Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

My father was a god; my grandfather was a god. My aunt killed my mother, and my grandfather plans on killing me. I guess you might call us a dysfunctional family. Some people also say I am a god, but I don’t see it that way. There’s no accounting for what people believe in. The ancient Greeks and Romans liked to make up stories about me; sometimes even I am not sure what is truth and what is fiction. I thought I’d take this chance to tell you about myself. If you are a modern-day proponent of the healing arts, perhaps you will find this of interest.

Dear Old Dad

My father was Apollo, son of Jupiter. He wasn’t a great dad; he was more interested in his godly duties and romantic liaisons than in my upbringing. My mother was a nymph named Coronis. I never met her. She was obviously beautiful and alluring; it’s a nymph thing. She met Apollo, and they spent many happy days in the olive groves. I was conceived on a beautiful hillside above the Aegean Sea.

Apollo soon lost interest in Coronis; he was busy with the family business: causing plagues, driving the chariot of fire across the sky, and so on. Coronis discovered she was pregnant and met a heroic mortal, Ischys; together, they tried to start a new life. There was no way Apollo was going to go along with this. No one leaves a god; it’s supposed to be the other way around. Apollo killed the mortal Ischys and had his sister Diana shoot an arrow into Coronis’ heart. As my mother’s body burned on a funeral pyre, Apollo had a fit of remorse and cut me from my mother’s womb—the first of what would eventually be called cesarean sections. Welcome to my life.

The Early Years

My home was on Mount Pelion. Chiron, a centaur, was my nanny and mentor. He was an expert hunter and was well versed in medicine and music. He was always horsing around. His daughter, Ocyrhoe, prophesied that I would become a great healer; with my heritage, it seemed a safe bet. When Chiron died, years later, Jupiter placed him in the sky; you might recognize him as Sagittarius. One day, millennia later, a company would take his name and would have trouble making influenza vaccine. I grew up under his tutelage and, in time, became an adequate healer myself.

The Wife and Kids

When I grew older, it was time to take a wife. I found a woman with an interest in botanicals. Her name was Epione. We had many children together, but things eroded in our relationship after that. It might have been a postpartum thing, or maybe I spent too much time at work. I’ll never know. She became more interested in soporifics—mandrake especially. She started spending a lot of time in her cave. She and Bacchus were always sitting around our home partying and listening to Pluto’s underworld band, The Dead, and enjoying their favorite song, “The Deadly Nightshade.”

I did pretty well with my children; they all went into the family healing business. My first daughter was named Hygeia. She was always by my side and a great help in my practice. She specialized in preventing disease. My second daughter was Panacea. She was pretty good with a cure and was always in high demand. She started hanging around with some chick named Placebo. Her name in Latin means “I will please,” and she always did. Two of my sons, Machaon and Podalirius, became naval surgeons; one was wounded at Troy but survived. My third son, Telosophorus, was born a dwarf and specialized in rehabilitation.

 

Things Take a Turn for the Worse

Life was going pretty well until I was lured into the shadowy realms of life and death. I had always believed that if the gods decided a patient was to get better, then I must use my skill to aid in this endeavor. If the Fates had decreed a patient was to die, there was little I could do against the will of the gods. Then events occurred that would enable me to take things to a whole new level, and—once again—it was because of sex.

Theseus was the king of Athens. He became king when his father committed suicide, thinking wrongly that Theseus was dead. This was not an auspicious start for a ruler. When Theseus’ first wife died, he married the princess Phaedra, daughter of the Cretan King Minos—a truly freaky chick. Theseus had a grown son, Hippolytus, who had rugged good looks and a bright future, a real stud. Phaedra decided Hippolytus would be a better husband for her than his father, but Hippolytus spurned her advances. Phaedra, in her wrath, turned Theseus against his son. Theseus used his own godly contacts and convinced Neptune to deal with Hippolytus. While Hippolytus was driving a chariot along a coastal road, Neptune set a sea monster to rise up from the ocean, scaring Theseus’ horse, which led to a fatal crash.

The goddess Diana, my aunt, came to me and taught me the secret to reviving the dead. Don’t expect me to share it with you. No “see one, do one, teach one” from me. I’ll just say it involves very small thunderbolts. I would have been better off without the knowledge. Using the new technique, I revived Hippolytus, who spent the rest of his days in Italy with a water nymph named Egeria. Not a bad afterlife. My trouble, on the other hand, had just begun. Pluto, god of the underworld, was furious. He thought no man should remove the dead from his realm. It was a classic turf battle, and I lost. Jupiter, my grandfather, was forced to put me to death with a thunderbolt.

