Commentary

How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.

megaflopp/Thinkstock

What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?

Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.

You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.

Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?

What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.

And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?

Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?

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].

How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.

megaflopp/Thinkstock

What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?

Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.

You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.

Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?

What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.

And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?

Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?

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].

How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.

megaflopp/Thinkstock

What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?

Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.

You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.

Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?

What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.

And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?

Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?

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].

Just when I thought that all the nonsense about the benefits of aspirin for the prevention of heart attack had been obliterated with a series of reports on its danger and lack of benefit, more fake news arrived in the form of a proposal by the Centers for Disease Control and Prevention.

It proclaimed that there were “213 million opportunities to improve cardiovascular risks in America,” one of which would be to change behavior so that 9 million Americans would take a daily baby aspirin (MMWR 2018 Sep 7;67[35];983–91). Although the proposed benefits of aspirin have been around for a long time, the major contemporary emphasis resulted from the report of the Physicians’ Heart Study in healthy men in 1989 that there was a decrease in fatal and nonfatal MIs as a result of taking daily aspirin. However, listed in a separate endpoint analysis, sudden death, for some reason not considered to be a fatal event, was twice as frequent in the aspirin treated group compared to the placebo, and when included with fatal events wiped out most of the benefit of aspirin (N Engl J Med. 1989 Jul 20;321:129-35). Ask your friends like I do, if they take a baby aspirin daily and they all smile innocently and complacently and say, “Yes.”

Over the intervening years, there has been a general jousting around the benefits of aspirin with conflicting data and little convincing evidence. With the recent publications, there seems to be at least some glimmer hope that the public and medicine may come to their collective senses. In a series of articles published from the ASPREE and ASCEND trials, which included 19,114 and 15,480 healthy and diabetic patients, respectively, there is little benefit and significant risks to taking aspirin, not the least of which is severe bleeding and cancer.

In the ASPREE trial of healthy elderly men over 70, aspirin has no effect on both total all-cause mortality and cardiovascular mortality and is associated with increased major bleeding. ASPREE also reported that, in healthy elderly men, aspirin was associated with an increase in mortality because of increased cancer incidence (N Engl J Med. 2018 Oct 18;379:1499-529).

The ASCEND trial, which included in the patients with diabetes and without evidence of coronary vascular disease, aspirin use as primary prevention was associated with a decrease in cardiovascular mortality, which was erased by an increase in serious bleeding (N Engl J Med. 2018 Oct 18; 379:1529-39). In a companion review, Paul M. Ridker, MD, of Brigham and Women’s Hospital, Boston, concludes that “the best strategy for the use of aspirin in the prevention of cardiovascular disease may simply be to prescribe a statin instead” (N Engl J Med 2018 Oct. 18; 379:1572-4)

Someone needs to call the CDC.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Just when I thought that all the nonsense about the benefits of aspirin for the prevention of heart attack had been obliterated with a series of reports on its danger and lack of benefit, more fake news arrived in the form of a proposal by the Centers for Disease Control and Prevention.

It proclaimed that there were “213 million opportunities to improve cardiovascular risks in America,” one of which would be to change behavior so that 9 million Americans would take a daily baby aspirin (MMWR 2018 Sep 7;67[35];983–91). Although the proposed benefits of aspirin have been around for a long time, the major contemporary emphasis resulted from the report of the Physicians’ Heart Study in healthy men in 1989 that there was a decrease in fatal and nonfatal MIs as a result of taking daily aspirin. However, listed in a separate endpoint analysis, sudden death, for some reason not considered to be a fatal event, was twice as frequent in the aspirin treated group compared to the placebo, and when included with fatal events wiped out most of the benefit of aspirin (N Engl J Med. 1989 Jul 20;321:129-35). Ask your friends like I do, if they take a baby aspirin daily and they all smile innocently and complacently and say, “Yes.”

Over the intervening years, there has been a general jousting around the benefits of aspirin with conflicting data and little convincing evidence. With the recent publications, there seems to be at least some glimmer hope that the public and medicine may come to their collective senses. In a series of articles published from the ASPREE and ASCEND trials, which included 19,114 and 15,480 healthy and diabetic patients, respectively, there is little benefit and significant risks to taking aspirin, not the least of which is severe bleeding and cancer.

In the ASPREE trial of healthy elderly men over 70, aspirin has no effect on both total all-cause mortality and cardiovascular mortality and is associated with increased major bleeding. ASPREE also reported that, in healthy elderly men, aspirin was associated with an increase in mortality because of increased cancer incidence (N Engl J Med. 2018 Oct 18;379:1499-529).

The ASCEND trial, which included in the patients with diabetes and without evidence of coronary vascular disease, aspirin use as primary prevention was associated with a decrease in cardiovascular mortality, which was erased by an increase in serious bleeding (N Engl J Med. 2018 Oct 18; 379:1529-39). In a companion review, Paul M. Ridker, MD, of Brigham and Women’s Hospital, Boston, concludes that “the best strategy for the use of aspirin in the prevention of cardiovascular disease may simply be to prescribe a statin instead” (N Engl J Med 2018 Oct. 18; 379:1572-4)

Someone needs to call the CDC.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Just when I thought that all the nonsense about the benefits of aspirin for the prevention of heart attack had been obliterated with a series of reports on its danger and lack of benefit, more fake news arrived in the form of a proposal by the Centers for Disease Control and Prevention.

It proclaimed that there were “213 million opportunities to improve cardiovascular risks in America,” one of which would be to change behavior so that 9 million Americans would take a daily baby aspirin (MMWR 2018 Sep 7;67[35];983–91). Although the proposed benefits of aspirin have been around for a long time, the major contemporary emphasis resulted from the report of the Physicians’ Heart Study in healthy men in 1989 that there was a decrease in fatal and nonfatal MIs as a result of taking daily aspirin. However, listed in a separate endpoint analysis, sudden death, for some reason not considered to be a fatal event, was twice as frequent in the aspirin treated group compared to the placebo, and when included with fatal events wiped out most of the benefit of aspirin (N Engl J Med. 1989 Jul 20;321:129-35). Ask your friends like I do, if they take a baby aspirin daily and they all smile innocently and complacently and say, “Yes.”

Over the intervening years, there has been a general jousting around the benefits of aspirin with conflicting data and little convincing evidence. With the recent publications, there seems to be at least some glimmer hope that the public and medicine may come to their collective senses. In a series of articles published from the ASPREE and ASCEND trials, which included 19,114 and 15,480 healthy and diabetic patients, respectively, there is little benefit and significant risks to taking aspirin, not the least of which is severe bleeding and cancer.

In the ASPREE trial of healthy elderly men over 70, aspirin has no effect on both total all-cause mortality and cardiovascular mortality and is associated with increased major bleeding. ASPREE also reported that, in healthy elderly men, aspirin was associated with an increase in mortality because of increased cancer incidence (N Engl J Med. 2018 Oct 18;379:1499-529).

The ASCEND trial, which included in the patients with diabetes and without evidence of coronary vascular disease, aspirin use as primary prevention was associated with a decrease in cardiovascular mortality, which was erased by an increase in serious bleeding (N Engl J Med. 2018 Oct 18; 379:1529-39). In a companion review, Paul M. Ridker, MD, of Brigham and Women’s Hospital, Boston, concludes that “the best strategy for the use of aspirin in the prevention of cardiovascular disease may simply be to prescribe a statin instead” (N Engl J Med 2018 Oct. 18; 379:1572-4)

Someone needs to call the CDC.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Consider Ashley, a 22-year-old G3P2, 8 weeks pregnant, on Medicaid and living in rural Arkansas. The victim of intimate partner violence, she just broke up with her boyfriend and feels she does not have the financial or emotional resources to raise another child; she has no family in town to turn to and wants to be the best parent she can be to her 10-month-old and 3-year old.

In Arkansas, as in many other states and the District of Columbia, Medicaid covers abortion only for rape, incest, or danger to the woman’s life. Arkansas, as well as many other states, requires women to wait 48 hours following counseling before they can proceed with abortion. Waiting periods exacerbate Ashley’s tenuous situation. Will her boss give her time off from work? How will she get to the clinic? Who will watch her children? And lost wages and greater expenses are not the only problems she faces. Arkansas requires a legal contract between the abortion provider and a physician with hospital admitting privileges to provide medical abortion. The result: Only one clinic in Arkansas can legally provide medical abortion for its entire female population. For our impoverished young mother of two, the best choice is the most difficult. And she is far from alone.

