.

Bob Hollis,

SEP Hospitalists,

Florence, Ky.

In response to Dr. Leland Allen and his contention that family medicine hospitalists are less prepared to handle inpatient infectious disease (ID) issues in Birmingham, Ala., I would like to point out the following:

• Family medicine hospitalists do have much more outpatient training than internal medicine (IM) residents, and in the early part of their careers, they will be at a slight disadvantage. After a year or so, the difference will be nil.
• The additional exposure to outpatient care allows family medicine graduates to be in a better position to integrate care of hospitalized patients from Day One.

We have internal medicine and family medicine working together well on our hospitalist teams. Other programs should consider the advantages of benefiting from adding family medicine hospitalists to their teams.

Bob Hollis,

SEP Hospitalists,

Florence, Ky.

On April 17, the U.S. Department of Health and Human Services (HHS) published a proposed rule to delay the compliance date for the International Classification of Diseases, 10th Edition, diagnosis and procedure codes (ICD-10) from Oct. 1, 2013, to Oct. 1, 2014.2

Per HHS, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS proposes that covered entities must be in compliance with ICD-10 by Oct. 1, 2014.

On April 17, the U.S. Department of Health and Human Services (HHS) published a proposed rule to delay the compliance date for the International Classification of Diseases, 10th Edition, diagnosis and procedure codes (ICD-10) from Oct. 1, 2013, to Oct. 1, 2014.2

Per HHS, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS proposes that covered entities must be in compliance with ICD-10 by Oct. 1, 2014.

On April 17, the U.S. Department of Health and Human Services (HHS) published a proposed rule to delay the compliance date for the International Classification of Diseases, 10th Edition, diagnosis and procedure codes (ICD-10) from Oct. 1, 2013, to Oct. 1, 2014.2

Per HHS, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS proposes that covered entities must be in compliance with ICD-10 by Oct. 1, 2014.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

Click here to listen to Dr. Arora

Click here to listen to Dr. Arora

Click here to listen to Dr. Arora

Click here to listen to Dr. Wanski

Click here to listen to Dr. Wanski

Click here to listen to Dr. Wanski

When parents say their child stopped breathing for a few seconds, suddenly fell to the floor, or sometimes stares off into space, you might immediately think "epilepsy." But several conditions can trigger these events and should be included in your differential diagnosis.

Breath-holding spells, staring off, and gastroesophageal reflux are probably the most common conditions that can mimic epilepsy, but there are many others. Awareness of all the possible etiologies is important because pediatricians are on the front line for diagnosis and initial management of these patients.

Begin by asking for a very detailed description of the spells, including circumstances, timing, and any triggers. Even neurologists who specialize in epilepsy may not spend enough time getting a very, very precise description from the patient and witnesses. Take a thorough medical history of the patient and family to narrow down your differential possibilities. Combined, this information will foster an accurate diagnosis or determine which tests or referrals are indicated.

Depending on your initial assessment, consider blood tests for glucose, calcium, electrolytes, and thyroid function. In some cases, a toxic screen also is appropriate. ECGs and EEGs can be diagnostic as well, although not every pediatrician’s office has these capabilities. It also may be appropriate to refer for polysomnography if you suspect a sleep disorder, including apnea.

In contrast, a CT scan is rarely helpful and in general should not be ordered for these patients. If epilepsy remains a consideration, a head MRI is the more appropriate test.

Because only rarely will you witness a spell in your office, you have to rely on patient and caregiver reports. A useful tip is to ask parents for a video of the event. This is very feasible given the widespread use of smart phones.

Most pediatricians feel comfortable managing the patient with breath-holding spells, tics (including those associated with Tourette syndrome), self-stimulatory behavior, head banging, and night terrors. In contrast, a specialist referral might be appropriate for the child with more severe gastroesophageal reflux, opsoclonus (rapid and irregular eye movements), or one of the psychiatric disorders with manifestations that can mimic epileptic seizures.

Do not hesitate to refer if you remain at all unsure after going through your differential diagnosis. Most pediatricians appropriately refer children to me for further evaluation; only infrequently do I assess a child who obviously does not have epilepsy.

Within the following broad categories are some specific conditions and potential concerns:

• Unusual movements. Newborns can experience seizures, jitteriness, and nonepileptic jerks. Benign sleep myoclonus is very common but parents may come in concerned about these jerky movements. Tics (including motor and vocal tics that characterize Tourette syndrome) can look like seizures. Tics also can point to epileptic myoclonus, in which case further evaluation with EEG is warranted.

