As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

Imagine if you will that you’re in the throes of labor (there is a point to this exercise in unplanned parenthood, so bear with me).

Between contractions, there’s a nattering in your ear about the use of local anesthesia prior to the epidural that friends swear will allow you to actually consider doing this again.

The injection is announced by someone saying either, "We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure" or "You are going to feel a big bee sting; this is the worst part of the procedure."

Not surprising, the perceived pain was found to be significantly greater after the latter statement.

German investigators highlight this experiment as part of a detailed and fascinating look at the nocebo phenomenon, or the opposite of the placebo phenomenon, in medicine.

The topic has apparently been given the short shrift by scientists and clinicians. A recent PubMed search by the Germans revealed roughly 2,200 studies penned on the placebo effect, but only 151 publications on the nocebo effect, with the vast majority of these being editorials, commentaries, and reviews, rather than empirical studies.

Dr. Winfried Häuser of the Klinikum Saarbrücken and his associates, nail the crux of the issue with a quote from cardiologist and Nobel laureate Dr. Bernard Lown that "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal."

The article touches on the neurobiological mechanisms of the nocebo effect, which like those for the placebo effect, center around conditioning and reaction to expectations – albeit in this case negative expectations.

There is a discussion about who might be at risk of nocebo responses (yes, ladies he’s speaking to us), and an amusing array of clinical studies illustrating the nocebo effect.

There’s a randomized controlled trial (RCT) of finasteride in benign prostate hyperplasia, in which sexual dysfunction was reported by 44% of patients informed of this possible side effect, compared with only 15% of those not informed.

Similarly, there’s another RCT of the beta-blocker atenolol in coronary heart disease. Rates of sexual dysfunction jumped from 3% of patients not told of the drug or side effect to 31% of those treated to complete details about both the drug and the possible sexual dysfunction

Where the review really hits its stride, however, is in the discussion of ethical problems that arise in everyday clinical practice where the nocebo phenomenon may be triggered by verbal and non-verbal communications by physicians and nurses.

The authors note that physicians are obliged to inform patients about the possible adverse events of a proposed treatment so they can make an informed decision, but also have a duty to minimize the risks of a medical intervention, including those induced by the patient briefing.

Strategies are offered to reduce this dilemma with the most obvious being patient education and communications training for medical staff.

Clinicians are also advised to focus on the proportion of patients who tolerate a procedure or drug rather than the proportion experiencing adverse events.

The most controversial suggestion is the concept of "permitted non-information." Patients agree not to receive information on mild and/or transient side effects, but must be briefed about severe and/or irreversible side effects. To respect their autonomy and preferences, patients could pick and chose what side effects they want to briefed on (or forego) from a list of categories of possible side effects for a drug or procedure.

When the German Medical Association gets round to updating its 1990 recommendations on patient briefing, the authors say there needs to be discussion on "whether it is legitimate to express a right of the patient not to know about complications and side effects of medical procedures and whether this must be respected by the physician."

There should also be debate on whether some patients might be left confused or uncertain by their inability to follow the comprehensive adverse event information found on package inserts or consent forms.

Such a strategy could be problematic in the United States, where nearly half of all adults (90 million people) have difficulty understanding and acting upon health information, according to the Institute of Medicine report "Health Literacy: A Prescription to End Confusion."

Throw in the wracking pain of childbirth, the instability of bipolarity, or the confusion of Parkinson’s, and you’ve just made the lawyers of America incandescently happy.

Dr. Häuser reports reimbursement for training and travel costs from Eli Lilly and the Falk Foundation, and lecture fees from Lilly, the Falk Foundation and Janssen-Cilag. A co-author reports research funds from Sorin, Italy.

Imagine if you will that you’re in the throes of labor (there is a point to this exercise in unplanned parenthood, so bear with me).

Between contractions, there’s a nattering in your ear about the use of local anesthesia prior to the epidural that friends swear will allow you to actually consider doing this again.

The injection is announced by someone saying either, "We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure" or "You are going to feel a big bee sting; this is the worst part of the procedure."

Not surprising, the perceived pain was found to be significantly greater after the latter statement.

German investigators highlight this experiment as part of a detailed and fascinating look at the nocebo phenomenon, or the opposite of the placebo phenomenon, in medicine.