Since 2010, many states have passed numerous laws restricting access to safe abortion. As geography plays a growing role in determining access, women and health care providers actively seek ways to circumvent barriers. Telemedicine, initially designed to expedite primary care for patients whose access was hampered by Boston traffic, now brings quality health care to areas lacking providers.¹ Telemedicine works for a variety of medical services, from prescribing antibiotics to performing neurosurgery; reproductive health care is part of this digital revolution.² In 2008, Iowa’s Planned Parenthood of the Heartland began using telemedicine to offer medical abortion.³

As approved by the Food and Drug Administration, medical abortion is the termination of a pregnancy of up to 10 weeks’ gestation using a combination of mifepristone and misoprostol, the former taken to block progesterone receptors, the latter to cause expulsion of the pregnancy. Today, about a third of all abortions in the United States are medical abortions. Because current FDA regulations require that mifepristone be dispensed by a physician, patients usually receive the medications after an in-person evaluation by a health care provider in a clinic.

Two models of telemedicine could improve access for Ashley.

In the first, like the Iowa Planned Parenthood model, remote clinic staff evaluate patients with history and physical examination, ultrasonography, and hemoglobin measurement; the information is forwarded to an off-site physician who has a video discussion with the patient and remotely dispenses the medication for eligible candidates. Between 2008 and 2015, Iowa Planned Parenthood provided 8,765 medical abortions using this model.³ Clinically adverse events, such as hospital admission, surgery, blood transfusion, and death occurred in 16 (0.18%) with no ectopic pregnancies or death.³ For comparison, the rate of severe maternal morbidity in the United States is 1.4%, approximately 10 times the rate with this model of medical abortion.⁴

In the second model of fully self-managed telemedicine abortion, patients complete a checklist that is reviewed by a provider who sends the medications through the mail. For safety, women must be able to determine their eligibility through the checklist, manage the medications, and self-assess for abortion completion. The World Health Organization endorses self-managed abortion as an option when there is “a source of accurate information and access to a health care provider should they need or want it at any stage of the process.”⁵ Women on Web, an organization that has provided telemedicine abortion to women globally, has recently begun providing services to the United States after sweeping restrictions vastly increased the number of requests from U.S. women. The U.S. service, Aid Access, operates similarly and for $95 provides online consultation, shipping of the medications, and Skype or phone calls for questions.⁶

Self-managed abortion has a bad reputation, in part from anti-abortion activists who seek to punish women who attempt to end their pregnancies themselves, but also because of its association with pre–Roe v. Wade “back alley” unsafe abortions. Neither perspective recognizes the benefits of safe self-managed abortion. Some states have criminalized self-induced abortion; both the American College of Obstetricians and Gynecologists and the American Medical Association have voiced opposition to such laws to ensure that women do not fear prosecution for seeking medical care for complications.

• Access barriers: The complexity and number of legal restrictions to abortion care have made it unavailable/unaffordable through traditional clinic visits in many parts of the United States. With the addition of Justice Brett M. Kavanaugh to the Supreme Court, restrictions are likely to increase.
• Safety: The evidence-based assessment of the World Health Organization is that in-person clinical evaluation is unnecessary if the appropriate checklists, educational information, and access to a provider are available.
• Autonomy and equity: Even without the barriers mentioned above, self-managed telemedicine abortion remains a patient-centered option. Often more accessible and less expensive, inherently more private, it is bound to appeal to many women.

This decade has seen unprecedented challenges to comprehensive safe reproductive health care, with no relief in sight. In the decades prior to Roe v. Wade, illegal abortions were responsible for 20% of all maternal mortality in the United States. As government, national medical organizations, and the public become more aware of our intolerably high maternal mortality rate, these actors are increasingly driven to bring our maternal health to parity with our industrialized peers. Restricting access to safe abortion runs counter to that goal. Two hundred forty years of American history teach us that legal restrictions do not prevent abortions, because they do not eliminate the reasons for which women seek abortion. Legal restrictions do, however, prevent women from ending pregnancies in the safest manner possible. The inability to obtain safe abortions invariably leads to dead women – our mothers, daughters, sisters, and wives. In this country’s harsh political climate, we must protect a woman’s right to choose. By advocating for innovative approaches to protect women’s reproductive choices, we empower women and save lives.

Dr. Anwar is an obstetrician/gynecologist at Michigan State University in Flint and Dr. Espey is professor and chair of obstetrics and gynecology at the University of New Mexico, Albuquerque. Neither of them have conflicts of interest. Email them at [email protected].

References

1. “How a ‘Stupid Idea’ Gave Birth to Telemedicine,” MedPageToday. Dec 15, .

2. J Neurosurg Pediatr. 2016 Dec;25(6):753-7.

3. Obstet Gynecol. 2017 Oct;130(4):778-82.

4. Centers for Disease Control and Prevention. Severe Maternal Morbidity in the United States.

5. Guttmacher Rep Public Policy. 2018;21:41-7.

6. “International ‘safe abortions by mail’ service can now ship to women in US,” The Hill, Nov 7, 2018.

Consider Ashley, a 22-year-old G3P2, 8 weeks pregnant, on Medicaid and living in rural Arkansas. The victim of intimate partner violence, she just broke up with her boyfriend and feels she does not have the financial or emotional resources to raise another child; she has no family in town to turn to and wants to be the best parent she can be to her 10-month-old and 3-year old.

In Arkansas, as in many other states and the District of Columbia, Medicaid covers abortion only for rape, incest, or danger to the woman’s life. Arkansas, as well as many other states, requires women to wait 48 hours following counseling before they can proceed with abortion. Waiting periods exacerbate Ashley’s tenuous situation. Will her boss give her time off from work? How will she get to the clinic? Who will watch her children? And lost wages and greater expenses are not the only problems she faces. Arkansas requires a legal contract between the abortion provider and a physician with hospital admitting privileges to provide medical abortion. The result: Only one clinic in Arkansas can legally provide medical abortion for its entire female population. For our impoverished young mother of two, the best choice is the most difficult. And she is far from alone.

Since 2010, many states have passed numerous laws restricting access to safe abortion. As geography plays a growing role in determining access, women and health care providers actively seek ways to circumvent barriers. Telemedicine, initially designed to expedite primary care for patients whose access was hampered by Boston traffic, now brings quality health care to areas lacking providers.¹ Telemedicine works for a variety of medical services, from prescribing antibiotics to performing neurosurgery; reproductive health care is part of this digital revolution.² In 2008, Iowa’s Planned Parenthood of the Heartland began using telemedicine to offer medical abortion.³

As approved by the Food and Drug Administration, medical abortion is the termination of a pregnancy of up to 10 weeks’ gestation using a combination of mifepristone and misoprostol, the former taken to block progesterone receptors, the latter to cause expulsion of the pregnancy. Today, about a third of all abortions in the United States are medical abortions. Because current FDA regulations require that mifepristone be dispensed by a physician, patients usually receive the medications after an in-person evaluation by a health care provider in a clinic.

Two models of telemedicine could improve access for Ashley.

In the first, like the Iowa Planned Parenthood model, remote clinic staff evaluate patients with history and physical examination, ultrasonography, and hemoglobin measurement; the information is forwarded to an off-site physician who has a video discussion with the patient and remotely dispenses the medication for eligible candidates. Between 2008 and 2015, Iowa Planned Parenthood provided 8,765 medical abortions using this model.³ Clinically adverse events, such as hospital admission, surgery, blood transfusion, and death occurred in 16 (0.18%) with no ectopic pregnancies or death.³ For comparison, the rate of severe maternal morbidity in the United States is 1.4%, approximately 10 times the rate with this model of medical abortion.⁴

In the second model of fully self-managed telemedicine abortion, patients complete a checklist that is reviewed by a provider who sends the medications through the mail. For safety, women must be able to determine their eligibility through the checklist, manage the medications, and self-assess for abortion completion. The World Health Organization endorses self-managed abortion as an option when there is “a source of accurate information and access to a health care provider should they need or want it at any stage of the process.”⁵ Women on Web, an organization that has provided telemedicine abortion to women globally, has recently begun providing services to the United States after sweeping restrictions vastly increased the number of requests from U.S. women. The U.S. service, Aid Access, operates similarly and for $95 provides online consultation, shipping of the medications, and Skype or phone calls for questions.⁶

Self-managed abortion has a bad reputation, in part from anti-abortion activists who seek to punish women who attempt to end their pregnancies themselves, but also because of its association with pre–Roe v. Wade “back alley” unsafe abortions. Neither perspective recognizes the benefits of safe self-managed abortion. Some states have criminalized self-induced abortion; both the American College of Obstetricians and Gynecologists and the American Medical Association have voiced opposition to such laws to ensure that women do not fear prosecution for seeking medical care for complications.

• Access barriers: The complexity and number of legal restrictions to abortion care have made it unavailable/unaffordable through traditional clinic visits in many parts of the United States. With the addition of Justice Brett M. Kavanaugh to the Supreme Court, restrictions are likely to increase.
• Safety: The evidence-based assessment of the World Health Organization is that in-person clinical evaluation is unnecessary if the appropriate checklists, educational information, and access to a provider are available.
• Autonomy and equity: Even without the barriers mentioned above, self-managed telemedicine abortion remains a patient-centered option. Often more accessible and less expensive, inherently more private, it is bound to appeal to many women.

