Commentary

Shining a spotlight on physician well-being

In “Physician impairment”¹ (Current Psychiatry, October 2017, p. 8), I explained that the rules and regulations of the Americans with Disabilities Act (ADA) supersede state laws, the American Medical Association (AMA), and other professional guidance related to physician impairment. In her article “Physician impairment: A need for prevention”² (Psychiatry 2.0, Current Psychiatry, September 2018, p. 41-44), Dr. Helen M. Farrell urged readers to abide by the rules of the AMA and the Federation of State Medical Boards on physician impairment, but she neglected to mention the ADA.

Dr. Farrell’s article does not acknowledge the rule of law. I do not understand why anyone wanting to help physicians would not want them to be aware of their employment rights under the ADA or advise that their ADA rights protect them from unwarranted medical inquiries and referrals to physician health programs (PHPs) or other entities for evaluation.

Dr. Farrell also claims that burnout, poor well-being, and mental disorders cause medical errors and low quality of patient care, but there are many reasons to doubt that this is the case.^3,4 Readers should be wary of medical journal articles that cover topics related to physician well-being. Articles related to PHPs, in particular, typically paint an overly rosy picture of the effectiveness of these programs and fail to note important problematic aspects.^5,6

Nicholas D. Lawson, MD
Georgetown University Law Center
Washington, DC

References
1. Lawson ND. Physician impairment. Current Psychiatry. 2017;16(10):8.
2. Farrell H. Physician impairment: a need for prevention. Current Psychiatry. 2018;17(9):41-44.
3. Lawson ND. Burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1683.
4. Tyssen R. What is the level of burnout that impairs functioning? J Intern Med. 2018;283(6):594-596.
5. Lawson ND, Boyd JW. Flaws in the methods and reporting of physician health program outcome studies. Gen Hosp Psychiatry. 2018;54:65-66.
6. Lawson ND, Boyd JW. Physician health program outcome data should be viewed with caution. Judges J. 2018;57(4):36.

The author responds

I thank Dr. Lawson for his interest in my article. In this extremely challenging work that we do as psychiatrists, which can sometimes be quite isolating, there is a long continuum of experience, reward, and challenge. Dr. Lawson’s research and publication on the topic of physician’s health issues are very much respected and appreciated. In fact, I see no conflict between Dr. Lawson’s letter and my 2018 column on the prevention of impairment.

Given the extensive continuum of our work, my article on physician’s health issues sought to shine a bright spotlight solely on the topic of prevention. As colleagues, there is significant value in supporting rather than reporting one another. Awareness of and sensitivity to physician vulnerability, early detection, and prevention will hopefully continue to gain traction in the future.

By putting the focus on proactively helping colleagues, my hope is that my article will spark an ongoing conversation about how we can work collaboratively to make well-being a priority.

Dr. Lawson’s thoughtful letter is much appreciated because it continues the discussion by shining a spotlight further down the continuum. He focuses on the aftermath of impairment and aptly points out the complications in reporting, confusion about duty, and the protections provided by the ADA. Also, I support Dr. Lawson’s cautions regarding PHPs—all the more reason to join together in shifting the dialogue from management of a crisis to prevention of it.

Helen M. Farrell, MD
Lecturer
Harvard Medical School
Psychiatrist
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Continue to: Neuropolitics

Regarding Dr. Nasrallah’s editorial “Neuropolitics in the age of extremism: Brain regions involved in hatred” (Current Psychiatry, October 2018, p. 6-7), while it’s interesting to learn about the neurophysiological correlates of human experience in the context of current politics, I am concerned that focusing on neural circuits has the potential to distract us from a disturbing new societal dynamic, which is as dangerous as it is atypical. I’m also concerned about the implication that there is currently an equivalent “bidirectionality” of hostility in heated political debate, as if it were simply a matter of 2 equivalent partisan groups that suddenly became more warlike in their opposition to each other.

I agree with Dr. Nasrallah that “even the most skillful psychiatrists” cannot “repair a nation caught up in poisonous emotional turmoil”—at least not by employing clinical skills alone. But that doesn’t mean we shouldn’t try, and the American Psychiatric Association (APA) ethics code (Sections 1.2, 3, and 7) compels us to speak out when our patients or the public are being harmed by public policy.¹ We are much more likely to have an impact when we speak with one voice, as is the case with professional medical organizations such as the APA. In December 2018, APA President Dr. Altha J. Stewart issued a call to action addressing “the current climate of hateful and divisive rhetoric that leads to senseless violence and tragic loss of life,” stating “… we members must speak out, use our specialized training and expertise for the public’s benefit, and apply it to not only healing, but also preventing psychological trauma and senseless tragedies.”²

James L. Fleming, MD
Psychiatric Medical Care
Lee’s Summit, Missouri

References
1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry, 2013 edition. https://www.psychiatry.org/psychiatrists/practice/ethics. Published 2013. Accessed February 5, 2019.
2. Stewart A, Pozios, V. Forget about staying in our lane: let’s connect the dots. American Psychiatric Association Publishing. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2018.12a20. Published December 3, 2018. Accessed February 3, 2019.

Shining a spotlight on physician well-being

In “Physician impairment”¹ (Current Psychiatry, October 2017, p. 8), I explained that the rules and regulations of the Americans with Disabilities Act (ADA) supersede state laws, the American Medical Association (AMA), and other professional guidance related to physician impairment. In her article “Physician impairment: A need for prevention”² (Psychiatry 2.0, Current Psychiatry, September 2018, p. 41-44), Dr. Helen M. Farrell urged readers to abide by the rules of the AMA and the Federation of State Medical Boards on physician impairment, but she neglected to mention the ADA.

Dr. Farrell’s article does not acknowledge the rule of law. I do not understand why anyone wanting to help physicians would not want them to be aware of their employment rights under the ADA or advise that their ADA rights protect them from unwarranted medical inquiries and referrals to physician health programs (PHPs) or other entities for evaluation.

Dr. Farrell also claims that burnout, poor well-being, and mental disorders cause medical errors and low quality of patient care, but there are many reasons to doubt that this is the case.^3,4 Readers should be wary of medical journal articles that cover topics related to physician well-being. Articles related to PHPs, in particular, typically paint an overly rosy picture of the effectiveness of these programs and fail to note important problematic aspects.^5,6

Nicholas D. Lawson, MD
Georgetown University Law Center
Washington, DC

References
1. Lawson ND. Physician impairment. Current Psychiatry. 2017;16(10):8.
2. Farrell H. Physician impairment: a need for prevention. Current Psychiatry. 2018;17(9):41-44.
3. Lawson ND. Burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1683.
4. Tyssen R. What is the level of burnout that impairs functioning? J Intern Med. 2018;283(6):594-596.
5. Lawson ND, Boyd JW. Flaws in the methods and reporting of physician health program outcome studies. Gen Hosp Psychiatry. 2018;54:65-66.
6. Lawson ND, Boyd JW. Physician health program outcome data should be viewed with caution. Judges J. 2018;57(4):36.

The author responds

I thank Dr. Lawson for his interest in my article. In this extremely challenging work that we do as psychiatrists, which can sometimes be quite isolating, there is a long continuum of experience, reward, and challenge. Dr. Lawson’s research and publication on the topic of physician’s health issues are very much respected and appreciated. In fact, I see no conflict between Dr. Lawson’s letter and my 2018 column on the prevention of impairment.

Given the extensive continuum of our work, my article on physician’s health issues sought to shine a bright spotlight solely on the topic of prevention. As colleagues, there is significant value in supporting rather than reporting one another. Awareness of and sensitivity to physician vulnerability, early detection, and prevention will hopefully continue to gain traction in the future.

By putting the focus on proactively helping colleagues, my hope is that my article will spark an ongoing conversation about how we can work collaboratively to make well-being a priority.

Dr. Lawson’s thoughtful letter is much appreciated because it continues the discussion by shining a spotlight further down the continuum. He focuses on the aftermath of impairment and aptly points out the complications in reporting, confusion about duty, and the protections provided by the ADA. Also, I support Dr. Lawson’s cautions regarding PHPs—all the more reason to join together in shifting the dialogue from management of a crisis to prevention of it.

Helen M. Farrell, MD
Lecturer
Harvard Medical School
Psychiatrist
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Continue to: Neuropolitics

Regarding Dr. Nasrallah’s editorial “Neuropolitics in the age of extremism: Brain regions involved in hatred” (Current Psychiatry, October 2018, p. 6-7), while it’s interesting to learn about the neurophysiological correlates of human experience in the context of current politics, I am concerned that focusing on neural circuits has the potential to distract us from a disturbing new societal dynamic, which is as dangerous as it is atypical. I’m also concerned about the implication that there is currently an equivalent “bidirectionality” of hostility in heated political debate, as if it were simply a matter of 2 equivalent partisan groups that suddenly became more warlike in their opposition to each other.

I agree with Dr. Nasrallah that “even the most skillful psychiatrists” cannot “repair a nation caught up in poisonous emotional turmoil”—at least not by employing clinical skills alone. But that doesn’t mean we shouldn’t try, and the American Psychiatric Association (APA) ethics code (Sections 1.2, 3, and 7) compels us to speak out when our patients or the public are being harmed by public policy.¹ We are much more likely to have an impact when we speak with one voice, as is the case with professional medical organizations such as the APA. In December 2018, APA President Dr. Altha J. Stewart issued a call to action addressing “the current climate of hateful and divisive rhetoric that leads to senseless violence and tragic loss of life,” stating “… we members must speak out, use our specialized training and expertise for the public’s benefit, and apply it to not only healing, but also preventing psychological trauma and senseless tragedies.”²

James L. Fleming, MD
Psychiatric Medical Care
Lee’s Summit, Missouri

References
1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry, 2013 edition. https://www.psychiatry.org/psychiatrists/practice/ethics. Published 2013. Accessed February 5, 2019.
2. Stewart A, Pozios, V. Forget about staying in our lane: let’s connect the dots. American Psychiatric Association Publishing. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2018.12a20. Published December 3, 2018. Accessed February 3, 2019.

Shining a spotlight on physician well-being

In “Physician impairment”¹ (Current Psychiatry, October 2017, p. 8), I explained that the rules and regulations of the Americans with Disabilities Act (ADA) supersede state laws, the American Medical Association (AMA), and other professional guidance related to physician impairment. In her article “Physician impairment: A need for prevention”² (Psychiatry 2.0, Current Psychiatry, September 2018, p. 41-44), Dr. Helen M. Farrell urged readers to abide by the rules of the AMA and the Federation of State Medical Boards on physician impairment, but she neglected to mention the ADA.

Dr. Farrell’s article does not acknowledge the rule of law. I do not understand why anyone wanting to help physicians would not want them to be aware of their employment rights under the ADA or advise that their ADA rights protect them from unwarranted medical inquiries and referrals to physician health programs (PHPs) or other entities for evaluation.

Dr. Farrell also claims that burnout, poor well-being, and mental disorders cause medical errors and low quality of patient care, but there are many reasons to doubt that this is the case.^3,4 Readers should be wary of medical journal articles that cover topics related to physician well-being. Articles related to PHPs, in particular, typically paint an overly rosy picture of the effectiveness of these programs and fail to note important problematic aspects.^5,6

Nicholas D. Lawson, MD
Georgetown University Law Center
Washington, DC

References
1. Lawson ND. Physician impairment. Current Psychiatry. 2017;16(10):8.
2. Farrell H. Physician impairment: a need for prevention. Current Psychiatry. 2018;17(9):41-44.
3. Lawson ND. Burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1683.
4. Tyssen R. What is the level of burnout that impairs functioning? J Intern Med. 2018;283(6):594-596.
5. Lawson ND, Boyd JW. Flaws in the methods and reporting of physician health program outcome studies. Gen Hosp Psychiatry. 2018;54:65-66.
6. Lawson ND, Boyd JW. Physician health program outcome data should be viewed with caution. Judges J. 2018;57(4):36.

The author responds

I thank Dr. Lawson for his interest in my article. In this extremely challenging work that we do as psychiatrists, which can sometimes be quite isolating, there is a long continuum of experience, reward, and challenge. Dr. Lawson’s research and publication on the topic of physician’s health issues are very much respected and appreciated. In fact, I see no conflict between Dr. Lawson’s letter and my 2018 column on the prevention of impairment.

Given the extensive continuum of our work, my article on physician’s health issues sought to shine a bright spotlight solely on the topic of prevention. As colleagues, there is significant value in supporting rather than reporting one another. Awareness of and sensitivity to physician vulnerability, early detection, and prevention will hopefully continue to gain traction in the future.

By putting the focus on proactively helping colleagues, my hope is that my article will spark an ongoing conversation about how we can work collaboratively to make well-being a priority.

Dr. Lawson’s thoughtful letter is much appreciated because it continues the discussion by shining a spotlight further down the continuum. He focuses on the aftermath of impairment and aptly points out the complications in reporting, confusion about duty, and the protections provided by the ADA. Also, I support Dr. Lawson’s cautions regarding PHPs—all the more reason to join together in shifting the dialogue from management of a crisis to prevention of it.

Helen M. Farrell, MD
Lecturer
Harvard Medical School
Psychiatrist
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Continue to: Neuropolitics

Regarding Dr. Nasrallah’s editorial “Neuropolitics in the age of extremism: Brain regions involved in hatred” (Current Psychiatry, October 2018, p. 6-7), while it’s interesting to learn about the neurophysiological correlates of human experience in the context of current politics, I am concerned that focusing on neural circuits has the potential to distract us from a disturbing new societal dynamic, which is as dangerous as it is atypical. I’m also concerned about the implication that there is currently an equivalent “bidirectionality” of hostility in heated political debate, as if it were simply a matter of 2 equivalent partisan groups that suddenly became more warlike in their opposition to each other.