The topic has apparently been given the short shrift by scientists and clinicians. A recent PubMed search by the Germans revealed roughly 2,200 studies penned on the placebo effect, but only 151 publications on the nocebo effect, with the vast majority of these being editorials, commentaries, and reviews, rather than empirical studies.

Dr. Winfried Häuser of the Klinikum Saarbrücken and his associates, nail the crux of the issue with a quote from cardiologist and Nobel laureate Dr. Bernard Lown that "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal."

The article touches on the neurobiological mechanisms of the nocebo effect, which like those for the placebo effect, center around conditioning and reaction to expectations – albeit in this case negative expectations.

There is a discussion about who might be at risk of nocebo responses (yes, ladies he’s speaking to us), and an amusing array of clinical studies illustrating the nocebo effect.

There’s a randomized controlled trial (RCT) of finasteride in benign prostate hyperplasia, in which sexual dysfunction was reported by 44% of patients informed of this possible side effect, compared with only 15% of those not informed.

Similarly, there’s another RCT of the beta-blocker atenolol in coronary heart disease. Rates of sexual dysfunction jumped from 3% of patients not told of the drug or side effect to 31% of those treated to complete details about both the drug and the possible sexual dysfunction

Where the review really hits its stride, however, is in the discussion of ethical problems that arise in everyday clinical practice where the nocebo phenomenon may be triggered by verbal and non-verbal communications by physicians and nurses.

The authors note that physicians are obliged to inform patients about the possible adverse events of a proposed treatment so they can make an informed decision, but also have a duty to minimize the risks of a medical intervention, including those induced by the patient briefing.

Strategies are offered to reduce this dilemma with the most obvious being patient education and communications training for medical staff.

Clinicians are also advised to focus on the proportion of patients who tolerate a procedure or drug rather than the proportion experiencing adverse events.

The most controversial suggestion is the concept of "permitted non-information." Patients agree not to receive information on mild and/or transient side effects, but must be briefed about severe and/or irreversible side effects. To respect their autonomy and preferences, patients could pick and chose what side effects they want to briefed on (or forego) from a list of categories of possible side effects for a drug or procedure.

When the German Medical Association gets round to updating its 1990 recommendations on patient briefing, the authors say there needs to be discussion on "whether it is legitimate to express a right of the patient not to know about complications and side effects of medical procedures and whether this must be respected by the physician."

There should also be debate on whether some patients might be left confused or uncertain by their inability to follow the comprehensive adverse event information found on package inserts or consent forms.

Such a strategy could be problematic in the United States, where nearly half of all adults (90 million people) have difficulty understanding and acting upon health information, according to the Institute of Medicine report "Health Literacy: A Prescription to End Confusion."

Throw in the wracking pain of childbirth, the instability of bipolarity, or the confusion of Parkinson’s, and you’ve just made the lawyers of America incandescently happy.

Dr. Häuser reports reimbursement for training and travel costs from Eli Lilly and the Falk Foundation, and lecture fees from Lilly, the Falk Foundation and Janssen-Cilag. A co-author reports research funds from Sorin, Italy.

Imagine if you will that you’re in the throes of labor (there is a point to this exercise in unplanned parenthood, so bear with me).

Between contractions, there’s a nattering in your ear about the use of local anesthesia prior to the epidural that friends swear will allow you to actually consider doing this again.

The injection is announced by someone saying either, "We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure" or "You are going to feel a big bee sting; this is the worst part of the procedure."

Not surprising, the perceived pain was found to be significantly greater after the latter statement.

German investigators highlight this experiment as part of a detailed and fascinating look at the nocebo phenomenon, or the opposite of the placebo phenomenon, in medicine.

The topic has apparently been given the short shrift by scientists and clinicians. A recent PubMed search by the Germans revealed roughly 2,200 studies penned on the placebo effect, but only 151 publications on the nocebo effect, with the vast majority of these being editorials, commentaries, and reviews, rather than empirical studies.

Dr. Winfried Häuser of the Klinikum Saarbrücken and his associates, nail the crux of the issue with a quote from cardiologist and Nobel laureate Dr. Bernard Lown that "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal."

The article touches on the neurobiological mechanisms of the nocebo effect, which like those for the placebo effect, center around conditioning and reaction to expectations – albeit in this case negative expectations.