This decade has seen unprecedented challenges to comprehensive safe reproductive health care, with no relief in sight. In the decades prior to Roe v. Wade, illegal abortions were responsible for 20% of all maternal mortality in the United States. As government, national medical organizations, and the public become more aware of our intolerably high maternal mortality rate, these actors are increasingly driven to bring our maternal health to parity with our industrialized peers. Restricting access to safe abortion runs counter to that goal. Two hundred forty years of American history teach us that legal restrictions do not prevent abortions, because they do not eliminate the reasons for which women seek abortion. Legal restrictions do, however, prevent women from ending pregnancies in the safest manner possible. The inability to obtain safe abortions invariably leads to dead women – our mothers, daughters, sisters, and wives. In this country’s harsh political climate, we must protect a woman’s right to choose. By advocating for innovative approaches to protect women’s reproductive choices, we empower women and save lives.

Dr. Anwar is an obstetrician/gynecologist at Michigan State University in Flint and Dr. Espey is professor and chair of obstetrics and gynecology at the University of New Mexico, Albuquerque. Neither of them have conflicts of interest. Email them at [email protected].

References

1. “How a ‘Stupid Idea’ Gave Birth to Telemedicine,” MedPageToday. Dec 15, .

2. J Neurosurg Pediatr. 2016 Dec;25(6):753-7.

3. Obstet Gynecol. 2017 Oct;130(4):778-82.

4. Centers for Disease Control and Prevention. Severe Maternal Morbidity in the United States.

5. Guttmacher Rep Public Policy. 2018;21:41-7.

6. “International ‘safe abortions by mail’ service can now ship to women in US,” The Hill, Nov 7, 2018.

Consider Ashley, a 22-year-old G3P2, 8 weeks pregnant, on Medicaid and living in rural Arkansas. The victim of intimate partner violence, she just broke up with her boyfriend and feels she does not have the financial or emotional resources to raise another child; she has no family in town to turn to and wants to be the best parent she can be to her 10-month-old and 3-year old.

In Arkansas, as in many other states and the District of Columbia, Medicaid covers abortion only for rape, incest, or danger to the woman’s life. Arkansas, as well as many other states, requires women to wait 48 hours following counseling before they can proceed with abortion. Waiting periods exacerbate Ashley’s tenuous situation. Will her boss give her time off from work? How will she get to the clinic? Who will watch her children? And lost wages and greater expenses are not the only problems she faces. Arkansas requires a legal contract between the abortion provider and a physician with hospital admitting privileges to provide medical abortion. The result: Only one clinic in Arkansas can legally provide medical abortion for its entire female population. For our impoverished young mother of two, the best choice is the most difficult. And she is far from alone.

Since 2010, many states have passed numerous laws restricting access to safe abortion. As geography plays a growing role in determining access, women and health care providers actively seek ways to circumvent barriers. Telemedicine, initially designed to expedite primary care for patients whose access was hampered by Boston traffic, now brings quality health care to areas lacking providers.¹ Telemedicine works for a variety of medical services, from prescribing antibiotics to performing neurosurgery; reproductive health care is part of this digital revolution.² In 2008, Iowa’s Planned Parenthood of the Heartland began using telemedicine to offer medical abortion.³

As approved by the Food and Drug Administration, medical abortion is the termination of a pregnancy of up to 10 weeks’ gestation using a combination of mifepristone and misoprostol, the former taken to block progesterone receptors, the latter to cause expulsion of the pregnancy. Today, about a third of all abortions in the United States are medical abortions. Because current FDA regulations require that mifepristone be dispensed by a physician, patients usually receive the medications after an in-person evaluation by a health care provider in a clinic.

Two models of telemedicine could improve access for Ashley.

In the first, like the Iowa Planned Parenthood model, remote clinic staff evaluate patients with history and physical examination, ultrasonography, and hemoglobin measurement; the information is forwarded to an off-site physician who has a video discussion with the patient and remotely dispenses the medication for eligible candidates. Between 2008 and 2015, Iowa Planned Parenthood provided 8,765 medical abortions using this model.³ Clinically adverse events, such as hospital admission, surgery, blood transfusion, and death occurred in 16 (0.18%) with no ectopic pregnancies or death.³ For comparison, the rate of severe maternal morbidity in the United States is 1.4%, approximately 10 times the rate with this model of medical abortion.⁴

In the second model of fully self-managed telemedicine abortion, patients complete a checklist that is reviewed by a provider who sends the medications through the mail. For safety, women must be able to determine their eligibility through the checklist, manage the medications, and self-assess for abortion completion. The World Health Organization endorses self-managed abortion as an option when there is “a source of accurate information and access to a health care provider should they need or want it at any stage of the process.”⁵ Women on Web, an organization that has provided telemedicine abortion to women globally, has recently begun providing services to the United States after sweeping restrictions vastly increased the number of requests from U.S. women. The U.S. service, Aid Access, operates similarly and for $95 provides online consultation, shipping of the medications, and Skype or phone calls for questions.⁶

Self-managed abortion has a bad reputation, in part from anti-abortion activists who seek to punish women who attempt to end their pregnancies themselves, but also because of its association with pre–Roe v. Wade “back alley” unsafe abortions. Neither perspective recognizes the benefits of safe self-managed abortion. Some states have criminalized self-induced abortion; both the American College of Obstetricians and Gynecologists and the American Medical Association have voiced opposition to such laws to ensure that women do not fear prosecution for seeking medical care for complications.

• Access barriers: The complexity and number of legal restrictions to abortion care have made it unavailable/unaffordable through traditional clinic visits in many parts of the United States. With the addition of Justice Brett M. Kavanaugh to the Supreme Court, restrictions are likely to increase.
• Safety: The evidence-based assessment of the World Health Organization is that in-person clinical evaluation is unnecessary if the appropriate checklists, educational information, and access to a provider are available.
• Autonomy and equity: Even without the barriers mentioned above, self-managed telemedicine abortion remains a patient-centered option. Often more accessible and less expensive, inherently more private, it is bound to appeal to many women.

This decade has seen unprecedented challenges to comprehensive safe reproductive health care, with no relief in sight. In the decades prior to Roe v. Wade, illegal abortions were responsible for 20% of all maternal mortality in the United States. As government, national medical organizations, and the public become more aware of our intolerably high maternal mortality rate, these actors are increasingly driven to bring our maternal health to parity with our industrialized peers. Restricting access to safe abortion runs counter to that goal. Two hundred forty years of American history teach us that legal restrictions do not prevent abortions, because they do not eliminate the reasons for which women seek abortion. Legal restrictions do, however, prevent women from ending pregnancies in the safest manner possible. The inability to obtain safe abortions invariably leads to dead women – our mothers, daughters, sisters, and wives. In this country’s harsh political climate, we must protect a woman’s right to choose. By advocating for innovative approaches to protect women’s reproductive choices, we empower women and save lives.

Dr. Anwar is an obstetrician/gynecologist at Michigan State University in Flint and Dr. Espey is professor and chair of obstetrics and gynecology at the University of New Mexico, Albuquerque. Neither of them have conflicts of interest. Email them at [email protected].

References

1. “How a ‘Stupid Idea’ Gave Birth to Telemedicine,” MedPageToday. Dec 15, .

2. J Neurosurg Pediatr. 2016 Dec;25(6):753-7.

3. Obstet Gynecol. 2017 Oct;130(4):778-82.

4. Centers for Disease Control and Prevention. Severe Maternal Morbidity in the United States.

5. Guttmacher Rep Public Policy. 2018;21:41-7.

6. “International ‘safe abortions by mail’ service can now ship to women in US,” The Hill, Nov 7, 2018.

Health care is a constantly changing field, thanks to innovative research and technological advancements. And with optimal team practice and full practice authority, PAs and NPs are poised to drive further improvements to patient care. But while we all recognize the need to keep learning, some of the greatest lessons I’ve learned in my career have little to do with the “latest and greatest” tools—they are fundamentals of being a good person and effective health care provider. I would like to share some of them with you.

1 It’s OK to make a mistake, but be sure to own it and learn from it.

You can’t grow as a person or a provider if you can’t acknowledge failure and vow to improve. Don’t become complacent; a little bit of fear keeps us on our toes and hopefully out of trouble.

It always seems to be Friday at 4:45 pm when you receive that phone call from the pharmacist asking, “Did you really want to prescribe amoxicillin/clavulanate to Mrs. Jones? She’s allergic to penicillin.” You quickly check the EMR and don’t see that specific allergy listed. You choose an alternative medication and send the prescription back to the pharmacy.

But while many providers would stop there, assuming that they have solved the problem, I would advocate for calling the patient directly and addressing the issue head-on. The patient may be thinking, “What an idiot, she missed that in my chart.” Clearly, there was a breakdown in the process, but you are the one who is ultimately responsible.

A phone call to verify the allergy and the type of reaction is very valuable. It proves to the patient that you take patient care seriously and that you recognize that the system needs to be improved.