Paroxysmal torticollis or head turning in infants is generally benign and well within the purview of pediatricians to diagnose and manage. Different eye movement disorders occur both with and without seizures as well. Be more concerned if you see opsoclonus or "dancing eyes," because you may need to rule out neuroblastoma.

"Paroxysmal kinesigenic dyskinesia" is a good example of a condition that can mimic epilepsy. The characteristic unusual writhing of extremities that is triggered by movement (such as rising from a chair) is a relatively rare condition.

Self-stimulatory behavior also is commonly mistaken for seizures. Typically children place their hands between their thighs, thrust their pelvis back and forth, and then after a few minutes fall asleep. Some refer to this behavior as "infantile masturbation.’"

• Loss of tone or consciousness. Syncope or fainting spells are common and can appear similar to seizures as well.

The typical loss of consciousness presentation is orthostatic. These patients reliably will say that they faint upon standing.

Occasionally, you may hear about patients whose knees buckle and they fall, right after a surge of negative emotion such anger. This is called cataplexy, and it’s one of the symptoms of narcolepsy; it is not epilepsy.

Hemiplegia and certain migraines can mimic seizures as well, so keep these in mind with your differential diagnosis.

You are more likely to hear reports about children who "stare off" for minutes at a time. If you hyperventilate a child in your office and this triggers a staring spell, the child might have absence seizures. In contrast, these spells are less concerning if parents report they can get the child’s attention during the staring. So, as part of your differential, ask parents if they can get the child’s attention during one of these spells. Another tip is to test recall: Instruct the parents to tell the child to remember a specific color and number during the spell; if the child can recall the information a few minutes later, this helps to rule out absence seizures.

• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.

• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.

Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.

• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.

Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.

Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.

• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.

• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.

In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.

A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.

Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.

When parents say their child stopped breathing for a few seconds, suddenly fell to the floor, or sometimes stares off into space, you might immediately think "epilepsy." But several conditions can trigger these events and should be included in your differential diagnosis.

Breath-holding spells, staring off, and gastroesophageal reflux are probably the most common conditions that can mimic epilepsy, but there are many others. Awareness of all the possible etiologies is important because pediatricians are on the front line for diagnosis and initial management of these patients.

Begin by asking for a very detailed description of the spells, including circumstances, timing, and any triggers. Even neurologists who specialize in epilepsy may not spend enough time getting a very, very precise description from the patient and witnesses. Take a thorough medical history of the patient and family to narrow down your differential possibilities. Combined, this information will foster an accurate diagnosis or determine which tests or referrals are indicated.

Depending on your initial assessment, consider blood tests for glucose, calcium, electrolytes, and thyroid function. In some cases, a toxic screen also is appropriate. ECGs and EEGs can be diagnostic as well, although not every pediatrician’s office has these capabilities. It also may be appropriate to refer for polysomnography if you suspect a sleep disorder, including apnea.

In contrast, a CT scan is rarely helpful and in general should not be ordered for these patients. If epilepsy remains a consideration, a head MRI is the more appropriate test.

Because only rarely will you witness a spell in your office, you have to rely on patient and caregiver reports. A useful tip is to ask parents for a video of the event. This is very feasible given the widespread use of smart phones.

Most pediatricians feel comfortable managing the patient with breath-holding spells, tics (including those associated with Tourette syndrome), self-stimulatory behavior, head banging, and night terrors. In contrast, a specialist referral might be appropriate for the child with more severe gastroesophageal reflux, opsoclonus (rapid and irregular eye movements), or one of the psychiatric disorders with manifestations that can mimic epileptic seizures.

Do not hesitate to refer if you remain at all unsure after going through your differential diagnosis. Most pediatricians appropriately refer children to me for further evaluation; only infrequently do I assess a child who obviously does not have epilepsy.

Within the following broad categories are some specific conditions and potential concerns:

• Unusual movements. Newborns can experience seizures, jitteriness, and nonepileptic jerks. Benign sleep myoclonus is very common but parents may come in concerned about these jerky movements. Tics (including motor and vocal tics that characterize Tourette syndrome) can look like seizures. Tics also can point to epileptic myoclonus, in which case further evaluation with EEG is warranted.

Paroxysmal torticollis or head turning in infants is generally benign and well within the purview of pediatricians to diagnose and manage. Different eye movement disorders occur both with and without seizures as well. Be more concerned if you see opsoclonus or "dancing eyes," because you may need to rule out neuroblastoma.