There is a discussion about who might be at risk of nocebo responses (yes, ladies he’s speaking to us), and an amusing array of clinical studies illustrating the nocebo effect.

There’s a randomized controlled trial (RCT) of finasteride in benign prostate hyperplasia, in which sexual dysfunction was reported by 44% of patients informed of this possible side effect, compared with only 15% of those not informed.

Similarly, there’s another RCT of the beta-blocker atenolol in coronary heart disease. Rates of sexual dysfunction jumped from 3% of patients not told of the drug or side effect to 31% of those treated to complete details about both the drug and the possible sexual dysfunction

Where the review really hits its stride, however, is in the discussion of ethical problems that arise in everyday clinical practice where the nocebo phenomenon may be triggered by verbal and non-verbal communications by physicians and nurses.

The authors note that physicians are obliged to inform patients about the possible adverse events of a proposed treatment so they can make an informed decision, but also have a duty to minimize the risks of a medical intervention, including those induced by the patient briefing.

Strategies are offered to reduce this dilemma with the most obvious being patient education and communications training for medical staff.

Clinicians are also advised to focus on the proportion of patients who tolerate a procedure or drug rather than the proportion experiencing adverse events.

The most controversial suggestion is the concept of "permitted non-information." Patients agree not to receive information on mild and/or transient side effects, but must be briefed about severe and/or irreversible side effects. To respect their autonomy and preferences, patients could pick and chose what side effects they want to briefed on (or forego) from a list of categories of possible side effects for a drug or procedure.

When the German Medical Association gets round to updating its 1990 recommendations on patient briefing, the authors say there needs to be discussion on "whether it is legitimate to express a right of the patient not to know about complications and side effects of medical procedures and whether this must be respected by the physician."

There should also be debate on whether some patients might be left confused or uncertain by their inability to follow the comprehensive adverse event information found on package inserts or consent forms.

Such a strategy could be problematic in the United States, where nearly half of all adults (90 million people) have difficulty understanding and acting upon health information, according to the Institute of Medicine report "Health Literacy: A Prescription to End Confusion."

Throw in the wracking pain of childbirth, the instability of bipolarity, or the confusion of Parkinson’s, and you’ve just made the lawyers of America incandescently happy.

Dr. Häuser reports reimbursement for training and travel costs from Eli Lilly and the Falk Foundation, and lecture fees from Lilly, the Falk Foundation and Janssen-Cilag. A co-author reports research funds from Sorin, Italy.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at [email protected].

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at [email protected].

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at [email protected].

Seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, modeled after Project BOOST and sponsored by SHM and the Hospital Association of Southern California (HASC), reported on their experience at a June meeting in Montebello, Calif. Quality teams from four of the seven hospitals demonstrated reductions in readmission rates ranging from 24% to 55%. The other three hospitals are still implementing quality processes and are just now starting to see measurable results.

Several of the participating hospitals do not employ traditional hospitalist services. However, all seven benefit from mentoring by Project BOOST experts and have adopted a number of its approaches and techniques: 72-hour follow-up calls to discharged patients, the use of discharge advocates, medication reconciliation at time of discharge, enhanced discharge planning, and BOOST’s “8Ps” patient risk stratification tool. Another popular approach in use is the “teachback” communication technique, in which patients are asked to repeat in their own words what they understand the professional has told them about their condition and self-care.

One reason many Southern California hospitals do not have a strong hospitalist presence is the widespread prevalence of independent practice associations (IPAs), which often designate members of their medical groups to fill the hospitalist role for patients at a given hospital, says Z. Joseph Wanski, MD, FA

CE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care will be testing the use of hospitalists at some of its contracted acute-care facilities starting in July. (Click here to listen to more of Dr. Wanski’s interview.)

At Harbor UCLA Medical Center in Torrance, a major safety-net facility for Los Angeles County, the readmissions team initially focused on heart failure patients and was able to demonstrate a 5.5% decrease in readmissions for all heart failure patients at a time when readmissions for the hospital as a whole remained the same. The team built relationships with outside partners, including a nearby adult daycare center, home health agencies, and a care-transitions coach while emphasizing early identification of patients for referral to a heart failure disease management registry. The readmissions team also was instrumental in developing the Cardiovascular Open Access Rapid Evaluation (CORE) service, an observation unit for heart failure patients aimed at allieviating ED overcrowding.

“Hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the full-time Project BOOST facilitator at Valley Presbyterian Hospital in Van Nuys. “They see a lot of our patients in their offices.”

Three Valley Presbyterian physicians who work part-time as hospitalists and maintain office practices have agreed to carve out time to see patients who are going home without scheduled appointments with their primary-care physicians (PCPs) within seven days of discharge.

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments,” says Quintero, adding that such patients often decline the hospital team’s offers for help. The readmissions team at Valley Presbyterian is redesigning its clinical multidisciplinary rounds using a rounding script focusing more on discharge planning in rounding.

Larry Beresford is a freelance writer in Oakland, Calif.

Seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, modeled after Project BOOST and sponsored by SHM and the Hospital Association of Southern California (HASC), reported on their experience at a June meeting in Montebello, Calif. Quality teams from four of the seven hospitals demonstrated reductions in readmission rates ranging from 24% to 55%. The other three hospitals are still implementing quality processes and are just now starting to see measurable results.

Several of the participating hospitals do not employ traditional hospitalist services. However, all seven benefit from mentoring by Project BOOST experts and have adopted a number of its approaches and techniques: 72-hour follow-up calls to discharged patients, the use of discharge advocates, medication reconciliation at time of discharge, enhanced discharge planning, and BOOST’s “8Ps” patient risk stratification tool. Another popular approach in use is the “teachback” communication technique, in which patients are asked to repeat in their own words what they understand the professional has told them about their condition and self-care.

One reason many Southern California hospitals do not have a strong hospitalist presence is the widespread prevalence of independent practice associations (IPAs), which often designate members of their medical groups to fill the hospitalist role for patients at a given hospital, says Z. Joseph Wanski, MD, FA

CE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care will be testing the use of hospitalists at some of its contracted acute-care facilities starting in July. (Click here to listen to more of Dr. Wanski’s interview.)

At Harbor UCLA Medical Center in Torrance, a major safety-net facility for Los Angeles County, the readmissions team initially focused on heart failure patients and was able to demonstrate a 5.5% decrease in readmissions for all heart failure patients at a time when readmissions for the hospital as a whole remained the same. The team built relationships with outside partners, including a nearby adult daycare center, home health agencies, and a care-transitions coach while emphasizing early identification of patients for referral to a heart failure disease management registry. The readmissions team also was instrumental in developing the Cardiovascular Open Access Rapid Evaluation (CORE) service, an observation unit for heart failure patients aimed at allieviating ED overcrowding.

“Hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the full-time Project BOOST facilitator at Valley Presbyterian Hospital in Van Nuys. “They see a lot of our patients in their offices.”

Three Valley Presbyterian physicians who work part-time as hospitalists and maintain office practices have agreed to carve out time to see patients who are going home without scheduled appointments with their primary-care physicians (PCPs) within seven days of discharge.

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments,” says Quintero, adding that such patients often decline the hospital team’s offers for help. The readmissions team at Valley Presbyterian is redesigning its clinical multidisciplinary rounds using a rounding script focusing more on discharge planning in rounding.

Larry Beresford is a freelance writer in Oakland, Calif.

Seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, modeled after Project BOOST and sponsored by SHM and the Hospital Association of Southern California (HASC), reported on their experience at a June meeting in Montebello, Calif. Quality teams from four of the seven hospitals demonstrated reductions in readmission rates ranging from 24% to 55%. The other three hospitals are still implementing quality processes and are just now starting to see measurable results.

Several of the participating hospitals do not employ traditional hospitalist services. However, all seven benefit from mentoring by Project BOOST experts and have adopted a number of its approaches and techniques: 72-hour follow-up calls to discharged patients, the use of discharge advocates, medication reconciliation at time of discharge, enhanced discharge planning, and BOOST’s “8Ps” patient risk stratification tool. Another popular approach in use is the “teachback” communication technique, in which patients are asked to repeat in their own words what they understand the professional has told them about their condition and self-care.

One reason many Southern California hospitals do not have a strong hospitalist presence is the widespread prevalence of independent practice associations (IPAs), which often designate members of their medical groups to fill the hospitalist role for patients at a given hospital, says Z. Joseph Wanski, MD, FA

CE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care will be testing the use of hospitalists at some of its contracted acute-care facilities starting in July. (Click here to listen to more of Dr. Wanski’s interview.)