2 Find one thing in common with each patient, even if it is something small.

Maybe you grew up in the same town, or like the same sports team, or enjoy the same type of food. It isn’t difficult to find a commonality; a note in the patient’s chart ensures you’ll remember. That personal touch demonstrates that you care and increases the patient’s comfort with you.

This technique can make a huge difference with a “difficult” patient. One day, a new patient presented to my office for a change in bowel habits. He was clearly anxious and angry with his wife (who accompanied him) for “making me come here.”

Continue to: During the social history...

During the social history, I learned that he owned a trucking business. I asked what kind of trucks. He said, “Big ones!” I was more specific in my next attempt, asking, “Volvo, Peterbilt, International, or Kenworth?” He looked puzzled and said, “I see you know something about trucks.” I explained that my husband is a diesel mechanic and that we play “identify the truck” when travelling with our young sons. It turned out that my husband had worked on the patient’s truck the week before.

The dynamic of our encounter changed immediately, and we were able to schedule him for a much-needed colonoscopy. He was diagnosed with a large precancerous colon polyp, and I was relieved that our “connection” smoothed the way to getting him the care he needed.

3 Always remember that people are watching.

Nothing is truly private anymore. Social media can be a great forum for exchanging information and knowledge, but you could become the latest YouTube sensation (not necessarily in a positive way) at any time.

When a patient asks if he can record our visit to share with family, I wonder how many have done so without permission. The bottom line is that we, as health care professionals, have a high standard to live up to.

This was brought home to me in my work as a volunteer firefighter and EMT. One night I had barely finished loading a patient from a serious motor vehicle collision into a helicopter to be transferred to definitive care when my phone started buzzing. A photographer from the local newspaper—whom I didn’t even know was on scene—had snapped a picture of me in action and posted it to his online news site and social media accounts. Within 5 minutes, several coworkers had seen it and texted me. My surname across the bottom of my jacket provided a clear indication of where I was and what I was doing. I was absolutely shocked at how quickly news spread, and although nothing untoward or inappropriate was documented, it was unsettling to realize that I was “in the public eye” while I was focused on doing my job.

Continue to: That photo is now the screensaver...

That photo is now the screensaver on my computer. It’s a daily reminder that someone is always watching and I must conduct myself accordingly.

4 Don’t be afraid to speak up.

Don’t be a tattletale, but do stand up for what you know is right. When presented with a choice, always do the right thing, even if it is more difficult.

This is harder than it sounds; I know how tough it was for me to find my voice. But I did during the case of a middle-aged woman with a significant upper GI bleed. She had been in her normal state of health until she experienced a sudden onset of nausea and vomiting; her husband called EMS when she began vomiting large amounts of bright red blood. Her care plan involved multiple members of our GI service, as well as colleagues from an affiliated tertiary care hospital, and I spent hours coordinating care and obtaining the necessary consults. When the patient subsequently developed abdominal compartment syndrome and required bedside surgical intervention, the attending surgeon proceeded to dress me down in front of the entire ICU team, screaming, “Why isn’t Dr. So-and-so here caring for this patient? Why aren’t you doing anything to care for this woman?”

In the old days, I would have walked away without saying anything—that’s what was expected. But, my own hurt feelings aside, I couldn’t stop thinking, “What if he treats others like that? If I don’t speak up, I’m an accomplice to his bad behavior.” So I waited for his team to perform the urgent procedure and then politely asked if I could speak with him. I was shaking in my shoes when I began by asking if he had read my notes in the patient’s chart. He grudgingly said, “No.” I listed the physicians who had been consulted about this patient and documented the time the team had spent developing a safe treatment plan for her. I ended by saying that it was unfair and unprofessional for him to yell at me, particularly in front of our colleagues, and I asked how he would have felt if treated the same way. He apologized and agreed to approach me privately if he had concerns in future. I can honestly say that encounter changed our working relationship in a very positive manner. One of the most difficult experiences of my entire career helped me to grow as a professional.

Continue to: Each and every one of us is an educator...

5 Each and every one of us is an educator, even if we don’t consciously choose to be.

You can be an educator without being employed as a teacher. Educators go above and beyond to make sure that learning is student centered and that knowledge is received and understood. Every day, we educate patients, families, friends, neighbors, and other members of the health care team.

A few months ago, I began a new paramedic job at a different agency. During training, one of my coworkers made an offhand comment: “It’s your fault that I’m here.” At my puzzled expression, he continued, “You don’t remember, do you? When you did my last firefighter physical, we talked about the best way to get a full-time job as a firefighter. You recommended that I consider a job in EMS to gain additional experience and interface with the fire departments, so here I am and I love it.” At that point, I did recall our conversation—but what I had seen as simple small talk with a patient had really been an educational moment. I had a smile on my face the whole drive home as I thought about how my casual conversation had a positive effect on him and his career path.

PAs and NPs are educators even when they are not presenting in the classroom or serving as a clinical preceptor. It doesn’t matter if you are new to the profession or have been working for many years—you have valuable experience that can help someone else. Please remember that even small moments can make a large impact. Strive to be a good educator at all times.

Health care is a constantly changing field, thanks to innovative research and technological advancements. And with optimal team practice and full practice authority, PAs and NPs are poised to drive further improvements to patient care. But while we all recognize the need to keep learning, some of the greatest lessons I’ve learned in my career have little to do with the “latest and greatest” tools—they are fundamentals of being a good person and effective health care provider. I would like to share some of them with you.

1 It’s OK to make a mistake, but be sure to own it and learn from it.

You can’t grow as a person or a provider if you can’t acknowledge failure and vow to improve. Don’t become complacent; a little bit of fear keeps us on our toes and hopefully out of trouble.

It always seems to be Friday at 4:45 pm when you receive that phone call from the pharmacist asking, “Did you really want to prescribe amoxicillin/clavulanate to Mrs. Jones? She’s allergic to penicillin.” You quickly check the EMR and don’t see that specific allergy listed. You choose an alternative medication and send the prescription back to the pharmacy.

But while many providers would stop there, assuming that they have solved the problem, I would advocate for calling the patient directly and addressing the issue head-on. The patient may be thinking, “What an idiot, she missed that in my chart.” Clearly, there was a breakdown in the process, but you are the one who is ultimately responsible.

A phone call to verify the allergy and the type of reaction is very valuable. It proves to the patient that you take patient care seriously and that you recognize that the system needs to be improved.

2 Find one thing in common with each patient, even if it is something small.

Maybe you grew up in the same town, or like the same sports team, or enjoy the same type of food. It isn’t difficult to find a commonality; a note in the patient’s chart ensures you’ll remember. That personal touch demonstrates that you care and increases the patient’s comfort with you.

This technique can make a huge difference with a “difficult” patient. One day, a new patient presented to my office for a change in bowel habits. He was clearly anxious and angry with his wife (who accompanied him) for “making me come here.”

Continue to: During the social history...

During the social history, I learned that he owned a trucking business. I asked what kind of trucks. He said, “Big ones!” I was more specific in my next attempt, asking, “Volvo, Peterbilt, International, or Kenworth?” He looked puzzled and said, “I see you know something about trucks.” I explained that my husband is a diesel mechanic and that we play “identify the truck” when travelling with our young sons. It turned out that my husband had worked on the patient’s truck the week before.

The dynamic of our encounter changed immediately, and we were able to schedule him for a much-needed colonoscopy. He was diagnosed with a large precancerous colon polyp, and I was relieved that our “connection” smoothed the way to getting him the care he needed.

3 Always remember that people are watching.

Nothing is truly private anymore. Social media can be a great forum for exchanging information and knowledge, but you could become the latest YouTube sensation (not necessarily in a positive way) at any time.

When a patient asks if he can record our visit to share with family, I wonder how many have done so without permission. The bottom line is that we, as health care professionals, have a high standard to live up to.

This was brought home to me in my work as a volunteer firefighter and EMT. One night I had barely finished loading a patient from a serious motor vehicle collision into a helicopter to be transferred to definitive care when my phone started buzzing. A photographer from the local newspaper—whom I didn’t even know was on scene—had snapped a picture of me in action and posted it to his online news site and social media accounts. Within 5 minutes, several coworkers had seen it and texted me. My surname across the bottom of my jacket provided a clear indication of where I was and what I was doing. I was absolutely shocked at how quickly news spread, and although nothing untoward or inappropriate was documented, it was unsettling to realize that I was “in the public eye” while I was focused on doing my job.

Continue to: That photo is now the screensaver...

That photo is now the screensaver on my computer. It’s a daily reminder that someone is always watching and I must conduct myself accordingly.

4 Don’t be afraid to speak up.

Don’t be a tattletale, but do stand up for what you know is right. When presented with a choice, always do the right thing, even if it is more difficult.