I agree with Dr. Nasrallah that “even the most skillful psychiatrists” cannot “repair a nation caught up in poisonous emotional turmoil”—at least not by employing clinical skills alone. But that doesn’t mean we shouldn’t try, and the American Psychiatric Association (APA) ethics code (Sections 1.2, 3, and 7) compels us to speak out when our patients or the public are being harmed by public policy.¹ We are much more likely to have an impact when we speak with one voice, as is the case with professional medical organizations such as the APA. In December 2018, APA President Dr. Altha J. Stewart issued a call to action addressing “the current climate of hateful and divisive rhetoric that leads to senseless violence and tragic loss of life,” stating “… we members must speak out, use our specialized training and expertise for the public’s benefit, and apply it to not only healing, but also preventing psychological trauma and senseless tragedies.”²

James L. Fleming, MD
Psychiatric Medical Care
Lee’s Summit, Missouri

References
1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry, 2013 edition. https://www.psychiatry.org/psychiatrists/practice/ethics. Published 2013. Accessed February 5, 2019.
2. Stewart A, Pozios, V. Forget about staying in our lane: let’s connect the dots. American Psychiatric Association Publishing. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2018.12a20. Published December 3, 2018. Accessed February 3, 2019.

This month I am reading The Poison Squad, by Deborah Blum. It’s a fascinating book about Harvey Wiley, the first commissioner of the FDA and head chemist for 29 years (until 1912). He spearheaded passage of the Pure Food and Drug Act of 1906, the first legislation to regulate what could be put into our food and drink. Prior to (and even subsequent to) passage, hundreds of deaths, mostly children, were linked to toxic additives or adulteration of food. Formaldehyde, for example, was routinely added to milk as a preservative and was linked to dozens of children’s deaths. This single, dedicated scientist fought governmental corruption and big business to protect the public.

The book describes dark money corrupting senators, fake news, denigration of science, suppression of FDA scientific studies that ran counter to administration goals, solicitation of “scientists” who would publicly denounce test results, advocates of states’ rights who fought federal overreach, those that predicted regulation would “ruin American business” and other themes that parallel what we encounter in current news. There are even examples of policy by Executive Order (related to purity of whiskey of all things). One could easily be reading about tobacco, climate change, or vaccines and encounter the same themes. “Those who fail to learn from history are doomed to repeat it” (Santayana 1905 and Churchill 1948).

We are covering a number of important articles this issue. Our cover stories concern surgery in patients with cirrhosis, post colonoscopy FIT testing, and liver transplant in patients with alcoholic liver disease. Another important story reminds us to help our IBD patients with reproductive counseling.

Just a few months to go before Digestive Disease Week^® (DDW) in San Diego. Registration is open and hotels are filling; visit www.DDW.org/registration for more information. This year’s scientific lineup is stellar.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This month I am reading The Poison Squad, by Deborah Blum. It’s a fascinating book about Harvey Wiley, the first commissioner of the FDA and head chemist for 29 years (until 1912). He spearheaded passage of the Pure Food and Drug Act of 1906, the first legislation to regulate what could be put into our food and drink. Prior to (and even subsequent to) passage, hundreds of deaths, mostly children, were linked to toxic additives or adulteration of food. Formaldehyde, for example, was routinely added to milk as a preservative and was linked to dozens of children’s deaths. This single, dedicated scientist fought governmental corruption and big business to protect the public.

The book describes dark money corrupting senators, fake news, denigration of science, suppression of FDA scientific studies that ran counter to administration goals, solicitation of “scientists” who would publicly denounce test results, advocates of states’ rights who fought federal overreach, those that predicted regulation would “ruin American business” and other themes that parallel what we encounter in current news. There are even examples of policy by Executive Order (related to purity of whiskey of all things). One could easily be reading about tobacco, climate change, or vaccines and encounter the same themes. “Those who fail to learn from history are doomed to repeat it” (Santayana 1905 and Churchill 1948).

We are covering a number of important articles this issue. Our cover stories concern surgery in patients with cirrhosis, post colonoscopy FIT testing, and liver transplant in patients with alcoholic liver disease. Another important story reminds us to help our IBD patients with reproductive counseling.

Just a few months to go before Digestive Disease Week^® (DDW) in San Diego. Registration is open and hotels are filling; visit www.DDW.org/registration for more information. This year’s scientific lineup is stellar.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This month I am reading The Poison Squad, by Deborah Blum. It’s a fascinating book about Harvey Wiley, the first commissioner of the FDA and head chemist for 29 years (until 1912). He spearheaded passage of the Pure Food and Drug Act of 1906, the first legislation to regulate what could be put into our food and drink. Prior to (and even subsequent to) passage, hundreds of deaths, mostly children, were linked to toxic additives or adulteration of food. Formaldehyde, for example, was routinely added to milk as a preservative and was linked to dozens of children’s deaths. This single, dedicated scientist fought governmental corruption and big business to protect the public.

The book describes dark money corrupting senators, fake news, denigration of science, suppression of FDA scientific studies that ran counter to administration goals, solicitation of “scientists” who would publicly denounce test results, advocates of states’ rights who fought federal overreach, those that predicted regulation would “ruin American business” and other themes that parallel what we encounter in current news. There are even examples of policy by Executive Order (related to purity of whiskey of all things). One could easily be reading about tobacco, climate change, or vaccines and encounter the same themes. “Those who fail to learn from history are doomed to repeat it” (Santayana 1905 and Churchill 1948).

We are covering a number of important articles this issue. Our cover stories concern surgery in patients with cirrhosis, post colonoscopy FIT testing, and liver transplant in patients with alcoholic liver disease. Another important story reminds us to help our IBD patients with reproductive counseling.

Just a few months to go before Digestive Disease Week^® (DDW) in San Diego. Registration is open and hotels are filling; visit www.DDW.org/registration for more information. This year’s scientific lineup is stellar.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Hemodynamic complications of arteriovenous (AV) access are uncommon but can be potentially life threatening. Fistulas and grafts can cause a decrease in systemic vascular resistance and secondary increase in cardiac output in patients who may already have myocardial dysfunction secondary to their end-stage renal disease.¹ This increased cardiac output is usually insignificant but in rare cases can result in clinically significant cardiac failure. Patients with high-output fistulas with volume flow greater than 2 L/min may be at increased risk of heart failure but volume flow less than 2 L/min does not preclude this complication.²

In patients with AV access–related heart failure, optimal medical management and reduction of fistula flow or ligation of the dialysis access should be considered. If continued hemodialysis is necessary, loss of a functioning dialysis access is problematic and difficult management decisions must be made. Following successful renal transplantation, ligation of vascular access in the presence of symptomatic heart failure may represent a straightforward decision. Nonetheless, there is no clear consensus of how to manage patent fistulas or grafts in patients following renal transplantation in the absence of significant cardiac symptoms with particular concern to the important issues of transplant survival and long-term cardiac prognosis. Yaffe and Greenstein³ recommend preservation of almost all fistulas after transplantation in the absence of significant complications such as venous hypertension, pseudoaneurysm, significant high-output cardiac failure or hand ischemia. They recommend taking into account the 10-year adjusted renal transplantation graft survival rates and the relative paucity of donors, recognizing the possibility that the patient may have to return to dialysis at some point in the future. They also reference the lack of information regarding the beneficial impact of fistula ligation on cardiac morphology and function as a rationale for access preservation.

A recent presentation at the American Heart Association Scientific Sessions by Michael B. Stokes, MD,⁴ from the department of cardiology at Royal Adelaide Hospital in Australia, suggests that cardiovascular disease is responsible for 40% of deaths among kidney transplant recipients and that left ventricular (LV) mass is strongly associated with cardiovascular mortality.

He states that, although there is no guideline consensus on the management of an AV fistula following successful renal transplantation, the fistula continues to contribute adversely to cardiac remodeling and function. The lack of previous randomized controlled trials in this area led Dr. Stokes and his colleagues to randomly assign 64 patients at least 1 year following successful kidney transplantation with stable renal function and a functioning AV fistula to either fistula ligation or no intervention. All patients underwent cardiac MRI at baseline and 6 months.

The primary endpoint of decrease in LV mass at 6 months was significant in the ligation group but not in the control group. The ligation group also had significant decrease in LV end diastolic volume, LV end systolic volume, and multiple other parameters. In addition, NT-proBNP levels and left atrial volume were significantly reduced in the ligation group when compared with the control group. Complications in the ligation group included six patients with thrombosis of their fistula vein and two infections, all of which resolved with outpatient anti-inflammatory or antimicrobial therapy.

Dr. Stokes believes that control patients in his study face “persisting and substantial deleterious cardiac remodeling” and that “further investigation would clarify the impact of AV fistula ligation on clinical outcomes following kidney transplantation.”

I believe this is important information and represents the first randomized controlled data regarding the long-term adverse cardiac effects of a patent fistula after renal transplantation. Unfortunately, information regarding baseline fistula volume flow is not provided in this abstract. As discussed earlier, patients with high-flow fistulas may be at increased risk of heart failure and hemodynamic data can be critical in establishing an algorithm for managing these challenging patients.

Ligation of a functioning and asymptomatic access in a patient with a successful renal transplant should be recommended only after informed discussion with the patient weighing the ongoing potential negative effects on cardiac function of continued access patency versus the potential need for future hemodialysis. Dr. Stokes presents interesting data that must be considered in this controversy. I believe that, in the absence of a universally applicable algorithm, the clinical decision to recommend AV fistula ligation after successful kidney transplantation should be individualized and based on ongoing assessment of cardiac and renal function and fistula complications and hemodynamics.

References

1. Eur Heart J 2017;38:1913-23.

2. Nephrol Dial Transplant 2008;23:282-7.

3. J Vasc Access 2012;13:405-8.

4. Stokes MB, et al. LBS.05 – Late Breaking Clinical Trial: Hot News in HF. Presented at American Heart Association Scientific Sessions. 2018 Nov 10-12. Chicago.
 

Larry A. Scher, MD, is a vascular surgeon at the Montefiore Greene Medical Arts Pavilion, New York, and an associate medical editor for Vascular Specialist.

Hemodynamic complications of arteriovenous (AV) access are uncommon but can be potentially life threatening. Fistulas and grafts can cause a decrease in systemic vascular resistance and secondary increase in cardiac output in patients who may already have myocardial dysfunction secondary to their end-stage renal disease.¹ This increased cardiac output is usually insignificant but in rare cases can result in clinically significant cardiac failure. Patients with high-output fistulas with volume flow greater than 2 L/min may be at increased risk of heart failure but volume flow less than 2 L/min does not preclude this complication.²

In patients with AV access–related heart failure, optimal medical management and reduction of fistula flow or ligation of the dialysis access should be considered. If continued hemodialysis is necessary, loss of a functioning dialysis access is problematic and difficult management decisions must be made. Following successful renal transplantation, ligation of vascular access in the presence of symptomatic heart failure may represent a straightforward decision. Nonetheless, there is no clear consensus of how to manage patent fistulas or grafts in patients following renal transplantation in the absence of significant cardiac symptoms with particular concern to the important issues of transplant survival and long-term cardiac prognosis. Yaffe and Greenstein³ recommend preservation of almost all fistulas after transplantation in the absence of significant complications such as venous hypertension, pseudoaneurysm, significant high-output cardiac failure or hand ischemia. They recommend taking into account the 10-year adjusted renal transplantation graft survival rates and the relative paucity of donors, recognizing the possibility that the patient may have to return to dialysis at some point in the future. They also reference the lack of information regarding the beneficial impact of fistula ligation on cardiac morphology and function as a rationale for access preservation.

A recent presentation at the American Heart Association Scientific Sessions by Michael B. Stokes, MD,⁴ from the department of cardiology at Royal Adelaide Hospital in Australia, suggests that cardiovascular disease is responsible for 40% of deaths among kidney transplant recipients and that left ventricular (LV) mass is strongly associated with cardiovascular mortality.

He states that, although there is no guideline consensus on the management of an AV fistula following successful renal transplantation, the fistula continues to contribute adversely to cardiac remodeling and function. The lack of previous randomized controlled trials in this area led Dr. Stokes and his colleagues to randomly assign 64 patients at least 1 year following successful kidney transplantation with stable renal function and a functioning AV fistula to either fistula ligation or no intervention. All patients underwent cardiac MRI at baseline and 6 months.

The primary endpoint of decrease in LV mass at 6 months was significant in the ligation group but not in the control group. The ligation group also had significant decrease in LV end diastolic volume, LV end systolic volume, and multiple other parameters. In addition, NT-proBNP levels and left atrial volume were significantly reduced in the ligation group when compared with the control group. Complications in the ligation group included six patients with thrombosis of their fistula vein and two infections, all of which resolved with outpatient anti-inflammatory or antimicrobial therapy.

Dr. Stokes believes that control patients in his study face “persisting and substantial deleterious cardiac remodeling” and that “further investigation would clarify the impact of AV fistula ligation on clinical outcomes following kidney transplantation.”

I believe this is important information and represents the first randomized controlled data regarding the long-term adverse cardiac effects of a patent fistula after renal transplantation. Unfortunately, information regarding baseline fistula volume flow is not provided in this abstract. As discussed earlier, patients with high-flow fistulas may be at increased risk of heart failure and hemodynamic data can be critical in establishing an algorithm for managing these challenging patients.

Ligation of a functioning and asymptomatic access in a patient with a successful renal transplant should be recommended only after informed discussion with the patient weighing the ongoing potential negative effects on cardiac function of continued access patency versus the potential need for future hemodialysis. Dr. Stokes presents interesting data that must be considered in this controversy. I believe that, in the absence of a universally applicable algorithm, the clinical decision to recommend AV fistula ligation after successful kidney transplantation should be individualized and based on ongoing assessment of cardiac and renal function and fistula complications and hemodynamics.

References

1. Eur Heart J 2017;38:1913-23.

2. Nephrol Dial Transplant 2008;23:282-7.

3. J Vasc Access 2012;13:405-8.

4. Stokes MB, et al. LBS.05 – Late Breaking Clinical Trial: Hot News in HF. Presented at American Heart Association Scientific Sessions. 2018 Nov 10-12. Chicago.
 