Life after Death

My name lived on. The earliest places of healing were temples of Aesculapius; the Iatros, who worked there, were the earliest physicians. Yes, they did make me a god, but it’s not like I could stop them. On the island of Kós, my thousandth grandson was named Hippocrates—you may have heard of him. Another of my descendants, Galen, trained at my temple in Pergamon.

It’s been a few thousand years since all of this happened. Don’t ask how you can be reading my words—it’s a mythology thing. Things did not go well for Apollo after I died. When he heard I had been killed, my father lost his temper and took out his wrath on the cyclops who had made Jupiter’s thunderbolts on Mount Aetna. His punishment for that temper tantrum was to serve a mortal, Admetus, for a year. Admetus fell ill; near death, he convinced Apollo to appeal to the Fates. They agreed that someone would take his place. Nobody in the kingdom volunteered for this duty, not even his elderly parents. Finally his wife Alcestis volunteered, and her fate was set. When Death came for her, Hercules, who was passing through, seized Death and would not let him go until she was spared.

 

Lessons from the Past

You, the modern hospitalist, may read this tale and wonder what it has to do with modern-day medicine and why it is in this publication. Perhaps the Fates have had their way with the medical editor—hence this topic in this publication. Some parts of the tale are of etymological interest: Panacea, Hygeia, Iatros, Aesculapius, Chiron, and Aetna, to name a few. The bigger issue is the question of how your medical forefathers looked at life and death. Perhaps a patient might be healed, but if not, it was the gods’ will. Death was not easily cheated. Ademetus was saved by his wife’s sacrifice; she was willing to donate her life for his. There is something in this tale about futile resuscitation as well. And of course, the most important message: It never pays to get involved in sex or politics. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

My father was a god; my grandfather was a god. My aunt killed my mother, and my grandfather plans on killing me. I guess you might call us a dysfunctional family. Some people also say I am a god, but I don’t see it that way. There’s no accounting for what people believe in. The ancient Greeks and Romans liked to make up stories about me; sometimes even I am not sure what is truth and what is fiction. I thought I’d take this chance to tell you about myself. If you are a modern-day proponent of the healing arts, perhaps you will find this of interest.

Dear Old Dad

My father was Apollo, son of Jupiter. He wasn’t a great dad; he was more interested in his godly duties and romantic liaisons than in my upbringing. My mother was a nymph named Coronis. I never met her. She was obviously beautiful and alluring; it’s a nymph thing. She met Apollo, and they spent many happy days in the olive groves. I was conceived on a beautiful hillside above the Aegean Sea.

Apollo soon lost interest in Coronis; he was busy with the family business: causing plagues, driving the chariot of fire across the sky, and so on. Coronis discovered she was pregnant and met a heroic mortal, Ischys; together, they tried to start a new life. There was no way Apollo was going to go along with this. No one leaves a god; it’s supposed to be the other way around. Apollo killed the mortal Ischys and had his sister Diana shoot an arrow into Coronis’ heart. As my mother’s body burned on a funeral pyre, Apollo had a fit of remorse and cut me from my mother’s womb—the first of what would eventually be called cesarean sections. Welcome to my life.

The Early Years

My home was on Mount Pelion. Chiron, a centaur, was my nanny and mentor. He was an expert hunter and was well versed in medicine and music. He was always horsing around. His daughter, Ocyrhoe, prophesied that I would become a great healer; with my heritage, it seemed a safe bet. When Chiron died, years later, Jupiter placed him in the sky; you might recognize him as Sagittarius. One day, millennia later, a company would take his name and would have trouble making influenza vaccine. I grew up under his tutelage and, in time, became an adequate healer myself.

The Wife and Kids

When I grew older, it was time to take a wife. I found a woman with an interest in botanicals. Her name was Epione. We had many children together, but things eroded in our relationship after that. It might have been a postpartum thing, or maybe I spent too much time at work. I’ll never know. She became more interested in soporifics—mandrake especially. She started spending a lot of time in her cave. She and Bacchus were always sitting around our home partying and listening to Pluto’s underworld band, The Dead, and enjoying their favorite song, “The Deadly Nightshade.”

I did pretty well with my children; they all went into the family healing business. My first daughter was named Hygeia. She was always by my side and a great help in my practice. She specialized in preventing disease. My second daughter was Panacea. She was pretty good with a cure and was always in high demand. She started hanging around with some chick named Placebo. Her name in Latin means “I will please,” and she always did. Two of my sons, Machaon and Podalirius, became naval surgeons; one was wounded at Troy but survived. My third son, Telosophorus, was born a dwarf and specialized in rehabilitation.

 

Things Take a Turn for the Worse

Life was going pretty well until I was lured into the shadowy realms of life and death. I had always believed that if the gods decided a patient was to get better, then I must use my skill to aid in this endeavor. If the Fates had decreed a patient was to die, there was little I could do against the will of the gods. Then events occurred that would enable me to take things to a whole new level, and—once again—it was because of sex.