This is harder than it sounds; I know how tough it was for me to find my voice. But I did during the case of a middle-aged woman with a significant upper GI bleed. She had been in her normal state of health until she experienced a sudden onset of nausea and vomiting; her husband called EMS when she began vomiting large amounts of bright red blood. Her care plan involved multiple members of our GI service, as well as colleagues from an affiliated tertiary care hospital, and I spent hours coordinating care and obtaining the necessary consults. When the patient subsequently developed abdominal compartment syndrome and required bedside surgical intervention, the attending surgeon proceeded to dress me down in front of the entire ICU team, screaming, “Why isn’t Dr. So-and-so here caring for this patient? Why aren’t you doing anything to care for this woman?”

In the old days, I would have walked away without saying anything—that’s what was expected. But, my own hurt feelings aside, I couldn’t stop thinking, “What if he treats others like that? If I don’t speak up, I’m an accomplice to his bad behavior.” So I waited for his team to perform the urgent procedure and then politely asked if I could speak with him. I was shaking in my shoes when I began by asking if he had read my notes in the patient’s chart. He grudgingly said, “No.” I listed the physicians who had been consulted about this patient and documented the time the team had spent developing a safe treatment plan for her. I ended by saying that it was unfair and unprofessional for him to yell at me, particularly in front of our colleagues, and I asked how he would have felt if treated the same way. He apologized and agreed to approach me privately if he had concerns in future. I can honestly say that encounter changed our working relationship in a very positive manner. One of the most difficult experiences of my entire career helped me to grow as a professional.

Continue to: Each and every one of us is an educator...

5 Each and every one of us is an educator, even if we don’t consciously choose to be.

You can be an educator without being employed as a teacher. Educators go above and beyond to make sure that learning is student centered and that knowledge is received and understood. Every day, we educate patients, families, friends, neighbors, and other members of the health care team.

A few months ago, I began a new paramedic job at a different agency. During training, one of my coworkers made an offhand comment: “It’s your fault that I’m here.” At my puzzled expression, he continued, “You don’t remember, do you? When you did my last firefighter physical, we talked about the best way to get a full-time job as a firefighter. You recommended that I consider a job in EMS to gain additional experience and interface with the fire departments, so here I am and I love it.” At that point, I did recall our conversation—but what I had seen as simple small talk with a patient had really been an educational moment. I had a smile on my face the whole drive home as I thought about how my casual conversation had a positive effect on him and his career path.

PAs and NPs are educators even when they are not presenting in the classroom or serving as a clinical preceptor. It doesn’t matter if you are new to the profession or have been working for many years—you have valuable experience that can help someone else. Please remember that even small moments can make a large impact. Strive to be a good educator at all times.

Health care is a constantly changing field, thanks to innovative research and technological advancements. And with optimal team practice and full practice authority, PAs and NPs are poised to drive further improvements to patient care. But while we all recognize the need to keep learning, some of the greatest lessons I’ve learned in my career have little to do with the “latest and greatest” tools—they are fundamentals of being a good person and effective health care provider. I would like to share some of them with you.

1 It’s OK to make a mistake, but be sure to own it and learn from it.

You can’t grow as a person or a provider if you can’t acknowledge failure and vow to improve. Don’t become complacent; a little bit of fear keeps us on our toes and hopefully out of trouble.

It always seems to be Friday at 4:45 pm when you receive that phone call from the pharmacist asking, “Did you really want to prescribe amoxicillin/clavulanate to Mrs. Jones? She’s allergic to penicillin.” You quickly check the EMR and don’t see that specific allergy listed. You choose an alternative medication and send the prescription back to the pharmacy.

But while many providers would stop there, assuming that they have solved the problem, I would advocate for calling the patient directly and addressing the issue head-on. The patient may be thinking, “What an idiot, she missed that in my chart.” Clearly, there was a breakdown in the process, but you are the one who is ultimately responsible.

A phone call to verify the allergy and the type of reaction is very valuable. It proves to the patient that you take patient care seriously and that you recognize that the system needs to be improved.

2 Find one thing in common with each patient, even if it is something small.

Maybe you grew up in the same town, or like the same sports team, or enjoy the same type of food. It isn’t difficult to find a commonality; a note in the patient’s chart ensures you’ll remember. That personal touch demonstrates that you care and increases the patient’s comfort with you.

This technique can make a huge difference with a “difficult” patient. One day, a new patient presented to my office for a change in bowel habits. He was clearly anxious and angry with his wife (who accompanied him) for “making me come here.”

Continue to: During the social history...

During the social history, I learned that he owned a trucking business. I asked what kind of trucks. He said, “Big ones!” I was more specific in my next attempt, asking, “Volvo, Peterbilt, International, or Kenworth?” He looked puzzled and said, “I see you know something about trucks.” I explained that my husband is a diesel mechanic and that we play “identify the truck” when travelling with our young sons. It turned out that my husband had worked on the patient’s truck the week before.

The dynamic of our encounter changed immediately, and we were able to schedule him for a much-needed colonoscopy. He was diagnosed with a large precancerous colon polyp, and I was relieved that our “connection” smoothed the way to getting him the care he needed.

3 Always remember that people are watching.

Nothing is truly private anymore. Social media can be a great forum for exchanging information and knowledge, but you could become the latest YouTube sensation (not necessarily in a positive way) at any time.

When a patient asks if he can record our visit to share with family, I wonder how many have done so without permission. The bottom line is that we, as health care professionals, have a high standard to live up to.

This was brought home to me in my work as a volunteer firefighter and EMT. One night I had barely finished loading a patient from a serious motor vehicle collision into a helicopter to be transferred to definitive care when my phone started buzzing. A photographer from the local newspaper—whom I didn’t even know was on scene—had snapped a picture of me in action and posted it to his online news site and social media accounts. Within 5 minutes, several coworkers had seen it and texted me. My surname across the bottom of my jacket provided a clear indication of where I was and what I was doing. I was absolutely shocked at how quickly news spread, and although nothing untoward or inappropriate was documented, it was unsettling to realize that I was “in the public eye” while I was focused on doing my job.

Continue to: That photo is now the screensaver...

That photo is now the screensaver on my computer. It’s a daily reminder that someone is always watching and I must conduct myself accordingly.

4 Don’t be afraid to speak up.

Don’t be a tattletale, but do stand up for what you know is right. When presented with a choice, always do the right thing, even if it is more difficult.

This is harder than it sounds; I know how tough it was for me to find my voice. But I did during the case of a middle-aged woman with a significant upper GI bleed. She had been in her normal state of health until she experienced a sudden onset of nausea and vomiting; her husband called EMS when she began vomiting large amounts of bright red blood. Her care plan involved multiple members of our GI service, as well as colleagues from an affiliated tertiary care hospital, and I spent hours coordinating care and obtaining the necessary consults. When the patient subsequently developed abdominal compartment syndrome and required bedside surgical intervention, the attending surgeon proceeded to dress me down in front of the entire ICU team, screaming, “Why isn’t Dr. So-and-so here caring for this patient? Why aren’t you doing anything to care for this woman?”

In the old days, I would have walked away without saying anything—that’s what was expected. But, my own hurt feelings aside, I couldn’t stop thinking, “What if he treats others like that? If I don’t speak up, I’m an accomplice to his bad behavior.” So I waited for his team to perform the urgent procedure and then politely asked if I could speak with him. I was shaking in my shoes when I began by asking if he had read my notes in the patient’s chart. He grudgingly said, “No.” I listed the physicians who had been consulted about this patient and documented the time the team had spent developing a safe treatment plan for her. I ended by saying that it was unfair and unprofessional for him to yell at me, particularly in front of our colleagues, and I asked how he would have felt if treated the same way. He apologized and agreed to approach me privately if he had concerns in future. I can honestly say that encounter changed our working relationship in a very positive manner. One of the most difficult experiences of my entire career helped me to grow as a professional.

Continue to: Each and every one of us is an educator...

5 Each and every one of us is an educator, even if we don’t consciously choose to be.

You can be an educator without being employed as a teacher. Educators go above and beyond to make sure that learning is student centered and that knowledge is received and understood. Every day, we educate patients, families, friends, neighbors, and other members of the health care team.

A few months ago, I began a new paramedic job at a different agency. During training, one of my coworkers made an offhand comment: “It’s your fault that I’m here.” At my puzzled expression, he continued, “You don’t remember, do you? When you did my last firefighter physical, we talked about the best way to get a full-time job as a firefighter. You recommended that I consider a job in EMS to gain additional experience and interface with the fire departments, so here I am and I love it.” At that point, I did recall our conversation—but what I had seen as simple small talk with a patient had really been an educational moment. I had a smile on my face the whole drive home as I thought about how my casual conversation had a positive effect on him and his career path.

PAs and NPs are educators even when they are not presenting in the classroom or serving as a clinical preceptor. It doesn’t matter if you are new to the profession or have been working for many years—you have valuable experience that can help someone else. Please remember that even small moments can make a large impact. Strive to be a good educator at all times.