At Harbor UCLA Medical Center in Torrance, a major safety-net facility for Los Angeles County, the readmissions team initially focused on heart failure patients and was able to demonstrate a 5.5% decrease in readmissions for all heart failure patients at a time when readmissions for the hospital as a whole remained the same. The team built relationships with outside partners, including a nearby adult daycare center, home health agencies, and a care-transitions coach while emphasizing early identification of patients for referral to a heart failure disease management registry. The readmissions team also was instrumental in developing the Cardiovascular Open Access Rapid Evaluation (CORE) service, an observation unit for heart failure patients aimed at allieviating ED overcrowding.

“Hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the full-time Project BOOST facilitator at Valley Presbyterian Hospital in Van Nuys. “They see a lot of our patients in their offices.”

Three Valley Presbyterian physicians who work part-time as hospitalists and maintain office practices have agreed to carve out time to see patients who are going home without scheduled appointments with their primary-care physicians (PCPs) within seven days of discharge.

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments,” says Quintero, adding that such patients often decline the hospital team’s offers for help. The readmissions team at Valley Presbyterian is redesigning its clinical multidisciplinary rounds using a rounding script focusing more on discharge planning in rounding.

Larry Beresford is a freelance writer in Oakland, Calif.

Antegrade enteroscopy had a significantly greater diagnostic and therapeutic yield in small bowel disease, compared with retrograde enteroscopy, reported Dr. Madhusudhan R. Sanaka and colleagues in the August issue of Clinical Gastroenterology and Hepatology.

Moreover, antegrade enteroscopy had a significantly shorter mean duration, with a greater mean depth of maximal insertion, the authors added.

In what the researchers called "the first study ... to compare the efficacy of all three available enteroscopy systems between antegrade and retrograde approach" in small bowel disease, Dr. Sanaka, of the Digestive Disease Institute at the Cleveland Clinic, studied 250 such procedures performed at that institution between January 2008 and August 2009.

A total of 182 procedures were antegrade (91 with a single-balloon enteroscope, 52 with a double-balloon enteroscope, and 39 with a spiral enteroscope), and 68 were retrograde (23 with a single balloon, 37 with a double balloon, and 8 with a spiral enteroscope).

The mean age of all participants was 61.5 years, and the antegrade and retrograde groups did not differ significantly on any of the demographic factors or history of prior capsule endoscopies.

Although obscure gastrointestinal bleeding was the most common indication in both groups, "abdominal pain or suspected Crohn’s disease was a much more common indication for antegrade enteroscopy when compared to retrograde (18.7% vs. 4.4%, P less than .001)," wrote the authors.

Overall, the diagnostic yield of antegrade enteroscopy was significantly greater, at 63.7%, than the yield of the retrograde procedures (39.7%), with P less than .001 (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.04.020]).

The investigators then looked at the therapeutic yield of the two procedures. "With the antegrade approach, in 59 procedures (32.4%), a therapeutic intervention was performed," including argon plasma coagulation in 52 cases (28.6%), dilatation in 1 (0.6%), and polypectomy in 4 cases (2.2%).

With the retrograde approach, therapies were initiated in just 14.7% of cases, which was significantly lower than the percentage for the antegrade approach (P less than .001).

The authors also compared the technical aspects of the different procedure types. In this study, antegrade enteroscopies lasted 44.3 minutes on average, versus 58.9 minutes for the retrograde procedures (P less than .001).

Antegrade procedures also achieved a significantly greater depth of maximal insertion on average, at 231.8 cm, compared with 103.4 cm for retrograde procedures (P less than .001).

The authors conceded that the study had several limitations. Not only was it retrospective, they wrote, "there was no randomization and hence there could have been a significant bias in patient selection and use of a particular enteroscopy approach in individual cases, particularly in patients in whom the source of small bowel disorder was not known."

Nevertheless, "our findings of higher diagnostic and therapeutic yields with antegrade enteroscopy compared to retrograde enteroscopy support the expert opinion to consider antegrade enteroscopy as a default initial approach for suspected small bowel disease," the authors concluded.

"Retrograde enteroscopy may be considered when the antegrade enteroscopy is either nondiagnostic or if the abnormalities identified are unlikely to account for the patient’s symptoms," or when capsule endoscopy or radiologic imaging studies indicate that distal small bowel disease is likely, such as in suspected Crohn’s disease.