Theseus was the king of Athens. He became king when his father committed suicide, thinking wrongly that Theseus was dead. This was not an auspicious start for a ruler. When Theseus’ first wife died, he married the princess Phaedra, daughter of the Cretan King Minos—a truly freaky chick. Theseus had a grown son, Hippolytus, who had rugged good looks and a bright future, a real stud. Phaedra decided Hippolytus would be a better husband for her than his father, but Hippolytus spurned her advances. Phaedra, in her wrath, turned Theseus against his son. Theseus used his own godly contacts and convinced Neptune to deal with Hippolytus. While Hippolytus was driving a chariot along a coastal road, Neptune set a sea monster to rise up from the ocean, scaring Theseus’ horse, which led to a fatal crash.

The goddess Diana, my aunt, came to me and taught me the secret to reviving the dead. Don’t expect me to share it with you. No “see one, do one, teach one” from me. I’ll just say it involves very small thunderbolts. I would have been better off without the knowledge. Using the new technique, I revived Hippolytus, who spent the rest of his days in Italy with a water nymph named Egeria. Not a bad afterlife. My trouble, on the other hand, had just begun. Pluto, god of the underworld, was furious. He thought no man should remove the dead from his realm. It was a classic turf battle, and I lost. Jupiter, my grandfather, was forced to put me to death with a thunderbolt.

Life after Death

My name lived on. The earliest places of healing were temples of Aesculapius; the Iatros, who worked there, were the earliest physicians. Yes, they did make me a god, but it’s not like I could stop them. On the island of Kós, my thousandth grandson was named Hippocrates—you may have heard of him. Another of my descendants, Galen, trained at my temple in Pergamon.

It’s been a few thousand years since all of this happened. Don’t ask how you can be reading my words—it’s a mythology thing. Things did not go well for Apollo after I died. When he heard I had been killed, my father lost his temper and took out his wrath on the cyclops who had made Jupiter’s thunderbolts on Mount Aetna. His punishment for that temper tantrum was to serve a mortal, Admetus, for a year. Admetus fell ill; near death, he convinced Apollo to appeal to the Fates. They agreed that someone would take his place. Nobody in the kingdom volunteered for this duty, not even his elderly parents. Finally his wife Alcestis volunteered, and her fate was set. When Death came for her, Hercules, who was passing through, seized Death and would not let him go until she was spared.

 

Lessons from the Past

You, the modern hospitalist, may read this tale and wonder what it has to do with modern-day medicine and why it is in this publication. Perhaps the Fates have had their way with the medical editor—hence this topic in this publication. Some parts of the tale are of etymological interest: Panacea, Hygeia, Iatros, Aesculapius, Chiron, and Aetna, to name a few. The bigger issue is the question of how your medical forefathers looked at life and death. Perhaps a patient might be healed, but if not, it was the gods’ will. Death was not easily cheated. Ademetus was saved by his wife’s sacrifice; she was willing to donate her life for his. There is something in this tale about futile resuscitation as well. And of course, the most important message: It never pays to get involved in sex or politics. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

My father was a god; my grandfather was a god. My aunt killed my mother, and my grandfather plans on killing me. I guess you might call us a dysfunctional family. Some people also say I am a god, but I don’t see it that way. There’s no accounting for what people believe in. The ancient Greeks and Romans liked to make up stories about me; sometimes even I am not sure what is truth and what is fiction. I thought I’d take this chance to tell you about myself. If you are a modern-day proponent of the healing arts, perhaps you will find this of interest.

Dear Old Dad

My father was Apollo, son of Jupiter. He wasn’t a great dad; he was more interested in his godly duties and romantic liaisons than in my upbringing. My mother was a nymph named Coronis. I never met her. She was obviously beautiful and alluring; it’s a nymph thing. She met Apollo, and they spent many happy days in the olive groves. I was conceived on a beautiful hillside above the Aegean Sea.

Apollo soon lost interest in Coronis; he was busy with the family business: causing plagues, driving the chariot of fire across the sky, and so on. Coronis discovered she was pregnant and met a heroic mortal, Ischys; together, they tried to start a new life. There was no way Apollo was going to go along with this. No one leaves a god; it’s supposed to be the other way around. Apollo killed the mortal Ischys and had his sister Diana shoot an arrow into Coronis’ heart. As my mother’s body burned on a funeral pyre, Apollo had a fit of remorse and cut me from my mother’s womb—the first of what would eventually be called cesarean sections. Welcome to my life.