Larry A. Scher, MD, is a vascular surgeon at the Montefiore Greene Medical Arts Pavilion, New York, and an associate medical editor for Vascular Specialist.

Hemodynamic complications of arteriovenous (AV) access are uncommon but can be potentially life threatening. Fistulas and grafts can cause a decrease in systemic vascular resistance and secondary increase in cardiac output in patients who may already have myocardial dysfunction secondary to their end-stage renal disease.¹ This increased cardiac output is usually insignificant but in rare cases can result in clinically significant cardiac failure. Patients with high-output fistulas with volume flow greater than 2 L/min may be at increased risk of heart failure but volume flow less than 2 L/min does not preclude this complication.²

In patients with AV access–related heart failure, optimal medical management and reduction of fistula flow or ligation of the dialysis access should be considered. If continued hemodialysis is necessary, loss of a functioning dialysis access is problematic and difficult management decisions must be made. Following successful renal transplantation, ligation of vascular access in the presence of symptomatic heart failure may represent a straightforward decision. Nonetheless, there is no clear consensus of how to manage patent fistulas or grafts in patients following renal transplantation in the absence of significant cardiac symptoms with particular concern to the important issues of transplant survival and long-term cardiac prognosis. Yaffe and Greenstein³ recommend preservation of almost all fistulas after transplantation in the absence of significant complications such as venous hypertension, pseudoaneurysm, significant high-output cardiac failure or hand ischemia. They recommend taking into account the 10-year adjusted renal transplantation graft survival rates and the relative paucity of donors, recognizing the possibility that the patient may have to return to dialysis at some point in the future. They also reference the lack of information regarding the beneficial impact of fistula ligation on cardiac morphology and function as a rationale for access preservation.

A recent presentation at the American Heart Association Scientific Sessions by Michael B. Stokes, MD,⁴ from the department of cardiology at Royal Adelaide Hospital in Australia, suggests that cardiovascular disease is responsible for 40% of deaths among kidney transplant recipients and that left ventricular (LV) mass is strongly associated with cardiovascular mortality.

He states that, although there is no guideline consensus on the management of an AV fistula following successful renal transplantation, the fistula continues to contribute adversely to cardiac remodeling and function. The lack of previous randomized controlled trials in this area led Dr. Stokes and his colleagues to randomly assign 64 patients at least 1 year following successful kidney transplantation with stable renal function and a functioning AV fistula to either fistula ligation or no intervention. All patients underwent cardiac MRI at baseline and 6 months.

The primary endpoint of decrease in LV mass at 6 months was significant in the ligation group but not in the control group. The ligation group also had significant decrease in LV end diastolic volume, LV end systolic volume, and multiple other parameters. In addition, NT-proBNP levels and left atrial volume were significantly reduced in the ligation group when compared with the control group. Complications in the ligation group included six patients with thrombosis of their fistula vein and two infections, all of which resolved with outpatient anti-inflammatory or antimicrobial therapy.

Dr. Stokes believes that control patients in his study face “persisting and substantial deleterious cardiac remodeling” and that “further investigation would clarify the impact of AV fistula ligation on clinical outcomes following kidney transplantation.”

I believe this is important information and represents the first randomized controlled data regarding the long-term adverse cardiac effects of a patent fistula after renal transplantation. Unfortunately, information regarding baseline fistula volume flow is not provided in this abstract. As discussed earlier, patients with high-flow fistulas may be at increased risk of heart failure and hemodynamic data can be critical in establishing an algorithm for managing these challenging patients.

Ligation of a functioning and asymptomatic access in a patient with a successful renal transplant should be recommended only after informed discussion with the patient weighing the ongoing potential negative effects on cardiac function of continued access patency versus the potential need for future hemodialysis. Dr. Stokes presents interesting data that must be considered in this controversy. I believe that, in the absence of a universally applicable algorithm, the clinical decision to recommend AV fistula ligation after successful kidney transplantation should be individualized and based on ongoing assessment of cardiac and renal function and fistula complications and hemodynamics.

References

1. Eur Heart J 2017;38:1913-23.

2. Nephrol Dial Transplant 2008;23:282-7.

3. J Vasc Access 2012;13:405-8.

4. Stokes MB, et al. LBS.05 – Late Breaking Clinical Trial: Hot News in HF. Presented at American Heart Association Scientific Sessions. 2018 Nov 10-12. Chicago.
 

Larry A. Scher, MD, is a vascular surgeon at the Montefiore Greene Medical Arts Pavilion, New York, and an associate medical editor for Vascular Specialist.

The web is full of doctor discussion sites. Sermo, Doximity, and many others. Each is slightly different, but the idea is similar. Give docs a place to joke, discuss cases, etc. A virtual doctors’ lounge.

cyano66/Thinkstock

Roughly 10 years ago I was active on Sermo. It was fun to check in a few days a week after work, ask questions about my own cases, and see if anyone had ideas on them, make a few suggestions on others, occasionally gripe about administrative issues at my hospital and commiserate about such online.

I don’t do that anymore.

This morning I logged in to see if anyone had previously encountered an unusual case, but was quickly pushed off by venom.

Anonymous websites, by their very nature, tend to attract nastiness since the writers can’t be held accountable. As a result, many of them have turned from medical sites to political vitriol.

Yes, they do have a political discussion board, but staying away from politics is easier said than done online. Like mud, it tends to ooze into places it doesn’t belong. Even a routine post asking about new treatments for multiple sclerosis quickly degenerates. In a demonstration of Godwin’s Law, any comment about the pros and cons of a new agent devolves into a fight over government vs. private insurance, the United States’ vs. other countries’ health systems, and, inevitably, Trump, Obama, and name calling.

Makes it hard to actually kick around thoughts on Ocrevus (or whatever).

Generally, this won’t happen in a real doctors’ lounge because you know each other. Even if you’re not friends, people generally (not always) tend to be civil in person. Even differences are usually handled with a polite agreement to disagree.

I suspect the majority of people on Sermo and similar sites are reasonable and joined the sites for the same reasons I did. Unfortunately, we’ve been drowned out by a handful of angry voices who hijack these sites by posting intentionally inflammatory statements just to pick a fight or derail a thoughtful discussion on epilepsy management with nasty jabs relating medical issues directly to politics.

So my time using these sites has dropped. Occasionally, if I was bored, I’d log in to see if there were any interesting cases in my field, but even those often get dragged down by the angry as you try to contribute thoughts and answer questions in the comments.

Sadly, this has became the norm rather then the exception. For me, at least, it’s easier to just walk away entirely.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The web is full of doctor discussion sites. Sermo, Doximity, and many others. Each is slightly different, but the idea is similar. Give docs a place to joke, discuss cases, etc. A virtual doctors’ lounge.

cyano66/Thinkstock

Roughly 10 years ago I was active on Sermo. It was fun to check in a few days a week after work, ask questions about my own cases, and see if anyone had ideas on them, make a few suggestions on others, occasionally gripe about administrative issues at my hospital and commiserate about such online.

I don’t do that anymore.

This morning I logged in to see if anyone had previously encountered an unusual case, but was quickly pushed off by venom.

Anonymous websites, by their very nature, tend to attract nastiness since the writers can’t be held accountable. As a result, many of them have turned from medical sites to political vitriol.

Yes, they do have a political discussion board, but staying away from politics is easier said than done online. Like mud, it tends to ooze into places it doesn’t belong. Even a routine post asking about new treatments for multiple sclerosis quickly degenerates. In a demonstration of Godwin’s Law, any comment about the pros and cons of a new agent devolves into a fight over government vs. private insurance, the United States’ vs. other countries’ health systems, and, inevitably, Trump, Obama, and name calling.

Makes it hard to actually kick around thoughts on Ocrevus (or whatever).

Generally, this won’t happen in a real doctors’ lounge because you know each other. Even if you’re not friends, people generally (not always) tend to be civil in person. Even differences are usually handled with a polite agreement to disagree.

I suspect the majority of people on Sermo and similar sites are reasonable and joined the sites for the same reasons I did. Unfortunately, we’ve been drowned out by a handful of angry voices who hijack these sites by posting intentionally inflammatory statements just to pick a fight or derail a thoughtful discussion on epilepsy management with nasty jabs relating medical issues directly to politics.

So my time using these sites has dropped. Occasionally, if I was bored, I’d log in to see if there were any interesting cases in my field, but even those often get dragged down by the angry as you try to contribute thoughts and answer questions in the comments.

Sadly, this has became the norm rather then the exception. For me, at least, it’s easier to just walk away entirely.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The web is full of doctor discussion sites. Sermo, Doximity, and many others. Each is slightly different, but the idea is similar. Give docs a place to joke, discuss cases, etc. A virtual doctors’ lounge.

cyano66/Thinkstock

Roughly 10 years ago I was active on Sermo. It was fun to check in a few days a week after work, ask questions about my own cases, and see if anyone had ideas on them, make a few suggestions on others, occasionally gripe about administrative issues at my hospital and commiserate about such online.

I don’t do that anymore.

This morning I logged in to see if anyone had previously encountered an unusual case, but was quickly pushed off by venom.

Anonymous websites, by their very nature, tend to attract nastiness since the writers can’t be held accountable. As a result, many of them have turned from medical sites to political vitriol.

Yes, they do have a political discussion board, but staying away from politics is easier said than done online. Like mud, it tends to ooze into places it doesn’t belong. Even a routine post asking about new treatments for multiple sclerosis quickly degenerates. In a demonstration of Godwin’s Law, any comment about the pros and cons of a new agent devolves into a fight over government vs. private insurance, the United States’ vs. other countries’ health systems, and, inevitably, Trump, Obama, and name calling.

Makes it hard to actually kick around thoughts on Ocrevus (or whatever).

Generally, this won’t happen in a real doctors’ lounge because you know each other. Even if you’re not friends, people generally (not always) tend to be civil in person. Even differences are usually handled with a polite agreement to disagree.

I suspect the majority of people on Sermo and similar sites are reasonable and joined the sites for the same reasons I did. Unfortunately, we’ve been drowned out by a handful of angry voices who hijack these sites by posting intentionally inflammatory statements just to pick a fight or derail a thoughtful discussion on epilepsy management with nasty jabs relating medical issues directly to politics.

So my time using these sites has dropped. Occasionally, if I was bored, I’d log in to see if there were any interesting cases in my field, but even those often get dragged down by the angry as you try to contribute thoughts and answer questions in the comments.

Sadly, this has became the norm rather then the exception. For me, at least, it’s easier to just walk away entirely.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Bias can be defined as a prejudice or a preformed inclination. Bias is reflective of one’s inherent mind set about any thing, concept, ideology, claim, product, person, or group of people. Since biases are well known to be inherent in human nature, one can fairly ask how important and how widespread are they and what are their effects?

Bias affects many fields including medicine. One example is the statin controversy. Some experts interpret existing data, which includes randomized controlled trials, to make a strong case that statins are harmful and do little good. In contrast, other qualified experts interpret precisely the same data to conclude that statins are miracle drugs that sharply diminish the mortality and morbidity from atherosclerosis. Again bias rules and leads to disagreement, controversy, and damaging public uncertainty.

A second examples in medicine – and there are many – is the current controversy over what constitutes the optimal treatment for patients with asymptomatic carotid stenosis. Some authorities believe no such patients should be treated invasively, while others hold the position that many should be. Still other experts opine that only a rare asymptomatic patient should undergo invasive treatment. All three groups use the same existing factual data to support their differing and sometimes totally opposite opinions. These contrasting views are reflected in articles in leading journals and differences among various guidelines from prestigious learned groups. The only explanation for their differing conclusions appears to be the fact that they are largely based on the bias of the authors of the articles or guidelines. Again, bias rules.

So these and many other examples exist in every phase of human endeavor. Biases are omnipresent and critically important in everything people do. They control our thinking, our opinions, our reasoning, our behavior, and most importantly, our decisions. They override most other forces that influence how we humans behave.

What can be done about this dominance of bias? The main safeguard against it is to recognize its controlling importance in all human thinking. Such recognition will help to offset the harmful effects of bias and encourage other, more laudable forces to influence behavior and actions. Logic is one such force. Even more important is objective interpretation of facts and a clear assessment of their validity.

Such objectivity may be difficult currently because of the overt bias expressed in our media and publications. If one doubts the influence of such bias, watch reports of the same event on CNN and Fox News. It is hard to believe the two sources are describing the same event. The same can be true of news reports in the New York Times and the Wall Street Journal. Bias often overrides objective reporting.

Somewhat surprisingly, even articles in our highly rated scientific journals are subject to the influences of bias. As in the lay press, scientific authors, reviewers, and editors all function under its spell.

By recognizing the importance, the dominance, and the universality of bias, individuals and groups can move toward neutralizing its divisive, damaging, and overall negative effects. Such recognition of bias will not eliminate it, but it would help to make the world a better place.

Dr. Veith is professor of surgery at New York University Langone Medical Center and Case Western Reserve University, Cleveland, as well as the William J. von Liebig Chair in Vascular Surgery at the Cleveland Clinic Foundation.

Bias can be defined as a prejudice or a preformed inclination. Bias is reflective of one’s inherent mind set about any thing, concept, ideology, claim, product, person, or group of people. Since biases are well known to be inherent in human nature, one can fairly ask how important and how widespread are they and what are their effects?

Bias affects many fields including medicine. One example is the statin controversy. Some experts interpret existing data, which includes randomized controlled trials, to make a strong case that statins are harmful and do little good. In contrast, other qualified experts interpret precisely the same data to conclude that statins are miracle drugs that sharply diminish the mortality and morbidity from atherosclerosis. Again bias rules and leads to disagreement, controversy, and damaging public uncertainty.