One of the authors, Dr. John Vargo, declared that he is a consultant for Olympus America, maker of enteroscopes and other devices. The authors stated that there was no outside funding.

Antegrade enteroscopy had a significantly greater diagnostic and therapeutic yield in small bowel disease, compared with retrograde enteroscopy, reported Dr. Madhusudhan R. Sanaka and colleagues in the August issue of Clinical Gastroenterology and Hepatology.

Moreover, antegrade enteroscopy had a significantly shorter mean duration, with a greater mean depth of maximal insertion, the authors added.

In what the researchers called "the first study ... to compare the efficacy of all three available enteroscopy systems between antegrade and retrograde approach" in small bowel disease, Dr. Sanaka, of the Digestive Disease Institute at the Cleveland Clinic, studied 250 such procedures performed at that institution between January 2008 and August 2009.

A total of 182 procedures were antegrade (91 with a single-balloon enteroscope, 52 with a double-balloon enteroscope, and 39 with a spiral enteroscope), and 68 were retrograde (23 with a single balloon, 37 with a double balloon, and 8 with a spiral enteroscope).

The mean age of all participants was 61.5 years, and the antegrade and retrograde groups did not differ significantly on any of the demographic factors or history of prior capsule endoscopies.

Although obscure gastrointestinal bleeding was the most common indication in both groups, "abdominal pain or suspected Crohn’s disease was a much more common indication for antegrade enteroscopy when compared to retrograde (18.7% vs. 4.4%, P less than .001)," wrote the authors.

Overall, the diagnostic yield of antegrade enteroscopy was significantly greater, at 63.7%, than the yield of the retrograde procedures (39.7%), with P less than .001 (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.04.020]).

The investigators then looked at the therapeutic yield of the two procedures. "With the antegrade approach, in 59 procedures (32.4%), a therapeutic intervention was performed," including argon plasma coagulation in 52 cases (28.6%), dilatation in 1 (0.6%), and polypectomy in 4 cases (2.2%).

With the retrograde approach, therapies were initiated in just 14.7% of cases, which was significantly lower than the percentage for the antegrade approach (P less than .001).

The authors also compared the technical aspects of the different procedure types. In this study, antegrade enteroscopies lasted 44.3 minutes on average, versus 58.9 minutes for the retrograde procedures (P less than .001).

Antegrade procedures also achieved a significantly greater depth of maximal insertion on average, at 231.8 cm, compared with 103.4 cm for retrograde procedures (P less than .001).

The authors conceded that the study had several limitations. Not only was it retrospective, they wrote, "there was no randomization and hence there could have been a significant bias in patient selection and use of a particular enteroscopy approach in individual cases, particularly in patients in whom the source of small bowel disorder was not known."

Nevertheless, "our findings of higher diagnostic and therapeutic yields with antegrade enteroscopy compared to retrograde enteroscopy support the expert opinion to consider antegrade enteroscopy as a default initial approach for suspected small bowel disease," the authors concluded.

"Retrograde enteroscopy may be considered when the antegrade enteroscopy is either nondiagnostic or if the abnormalities identified are unlikely to account for the patient’s symptoms," or when capsule endoscopy or radiologic imaging studies indicate that distal small bowel disease is likely, such as in suspected Crohn’s disease.

One of the authors, Dr. John Vargo, declared that he is a consultant for Olympus America, maker of enteroscopes and other devices. The authors stated that there was no outside funding.

Antegrade enteroscopy had a significantly greater diagnostic and therapeutic yield in small bowel disease, compared with retrograde enteroscopy, reported Dr. Madhusudhan R. Sanaka and colleagues in the August issue of Clinical Gastroenterology and Hepatology.

Moreover, antegrade enteroscopy had a significantly shorter mean duration, with a greater mean depth of maximal insertion, the authors added.

In what the researchers called "the first study ... to compare the efficacy of all three available enteroscopy systems between antegrade and retrograde approach" in small bowel disease, Dr. Sanaka, of the Digestive Disease Institute at the Cleveland Clinic, studied 250 such procedures performed at that institution between January 2008 and August 2009.