Telemedicine has been used successfully to improve patient access to medical care while reducing healthcare costs. In 2016, an estimated 61% of US healthcare institutions and 40% to 50% of US hospitals used telemedicine.¹ From 2012 to 2013, the telemedicine market grew by 60%. However, its widespread use has been limited by low reimbursement rates and interstate licensing and practice issues.

In this commentary, we discuss the history of telemedicine, current uses and challenges, and areas of future growth.

DEFINITION AND HISTORY

The World Health Organization defines telemedicine as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”²

Modern telemedicine began in the early 1900s in the Netherlands with the transmission of heart rhythms over the telephone,³ which was followed by transmissions to radio consultation centers in Europe in the 1920s. In the 1940s, radiographic images were transmitted by telephone between cities in Pennsylvania.⁴

Today, telemedicine is used in a variety of specialties including radiology, neurology, and pathology⁵ and by organizations in the United States ranging from the National Aeronautics and Space Administration and Kaiser Permanente to the US Department of Veterans Affairs (VA). The VA, in particular, is a leader in telemedicine. In 2012, it reduced mental health hospitalizations by over 40%, heart failure hospitalizations by 25%, and diabetes and chronic obstructive pulmonary disease hospitalizations by about 20% using telemedicine programs.⁶ In 2015, it provided about 2.1 million telemedicine consultations to 677,000 veterans.⁷

TYPES OF TELEMEDICINE PROGRAMS

There are 2 types of telemedicine programs.

Synchronous programs take place in real time and are a live 2-way interaction between the patient and healthcare provider. This includes virtual appointments that are conducted using the patient’s smartphone, tablet, or computer with a camera. When using a smartphone or tablet, patients must first download an app that connects them with a provider.

Asynchronous programs, also known as “store and forward” applications, are not live and involve the transfer of images, videos, and other clinical information that a healthcare provider views and responds to at a later time. In this case, patients may wear medical devices to monitor and track health information (eg, blood pressure) in a personal health application that they forward to their healthcare provider.

IMPROVING PATIENT ACCESS TO CARE WHILE REDUCING COSTS

Telemedicine allows patients living in both rural and urban areas to access healthcare when they need it. Currently, about 59 million Americans reside in health professional-shortage areas, which are rural and urban areas with shortages of primary care providers.¹ These patients often experience long delays when attempting to schedule a healthcare visit⁷ and may experience issues with continuity of care if they are unable to see the same care provider at every visit.

It also provides access to care to patients without reliable transportation or those who may be too sick to travel long distances. For some patients, such as those with cystic fibrosis who do not want to come to the hospital for fear of contracting multiple antibiotic-resistant bacteria, a virtual office visit may be safer.

At the same time, telemedicine helps reduce healthcare costs. For example, it:

• Optimizes staff distribution and healthcare resources within a healthcare facility and across an entire system
• Enables primary care providers to conduct appointments without additional office staff at any time, thereby extending office hours and availability
• Reduces the financial impact of patient no-shows
• Improves patient engagement and outcomes
• Reduces unnecessary office and emergency room visits and hospital admissions.

The last point is especially important for senior living and skilled nursing centers whose residents are known to have high rates of hospital admissions.^8,9 In these facilities, 24-hour medical assistance may not be available, and telemedicine can help troubleshoot common problems.

LOW REIMBURSEMENT RATES CURTAIL USE

Limited reimbursement has curtailed the widespread use of telemedicine. Although rules for reimbursement are evolving, telemedicine still represents a small amount of total healthcare expenditures. In 2015, Medicare spent approximately $14.4 million on services delivered via telemedicine—less than 0.01% of total spending on healthcare services.¹

Currently, 31 states and the District of Columbia have telemedicine parity laws that mandate private commercial insurers to pay for telemedicine services.¹⁰ Unfortunately, there is a lack of uniformity in the specifics of these laws, resulting in variations in reimbursement rates. Furthermore, a large number of larger insurers such as Medicare and Medicaid and many self-insured plans do not fall under these mandates.

Another factor that affects reimbursement for telemedicine services is the setting of the medical encounter. Medicare reimburses providers for telemedicine services only when they are conducted at specific sites such as physician’s offices, hospitals, rural health centers, and skilled nursing facilities. Additionally, Medicare only reimburses for services in areas with a shortage of healthcare professionals and in non-metropolitan areas, which excludes many urban patients.¹¹

In contrast, more commercial reimbursement is occurring for online urgent care, and options for commercial reimbursement of online behavioral services are being explored.

Current licensure laws also limit the ability of many healthcare providers to offer telemedicine services. Federal law requires providers to be fully licensed to practice medicine in the state where the patient is physically located. In cases of health systems that have locations in more than one state, providers may need to apply for and pay to maintain multiple licenses (current interstate licensing laws vary across states).

Interstate licensure is one way to solve this problem. Thus far, a number of states have joined the Interstate Medical Licensure Compact that intends to allow physicians to obtain expedited licenses to practice in multiple states.¹²

The federal TELE-MED Act was introduced in 2015 but not passed. It proposed to “allow a Medicare provider to provide telemedicine services to a Medicare beneficiary who is in a different state from the one in which the provider is licensed or authorized to provide healthcare services.”

CAN TELEMEDICINE FOSTER A GOOD PROVIDER-PATIENT RELATIONSHIP?

In-person encounters provide healthcare providers with the opportunity to build a therapeutic relationship with their patients. Face-to-face encounters also increase patient satisfaction scores and outcomes. As such, critics fear that patient relationships may suffer with the use of telemedicine. However, using video technology for new patient encounters may help overcome this challenge. During a video encounter, the provider can see the patient’s facial expressions and take cues from nonverbal behaviors.

At times, the element of distance may enhance the encounter. For example, in behavioral health, patients often feel more comfortable in their home environment than in a sterile office environment.

Telemedicine patients often have positive experiences, given the speed of access, precision, time savings, and the ability to stay in contact with healthcare providers from the comfort of their homes. Ultimately, these virtual visits may help improve compliance with follow-up consultations since the barriers of distance and transportation are circumvented.

WHO CAN CONDUCT TELEMEDICINE VISITS?

Although a patient’s healthcare team is likely to consist of members who are not physicians, including nurse practitioners, physician assistants, social workers, and psychologists, not everyone can, by law, conduct telemedicine visits. Currently, the rules and regulations addressing ancillary team members’ participation in telemedicine vary from state to state.

TELEMEDICINE VISITS AT CLEVELAND CLINIC

Our health system has several telemedicine programs, including our eHospital program. Launched in 2014, this program provides patients at 4 hospitals with input from staff intensivists and experienced critical care nurses during the night (7 pm to 7 am) via remote monitoring. These remote caregivers have full access to patient charts and, when signalled, can activate an in-room camera to initiate 2-way audio communication with patients, their families, and bedside caregivers.

In addition, new patient consults are being offered via telemedicine for several services including dermatology, where pictures of skin lesions are reviewed and triaged, and management recommendations are provided accordingly.

In 2016, Cleveland Clinic launched its Remote Hypertension Improvement Program—an enterprise-wide initiative to minimize hypertension-associated mortality and morbidity with the assistance of telehealth services. The program was first piloted in a group of 80 high-risk hypertensive patients who were monitored and followed through a Bluetooth-enabled remote monitoring tool, which exported blood pressure readings to a central dashboard. A multidisciplinary team of doctors, nurses, and pharmacists used this dashboard to adjust medication when needed and provide virtual lifestyle coaching. Over a 24-week period, the patients’ systolic blood pressure decreased by an average of 7.5 mm Hg and diastolic blood pressure by 3.1 mm Hg (unpublished data).

Beginning this year, blood pressure readings will be directly exported from the remote monitoring tool into the patient’s electronic medical record, providing the healthcare team with the information needed to make informed decisions to remotely manage patients with hypertension.

Remote monitoring of patients with hypertension is also being used at other institutions such as the VA. In 2016, almost 19,000 veterans were using the remote monitoring system, and this number is expected to increase with the enhanced adaptation of telemedicine services.¹³

FUTURE DIRECTIONS

About 50% of all adults in the United States have at least 1 chronic disease. In all, chronic disease accounts for roughly 75% of the total healthcare expenditure and 70% of all deaths.^7,14 Recent data suggest that virtual chronic disease management represents an untapped market for telemedicine, given its relative underutilization compared to other services such as telebehavorial health and specialty telemedicine. These patients require frequent visits to the doctor, and targeting this patient population with telemedicine may decrease the number of emergency room visits and hospital admissions.

Another growing area in the field of telemedicine is the “hospital at home” model in which patients who meet the criteria for hospitalization but are otherwise stable are treated at home for diseases such as chronic obstructive pulmonary disease, pneumonia, and heart failure. Studies have shown that the hospital-at-home model, when used appropriately, is not only more cost-effective than hospitalization but results in a shorter treatment duration and lower rates of delirium.^15–17

Finally, in the acute setting, we have seen wide success with telemedicine programs in stroke care, radiology, intensive care, and psychiatry, and several studies have shown mortality rates comparable to those with the traditional model.^18,19 These encounters often require specialized skills and are the focus of multiple ongoing studies.           