A second examples in medicine – and there are many – is the current controversy over what constitutes the optimal treatment for patients with asymptomatic carotid stenosis. Some authorities believe no such patients should be treated invasively, while others hold the position that many should be. Still other experts opine that only a rare asymptomatic patient should undergo invasive treatment. All three groups use the same existing factual data to support their differing and sometimes totally opposite opinions. These contrasting views are reflected in articles in leading journals and differences among various guidelines from prestigious learned groups. The only explanation for their differing conclusions appears to be the fact that they are largely based on the bias of the authors of the articles or guidelines. Again, bias rules.

So these and many other examples exist in every phase of human endeavor. Biases are omnipresent and critically important in everything people do. They control our thinking, our opinions, our reasoning, our behavior, and most importantly, our decisions. They override most other forces that influence how we humans behave.

What can be done about this dominance of bias? The main safeguard against it is to recognize its controlling importance in all human thinking. Such recognition will help to offset the harmful effects of bias and encourage other, more laudable forces to influence behavior and actions. Logic is one such force. Even more important is objective interpretation of facts and a clear assessment of their validity.

Such objectivity may be difficult currently because of the overt bias expressed in our media and publications. If one doubts the influence of such bias, watch reports of the same event on CNN and Fox News. It is hard to believe the two sources are describing the same event. The same can be true of news reports in the New York Times and the Wall Street Journal. Bias often overrides objective reporting.

Somewhat surprisingly, even articles in our highly rated scientific journals are subject to the influences of bias. As in the lay press, scientific authors, reviewers, and editors all function under its spell.

By recognizing the importance, the dominance, and the universality of bias, individuals and groups can move toward neutralizing its divisive, damaging, and overall negative effects. Such recognition of bias will not eliminate it, but it would help to make the world a better place.

Dr. Veith is professor of surgery at New York University Langone Medical Center and Case Western Reserve University, Cleveland, as well as the William J. von Liebig Chair in Vascular Surgery at the Cleveland Clinic Foundation.

Bias can be defined as a prejudice or a preformed inclination. Bias is reflective of one’s inherent mind set about any thing, concept, ideology, claim, product, person, or group of people. Since biases are well known to be inherent in human nature, one can fairly ask how important and how widespread are they and what are their effects?

Bias affects many fields including medicine. One example is the statin controversy. Some experts interpret existing data, which includes randomized controlled trials, to make a strong case that statins are harmful and do little good. In contrast, other qualified experts interpret precisely the same data to conclude that statins are miracle drugs that sharply diminish the mortality and morbidity from atherosclerosis. Again bias rules and leads to disagreement, controversy, and damaging public uncertainty.

A second examples in medicine – and there are many – is the current controversy over what constitutes the optimal treatment for patients with asymptomatic carotid stenosis. Some authorities believe no such patients should be treated invasively, while others hold the position that many should be. Still other experts opine that only a rare asymptomatic patient should undergo invasive treatment. All three groups use the same existing factual data to support their differing and sometimes totally opposite opinions. These contrasting views are reflected in articles in leading journals and differences among various guidelines from prestigious learned groups. The only explanation for their differing conclusions appears to be the fact that they are largely based on the bias of the authors of the articles or guidelines. Again, bias rules.

So these and many other examples exist in every phase of human endeavor. Biases are omnipresent and critically important in everything people do. They control our thinking, our opinions, our reasoning, our behavior, and most importantly, our decisions. They override most other forces that influence how we humans behave.

What can be done about this dominance of bias? The main safeguard against it is to recognize its controlling importance in all human thinking. Such recognition will help to offset the harmful effects of bias and encourage other, more laudable forces to influence behavior and actions. Logic is one such force. Even more important is objective interpretation of facts and a clear assessment of their validity.

Such objectivity may be difficult currently because of the overt bias expressed in our media and publications. If one doubts the influence of such bias, watch reports of the same event on CNN and Fox News. It is hard to believe the two sources are describing the same event. The same can be true of news reports in the New York Times and the Wall Street Journal. Bias often overrides objective reporting.

Somewhat surprisingly, even articles in our highly rated scientific journals are subject to the influences of bias. As in the lay press, scientific authors, reviewers, and editors all function under its spell.

By recognizing the importance, the dominance, and the universality of bias, individuals and groups can move toward neutralizing its divisive, damaging, and overall negative effects. Such recognition of bias will not eliminate it, but it would help to make the world a better place.

Dr. Veith is professor of surgery at New York University Langone Medical Center and Case Western Reserve University, Cleveland, as well as the William J. von Liebig Chair in Vascular Surgery at the Cleveland Clinic Foundation.

There is a good chance that your car is equipped with a backup camera. It also may have sensors that alert you when there is another vehicle in one of your blind spots. These wonders of modern technology simply are vision enhancers much like an x-ray or an ultrasound. The sensors merely collect visual data, but the decision of what should be done with this additional information is up to you, just as you decide how to respond to your patient’s lab work and imaging studies.

Andrea Danti/Thinkstock

If you have more disposable income than I do, you may have a vehicle that not only gathers information but also makes decisions based on what it senses by slowing down, applying the brakes, or adjusting the steering. My friends who own these semi-autonomous cars generally have given these control systems positive grades once they have experienced a few events in which the vehicle took over in what it considered a dangerous situation. However, even my friends who are fans of their semi-autonomous cars are uncomfortable about the widespread introduction of fully autonomous vehicles.

The practice of medicine is riding the crest of this same wave of artificial intelligence that promises, or some might say threatens, to remove humans from the driver’s seat (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). As reported in the New York Times, a team of physicians has created a system capable of making diagnoses based on a “neural network” that uses complex computer algorithms to learn by analyzing extremely large amounts of data. Once this system had been “taught” to identify certain medical conditions in EMRs, the team tasked the system with analyzing the records of nearly 600,000 patients at a women and children’s hospital in southern China. The investigators claim that the system was able to diagnose asthma with more than 90% accuracy, while physicians can diagnose with an accuracy of 80%-94%, and the system diagnosed gastrointestinal disease with 87% accuracy, well within the physicians’ accuracy range of 82%-90%.

Does this apparent success for A.I. mean that not only will you be vacating your place behind the wheel of your car, but also taking down your shingle and hanging up your stethoscope? Before you rush out and sign up for a federally-funded retraining program, you should remember that this study was done in China, where the privacy laws are somewhat skimpy and the data more voluminous by several scales of magnitude than here. Replicating their results and scaling a similar A.I. neural network to the United States health care system will be difficult in the short term. However, this report should serve as wake-up call to those of you who believe that making diagnoses is at the core of what makes you a physician. If sorting through pages of data to arrive at an explanation for your patients’ complaints is the intellectual challenge that keeps the practice of medicine fresh and exciting, you may want to start looking for other sources of mental stimulation.

A.I. isn’t going to replace the primary care physician. There still will need to be someone available at the initial point of contact who can do a physical exam, take, or at least review, the patient’s history, and then order the lab work and imaging studies that the A.I. system will use to make the diagnosis. In other words, the physician will be primarily responsible for data collection. You may feel that you are almost there already. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

There is a good chance that your car is equipped with a backup camera. It also may have sensors that alert you when there is another vehicle in one of your blind spots. These wonders of modern technology simply are vision enhancers much like an x-ray or an ultrasound. The sensors merely collect visual data, but the decision of what should be done with this additional information is up to you, just as you decide how to respond to your patient’s lab work and imaging studies.

Andrea Danti/Thinkstock

If you have more disposable income than I do, you may have a vehicle that not only gathers information but also makes decisions based on what it senses by slowing down, applying the brakes, or adjusting the steering. My friends who own these semi-autonomous cars generally have given these control systems positive grades once they have experienced a few events in which the vehicle took over in what it considered a dangerous situation. However, even my friends who are fans of their semi-autonomous cars are uncomfortable about the widespread introduction of fully autonomous vehicles.

The practice of medicine is riding the crest of this same wave of artificial intelligence that promises, or some might say threatens, to remove humans from the driver’s seat (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). As reported in the New York Times, a team of physicians has created a system capable of making diagnoses based on a “neural network” that uses complex computer algorithms to learn by analyzing extremely large amounts of data. Once this system had been “taught” to identify certain medical conditions in EMRs, the team tasked the system with analyzing the records of nearly 600,000 patients at a women and children’s hospital in southern China. The investigators claim that the system was able to diagnose asthma with more than 90% accuracy, while physicians can diagnose with an accuracy of 80%-94%, and the system diagnosed gastrointestinal disease with 87% accuracy, well within the physicians’ accuracy range of 82%-90%.

Does this apparent success for A.I. mean that not only will you be vacating your place behind the wheel of your car, but also taking down your shingle and hanging up your stethoscope? Before you rush out and sign up for a federally-funded retraining program, you should remember that this study was done in China, where the privacy laws are somewhat skimpy and the data more voluminous by several scales of magnitude than here. Replicating their results and scaling a similar A.I. neural network to the United States health care system will be difficult in the short term. However, this report should serve as wake-up call to those of you who believe that making diagnoses is at the core of what makes you a physician. If sorting through pages of data to arrive at an explanation for your patients’ complaints is the intellectual challenge that keeps the practice of medicine fresh and exciting, you may want to start looking for other sources of mental stimulation.

A.I. isn’t going to replace the primary care physician. There still will need to be someone available at the initial point of contact who can do a physical exam, take, or at least review, the patient’s history, and then order the lab work and imaging studies that the A.I. system will use to make the diagnosis. In other words, the physician will be primarily responsible for data collection. You may feel that you are almost there already. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

There is a good chance that your car is equipped with a backup camera. It also may have sensors that alert you when there is another vehicle in one of your blind spots. These wonders of modern technology simply are vision enhancers much like an x-ray or an ultrasound. The sensors merely collect visual data, but the decision of what should be done with this additional information is up to you, just as you decide how to respond to your patient’s lab work and imaging studies.

Andrea Danti/Thinkstock

If you have more disposable income than I do, you may have a vehicle that not only gathers information but also makes decisions based on what it senses by slowing down, applying the brakes, or adjusting the steering. My friends who own these semi-autonomous cars generally have given these control systems positive grades once they have experienced a few events in which the vehicle took over in what it considered a dangerous situation. However, even my friends who are fans of their semi-autonomous cars are uncomfortable about the widespread introduction of fully autonomous vehicles.

The practice of medicine is riding the crest of this same wave of artificial intelligence that promises, or some might say threatens, to remove humans from the driver’s seat (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). As reported in the New York Times, a team of physicians has created a system capable of making diagnoses based on a “neural network” that uses complex computer algorithms to learn by analyzing extremely large amounts of data. Once this system had been “taught” to identify certain medical conditions in EMRs, the team tasked the system with analyzing the records of nearly 600,000 patients at a women and children’s hospital in southern China. The investigators claim that the system was able to diagnose asthma with more than 90% accuracy, while physicians can diagnose with an accuracy of 80%-94%, and the system diagnosed gastrointestinal disease with 87% accuracy, well within the physicians’ accuracy range of 82%-90%.

Does this apparent success for A.I. mean that not only will you be vacating your place behind the wheel of your car, but also taking down your shingle and hanging up your stethoscope? Before you rush out and sign up for a federally-funded retraining program, you should remember that this study was done in China, where the privacy laws are somewhat skimpy and the data more voluminous by several scales of magnitude than here. Replicating their results and scaling a similar A.I. neural network to the United States health care system will be difficult in the short term. However, this report should serve as wake-up call to those of you who believe that making diagnoses is at the core of what makes you a physician. If sorting through pages of data to arrive at an explanation for your patients’ complaints is the intellectual challenge that keeps the practice of medicine fresh and exciting, you may want to start looking for other sources of mental stimulation.

A.I. isn’t going to replace the primary care physician. There still will need to be someone available at the initial point of contact who can do a physical exam, take, or at least review, the patient’s history, and then order the lab work and imaging studies that the A.I. system will use to make the diagnosis. In other words, the physician will be primarily responsible for data collection. You may feel that you are almost there already. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

My most recent column discussed the problem of pseudoscience that pervades some corners of the Internet. Personally, I respond to pseudoscience primarily by trying to provide accurate and less-biased information. I recognize that not everyone approaches decision making by seeking more information. When dealing a diverse public, a medical professional needs to have other approaches in the armamentarium.¹ When dealing with other physicians, I am less flexible. Either the profession of medicine believes in science or it doesn’t.

Since that column was published, there have been major developments. There are measles outbreaks in the states of Washington and New York, and more than 100 deaths from a measles epidemic in the Philippines. The World Health Organization has made vaccine hesitancy one of its ten threats to global health in 2019.

Facebook has indicated that it might demote the priority and frequency with which it recommends articles that promulgate anti-vax information and conspiracy theories.² Facebook isn’t doing this because it has had an epiphany; it has come under pressure for its role in the spread of misinformation. Current legislation was written before the rise of social media, when Internet Service Providers were primarily conduits to transfer bits and bytes between computers. Those ISPs were not liable for the content of the transmitted Web pages. Facebook, by producing what it called a newsfeed and by making personalized suggestions for other websites to browse, doesn’t fit the passive model of an ISP.

For alleged violations of user’s privacy, Facebook might be subject to billion dollar fines, according to a Washington Post article.³ Still, for a company whose revenue is $4 billion per month and whose stock market value is $400 billion, paying a billion dollar fine for years of alleged misbehaviors that have enabled it to become a giant empire is, “in the scheme of things ... a speeding ticket” in the parlance of the penultimate scene of the movie The Social Network. The real financial risk is people deciding they can’t trust the platform and going elsewhere.

Authorities in the United Kingdom in February 2019 released a highly critical, 108-page report about fake news, which said, “Facebook should not be allowed to behave like ‘digital gangsters’ in the online world.”⁴ The U.K. report urges new regulations to deal with privacy breaches and with fake news. It endeavors to create a duty for social media companies to combat the spread of misinformation.

Then the Wall Street Journal reported that Pinterest has stopped returning results for searches related to vaccination.⁵ Pinterest realized that most of the shared images on its platform cautioned against vaccination, which contradicts the recommendations of medical experts. Unable to otherwise combat the flow of misinformation, the company apparently has decided to eliminate returning results, pro or con, for any search terms related to vaccines.