"Paroxysmal kinesigenic dyskinesia" is a good example of a condition that can mimic epilepsy. The characteristic unusual writhing of extremities that is triggered by movement (such as rising from a chair) is a relatively rare condition.

Self-stimulatory behavior also is commonly mistaken for seizures. Typically children place their hands between their thighs, thrust their pelvis back and forth, and then after a few minutes fall asleep. Some refer to this behavior as "infantile masturbation.’"

• Loss of tone or consciousness. Syncope or fainting spells are common and can appear similar to seizures as well.

The typical loss of consciousness presentation is orthostatic. These patients reliably will say that they faint upon standing.

Occasionally, you may hear about patients whose knees buckle and they fall, right after a surge of negative emotion such anger. This is called cataplexy, and it’s one of the symptoms of narcolepsy; it is not epilepsy.

Hemiplegia and certain migraines can mimic seizures as well, so keep these in mind with your differential diagnosis.

You are more likely to hear reports about children who "stare off" for minutes at a time. If you hyperventilate a child in your office and this triggers a staring spell, the child might have absence seizures. In contrast, these spells are less concerning if parents report they can get the child’s attention during the staring. So, as part of your differential, ask parents if they can get the child’s attention during one of these spells. Another tip is to test recall: Instruct the parents to tell the child to remember a specific color and number during the spell; if the child can recall the information a few minutes later, this helps to rule out absence seizures.

• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.

• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.

Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.

• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.

Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.

Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.

• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.

• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.

In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.

A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.

Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.

When parents say their child stopped breathing for a few seconds, suddenly fell to the floor, or sometimes stares off into space, you might immediately think "epilepsy." But several conditions can trigger these events and should be included in your differential diagnosis.

Breath-holding spells, staring off, and gastroesophageal reflux are probably the most common conditions that can mimic epilepsy, but there are many others. Awareness of all the possible etiologies is important because pediatricians are on the front line for diagnosis and initial management of these patients.

Begin by asking for a very detailed description of the spells, including circumstances, timing, and any triggers. Even neurologists who specialize in epilepsy may not spend enough time getting a very, very precise description from the patient and witnesses. Take a thorough medical history of the patient and family to narrow down your differential possibilities. Combined, this information will foster an accurate diagnosis or determine which tests or referrals are indicated.

Depending on your initial assessment, consider blood tests for glucose, calcium, electrolytes, and thyroid function. In some cases, a toxic screen also is appropriate. ECGs and EEGs can be diagnostic as well, although not every pediatrician’s office has these capabilities. It also may be appropriate to refer for polysomnography if you suspect a sleep disorder, including apnea.

In contrast, a CT scan is rarely helpful and in general should not be ordered for these patients. If epilepsy remains a consideration, a head MRI is the more appropriate test.

Because only rarely will you witness a spell in your office, you have to rely on patient and caregiver reports. A useful tip is to ask parents for a video of the event. This is very feasible given the widespread use of smart phones.

Most pediatricians feel comfortable managing the patient with breath-holding spells, tics (including those associated with Tourette syndrome), self-stimulatory behavior, head banging, and night terrors. In contrast, a specialist referral might be appropriate for the child with more severe gastroesophageal reflux, opsoclonus (rapid and irregular eye movements), or one of the psychiatric disorders with manifestations that can mimic epileptic seizures.

Do not hesitate to refer if you remain at all unsure after going through your differential diagnosis. Most pediatricians appropriately refer children to me for further evaluation; only infrequently do I assess a child who obviously does not have epilepsy.

Within the following broad categories are some specific conditions and potential concerns:

• Unusual movements. Newborns can experience seizures, jitteriness, and nonepileptic jerks. Benign sleep myoclonus is very common but parents may come in concerned about these jerky movements. Tics (including motor and vocal tics that characterize Tourette syndrome) can look like seizures. Tics also can point to epileptic myoclonus, in which case further evaluation with EEG is warranted.

Paroxysmal torticollis or head turning in infants is generally benign and well within the purview of pediatricians to diagnose and manage. Different eye movement disorders occur both with and without seizures as well. Be more concerned if you see opsoclonus or "dancing eyes," because you may need to rule out neuroblastoma.

"Paroxysmal kinesigenic dyskinesia" is a good example of a condition that can mimic epilepsy. The characteristic unusual writhing of extremities that is triggered by movement (such as rising from a chair) is a relatively rare condition.

Self-stimulatory behavior also is commonly mistaken for seizures. Typically children place their hands between their thighs, thrust their pelvis back and forth, and then after a few minutes fall asleep. Some refer to this behavior as "infantile masturbation.’"