Acknowledgment: The authors would like to acknowledge and thank Matthew Faiman, MD, for providing information regarding the Remote Hypertension Program.

Telemedicine has been used successfully to improve patient access to medical care while reducing healthcare costs. In 2016, an estimated 61% of US healthcare institutions and 40% to 50% of US hospitals used telemedicine.¹ From 2012 to 2013, the telemedicine market grew by 60%. However, its widespread use has been limited by low reimbursement rates and interstate licensing and practice issues.

In this commentary, we discuss the history of telemedicine, current uses and challenges, and areas of future growth.

DEFINITION AND HISTORY

The World Health Organization defines telemedicine as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”²

Modern telemedicine began in the early 1900s in the Netherlands with the transmission of heart rhythms over the telephone,³ which was followed by transmissions to radio consultation centers in Europe in the 1920s. In the 1940s, radiographic images were transmitted by telephone between cities in Pennsylvania.⁴

Today, telemedicine is used in a variety of specialties including radiology, neurology, and pathology⁵ and by organizations in the United States ranging from the National Aeronautics and Space Administration and Kaiser Permanente to the US Department of Veterans Affairs (VA). The VA, in particular, is a leader in telemedicine. In 2012, it reduced mental health hospitalizations by over 40%, heart failure hospitalizations by 25%, and diabetes and chronic obstructive pulmonary disease hospitalizations by about 20% using telemedicine programs.⁶ In 2015, it provided about 2.1 million telemedicine consultations to 677,000 veterans.⁷

TYPES OF TELEMEDICINE PROGRAMS

There are 2 types of telemedicine programs.

Synchronous programs take place in real time and are a live 2-way interaction between the patient and healthcare provider. This includes virtual appointments that are conducted using the patient’s smartphone, tablet, or computer with a camera. When using a smartphone or tablet, patients must first download an app that connects them with a provider.

Asynchronous programs, also known as “store and forward” applications, are not live and involve the transfer of images, videos, and other clinical information that a healthcare provider views and responds to at a later time. In this case, patients may wear medical devices to monitor and track health information (eg, blood pressure) in a personal health application that they forward to their healthcare provider.

IMPROVING PATIENT ACCESS TO CARE WHILE REDUCING COSTS

Telemedicine allows patients living in both rural and urban areas to access healthcare when they need it. Currently, about 59 million Americans reside in health professional-shortage areas, which are rural and urban areas with shortages of primary care providers.¹ These patients often experience long delays when attempting to schedule a healthcare visit⁷ and may experience issues with continuity of care if they are unable to see the same care provider at every visit.

It also provides access to care to patients without reliable transportation or those who may be too sick to travel long distances. For some patients, such as those with cystic fibrosis who do not want to come to the hospital for fear of contracting multiple antibiotic-resistant bacteria, a virtual office visit may be safer.

At the same time, telemedicine helps reduce healthcare costs. For example, it:

• Optimizes staff distribution and healthcare resources within a healthcare facility and across an entire system
• Enables primary care providers to conduct appointments without additional office staff at any time, thereby extending office hours and availability
• Reduces the financial impact of patient no-shows
• Improves patient engagement and outcomes
• Reduces unnecessary office and emergency room visits and hospital admissions.

The last point is especially important for senior living and skilled nursing centers whose residents are known to have high rates of hospital admissions.^8,9 In these facilities, 24-hour medical assistance may not be available, and telemedicine can help troubleshoot common problems.

LOW REIMBURSEMENT RATES CURTAIL USE

Limited reimbursement has curtailed the widespread use of telemedicine. Although rules for reimbursement are evolving, telemedicine still represents a small amount of total healthcare expenditures. In 2015, Medicare spent approximately $14.4 million on services delivered via telemedicine—less than 0.01% of total spending on healthcare services.¹

Currently, 31 states and the District of Columbia have telemedicine parity laws that mandate private commercial insurers to pay for telemedicine services.¹⁰ Unfortunately, there is a lack of uniformity in the specifics of these laws, resulting in variations in reimbursement rates. Furthermore, a large number of larger insurers such as Medicare and Medicaid and many self-insured plans do not fall under these mandates.

Another factor that affects reimbursement for telemedicine services is the setting of the medical encounter. Medicare reimburses providers for telemedicine services only when they are conducted at specific sites such as physician’s offices, hospitals, rural health centers, and skilled nursing facilities. Additionally, Medicare only reimburses for services in areas with a shortage of healthcare professionals and in non-metropolitan areas, which excludes many urban patients.¹¹

In contrast, more commercial reimbursement is occurring for online urgent care, and options for commercial reimbursement of online behavioral services are being explored.

Current licensure laws also limit the ability of many healthcare providers to offer telemedicine services. Federal law requires providers to be fully licensed to practice medicine in the state where the patient is physically located. In cases of health systems that have locations in more than one state, providers may need to apply for and pay to maintain multiple licenses (current interstate licensing laws vary across states).

Interstate licensure is one way to solve this problem. Thus far, a number of states have joined the Interstate Medical Licensure Compact that intends to allow physicians to obtain expedited licenses to practice in multiple states.¹²

The federal TELE-MED Act was introduced in 2015 but not passed. It proposed to “allow a Medicare provider to provide telemedicine services to a Medicare beneficiary who is in a different state from the one in which the provider is licensed or authorized to provide healthcare services.”

CAN TELEMEDICINE FOSTER A GOOD PROVIDER-PATIENT RELATIONSHIP?

In-person encounters provide healthcare providers with the opportunity to build a therapeutic relationship with their patients. Face-to-face encounters also increase patient satisfaction scores and outcomes. As such, critics fear that patient relationships may suffer with the use of telemedicine. However, using video technology for new patient encounters may help overcome this challenge. During a video encounter, the provider can see the patient’s facial expressions and take cues from nonverbal behaviors.

At times, the element of distance may enhance the encounter. For example, in behavioral health, patients often feel more comfortable in their home environment than in a sterile office environment.

Telemedicine patients often have positive experiences, given the speed of access, precision, time savings, and the ability to stay in contact with healthcare providers from the comfort of their homes. Ultimately, these virtual visits may help improve compliance with follow-up consultations since the barriers of distance and transportation are circumvented.

WHO CAN CONDUCT TELEMEDICINE VISITS?

Although a patient’s healthcare team is likely to consist of members who are not physicians, including nurse practitioners, physician assistants, social workers, and psychologists, not everyone can, by law, conduct telemedicine visits. Currently, the rules and regulations addressing ancillary team members’ participation in telemedicine vary from state to state.

TELEMEDICINE VISITS AT CLEVELAND CLINIC

Our health system has several telemedicine programs, including our eHospital program. Launched in 2014, this program provides patients at 4 hospitals with input from staff intensivists and experienced critical care nurses during the night (7 pm to 7 am) via remote monitoring. These remote caregivers have full access to patient charts and, when signalled, can activate an in-room camera to initiate 2-way audio communication with patients, their families, and bedside caregivers.

In addition, new patient consults are being offered via telemedicine for several services including dermatology, where pictures of skin lesions are reviewed and triaged, and management recommendations are provided accordingly.

In 2016, Cleveland Clinic launched its Remote Hypertension Improvement Program—an enterprise-wide initiative to minimize hypertension-associated mortality and morbidity with the assistance of telehealth services. The program was first piloted in a group of 80 high-risk hypertensive patients who were monitored and followed through a Bluetooth-enabled remote monitoring tool, which exported blood pressure readings to a central dashboard. A multidisciplinary team of doctors, nurses, and pharmacists used this dashboard to adjust medication when needed and provide virtual lifestyle coaching. Over a 24-week period, the patients’ systolic blood pressure decreased by an average of 7.5 mm Hg and diastolic blood pressure by 3.1 mm Hg (unpublished data).

Beginning this year, blood pressure readings will be directly exported from the remote monitoring tool into the patient’s electronic medical record, providing the healthcare team with the information needed to make informed decisions to remotely manage patients with hypertension.

Remote monitoring of patients with hypertension is also being used at other institutions such as the VA. In 2016, almost 19,000 veterans were using the remote monitoring system, and this number is expected to increase with the enhanced adaptation of telemedicine services.¹³

FUTURE DIRECTIONS

About 50% of all adults in the United States have at least 1 chronic disease. In all, chronic disease accounts for roughly 75% of the total healthcare expenditure and 70% of all deaths.^7,14 Recent data suggest that virtual chronic disease management represents an untapped market for telemedicine, given its relative underutilization compared to other services such as telebehavorial health and specialty telemedicine. These patients require frequent visits to the doctor, and targeting this patient population with telemedicine may decrease the number of emergency room visits and hospital admissions.