While lamenting the public’s inability to distinguish misinformation on the Internet, I’ve also been observing the factors that lead physicians astray. I expect physicians, as trained scientists and as professionals, to be able to assimilate new information and change their practices accordingly. Those who do research on the translation of technology find that, this doesn’t happen with any regularity.

The February 2019 issue of Hospital Pediatrics has four items on the topic of treating bronchiolitis, including two research articles, a brief report, and a commentary. That is obviously a relevant topic this time of year. The impression after reading those four items is that hospitalists don’t really know how to best treat the most common illness they encounter. And even when they “know” how to do it, many factors distort the science. Those factors are highlighted in the article on barriers to minimizing viral testing.⁶

Rigorous, science-based medicine is hard.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

References

1. “Discussing immunization with vaccine-hesitant parents requires caring, individualized approach,” by Jeff Craven, Pediatric News, Nov. 7, 2018; “How do you get anti-vaxxers to vaccinate their kids? Talk to them – for hours,” by Nadine Gartner, Washington Post, Feb. 19, 2019.

2. “Facebook will consider removing or demoting anti-vaccination recommendations amid backlash,” by Taylor Telford, Washington Post, Feb. 15, 2019.

3. “U.S. regulators have met to discuss imposing a record-setting fine against Facebook for privacy violations,” by Tony Romm and Elizabeth Dwoskin, Washington Post, Jan. 18, 2019; “Report: Facebook, FTC discussing ‘multibillion dollar’ fine,” by Associated Press.

4. “Disinformation and ‘fake news’: Final Report,” House of Commons, Feb. 18, 2019, p. 42, item 139.

5. “Pinterest blocks vaccination searches in move to control the conversation,” by Robert McMillan and Daniela Hernandez, The Wall Street Journal, Feb. 20, 2019.

6. “Barriers to minimizing respiratory viral testing in bronchiolitis: Physician perceptions on testing practices,” by MZ Huang et al. Hospital Pediatrics 2019 Feb. doi: 10.1542/hpeds.2018-0108.

My most recent column discussed the problem of pseudoscience that pervades some corners of the Internet. Personally, I respond to pseudoscience primarily by trying to provide accurate and less-biased information. I recognize that not everyone approaches decision making by seeking more information. When dealing a diverse public, a medical professional needs to have other approaches in the armamentarium.¹ When dealing with other physicians, I am less flexible. Either the profession of medicine believes in science or it doesn’t.

Since that column was published, there have been major developments. There are measles outbreaks in the states of Washington and New York, and more than 100 deaths from a measles epidemic in the Philippines. The World Health Organization has made vaccine hesitancy one of its ten threats to global health in 2019.

Facebook has indicated that it might demote the priority and frequency with which it recommends articles that promulgate anti-vax information and conspiracy theories.² Facebook isn’t doing this because it has had an epiphany; it has come under pressure for its role in the spread of misinformation. Current legislation was written before the rise of social media, when Internet Service Providers were primarily conduits to transfer bits and bytes between computers. Those ISPs were not liable for the content of the transmitted Web pages. Facebook, by producing what it called a newsfeed and by making personalized suggestions for other websites to browse, doesn’t fit the passive model of an ISP.

For alleged violations of user’s privacy, Facebook might be subject to billion dollar fines, according to a Washington Post article.³ Still, for a company whose revenue is $4 billion per month and whose stock market value is $400 billion, paying a billion dollar fine for years of alleged misbehaviors that have enabled it to become a giant empire is, “in the scheme of things ... a speeding ticket” in the parlance of the penultimate scene of the movie The Social Network. The real financial risk is people deciding they can’t trust the platform and going elsewhere.

Authorities in the United Kingdom in February 2019 released a highly critical, 108-page report about fake news, which said, “Facebook should not be allowed to behave like ‘digital gangsters’ in the online world.”⁴ The U.K. report urges new regulations to deal with privacy breaches and with fake news. It endeavors to create a duty for social media companies to combat the spread of misinformation.

Then the Wall Street Journal reported that Pinterest has stopped returning results for searches related to vaccination.⁵ Pinterest realized that most of the shared images on its platform cautioned against vaccination, which contradicts the recommendations of medical experts. Unable to otherwise combat the flow of misinformation, the company apparently has decided to eliminate returning results, pro or con, for any search terms related to vaccines.

While lamenting the public’s inability to distinguish misinformation on the Internet, I’ve also been observing the factors that lead physicians astray. I expect physicians, as trained scientists and as professionals, to be able to assimilate new information and change their practices accordingly. Those who do research on the translation of technology find that, this doesn’t happen with any regularity.

The February 2019 issue of Hospital Pediatrics has four items on the topic of treating bronchiolitis, including two research articles, a brief report, and a commentary. That is obviously a relevant topic this time of year. The impression after reading those four items is that hospitalists don’t really know how to best treat the most common illness they encounter. And even when they “know” how to do it, many factors distort the science. Those factors are highlighted in the article on barriers to minimizing viral testing.⁶

Rigorous, science-based medicine is hard.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

References

1. “Discussing immunization with vaccine-hesitant parents requires caring, individualized approach,” by Jeff Craven, Pediatric News, Nov. 7, 2018; “How do you get anti-vaxxers to vaccinate their kids? Talk to them – for hours,” by Nadine Gartner, Washington Post, Feb. 19, 2019.

2. “Facebook will consider removing or demoting anti-vaccination recommendations amid backlash,” by Taylor Telford, Washington Post, Feb. 15, 2019.

3. “U.S. regulators have met to discuss imposing a record-setting fine against Facebook for privacy violations,” by Tony Romm and Elizabeth Dwoskin, Washington Post, Jan. 18, 2019; “Report: Facebook, FTC discussing ‘multibillion dollar’ fine,” by Associated Press.

4. “Disinformation and ‘fake news’: Final Report,” House of Commons, Feb. 18, 2019, p. 42, item 139.

5. “Pinterest blocks vaccination searches in move to control the conversation,” by Robert McMillan and Daniela Hernandez, The Wall Street Journal, Feb. 20, 2019.

6. “Barriers to minimizing respiratory viral testing in bronchiolitis: Physician perceptions on testing practices,” by MZ Huang et al. Hospital Pediatrics 2019 Feb. doi: 10.1542/hpeds.2018-0108.

My most recent column discussed the problem of pseudoscience that pervades some corners of the Internet. Personally, I respond to pseudoscience primarily by trying to provide accurate and less-biased information. I recognize that not everyone approaches decision making by seeking more information. When dealing a diverse public, a medical professional needs to have other approaches in the armamentarium.¹ When dealing with other physicians, I am less flexible. Either the profession of medicine believes in science or it doesn’t.

Since that column was published, there have been major developments. There are measles outbreaks in the states of Washington and New York, and more than 100 deaths from a measles epidemic in the Philippines. The World Health Organization has made vaccine hesitancy one of its ten threats to global health in 2019.

Facebook has indicated that it might demote the priority and frequency with which it recommends articles that promulgate anti-vax information and conspiracy theories.² Facebook isn’t doing this because it has had an epiphany; it has come under pressure for its role in the spread of misinformation. Current legislation was written before the rise of social media, when Internet Service Providers were primarily conduits to transfer bits and bytes between computers. Those ISPs were not liable for the content of the transmitted Web pages. Facebook, by producing what it called a newsfeed and by making personalized suggestions for other websites to browse, doesn’t fit the passive model of an ISP.

For alleged violations of user’s privacy, Facebook might be subject to billion dollar fines, according to a Washington Post article.³ Still, for a company whose revenue is $4 billion per month and whose stock market value is $400 billion, paying a billion dollar fine for years of alleged misbehaviors that have enabled it to become a giant empire is, “in the scheme of things ... a speeding ticket” in the parlance of the penultimate scene of the movie The Social Network. The real financial risk is people deciding they can’t trust the platform and going elsewhere.

Authorities in the United Kingdom in February 2019 released a highly critical, 108-page report about fake news, which said, “Facebook should not be allowed to behave like ‘digital gangsters’ in the online world.”⁴ The U.K. report urges new regulations to deal with privacy breaches and with fake news. It endeavors to create a duty for social media companies to combat the spread of misinformation.

Then the Wall Street Journal reported that Pinterest has stopped returning results for searches related to vaccination.⁵ Pinterest realized that most of the shared images on its platform cautioned against vaccination, which contradicts the recommendations of medical experts. Unable to otherwise combat the flow of misinformation, the company apparently has decided to eliminate returning results, pro or con, for any search terms related to vaccines.

While lamenting the public’s inability to distinguish misinformation on the Internet, I’ve also been observing the factors that lead physicians astray. I expect physicians, as trained scientists and as professionals, to be able to assimilate new information and change their practices accordingly. Those who do research on the translation of technology find that, this doesn’t happen with any regularity.

The February 2019 issue of Hospital Pediatrics has four items on the topic of treating bronchiolitis, including two research articles, a brief report, and a commentary. That is obviously a relevant topic this time of year. The impression after reading those four items is that hospitalists don’t really know how to best treat the most common illness they encounter. And even when they “know” how to do it, many factors distort the science. Those factors are highlighted in the article on barriers to minimizing viral testing.⁶

Rigorous, science-based medicine is hard.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

References

1. “Discussing immunization with vaccine-hesitant parents requires caring, individualized approach,” by Jeff Craven, Pediatric News, Nov. 7, 2018; “How do you get anti-vaxxers to vaccinate their kids? Talk to them – for hours,” by Nadine Gartner, Washington Post, Feb. 19, 2019.

2. “Facebook will consider removing or demoting anti-vaccination recommendations amid backlash,” by Taylor Telford, Washington Post, Feb. 15, 2019.

3. “U.S. regulators have met to discuss imposing a record-setting fine against Facebook for privacy violations,” by Tony Romm and Elizabeth Dwoskin, Washington Post, Jan. 18, 2019; “Report: Facebook, FTC discussing ‘multibillion dollar’ fine,” by Associated Press.

4. “Disinformation and ‘fake news’: Final Report,” House of Commons, Feb. 18, 2019, p. 42, item 139.

5. “Pinterest blocks vaccination searches in move to control the conversation,” by Robert McMillan and Daniela Hernandez, The Wall Street Journal, Feb. 20, 2019.

6. “Barriers to minimizing respiratory viral testing in bronchiolitis: Physician perceptions on testing practices,” by MZ Huang et al. Hospital Pediatrics 2019 Feb. doi: 10.1542/hpeds.2018-0108.

Global outbreaks of infectious diseases—such as smallpox, pertussis, dysentery, and scarlet fever—seem like fodder for the history books. It was centuries ago that epidemics wiped out large swathes of the world population. Many people living and raising children today have never witnessed the devastating effects of measles, mumps, polio, and influenza—diseases that have been substantially reduced or even eradicated.¹ Why? Because since the early 1900s, we have had scientifically developed and widely distributed vaccines at our disposal.

In context, it is incredible to realize that we are still in the beginning stages of vaccine research and development. From that perspective, it is perhaps not as surprising that some parents are hesitant to vaccinate their children—after all, do we really know everything we can and should know about inoculation? Parental resistance to or refusal of vaccination is further fueled by tainted research (Andrew Wakefield was forced to retract his findings that “validated” a link between thimerosal in vaccines and autism) and misinformation propagated on the Internet.²

But what has long been a source of frustration to those who support routine vaccination has, in recent years, started to become a public health issue. Measles outbreaks are no longer historical artifacts—they are real, as evidenced by the current rise in cases centered in Clark County, Washington. Through the first full week of February 2019, there were 101 confirmed cases of measles in the US, half of which occurred in Washington State—leading the governor to declare a public health emergency.³

This has, of course, reinvigorated the ongoing discussion about parental refusal to vaccinate. Enough has been said on this topic, by both public officials and private individuals, in a variety of venues over the years. So I’d like to focus instead on the role that individual health care providers can play in this situation.

Over the years, many of my colleagues have shared stories about parents who have refused to vaccinate their children. We know many things: These parents often fear complications from vaccination more than complications of disease. Many have religious or philosophical reasons for their reluctance or refusal to vaccinate their children. Some have concerns about vaccine safety or effectiveness. We know these things … but we don’t always know how to speak with parents about these issues.

It is somewhat ironic that the core motivation for hesitant parents and well-meaning clinicians is the same: care and protection of the child. The difficulty lies in the disparate view of what that entails. As NPs and PAs, though, our duty is to seek health benefits for and minimize harm to the patients in our care. Part of our role, when those patients are children, is to provide parents with the necessary risk-benefit information to help them make informed decisions. When the subject is vaccination, we must listen carefully and be respectful of parents’ concerns; we must recognize that their decision-making criteria may differ from ours.

So how can we bridge the gap with parents who “don’t see it the way we do”? We start by being honest with them about what is and isn’t known as far as the risks and benefits of vaccination in general or a vaccine in particular. This means acknowledging that although vaccines are very safe, they are not risk-free or 100% effective. But this also gives us the opportunity to provide them with validated data and to emphasize that the risks of any vaccine should not be considered in a silo but rather in comparison with the risks of the disease in question or of the lack of immunization.

Continue to: Helpfully, Leask and colleagues...

Helpfully, Leask and colleagues have classified parental positions on vaccination, which also provided the groundwork to offer strategies for communicating with each group.⁴ They identified five classes:

Unquestioning acceptors (30% to 40% of parents), who vaccinate their children and typically have no specific questions about the need for or safety of vaccines. Since this group tends to have a good relationship with their health care team but less detailed knowledge about vaccination, clinicians should continue to build rapport while providing scientific information about the vaccine being recommended or administered.⁴

Cautious acceptors (25% to 35%), who vaccinate their children despite having minor concerns. They tend to recognize the risk for adverse effects and hope their child will not be affected. In addition to building rapport, clinicians should provide verbal and numeric descriptions of relevant vaccine data and explain common adverse effects and disease risks.⁴

Hesitant vaccinators (20% to 30%), who are on the fence about the benefits and safety of vaccination. Their focus is more on the negative aspects, and they may not feel particularly trusting of their health care provider. Therefore, gaining trust is vital—parents in this group are eager to discuss their concerns with their clinician and have their questions answered satisfactorily. Motivational interviewing using a guiding style may be a helpful tool.⁴

Late or selective vaccinators (2% to 27%), who have significant doubts about the safety and necessity of vaccines, resulting in their choice to delay vaccination or select only some of the recommended vaccines for their child. These parents may require additional time—possibly a second appointment—in which to fully discuss their concerns. Be sure to provide up-to-date information on the risks and benefits of a vaccine, and use decision aids as appropriate.⁴

Continue to: Refusers...