• Loss of tone or consciousness. Syncope or fainting spells are common and can appear similar to seizures as well.

The typical loss of consciousness presentation is orthostatic. These patients reliably will say that they faint upon standing.

Occasionally, you may hear about patients whose knees buckle and they fall, right after a surge of negative emotion such anger. This is called cataplexy, and it’s one of the symptoms of narcolepsy; it is not epilepsy.

Hemiplegia and certain migraines can mimic seizures as well, so keep these in mind with your differential diagnosis.

You are more likely to hear reports about children who "stare off" for minutes at a time. If you hyperventilate a child in your office and this triggers a staring spell, the child might have absence seizures. In contrast, these spells are less concerning if parents report they can get the child’s attention during the staring. So, as part of your differential, ask parents if they can get the child’s attention during one of these spells. Another tip is to test recall: Instruct the parents to tell the child to remember a specific color and number during the spell; if the child can recall the information a few minutes later, this helps to rule out absence seizures.

• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.

• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.

Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.

• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.

Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.

Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.

• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.

• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.

In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.

A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.

Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.

Are a few animal studies and a handful of human case reports enough to let physicians skirt institutional review boards?

Two neurosurgeons in California did just that when they used Enterobacter aerogenes to infect the surgical wounds of three terminally ill glioblastoma patients. Two of the patients died from the infections.

Dr. J. Paul Muizelaar and Dr. Rudolph J. Schrot of the University of California, Davis, said their attempt to stimulate their patients’ immune response was not research but "a one-time procedure" – exempt from review, according to a report in the Sacramento Bee.

Now both are banned from human research projects and the institutional review board is the subject of its own investigation.

For an account of the scientific thinking behind the deployment of bacteria in these patients and of ongoing efforts to develop immunotherapies against cancer, see the journal Nature (2012 July 27 [doi:10.1038/nature.2012.11080]).

Are a few animal studies and a handful of human case reports enough to let physicians skirt institutional review boards?

Two neurosurgeons in California did just that when they used Enterobacter aerogenes to infect the surgical wounds of three terminally ill glioblastoma patients. Two of the patients died from the infections.

Dr. J. Paul Muizelaar and Dr. Rudolph J. Schrot of the University of California, Davis, said their attempt to stimulate their patients’ immune response was not research but "a one-time procedure" – exempt from review, according to a report in the Sacramento Bee.

Now both are banned from human research projects and the institutional review board is the subject of its own investigation.

For an account of the scientific thinking behind the deployment of bacteria in these patients and of ongoing efforts to develop immunotherapies against cancer, see the journal Nature (2012 July 27 [doi:10.1038/nature.2012.11080]).

Are a few animal studies and a handful of human case reports enough to let physicians skirt institutional review boards?

Two neurosurgeons in California did just that when they used Enterobacter aerogenes to infect the surgical wounds of three terminally ill glioblastoma patients. Two of the patients died from the infections.

Dr. J. Paul Muizelaar and Dr. Rudolph J. Schrot of the University of California, Davis, said their attempt to stimulate their patients’ immune response was not research but "a one-time procedure" – exempt from review, according to a report in the Sacramento Bee.

Now both are banned from human research projects and the institutional review board is the subject of its own investigation.

For an account of the scientific thinking behind the deployment of bacteria in these patients and of ongoing efforts to develop immunotherapies against cancer, see the journal Nature (2012 July 27 [doi:10.1038/nature.2012.11080]).

As the men and women who graciously serve our country return home, often times we can easily recognize the associated morbidity that resulted from their service. The physical injuries that can occur are obvious. But people have become more sensitive toward the injuries that are not so easily apparent, such as traumatic brain injury and posttraumatic stress disorder (PTSD). These injuries have been the targets of campaigns to increase awareness not only among practitioners, but also the lay population, particularly as they relate to concussive sports injuries.

Because these issues are on the forefront of our minds, it’s not hard to understand the misdiagnosis of PTSD in a young marine, Corporal Jordan Mills, who started having difficulty with left ptosis and episodic diplopia in 2008. It wasn’t until he became dysarthric and clumsy on the opposite side that he was transferred out of Afghanistan to a military facility in Germany, where an MRI of the brain revealed a mass raising concern for a brainstem glioma.