A total of 182 procedures were antegrade (91 with a single-balloon enteroscope, 52 with a double-balloon enteroscope, and 39 with a spiral enteroscope), and 68 were retrograde (23 with a single balloon, 37 with a double balloon, and 8 with a spiral enteroscope).

The mean age of all participants was 61.5 years, and the antegrade and retrograde groups did not differ significantly on any of the demographic factors or history of prior capsule endoscopies.

Although obscure gastrointestinal bleeding was the most common indication in both groups, "abdominal pain or suspected Crohn’s disease was a much more common indication for antegrade enteroscopy when compared to retrograde (18.7% vs. 4.4%, P less than .001)," wrote the authors.

Overall, the diagnostic yield of antegrade enteroscopy was significantly greater, at 63.7%, than the yield of the retrograde procedures (39.7%), with P less than .001 (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.04.020]).

The investigators then looked at the therapeutic yield of the two procedures. "With the antegrade approach, in 59 procedures (32.4%), a therapeutic intervention was performed," including argon plasma coagulation in 52 cases (28.6%), dilatation in 1 (0.6%), and polypectomy in 4 cases (2.2%).

With the retrograde approach, therapies were initiated in just 14.7% of cases, which was significantly lower than the percentage for the antegrade approach (P less than .001).

The authors also compared the technical aspects of the different procedure types. In this study, antegrade enteroscopies lasted 44.3 minutes on average, versus 58.9 minutes for the retrograde procedures (P less than .001).

Antegrade procedures also achieved a significantly greater depth of maximal insertion on average, at 231.8 cm, compared with 103.4 cm for retrograde procedures (P less than .001).

The authors conceded that the study had several limitations. Not only was it retrospective, they wrote, "there was no randomization and hence there could have been a significant bias in patient selection and use of a particular enteroscopy approach in individual cases, particularly in patients in whom the source of small bowel disorder was not known."

Nevertheless, "our findings of higher diagnostic and therapeutic yields with antegrade enteroscopy compared to retrograde enteroscopy support the expert opinion to consider antegrade enteroscopy as a default initial approach for suspected small bowel disease," the authors concluded.

"Retrograde enteroscopy may be considered when the antegrade enteroscopy is either nondiagnostic or if the abnormalities identified are unlikely to account for the patient’s symptoms," or when capsule endoscopy or radiologic imaging studies indicate that distal small bowel disease is likely, such as in suspected Crohn’s disease.

One of the authors, Dr. John Vargo, declared that he is a consultant for Olympus America, maker of enteroscopes and other devices. The authors stated that there was no outside funding.

PARIS—Results of a phase 3 study indicate that the recombinant antihemophilic factor octocog alfa is effective as secondary bleeding prophylaxis in patients with severe hemophilia A.

The product appeared to be well-tolerated, and it reduced bleeding frequency as secondary prophylaxis (ie, treatment after multiple bleeding episodes have occurred), when compared to on-demand treatment.

These results were presented as a late-breaking abstract at the World Federation of Hemophilia 2012 World Congress, which took place July 8-12. The study—called SPINART—was sponsored by Bayer Healthcare, the makers of octocog alfa (marketed as Kogenate).

“Patients on the prophylactic regimen experienced significantly fewer bleeds than those using on-demand treatment,” said the study’s principal investigator, Marilyn Manco-Johnson, MD, of the University of Colorado at Denver.

“Those bleeds that did occur on the prophylactic regimen were predominantly mild-to-moderate.”

Dr Manco-Johnson and her colleagues had randomized 84 patients with hemophilia A to receive either on-demand treatment or secondary prophylaxis at 25 IU/kg 3 times per week. The total follow-up was 3 years.

After a median follow-up of 1.7 years, the researchers observed significantly fewer total bleeding events per year with prophylaxis vs on-demand treatment. The median number of bleeding events were 0 and 27.9, respectively. However, 48% of patients in the prophylaxis arm did experience at least 1 bleeding event. 

There were significantly fewer joint bleeds with prophylaxis than with on-demand treatment. The median number of joint bleeds were 0 and 21.2, respectively. But 38% of patients in the prophylaxis arm did experience joint bleeds. 

In patients on prophylaxis who did experience bleeding, 20% of the episodes were severe, 44% were mild, and 36% were moderate. In patients receiving on-demand treatment, 19% of bleeding episodes were severe, 23% were mild, and 58% were moderate.