The Early Years

My home was on Mount Pelion. Chiron, a centaur, was my nanny and mentor. He was an expert hunter and was well versed in medicine and music. He was always horsing around. His daughter, Ocyrhoe, prophesied that I would become a great healer; with my heritage, it seemed a safe bet. When Chiron died, years later, Jupiter placed him in the sky; you might recognize him as Sagittarius. One day, millennia later, a company would take his name and would have trouble making influenza vaccine. I grew up under his tutelage and, in time, became an adequate healer myself.

The Wife and Kids

When I grew older, it was time to take a wife. I found a woman with an interest in botanicals. Her name was Epione. We had many children together, but things eroded in our relationship after that. It might have been a postpartum thing, or maybe I spent too much time at work. I’ll never know. She became more interested in soporifics—mandrake especially. She started spending a lot of time in her cave. She and Bacchus were always sitting around our home partying and listening to Pluto’s underworld band, The Dead, and enjoying their favorite song, “The Deadly Nightshade.”

I did pretty well with my children; they all went into the family healing business. My first daughter was named Hygeia. She was always by my side and a great help in my practice. She specialized in preventing disease. My second daughter was Panacea. She was pretty good with a cure and was always in high demand. She started hanging around with some chick named Placebo. Her name in Latin means “I will please,” and she always did. Two of my sons, Machaon and Podalirius, became naval surgeons; one was wounded at Troy but survived. My third son, Telosophorus, was born a dwarf and specialized in rehabilitation.

 

Things Take a Turn for the Worse

Life was going pretty well until I was lured into the shadowy realms of life and death. I had always believed that if the gods decided a patient was to get better, then I must use my skill to aid in this endeavor. If the Fates had decreed a patient was to die, there was little I could do against the will of the gods. Then events occurred that would enable me to take things to a whole new level, and—once again—it was because of sex.

Theseus was the king of Athens. He became king when his father committed suicide, thinking wrongly that Theseus was dead. This was not an auspicious start for a ruler. When Theseus’ first wife died, he married the princess Phaedra, daughter of the Cretan King Minos—a truly freaky chick. Theseus had a grown son, Hippolytus, who had rugged good looks and a bright future, a real stud. Phaedra decided Hippolytus would be a better husband for her than his father, but Hippolytus spurned her advances. Phaedra, in her wrath, turned Theseus against his son. Theseus used his own godly contacts and convinced Neptune to deal with Hippolytus. While Hippolytus was driving a chariot along a coastal road, Neptune set a sea monster to rise up from the ocean, scaring Theseus’ horse, which led to a fatal crash.

The goddess Diana, my aunt, came to me and taught me the secret to reviving the dead. Don’t expect me to share it with you. No “see one, do one, teach one” from me. I’ll just say it involves very small thunderbolts. I would have been better off without the knowledge. Using the new technique, I revived Hippolytus, who spent the rest of his days in Italy with a water nymph named Egeria. Not a bad afterlife. My trouble, on the other hand, had just begun. Pluto, god of the underworld, was furious. He thought no man should remove the dead from his realm. It was a classic turf battle, and I lost. Jupiter, my grandfather, was forced to put me to death with a thunderbolt.

Life after Death

My name lived on. The earliest places of healing were temples of Aesculapius; the Iatros, who worked there, were the earliest physicians. Yes, they did make me a god, but it’s not like I could stop them. On the island of Kós, my thousandth grandson was named Hippocrates—you may have heard of him. Another of my descendants, Galen, trained at my temple in Pergamon.

It’s been a few thousand years since all of this happened. Don’t ask how you can be reading my words—it’s a mythology thing. Things did not go well for Apollo after I died. When he heard I had been killed, my father lost his temper and took out his wrath on the cyclops who had made Jupiter’s thunderbolts on Mount Aetna. His punishment for that temper tantrum was to serve a mortal, Admetus, for a year. Admetus fell ill; near death, he convinced Apollo to appeal to the Fates. They agreed that someone would take his place. Nobody in the kingdom volunteered for this duty, not even his elderly parents. Finally his wife Alcestis volunteered, and her fate was set. When Death came for her, Hercules, who was passing through, seized Death and would not let him go until she was spared.

 

Lessons from the Past

You, the modern hospitalist, may read this tale and wonder what it has to do with modern-day medicine and why it is in this publication. Perhaps the Fates have had their way with the medical editor—hence this topic in this publication. Some parts of the tale are of etymological interest: Panacea, Hygeia, Iatros, Aesculapius, Chiron, and Aetna, to name a few. The bigger issue is the question of how your medical forefathers looked at life and death. Perhaps a patient might be healed, but if not, it was the gods’ will. Death was not easily cheated. Ademetus was saved by his wife’s sacrifice; she was willing to donate her life for his. There is something in this tale about futile resuscitation as well. And of course, the most important message: It never pays to get involved in sex or politics. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.