Brainstem glioma is a rare brain tumor that occurs mainly in the pediatric population and in young adults. Tissue diagnosis of brainstem glioma often is avoided in an attempt to first do no harm because of the tumor’s diffusely infiltrative nature and the distortion and expansion of the brainstem and its valuable inhabitants. Brainstem glioma is one of the rare instances in oncology when it has been accepted as appropriate to treat based on imaging alone without a tissue diagnosis. Conventional therapy includes radiation with or without the addition of chemotherapy. In spite of aggressive treatment strategies, this fulminating tumor is often fatal within months to years of diagnosis.

Colleagues at the Children’s National Medical Center have developed a protocol to collect serum, cerebrospinal fluid, urine, and tumor tissue of affected patients in an attempt to identify unique molecular abnormalities that would allow practitioners to target therapy more accurately to improve treatment efficacy. Brainstem glioma has been elusive given the lack of tissue to study up to this point, based on only tumor location and biopsy, as opposed to resection options.

In 2010, researchers at the Armed Forces Health Surveillance Center reviewed cancer data from 2000-2010 and found that service members have higher rates of melanoma, brain, non-Hodgkin’s lymphoma, and breast, prostate, and testicular cancers than civilians do. The strongest risk factor was associated with age. Interestingly, marines were found to have the lowest rate of cancer overall. Over the time period studied, 904 service members died of cancer, with 101 soldiers succumbing to brain or other nervous system types of cancer.

At the age of 22 years, it was accepted that this was Corp. Mills’s diagnosis and he was honorably discharged from his third and final tour with the marines. He was treated aggressively and went on to receive chemotherapy during his radiation phase and then received an additional 12 months of oral chemotherapy thereafter.

In addition to Jordan’s remarkable physical strength, his mental and emotional strength persevered. His attitude all the while was to continue to live life to the fullest and trust through his faith and his medical team that his tumor would be taken care of.

Jordan went on to marry, start a family, and enroll in the local community college where he graduated with an associate’s degree in accounting with honors. He was accepted into a prestigious school of business and is working to receive his bachelor’s degree in accounting.

Jordan’s tumor progressed in November 2011 and Jordan has reinitiated chemotherapy. His resolve is stronger than ever and he’s working to develop a foundation for marines with brain tumors. The goals of the foundation are to not only provide financial support to the marines and their immediate family, but also to support the education of military personnel on early detection of CNS disorders.

Dr. Porter is a neuro-oncologist in the department of neurology at the Mayo Clinic in Phoenix.

As the men and women who graciously serve our country return home, often times we can easily recognize the associated morbidity that resulted from their service. The physical injuries that can occur are obvious. But people have become more sensitive toward the injuries that are not so easily apparent, such as traumatic brain injury and posttraumatic stress disorder (PTSD). These injuries have been the targets of campaigns to increase awareness not only among practitioners, but also the lay population, particularly as they relate to concussive sports injuries.

Because these issues are on the forefront of our minds, it’s not hard to understand the misdiagnosis of PTSD in a young marine, Corporal Jordan Mills, who started having difficulty with left ptosis and episodic diplopia in 2008. It wasn’t until he became dysarthric and clumsy on the opposite side that he was transferred out of Afghanistan to a military facility in Germany, where an MRI of the brain revealed a mass raising concern for a brainstem glioma.

Brainstem glioma is a rare brain tumor that occurs mainly in the pediatric population and in young adults. Tissue diagnosis of brainstem glioma often is avoided in an attempt to first do no harm because of the tumor’s diffusely infiltrative nature and the distortion and expansion of the brainstem and its valuable inhabitants. Brainstem glioma is one of the rare instances in oncology when it has been accepted as appropriate to treat based on imaging alone without a tissue diagnosis. Conventional therapy includes radiation with or without the addition of chemotherapy. In spite of aggressive treatment strategies, this fulminating tumor is often fatal within months to years of diagnosis.

Colleagues at the Children’s National Medical Center have developed a protocol to collect serum, cerebrospinal fluid, urine, and tumor tissue of affected patients in an attempt to identify unique molecular abnormalities that would allow practitioners to target therapy more accurately to improve treatment efficacy. Brainstem glioma has been elusive given the lack of tissue to study up to this point, based on only tumor location and biopsy, as opposed to resection options.

In 2010, researchers at the Armed Forces Health Surveillance Center reviewed cancer data from 2000-2010 and found that service members have higher rates of melanoma, brain, non-Hodgkin’s lymphoma, and breast, prostate, and testicular cancers than civilians do. The strongest risk factor was associated with age. Interestingly, marines were found to have the lowest rate of cancer overall. Over the time period studied, 904 service members died of cancer, with 101 soldiers succumbing to brain or other nervous system types of cancer.