The researchers did not observe inhibitor formation in any of the patients. And adverse events were consistent with those observed in previous studies, including skin-associated hypersensitivity reactions, infusion site reactions, and central venous access device line-associated infections.

PARIS—Results of a phase 3 study indicate that the recombinant antihemophilic factor octocog alfa is effective as secondary bleeding prophylaxis in patients with severe hemophilia A.

The product appeared to be well-tolerated, and it reduced bleeding frequency as secondary prophylaxis (ie, treatment after multiple bleeding episodes have occurred), when compared to on-demand treatment.

These results were presented as a late-breaking abstract at the World Federation of Hemophilia 2012 World Congress, which took place July 8-12. The study—called SPINART—was sponsored by Bayer Healthcare, the makers of octocog alfa (marketed as Kogenate).

“Patients on the prophylactic regimen experienced significantly fewer bleeds than those using on-demand treatment,” said the study’s principal investigator, Marilyn Manco-Johnson, MD, of the University of Colorado at Denver.

“Those bleeds that did occur on the prophylactic regimen were predominantly mild-to-moderate.”

Dr Manco-Johnson and her colleagues had randomized 84 patients with hemophilia A to receive either on-demand treatment or secondary prophylaxis at 25 IU/kg 3 times per week. The total follow-up was 3 years.

After a median follow-up of 1.7 years, the researchers observed significantly fewer total bleeding events per year with prophylaxis vs on-demand treatment. The median number of bleeding events were 0 and 27.9, respectively. However, 48% of patients in the prophylaxis arm did experience at least 1 bleeding event. 

There were significantly fewer joint bleeds with prophylaxis than with on-demand treatment. The median number of joint bleeds were 0 and 21.2, respectively. But 38% of patients in the prophylaxis arm did experience joint bleeds. 

In patients on prophylaxis who did experience bleeding, 20% of the episodes were severe, 44% were mild, and 36% were moderate. In patients receiving on-demand treatment, 19% of bleeding episodes were severe, 23% were mild, and 58% were moderate.

The researchers did not observe inhibitor formation in any of the patients. And adverse events were consistent with those observed in previous studies, including skin-associated hypersensitivity reactions, infusion site reactions, and central venous access device line-associated infections.

PARIS—Results of a phase 3 study indicate that the recombinant antihemophilic factor octocog alfa is effective as secondary bleeding prophylaxis in patients with severe hemophilia A.

The product appeared to be well-tolerated, and it reduced bleeding frequency as secondary prophylaxis (ie, treatment after multiple bleeding episodes have occurred), when compared to on-demand treatment.

These results were presented as a late-breaking abstract at the World Federation of Hemophilia 2012 World Congress, which took place July 8-12. The study—called SPINART—was sponsored by Bayer Healthcare, the makers of octocog alfa (marketed as Kogenate).

“Patients on the prophylactic regimen experienced significantly fewer bleeds than those using on-demand treatment,” said the study’s principal investigator, Marilyn Manco-Johnson, MD, of the University of Colorado at Denver.

“Those bleeds that did occur on the prophylactic regimen were predominantly mild-to-moderate.”

Dr Manco-Johnson and her colleagues had randomized 84 patients with hemophilia A to receive either on-demand treatment or secondary prophylaxis at 25 IU/kg 3 times per week. The total follow-up was 3 years.

After a median follow-up of 1.7 years, the researchers observed significantly fewer total bleeding events per year with prophylaxis vs on-demand treatment. The median number of bleeding events were 0 and 27.9, respectively. However, 48% of patients in the prophylaxis arm did experience at least 1 bleeding event. 

There were significantly fewer joint bleeds with prophylaxis than with on-demand treatment. The median number of joint bleeds were 0 and 21.2, respectively. But 38% of patients in the prophylaxis arm did experience joint bleeds. 

In patients on prophylaxis who did experience bleeding, 20% of the episodes were severe, 44% were mild, and 36% were moderate. In patients receiving on-demand treatment, 19% of bleeding episodes were severe, 23% were mild, and 58% were moderate.

The researchers did not observe inhibitor formation in any of the patients. And adverse events were consistent with those observed in previous studies, including skin-associated hypersensitivity reactions, infusion site reactions, and central venous access device line-associated infections.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

 

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

 

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

 

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.