Refusers (<2%), who have concerns about the number of vaccines children receive and conflicting feelings about whom to trust and how best to get answers to their questions. This group tends to demonstrate high knowledge levels about vaccination but may be the most argumentative when presented with information. Emphasize the importance of protecting the child from an infectious disease and reinforce the effectiveness of the vaccine. Use statistics rather than anecdotes. But above all, spend the time needed to provide refusers with a thorough understanding of the risks of not immunizing their child.⁴

Although it is not a universal sentiment, many parents confer trust on their health care providers. We can use this trust in a respectful, noncoercive, and non-condescending manner by providing research-supported facts about vaccines. Clinicians who listen with a compassionate ear will be in the best position to lead the hesitant, late or selective, or refusing parents to confidently make an informed decision that immunization is the best way to protect their children from vaccine-preventable diseases.⁴

Rather than yet again focusing on the negative, I’d like to ask: Have you had a success story of helping parents to choose vaccination for their children? How did you overcome their concerns? Share your experience with me at [email protected].

Global outbreaks of infectious diseases—such as smallpox, pertussis, dysentery, and scarlet fever—seem like fodder for the history books. It was centuries ago that epidemics wiped out large swathes of the world population. Many people living and raising children today have never witnessed the devastating effects of measles, mumps, polio, and influenza—diseases that have been substantially reduced or even eradicated.¹ Why? Because since the early 1900s, we have had scientifically developed and widely distributed vaccines at our disposal.

In context, it is incredible to realize that we are still in the beginning stages of vaccine research and development. From that perspective, it is perhaps not as surprising that some parents are hesitant to vaccinate their children—after all, do we really know everything we can and should know about inoculation? Parental resistance to or refusal of vaccination is further fueled by tainted research (Andrew Wakefield was forced to retract his findings that “validated” a link between thimerosal in vaccines and autism) and misinformation propagated on the Internet.²

But what has long been a source of frustration to those who support routine vaccination has, in recent years, started to become a public health issue. Measles outbreaks are no longer historical artifacts—they are real, as evidenced by the current rise in cases centered in Clark County, Washington. Through the first full week of February 2019, there were 101 confirmed cases of measles in the US, half of which occurred in Washington State—leading the governor to declare a public health emergency.³

This has, of course, reinvigorated the ongoing discussion about parental refusal to vaccinate. Enough has been said on this topic, by both public officials and private individuals, in a variety of venues over the years. So I’d like to focus instead on the role that individual health care providers can play in this situation.

Over the years, many of my colleagues have shared stories about parents who have refused to vaccinate their children. We know many things: These parents often fear complications from vaccination more than complications of disease. Many have religious or philosophical reasons for their reluctance or refusal to vaccinate their children. Some have concerns about vaccine safety or effectiveness. We know these things … but we don’t always know how to speak with parents about these issues.

It is somewhat ironic that the core motivation for hesitant parents and well-meaning clinicians is the same: care and protection of the child. The difficulty lies in the disparate view of what that entails. As NPs and PAs, though, our duty is to seek health benefits for and minimize harm to the patients in our care. Part of our role, when those patients are children, is to provide parents with the necessary risk-benefit information to help them make informed decisions. When the subject is vaccination, we must listen carefully and be respectful of parents’ concerns; we must recognize that their decision-making criteria may differ from ours.

So how can we bridge the gap with parents who “don’t see it the way we do”? We start by being honest with them about what is and isn’t known as far as the risks and benefits of vaccination in general or a vaccine in particular. This means acknowledging that although vaccines are very safe, they are not risk-free or 100% effective. But this also gives us the opportunity to provide them with validated data and to emphasize that the risks of any vaccine should not be considered in a silo but rather in comparison with the risks of the disease in question or of the lack of immunization.

Continue to: Helpfully, Leask and colleagues...

Helpfully, Leask and colleagues have classified parental positions on vaccination, which also provided the groundwork to offer strategies for communicating with each group.⁴ They identified five classes:

Unquestioning acceptors (30% to 40% of parents), who vaccinate their children and typically have no specific questions about the need for or safety of vaccines. Since this group tends to have a good relationship with their health care team but less detailed knowledge about vaccination, clinicians should continue to build rapport while providing scientific information about the vaccine being recommended or administered.⁴

Cautious acceptors (25% to 35%), who vaccinate their children despite having minor concerns. They tend to recognize the risk for adverse effects and hope their child will not be affected. In addition to building rapport, clinicians should provide verbal and numeric descriptions of relevant vaccine data and explain common adverse effects and disease risks.⁴

Hesitant vaccinators (20% to 30%), who are on the fence about the benefits and safety of vaccination. Their focus is more on the negative aspects, and they may not feel particularly trusting of their health care provider. Therefore, gaining trust is vital—parents in this group are eager to discuss their concerns with their clinician and have their questions answered satisfactorily. Motivational interviewing using a guiding style may be a helpful tool.⁴

Late or selective vaccinators (2% to 27%), who have significant doubts about the safety and necessity of vaccines, resulting in their choice to delay vaccination or select only some of the recommended vaccines for their child. These parents may require additional time—possibly a second appointment—in which to fully discuss their concerns. Be sure to provide up-to-date information on the risks and benefits of a vaccine, and use decision aids as appropriate.⁴

Continue to: Refusers...

Refusers (<2%), who have concerns about the number of vaccines children receive and conflicting feelings about whom to trust and how best to get answers to their questions. This group tends to demonstrate high knowledge levels about vaccination but may be the most argumentative when presented with information. Emphasize the importance of protecting the child from an infectious disease and reinforce the effectiveness of the vaccine. Use statistics rather than anecdotes. But above all, spend the time needed to provide refusers with a thorough understanding of the risks of not immunizing their child.⁴

Although it is not a universal sentiment, many parents confer trust on their health care providers. We can use this trust in a respectful, noncoercive, and non-condescending manner by providing research-supported facts about vaccines. Clinicians who listen with a compassionate ear will be in the best position to lead the hesitant, late or selective, or refusing parents to confidently make an informed decision that immunization is the best way to protect their children from vaccine-preventable diseases.⁴

Rather than yet again focusing on the negative, I’d like to ask: Have you had a success story of helping parents to choose vaccination for their children? How did you overcome their concerns? Share your experience with me at [email protected].

Global outbreaks of infectious diseases—such as smallpox, pertussis, dysentery, and scarlet fever—seem like fodder for the history books. It was centuries ago that epidemics wiped out large swathes of the world population. Many people living and raising children today have never witnessed the devastating effects of measles, mumps, polio, and influenza—diseases that have been substantially reduced or even eradicated.¹ Why? Because since the early 1900s, we have had scientifically developed and widely distributed vaccines at our disposal.

In context, it is incredible to realize that we are still in the beginning stages of vaccine research and development. From that perspective, it is perhaps not as surprising that some parents are hesitant to vaccinate their children—after all, do we really know everything we can and should know about inoculation? Parental resistance to or refusal of vaccination is further fueled by tainted research (Andrew Wakefield was forced to retract his findings that “validated” a link between thimerosal in vaccines and autism) and misinformation propagated on the Internet.²

But what has long been a source of frustration to those who support routine vaccination has, in recent years, started to become a public health issue. Measles outbreaks are no longer historical artifacts—they are real, as evidenced by the current rise in cases centered in Clark County, Washington. Through the first full week of February 2019, there were 101 confirmed cases of measles in the US, half of which occurred in Washington State—leading the governor to declare a public health emergency.³

This has, of course, reinvigorated the ongoing discussion about parental refusal to vaccinate. Enough has been said on this topic, by both public officials and private individuals, in a variety of venues over the years. So I’d like to focus instead on the role that individual health care providers can play in this situation.

Over the years, many of my colleagues have shared stories about parents who have refused to vaccinate their children. We know many things: These parents often fear complications from vaccination more than complications of disease. Many have religious or philosophical reasons for their reluctance or refusal to vaccinate their children. Some have concerns about vaccine safety or effectiveness. We know these things … but we don’t always know how to speak with parents about these issues.

It is somewhat ironic that the core motivation for hesitant parents and well-meaning clinicians is the same: care and protection of the child. The difficulty lies in the disparate view of what that entails. As NPs and PAs, though, our duty is to seek health benefits for and minimize harm to the patients in our care. Part of our role, when those patients are children, is to provide parents with the necessary risk-benefit information to help them make informed decisions. When the subject is vaccination, we must listen carefully and be respectful of parents’ concerns; we must recognize that their decision-making criteria may differ from ours.

So how can we bridge the gap with parents who “don’t see it the way we do”? We start by being honest with them about what is and isn’t known as far as the risks and benefits of vaccination in general or a vaccine in particular. This means acknowledging that although vaccines are very safe, they are not risk-free or 100% effective. But this also gives us the opportunity to provide them with validated data and to emphasize that the risks of any vaccine should not be considered in a silo but rather in comparison with the risks of the disease in question or of the lack of immunization.

Continue to: Helpfully, Leask and colleagues...

Helpfully, Leask and colleagues have classified parental positions on vaccination, which also provided the groundwork to offer strategies for communicating with each group.⁴ They identified five classes:

Unquestioning acceptors (30% to 40% of parents), who vaccinate their children and typically have no specific questions about the need for or safety of vaccines. Since this group tends to have a good relationship with their health care team but less detailed knowledge about vaccination, clinicians should continue to build rapport while providing scientific information about the vaccine being recommended or administered.⁴

Cautious acceptors (25% to 35%), who vaccinate their children despite having minor concerns. They tend to recognize the risk for adverse effects and hope their child will not be affected. In addition to building rapport, clinicians should provide verbal and numeric descriptions of relevant vaccine data and explain common adverse effects and disease risks.⁴

Hesitant vaccinators (20% to 30%), who are on the fence about the benefits and safety of vaccination. Their focus is more on the negative aspects, and they may not feel particularly trusting of their health care provider. Therefore, gaining trust is vital—parents in this group are eager to discuss their concerns with their clinician and have their questions answered satisfactorily. Motivational interviewing using a guiding style may be a helpful tool.⁴

Late or selective vaccinators (2% to 27%), who have significant doubts about the safety and necessity of vaccines, resulting in their choice to delay vaccination or select only some of the recommended vaccines for their child. These parents may require additional time—possibly a second appointment—in which to fully discuss their concerns. Be sure to provide up-to-date information on the risks and benefits of a vaccine, and use decision aids as appropriate.⁴

Continue to: Refusers...

Refusers (<2%), who have concerns about the number of vaccines children receive and conflicting feelings about whom to trust and how best to get answers to their questions. This group tends to demonstrate high knowledge levels about vaccination but may be the most argumentative when presented with information. Emphasize the importance of protecting the child from an infectious disease and reinforce the effectiveness of the vaccine. Use statistics rather than anecdotes. But above all, spend the time needed to provide refusers with a thorough understanding of the risks of not immunizing their child.⁴

Although it is not a universal sentiment, many parents confer trust on their health care providers. We can use this trust in a respectful, noncoercive, and non-condescending manner by providing research-supported facts about vaccines. Clinicians who listen with a compassionate ear will be in the best position to lead the hesitant, late or selective, or refusing parents to confidently make an informed decision that immunization is the best way to protect their children from vaccine-preventable diseases.⁴

Rather than yet again focusing on the negative, I’d like to ask: Have you had a success story of helping parents to choose vaccination for their children? How did you overcome their concerns? Share your experience with me at [email protected].

Doctor, (fake) doctor, gimme the news

Florida Man strikes again, and this time he’s a faux MD.

wildpixel/iStock/Getty Images Plus

Onelio Hipolit-Gonzalez was charged with a felony for impersonating a doctor who promised patients he could easily diagnose their diabetes, cancer, multiple sclerosis, Parkinson’s, and pretty much any other malady … with a metal rod. The “doctor” would have patients hold on to a metal rod connected to a beeping machine (these are the scientific terms, of course), and then he would gravely diagnose them with a variety of ailments that he could cure for the low, low price of $2,000.

If you’re curious how he treated patients, fear not. This intrepid medical professional took the ingenious measure of drawing a patient’s blood and simply injecting it back inside them. Bada-bing, instant cure! Honestly, medical school these days is really overrated. Just learn to properly use a syringe, and you should be good to go. Just make sure not to attempt to treat/con any undercover cops.
 

Step away from the stinky socks

In another edition of “Humans: What Won’t They Do?” a Chinese man has developed a severe lung infection from prolonged, voluntary inhalation of his sweaty socks.

Ivan-balvan/iStock/Getty Images Plus

Take a moment to gag if you need it.

The man reportedly would finish his daily walk home from work with a deep, relaxing session of smelling his socks. Somewhat unsurprisingly, he developed a fungal infection and had to be hospitalized.

His doctor, perhaps in an effort to spare his feelings, conceded that the infection could be attributed to his weakened immune system from looking after his child. Sock-smelling weirdo, or just a good dad? Let’s just hope he doesn’t pass on this … unorthodox hobby to his offspring.
 

Turn down your eye beams

Do you remember the recent LOTME about a company selling tissues that have already been used by a sick person? Good news! This next item has nothing to do with that.

Sonsedska/iStock/Getty Images Plus

More good news! Belief in extramission – the ability to emit an invisible energy from the eyes – is down to about 5% among Americans after being greater than 50% at the turn of the century. The bad news? Belief in extramission is about 5% among Americans, according to investigators at Princeton (N.J.) University.