At the age of 22 years, it was accepted that this was Corp. Mills’s diagnosis and he was honorably discharged from his third and final tour with the marines. He was treated aggressively and went on to receive chemotherapy during his radiation phase and then received an additional 12 months of oral chemotherapy thereafter.

In addition to Jordan’s remarkable physical strength, his mental and emotional strength persevered. His attitude all the while was to continue to live life to the fullest and trust through his faith and his medical team that his tumor would be taken care of.

Jordan went on to marry, start a family, and enroll in the local community college where he graduated with an associate’s degree in accounting with honors. He was accepted into a prestigious school of business and is working to receive his bachelor’s degree in accounting.

Jordan’s tumor progressed in November 2011 and Jordan has reinitiated chemotherapy. His resolve is stronger than ever and he’s working to develop a foundation for marines with brain tumors. The goals of the foundation are to not only provide financial support to the marines and their immediate family, but also to support the education of military personnel on early detection of CNS disorders.

Dr. Porter is a neuro-oncologist in the department of neurology at the Mayo Clinic in Phoenix.

As the men and women who graciously serve our country return home, often times we can easily recognize the associated morbidity that resulted from their service. The physical injuries that can occur are obvious. But people have become more sensitive toward the injuries that are not so easily apparent, such as traumatic brain injury and posttraumatic stress disorder (PTSD). These injuries have been the targets of campaigns to increase awareness not only among practitioners, but also the lay population, particularly as they relate to concussive sports injuries.

Because these issues are on the forefront of our minds, it’s not hard to understand the misdiagnosis of PTSD in a young marine, Corporal Jordan Mills, who started having difficulty with left ptosis and episodic diplopia in 2008. It wasn’t until he became dysarthric and clumsy on the opposite side that he was transferred out of Afghanistan to a military facility in Germany, where an MRI of the brain revealed a mass raising concern for a brainstem glioma.

Brainstem glioma is a rare brain tumor that occurs mainly in the pediatric population and in young adults. Tissue diagnosis of brainstem glioma often is avoided in an attempt to first do no harm because of the tumor’s diffusely infiltrative nature and the distortion and expansion of the brainstem and its valuable inhabitants. Brainstem glioma is one of the rare instances in oncology when it has been accepted as appropriate to treat based on imaging alone without a tissue diagnosis. Conventional therapy includes radiation with or without the addition of chemotherapy. In spite of aggressive treatment strategies, this fulminating tumor is often fatal within months to years of diagnosis.

Colleagues at the Children’s National Medical Center have developed a protocol to collect serum, cerebrospinal fluid, urine, and tumor tissue of affected patients in an attempt to identify unique molecular abnormalities that would allow practitioners to target therapy more accurately to improve treatment efficacy. Brainstem glioma has been elusive given the lack of tissue to study up to this point, based on only tumor location and biopsy, as opposed to resection options.

In 2010, researchers at the Armed Forces Health Surveillance Center reviewed cancer data from 2000-2010 and found that service members have higher rates of melanoma, brain, non-Hodgkin’s lymphoma, and breast, prostate, and testicular cancers than civilians do. The strongest risk factor was associated with age. Interestingly, marines were found to have the lowest rate of cancer overall. Over the time period studied, 904 service members died of cancer, with 101 soldiers succumbing to brain or other nervous system types of cancer.

At the age of 22 years, it was accepted that this was Corp. Mills’s diagnosis and he was honorably discharged from his third and final tour with the marines. He was treated aggressively and went on to receive chemotherapy during his radiation phase and then received an additional 12 months of oral chemotherapy thereafter.

In addition to Jordan’s remarkable physical strength, his mental and emotional strength persevered. His attitude all the while was to continue to live life to the fullest and trust through his faith and his medical team that his tumor would be taken care of.

Jordan went on to marry, start a family, and enroll in the local community college where he graduated with an associate’s degree in accounting with honors. He was accepted into a prestigious school of business and is working to receive his bachelor’s degree in accounting.

Jordan’s tumor progressed in November 2011 and Jordan has reinitiated chemotherapy. His resolve is stronger than ever and he’s working to develop a foundation for marines with brain tumors. The goals of the foundation are to not only provide financial support to the marines and their immediate family, but also to support the education of military personnel on early detection of CNS disorders.

Dr. Porter is a neuro-oncologist in the department of neurology at the Mayo Clinic in Phoenix.