It’s not really a superhero thing, though. The researchers shared an explanation common among the extramission believers: “Light enters the eye, and there is a reflector piece inside the eye. The reflector reflects the light back out and hits the object, allowing the eye to see it.”

Now, we’d like to discount this whole eye-beam business, we really would, but there may be an exception that proves the rule. Ever had a staring contest with a cat? There’s got to be some sort of freaky power going on there.
 

The world’s worst superpower

Have you ever wondered what it would be like to live in the beginning of a science fiction novel? Well, worry no more – a group of researchers at the Georgia Institute of Technology and Emory University has you covered!

Rost-9D/iStock/Getty Images Plus

Okay, we’re pretty sure that the nanoparticles they’ve come up with won’t turn you into the Borg, but they will make your urine glow. Specifically, when injected into the bodies of people who’ve recently undergone transplants, they can help identify when an organ is failing.

The particles are tiny (duh), but they’re big enough that they won’t accumulate in normal, native tissue. However, they are small enough that, when a transplanted organ is being attacked by the body, the nanoparticles will end up getting through the kidneys and into urine. The particles are fluorescent and glow under near-infrared light.

The nanoparticles are aimed at replacing biopsies, as they are more predictive and less invasive. Also, who wouldn’t want to claim they’ve been enhanced by nanotechnology? Resistance is futile, after all.

Doctor, (fake) doctor, gimme the news

Florida Man strikes again, and this time he’s a faux MD.

wildpixel/iStock/Getty Images Plus

Onelio Hipolit-Gonzalez was charged with a felony for impersonating a doctor who promised patients he could easily diagnose their diabetes, cancer, multiple sclerosis, Parkinson’s, and pretty much any other malady … with a metal rod. The “doctor” would have patients hold on to a metal rod connected to a beeping machine (these are the scientific terms, of course), and then he would gravely diagnose them with a variety of ailments that he could cure for the low, low price of $2,000.

If you’re curious how he treated patients, fear not. This intrepid medical professional took the ingenious measure of drawing a patient’s blood and simply injecting it back inside them. Bada-bing, instant cure! Honestly, medical school these days is really overrated. Just learn to properly use a syringe, and you should be good to go. Just make sure not to attempt to treat/con any undercover cops.
 

Step away from the stinky socks

In another edition of “Humans: What Won’t They Do?” a Chinese man has developed a severe lung infection from prolonged, voluntary inhalation of his sweaty socks.

Ivan-balvan/iStock/Getty Images Plus

Take a moment to gag if you need it.

The man reportedly would finish his daily walk home from work with a deep, relaxing session of smelling his socks. Somewhat unsurprisingly, he developed a fungal infection and had to be hospitalized.

His doctor, perhaps in an effort to spare his feelings, conceded that the infection could be attributed to his weakened immune system from looking after his child. Sock-smelling weirdo, or just a good dad? Let’s just hope he doesn’t pass on this … unorthodox hobby to his offspring.
 

Turn down your eye beams

Do you remember the recent LOTME about a company selling tissues that have already been used by a sick person? Good news! This next item has nothing to do with that.

Sonsedska/iStock/Getty Images Plus

More good news! Belief in extramission – the ability to emit an invisible energy from the eyes – is down to about 5% among Americans after being greater than 50% at the turn of the century. The bad news? Belief in extramission is about 5% among Americans, according to investigators at Princeton (N.J.) University.

It’s not really a superhero thing, though. The researchers shared an explanation common among the extramission believers: “Light enters the eye, and there is a reflector piece inside the eye. The reflector reflects the light back out and hits the object, allowing the eye to see it.”

Now, we’d like to discount this whole eye-beam business, we really would, but there may be an exception that proves the rule. Ever had a staring contest with a cat? There’s got to be some sort of freaky power going on there.
 

The world’s worst superpower

Have you ever wondered what it would be like to live in the beginning of a science fiction novel? Well, worry no more – a group of researchers at the Georgia Institute of Technology and Emory University has you covered!

Rost-9D/iStock/Getty Images Plus

Okay, we’re pretty sure that the nanoparticles they’ve come up with won’t turn you into the Borg, but they will make your urine glow. Specifically, when injected into the bodies of people who’ve recently undergone transplants, they can help identify when an organ is failing.

The particles are tiny (duh), but they’re big enough that they won’t accumulate in normal, native tissue. However, they are small enough that, when a transplanted organ is being attacked by the body, the nanoparticles will end up getting through the kidneys and into urine. The particles are fluorescent and glow under near-infrared light.

The nanoparticles are aimed at replacing biopsies, as they are more predictive and less invasive. Also, who wouldn’t want to claim they’ve been enhanced by nanotechnology? Resistance is futile, after all.

Doctor, (fake) doctor, gimme the news

Florida Man strikes again, and this time he’s a faux MD.

wildpixel/iStock/Getty Images Plus

Onelio Hipolit-Gonzalez was charged with a felony for impersonating a doctor who promised patients he could easily diagnose their diabetes, cancer, multiple sclerosis, Parkinson’s, and pretty much any other malady … with a metal rod. The “doctor” would have patients hold on to a metal rod connected to a beeping machine (these are the scientific terms, of course), and then he would gravely diagnose them with a variety of ailments that he could cure for the low, low price of $2,000.

If you’re curious how he treated patients, fear not. This intrepid medical professional took the ingenious measure of drawing a patient’s blood and simply injecting it back inside them. Bada-bing, instant cure! Honestly, medical school these days is really overrated. Just learn to properly use a syringe, and you should be good to go. Just make sure not to attempt to treat/con any undercover cops.
 

Step away from the stinky socks

In another edition of “Humans: What Won’t They Do?” a Chinese man has developed a severe lung infection from prolonged, voluntary inhalation of his sweaty socks.

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Take a moment to gag if you need it.

The man reportedly would finish his daily walk home from work with a deep, relaxing session of smelling his socks. Somewhat unsurprisingly, he developed a fungal infection and had to be hospitalized.

His doctor, perhaps in an effort to spare his feelings, conceded that the infection could be attributed to his weakened immune system from looking after his child. Sock-smelling weirdo, or just a good dad? Let’s just hope he doesn’t pass on this … unorthodox hobby to his offspring.
 

Turn down your eye beams

Do you remember the recent LOTME about a company selling tissues that have already been used by a sick person? Good news! This next item has nothing to do with that.

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More good news! Belief in extramission – the ability to emit an invisible energy from the eyes – is down to about 5% among Americans after being greater than 50% at the turn of the century. The bad news? Belief in extramission is about 5% among Americans, according to investigators at Princeton (N.J.) University.

It’s not really a superhero thing, though. The researchers shared an explanation common among the extramission believers: “Light enters the eye, and there is a reflector piece inside the eye. The reflector reflects the light back out and hits the object, allowing the eye to see it.”

Now, we’d like to discount this whole eye-beam business, we really would, but there may be an exception that proves the rule. Ever had a staring contest with a cat? There’s got to be some sort of freaky power going on there.
 

The world’s worst superpower

Have you ever wondered what it would be like to live in the beginning of a science fiction novel? Well, worry no more – a group of researchers at the Georgia Institute of Technology and Emory University has you covered!

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Okay, we’re pretty sure that the nanoparticles they’ve come up with won’t turn you into the Borg, but they will make your urine glow. Specifically, when injected into the bodies of people who’ve recently undergone transplants, they can help identify when an organ is failing.

The particles are tiny (duh), but they’re big enough that they won’t accumulate in normal, native tissue. However, they are small enough that, when a transplanted organ is being attacked by the body, the nanoparticles will end up getting through the kidneys and into urine. The particles are fluorescent and glow under near-infrared light.

The nanoparticles are aimed at replacing biopsies, as they are more predictive and less invasive. Also, who wouldn’t want to claim they’ve been enhanced by nanotechnology? Resistance is futile, after all.

Question: Which one of the following statements regarding complementary and alternative medicine (CAM) is correct?

A. CAM practitioners are just as likely as medical doctors to be sued.

B. Damages arising out of the use of CAM may be compensable if there is clear and convincing evidence of substandard care, and the plaintiff can prove legal causation.

C. An acupuncturist who treats an asthmatic patient will be sued if he/she fails to refer the patient to a medical specialist.

D. Obtaining informed consent after discussing all therapeutic options and material risks is especially important for those who practice CAM.

E. It is not a valid defense that the patient had fully and willingly assumed the risk of treatment.

Answer: D. Compared with medical doctors, non-MD practitioners of CAM pay lower malpractice insurance premiums, as they are much less likely to be sued, and patient injuries are usually less severe.

CAM covers a broad range of healing philosophies, approaches, and therapies that are typically outside mainstream Western medicine. It comprises modalities such as chiropractic, acupuncture, massage therapy, naturopathic medicine, nutritional therapy, and others.

More than half of the U.S. population uses some form of CAM, which is widely perceived as a natural and effective means of promoting overall well being in addition to treating a specific illness. The scope of practice for CAM providers is defined and limited by state rather than federal statutes, and enforced by regulatory bodies.

CAM treatments are generally noninvasive, and there are fewer than 50 indemnity insurers in the country for chiropractors, massage therapists, and acupuncturists, underwriting some 5% of the total medical malpractice insurance market.

In the event of an injury, damages are recoverable if there is a preponderance of evidence to indicate substandard care. “Clear and convincing” is a higher evidentiary level of legal proof, and it is not required in a negligence action. Whether an acupuncturist will be sued successfully for treating an asthmatic patient will depend on many factors, for example, whether it is an acceptable CAM practice in the jurisdiction, whether there is any statutory restriction on such treatment, whether there was a failure of a timely referral, etc.

Finally, assumption of risk is a valid defense in a negligence tort action under some circumstances.

For a negligence claim to prevail, the plaintiff must establish breach of duty, i.e., that the defendant deviated from the standard of care ordinarily exercised by a similarly situated practitioner. In addition to falling below that level of skill, practitioners may also be sued for having failed to refer to a medical doctor, for practicing outside the scope of CAM, or for venturing into traditional Western medical practice.

In one instance, a plaintiff alleged that he was led to believe that chiropractic manipulation would help his diabetes. The court found in favor of the plaintiff and awarded damages.¹ In another, the plaintiff successfully sued a chiropractor for failing to take x-rays and refer to a medical doctor. The court held that the defendant fell below the standard of care, as the state licensing board required physician referral when the problem extended beyond the limits of chiropractic practice.²

However, an injured party does not always prevail. In Miyamoto v. Lazo, the plaintiff claimed that Dr. Lazo, a chiropractor, negligently treated his injuries from a car accident.³ The patient was taking Coumadin and developed a hematoma in his left shoulder following chiropractic treatment. This was complicated by neuropathy in his left hand when the hematoma expanded and required surgical drainage.

The jury, however, found Dr. Lazo not liable, because of evidence that a hematoma could spontaneously arise in someone on an anticoagulant.

Injured patients have also filed lawsuits against other CAM practitioners. Allegations against acupuncturists have included cases of pneumothorax, wrongful death in an adolescent girl with asthma, and burns from a heat lamp.⁴ And in Wallman v. Kelley,a plaintiff developed liver damage and filed negligence and breach of implied warranty claims against a seller of Chinese herbal medicine.⁵ The court held that the defendant was not liable, as the plaintiff failed to prove causation or give timely notice of suit.

Medical doctors are increasingly incorporating CAM into their practices, so they must adhere to CAM standards in addition to their own medical standards.

In Charell v. Gonzalez, a cancer patient refused conventional treatment by oncologists and opted instead for nutritional therapy by a physician.⁶ Her cancer metastasized, and she alleged negligence and failure to warn of risks. The jury found the physician 51% liable for departure from standard of care and lack of informed consent. The plaintiff was found to be 49% at fault for choosing to ignore the recommendations of her oncologists.

Even if it’s the patient’s choice, physicians must still exercise due care when implementing therapy.

In Gonzalez v. New York State Department of Health, Dr. Gonzales was charged with gross negligence and incompetence after he used nutritional therapies to treat six patients with incurable cancer who had failed or rejected conventional treatment.⁷

The hearing committee found that he missed signs of disease progression and failed to perform adequate assessments, testing, and follow-up evaluations. The court held that a patient’s consent to or even insistence upon a certain treatment does not relieve the physician from the obligation of treating the patient with the usual standard of care.

In general, a physician may employ several legal defenses to avert liability following an adverse event.

One defense is to assert the “respectable minority” standard of care, if it can be shown that a respectable minority in the medical community also accepts the treatment in question.

A second defense is assumption of risk. In Schneider v. Revici, a physician delivered nutritional (selenium and dietary restrictions) and other nonsurgical treatment for breast cancer after the patient refused conventional treatments offered by other physicians.⁸ The patient signed a detailed consent form releasing the physician from liability and acknowledging that the defendant’s treatments lacked Food and Drug Administration approval, and that no results could be guaranteed.

The cancer spread, and the patient sued for common law fraud, medical malpractice, and lack of informed consent. The court of appeals held that assumption of risk is a complete defense to malpractice. The same court also held in another case that a patient’s failure to sign a consent form did not preclude the jury from considering the assumption of risk defense.

A third defense, rarely successful, is to invoke “clinical innovation” when CAM is used to alleviate a desperate situation, for example, if the patient is terminal or has failed conventional therapy. The defendant-physician may plead involvement in a clinical trial study, or show that the unorthodox treatment is based on extensive personal experience or some newly discovered developments in the field.

When discussing CAM, the physician should first fully inform the patient about conventional treatments and their limitations. Next, the physician should explain why the “novel” rather than the recognized conventional therapy is being considered. Finally, whether the physician intends to carry out CAM therapy or refer to another practitioner, the patient must be warned about the potential risks associated with such therapy.
 

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is modified from a chapter in the author’s book, “Medical Malpractice: Understanding the Law, Managing the Risk.” It is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. Wengel v. Herfert, 473 N.W.2d 741 (1991).

2. Salazar v. Ehmann, 505 P.2d 387 (1972).

3. Miyamoto v. Lum and Lazo, 84 P.3d 509 (2004).

4. Rosenberg v. Jing Jiang, 153 A.D.3d 744 (2017).

5. Wallman v. Kelley, 976 P.2d 330 (1998).

6. Charell v. Gonzales, 673 N.Y.S. 2d 685 (1998).

7. Gonzales v. NYS DOH, 232 A.D.2d 886 (1996).

8. Schneider v. Revici, 817 F. 2d 987 (1987).

Question: Which one of the following statements regarding complementary and alternative medicine (CAM) is correct?

A. CAM practitioners are just as likely as medical doctors to be sued.

B. Damages arising out of the use of CAM may be compensable if there is clear and convincing evidence of substandard care, and the plaintiff can prove legal causation.

C. An acupuncturist who treats an asthmatic patient will be sued if he/she fails to refer the patient to a medical specialist.

D. Obtaining informed consent after discussing all therapeutic options and material risks is especially important for those who practice CAM.

E. It is not a valid defense that the patient had fully and willingly assumed the risk of treatment.

Answer: D. Compared with medical doctors, non-MD practitioners of CAM pay lower malpractice insurance premiums, as they are much less likely to be sued, and patient injuries are usually less severe.

CAM covers a broad range of healing philosophies, approaches, and therapies that are typically outside mainstream Western medicine. It comprises modalities such as chiropractic, acupuncture, massage therapy, naturopathic medicine, nutritional therapy, and others.

More than half of the U.S. population uses some form of CAM, which is widely perceived as a natural and effective means of promoting overall well being in addition to treating a specific illness. The scope of practice for CAM providers is defined and limited by state rather than federal statutes, and enforced by regulatory bodies.

CAM treatments are generally noninvasive, and there are fewer than 50 indemnity insurers in the country for chiropractors, massage therapists, and acupuncturists, underwriting some 5% of the total medical malpractice insurance market.

In the event of an injury, damages are recoverable if there is a preponderance of evidence to indicate substandard care. “Clear and convincing” is a higher evidentiary level of legal proof, and it is not required in a negligence action. Whether an acupuncturist will be sued successfully for treating an asthmatic patient will depend on many factors, for example, whether it is an acceptable CAM practice in the jurisdiction, whether there is any statutory restriction on such treatment, whether there was a failure of a timely referral, etc.

Finally, assumption of risk is a valid defense in a negligence tort action under some circumstances.

For a negligence claim to prevail, the plaintiff must establish breach of duty, i.e., that the defendant deviated from the standard of care ordinarily exercised by a similarly situated practitioner. In addition to falling below that level of skill, practitioners may also be sued for having failed to refer to a medical doctor, for practicing outside the scope of CAM, or for venturing into traditional Western medical practice.

In one instance, a plaintiff alleged that he was led to believe that chiropractic manipulation would help his diabetes. The court found in favor of the plaintiff and awarded damages.¹ In another, the plaintiff successfully sued a chiropractor for failing to take x-rays and refer to a medical doctor. The court held that the defendant fell below the standard of care, as the state licensing board required physician referral when the problem extended beyond the limits of chiropractic practice.²

However, an injured party does not always prevail. In Miyamoto v. Lazo, the plaintiff claimed that Dr. Lazo, a chiropractor, negligently treated his injuries from a car accident.³ The patient was taking Coumadin and developed a hematoma in his left shoulder following chiropractic treatment. This was complicated by neuropathy in his left hand when the hematoma expanded and required surgical drainage.

The jury, however, found Dr. Lazo not liable, because of evidence that a hematoma could spontaneously arise in someone on an anticoagulant.

Injured patients have also filed lawsuits against other CAM practitioners. Allegations against acupuncturists have included cases of pneumothorax, wrongful death in an adolescent girl with asthma, and burns from a heat lamp.⁴ And in Wallman v. Kelley,a plaintiff developed liver damage and filed negligence and breach of implied warranty claims against a seller of Chinese herbal medicine.⁵ The court held that the defendant was not liable, as the plaintiff failed to prove causation or give timely notice of suit.

Medical doctors are increasingly incorporating CAM into their practices, so they must adhere to CAM standards in addition to their own medical standards.

In Charell v. Gonzalez, a cancer patient refused conventional treatment by oncologists and opted instead for nutritional therapy by a physician.⁶ Her cancer metastasized, and she alleged negligence and failure to warn of risks. The jury found the physician 51% liable for departure from standard of care and lack of informed consent. The plaintiff was found to be 49% at fault for choosing to ignore the recommendations of her oncologists.

Even if it’s the patient’s choice, physicians must still exercise due care when implementing therapy.

In Gonzalez v. New York State Department of Health, Dr. Gonzales was charged with gross negligence and incompetence after he used nutritional therapies to treat six patients with incurable cancer who had failed or rejected conventional treatment.⁷

The hearing committee found that he missed signs of disease progression and failed to perform adequate assessments, testing, and follow-up evaluations. The court held that a patient’s consent to or even insistence upon a certain treatment does not relieve the physician from the obligation of treating the patient with the usual standard of care.

In general, a physician may employ several legal defenses to avert liability following an adverse event.

One defense is to assert the “respectable minority” standard of care, if it can be shown that a respectable minority in the medical community also accepts the treatment in question.

A second defense is assumption of risk. In Schneider v. Revici, a physician delivered nutritional (selenium and dietary restrictions) and other nonsurgical treatment for breast cancer after the patient refused conventional treatments offered by other physicians.⁸ The patient signed a detailed consent form releasing the physician from liability and acknowledging that the defendant’s treatments lacked Food and Drug Administration approval, and that no results could be guaranteed.

The cancer spread, and the patient sued for common law fraud, medical malpractice, and lack of informed consent. The court of appeals held that assumption of risk is a complete defense to malpractice. The same court also held in another case that a patient’s failure to sign a consent form did not preclude the jury from considering the assumption of risk defense.

A third defense, rarely successful, is to invoke “clinical innovation” when CAM is used to alleviate a desperate situation, for example, if the patient is terminal or has failed conventional therapy. The defendant-physician may plead involvement in a clinical trial study, or show that the unorthodox treatment is based on extensive personal experience or some newly discovered developments in the field.

When discussing CAM, the physician should first fully inform the patient about conventional treatments and their limitations. Next, the physician should explain why the “novel” rather than the recognized conventional therapy is being considered. Finally, whether the physician intends to carry out CAM therapy or refer to another practitioner, the patient must be warned about the potential risks associated with such therapy.
 

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is modified from a chapter in the author’s book, “Medical Malpractice: Understanding the Law, Managing the Risk.” It is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. Wengel v. Herfert, 473 N.W.2d 741 (1991).

2. Salazar v. Ehmann, 505 P.2d 387 (1972).

3. Miyamoto v. Lum and Lazo, 84 P.3d 509 (2004).

4. Rosenberg v. Jing Jiang, 153 A.D.3d 744 (2017).

5. Wallman v. Kelley, 976 P.2d 330 (1998).

6. Charell v. Gonzales, 673 N.Y.S. 2d 685 (1998).

7. Gonzales v. NYS DOH, 232 A.D.2d 886 (1996).

8. Schneider v. Revici, 817 F. 2d 987 (1987).

Question: Which one of the following statements regarding complementary and alternative medicine (CAM) is correct?

A. CAM practitioners are just as likely as medical doctors to be sued.

B. Damages arising out of the use of CAM may be compensable if there is clear and convincing evidence of substandard care, and the plaintiff can prove legal causation.

C. An acupuncturist who treats an asthmatic patient will be sued if he/she fails to refer the patient to a medical specialist.

D. Obtaining informed consent after discussing all therapeutic options and material risks is especially important for those who practice CAM.

E. It is not a valid defense that the patient had fully and willingly assumed the risk of treatment.

Answer: D. Compared with medical doctors, non-MD practitioners of CAM pay lower malpractice insurance premiums, as they are much less likely to be sued, and patient injuries are usually less severe.

CAM covers a broad range of healing philosophies, approaches, and therapies that are typically outside mainstream Western medicine. It comprises modalities such as chiropractic, acupuncture, massage therapy, naturopathic medicine, nutritional therapy, and others.

More than half of the U.S. population uses some form of CAM, which is widely perceived as a natural and effective means of promoting overall well being in addition to treating a specific illness. The scope of practice for CAM providers is defined and limited by state rather than federal statutes, and enforced by regulatory bodies.

CAM treatments are generally noninvasive, and there are fewer than 50 indemnity insurers in the country for chiropractors, massage therapists, and acupuncturists, underwriting some 5% of the total medical malpractice insurance market.

In the event of an injury, damages are recoverable if there is a preponderance of evidence to indicate substandard care. “Clear and convincing” is a higher evidentiary level of legal proof, and it is not required in a negligence action. Whether an acupuncturist will be sued successfully for treating an asthmatic patient will depend on many factors, for example, whether it is an acceptable CAM practice in the jurisdiction, whether there is any statutory restriction on such treatment, whether there was a failure of a timely referral, etc.

Finally, assumption of risk is a valid defense in a negligence tort action under some circumstances.

For a negligence claim to prevail, the plaintiff must establish breach of duty, i.e., that the defendant deviated from the standard of care ordinarily exercised by a similarly situated practitioner. In addition to falling below that level of skill, practitioners may also be sued for having failed to refer to a medical doctor, for practicing outside the scope of CAM, or for venturing into traditional Western medical practice.

In one instance, a plaintiff alleged that he was led to believe that chiropractic manipulation would help his diabetes. The court found in favor of the plaintiff and awarded damages.¹ In another, the plaintiff successfully sued a chiropractor for failing to take x-rays and refer to a medical doctor. The court held that the defendant fell below the standard of care, as the state licensing board required physician referral when the problem extended beyond the limits of chiropractic practice.²

However, an injured party does not always prevail. In Miyamoto v. Lazo, the plaintiff claimed that Dr. Lazo, a chiropractor, negligently treated his injuries from a car accident.³ The patient was taking Coumadin and developed a hematoma in his left shoulder following chiropractic treatment. This was complicated by neuropathy in his left hand when the hematoma expanded and required surgical drainage.

The jury, however, found Dr. Lazo not liable, because of evidence that a hematoma could spontaneously arise in someone on an anticoagulant.

Injured patients have also filed lawsuits against other CAM practitioners. Allegations against acupuncturists have included cases of pneumothorax, wrongful death in an adolescent girl with asthma, and burns from a heat lamp.⁴ And in Wallman v. Kelley,a plaintiff developed liver damage and filed negligence and breach of implied warranty claims against a seller of Chinese herbal medicine.⁵ The court held that the defendant was not liable, as the plaintiff failed to prove causation or give timely notice of suit.

Medical doctors are increasingly incorporating CAM into their practices, so they must adhere to CAM standards in addition to their own medical standards.

In Charell v. Gonzalez, a cancer patient refused conventional treatment by oncologists and opted instead for nutritional therapy by a physician.⁶ Her cancer metastasized, and she alleged negligence and failure to warn of risks. The jury found the physician 51% liable for departure from standard of care and lack of informed consent. The plaintiff was found to be 49% at fault for choosing to ignore the recommendations of her oncologists.

Even if it’s the patient’s choice, physicians must still exercise due care when implementing therapy.

In Gonzalez v. New York State Department of Health, Dr. Gonzales was charged with gross negligence and incompetence after he used nutritional therapies to treat six patients with incurable cancer who had failed or rejected conventional treatment.⁷

The hearing committee found that he missed signs of disease progression and failed to perform adequate assessments, testing, and follow-up evaluations. The court held that a patient’s consent to or even insistence upon a certain treatment does not relieve the physician from the obligation of treating the patient with the usual standard of care.

In general, a physician may employ several legal defenses to avert liability following an adverse event.

One defense is to assert the “respectable minority” standard of care, if it can be shown that a respectable minority in the medical community also accepts the treatment in question.

A second defense is assumption of risk. In Schneider v. Revici, a physician delivered nutritional (selenium and dietary restrictions) and other nonsurgical treatment for breast cancer after the patient refused conventional treatments offered by other physicians.⁸ The patient signed a detailed consent form releasing the physician from liability and acknowledging that the defendant’s treatments lacked Food and Drug Administration approval, and that no results could be guaranteed.

The cancer spread, and the patient sued for common law fraud, medical malpractice, and lack of informed consent. The court of appeals held that assumption of risk is a complete defense to malpractice. The same court also held in another case that a patient’s failure to sign a consent form did not preclude the jury from considering the assumption of risk defense.

A third defense, rarely successful, is to invoke “clinical innovation” when CAM is used to alleviate a desperate situation, for example, if the patient is terminal or has failed conventional therapy. The defendant-physician may plead involvement in a clinical trial study, or show that the unorthodox treatment is based on extensive personal experience or some newly discovered developments in the field.

When discussing CAM, the physician should first fully inform the patient about conventional treatments and their limitations. Next, the physician should explain why the “novel” rather than the recognized conventional therapy is being considered. Finally, whether the physician intends to carry out CAM therapy or refer to another practitioner, the patient must be warned about the potential risks associated with such therapy.
 

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is modified from a chapter in the author’s book, “Medical Malpractice: Understanding the Law, Managing the Risk.” It is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. Wengel v. Herfert, 473 N.W.2d 741 (1991).

2. Salazar v. Ehmann, 505 P.2d 387 (1972).

3. Miyamoto v. Lum and Lazo, 84 P.3d 509 (2004).

4. Rosenberg v. Jing Jiang, 153 A.D.3d 744 (2017).

5. Wallman v. Kelley, 976 P.2d 330 (1998).

6. Charell v. Gonzales, 673 N.Y.S. 2d 685 (1998).

7. Gonzales v. NYS DOH, 232 A.D.2d 886 (1996).

8. Schneider v. Revici, 817 F. 2d 987 (1987).