Another growing area in the field of telemedicine is the “hospital at home” model in which patients who meet the criteria for hospitalization but are otherwise stable are treated at home for diseases such as chronic obstructive pulmonary disease, pneumonia, and heart failure. Studies have shown that the hospital-at-home model, when used appropriately, is not only more cost-effective than hospitalization but results in a shorter treatment duration and lower rates of delirium.^15–17

Finally, in the acute setting, we have seen wide success with telemedicine programs in stroke care, radiology, intensive care, and psychiatry, and several studies have shown mortality rates comparable to those with the traditional model.^18,19 These encounters often require specialized skills and are the focus of multiple ongoing studies.           

Acknowledgment: The authors would like to acknowledge and thank Matthew Faiman, MD, for providing information regarding the Remote Hypertension Program.

Telemedicine has been used successfully to improve patient access to medical care while reducing healthcare costs. In 2016, an estimated 61% of US healthcare institutions and 40% to 50% of US hospitals used telemedicine.¹ From 2012 to 2013, the telemedicine market grew by 60%. However, its widespread use has been limited by low reimbursement rates and interstate licensing and practice issues.

In this commentary, we discuss the history of telemedicine, current uses and challenges, and areas of future growth.

DEFINITION AND HISTORY

The World Health Organization defines telemedicine as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”²

Modern telemedicine began in the early 1900s in the Netherlands with the transmission of heart rhythms over the telephone,³ which was followed by transmissions to radio consultation centers in Europe in the 1920s. In the 1940s, radiographic images were transmitted by telephone between cities in Pennsylvania.⁴

Today, telemedicine is used in a variety of specialties including radiology, neurology, and pathology⁵ and by organizations in the United States ranging from the National Aeronautics and Space Administration and Kaiser Permanente to the US Department of Veterans Affairs (VA). The VA, in particular, is a leader in telemedicine. In 2012, it reduced mental health hospitalizations by over 40%, heart failure hospitalizations by 25%, and diabetes and chronic obstructive pulmonary disease hospitalizations by about 20% using telemedicine programs.⁶ In 2015, it provided about 2.1 million telemedicine consultations to 677,000 veterans.⁷

TYPES OF TELEMEDICINE PROGRAMS

There are 2 types of telemedicine programs.

Synchronous programs take place in real time and are a live 2-way interaction between the patient and healthcare provider. This includes virtual appointments that are conducted using the patient’s smartphone, tablet, or computer with a camera. When using a smartphone or tablet, patients must first download an app that connects them with a provider.

Asynchronous programs, also known as “store and forward” applications, are not live and involve the transfer of images, videos, and other clinical information that a healthcare provider views and responds to at a later time. In this case, patients may wear medical devices to monitor and track health information (eg, blood pressure) in a personal health application that they forward to their healthcare provider.

IMPROVING PATIENT ACCESS TO CARE WHILE REDUCING COSTS

Telemedicine allows patients living in both rural and urban areas to access healthcare when they need it. Currently, about 59 million Americans reside in health professional-shortage areas, which are rural and urban areas with shortages of primary care providers.¹ These patients often experience long delays when attempting to schedule a healthcare visit⁷ and may experience issues with continuity of care if they are unable to see the same care provider at every visit.

It also provides access to care to patients without reliable transportation or those who may be too sick to travel long distances. For some patients, such as those with cystic fibrosis who do not want to come to the hospital for fear of contracting multiple antibiotic-resistant bacteria, a virtual office visit may be safer.

At the same time, telemedicine helps reduce healthcare costs. For example, it:

• Optimizes staff distribution and healthcare resources within a healthcare facility and across an entire system
• Enables primary care providers to conduct appointments without additional office staff at any time, thereby extending office hours and availability
• Reduces the financial impact of patient no-shows
• Improves patient engagement and outcomes
• Reduces unnecessary office and emergency room visits and hospital admissions.

The last point is especially important for senior living and skilled nursing centers whose residents are known to have high rates of hospital admissions.^8,9 In these facilities, 24-hour medical assistance may not be available, and telemedicine can help troubleshoot common problems.

LOW REIMBURSEMENT RATES CURTAIL USE

Limited reimbursement has curtailed the widespread use of telemedicine. Although rules for reimbursement are evolving, telemedicine still represents a small amount of total healthcare expenditures. In 2015, Medicare spent approximately $14.4 million on services delivered via telemedicine—less than 0.01% of total spending on healthcare services.¹

Currently, 31 states and the District of Columbia have telemedicine parity laws that mandate private commercial insurers to pay for telemedicine services.¹⁰ Unfortunately, there is a lack of uniformity in the specifics of these laws, resulting in variations in reimbursement rates. Furthermore, a large number of larger insurers such as Medicare and Medicaid and many self-insured plans do not fall under these mandates.

Another factor that affects reimbursement for telemedicine services is the setting of the medical encounter. Medicare reimburses providers for telemedicine services only when they are conducted at specific sites such as physician’s offices, hospitals, rural health centers, and skilled nursing facilities. Additionally, Medicare only reimburses for services in areas with a shortage of healthcare professionals and in non-metropolitan areas, which excludes many urban patients.¹¹

In contrast, more commercial reimbursement is occurring for online urgent care, and options for commercial reimbursement of online behavioral services are being explored.

Current licensure laws also limit the ability of many healthcare providers to offer telemedicine services. Federal law requires providers to be fully licensed to practice medicine in the state where the patient is physically located. In cases of health systems that have locations in more than one state, providers may need to apply for and pay to maintain multiple licenses (current interstate licensing laws vary across states).

Interstate licensure is one way to solve this problem. Thus far, a number of states have joined the Interstate Medical Licensure Compact that intends to allow physicians to obtain expedited licenses to practice in multiple states.¹²

The federal TELE-MED Act was introduced in 2015 but not passed. It proposed to “allow a Medicare provider to provide telemedicine services to a Medicare beneficiary who is in a different state from the one in which the provider is licensed or authorized to provide healthcare services.”

CAN TELEMEDICINE FOSTER A GOOD PROVIDER-PATIENT RELATIONSHIP?

In-person encounters provide healthcare providers with the opportunity to build a therapeutic relationship with their patients. Face-to-face encounters also increase patient satisfaction scores and outcomes. As such, critics fear that patient relationships may suffer with the use of telemedicine. However, using video technology for new patient encounters may help overcome this challenge. During a video encounter, the provider can see the patient’s facial expressions and take cues from nonverbal behaviors.

At times, the element of distance may enhance the encounter. For example, in behavioral health, patients often feel more comfortable in their home environment than in a sterile office environment.

Telemedicine patients often have positive experiences, given the speed of access, precision, time savings, and the ability to stay in contact with healthcare providers from the comfort of their homes. Ultimately, these virtual visits may help improve compliance with follow-up consultations since the barriers of distance and transportation are circumvented.

WHO CAN CONDUCT TELEMEDICINE VISITS?

Although a patient’s healthcare team is likely to consist of members who are not physicians, including nurse practitioners, physician assistants, social workers, and psychologists, not everyone can, by law, conduct telemedicine visits. Currently, the rules and regulations addressing ancillary team members’ participation in telemedicine vary from state to state.

TELEMEDICINE VISITS AT CLEVELAND CLINIC

Our health system has several telemedicine programs, including our eHospital program. Launched in 2014, this program provides patients at 4 hospitals with input from staff intensivists and experienced critical care nurses during the night (7 pm to 7 am) via remote monitoring. These remote caregivers have full access to patient charts and, when signalled, can activate an in-room camera to initiate 2-way audio communication with patients, their families, and bedside caregivers.

In addition, new patient consults are being offered via telemedicine for several services including dermatology, where pictures of skin lesions are reviewed and triaged, and management recommendations are provided accordingly.

In 2016, Cleveland Clinic launched its Remote Hypertension Improvement Program—an enterprise-wide initiative to minimize hypertension-associated mortality and morbidity with the assistance of telehealth services. The program was first piloted in a group of 80 high-risk hypertensive patients who were monitored and followed through a Bluetooth-enabled remote monitoring tool, which exported blood pressure readings to a central dashboard. A multidisciplinary team of doctors, nurses, and pharmacists used this dashboard to adjust medication when needed and provide virtual lifestyle coaching. Over a 24-week period, the patients’ systolic blood pressure decreased by an average of 7.5 mm Hg and diastolic blood pressure by 3.1 mm Hg (unpublished data).

Beginning this year, blood pressure readings will be directly exported from the remote monitoring tool into the patient’s electronic medical record, providing the healthcare team with the information needed to make informed decisions to remotely manage patients with hypertension.

Remote monitoring of patients with hypertension is also being used at other institutions such as the VA. In 2016, almost 19,000 veterans were using the remote monitoring system, and this number is expected to increase with the enhanced adaptation of telemedicine services.¹³

FUTURE DIRECTIONS

About 50% of all adults in the United States have at least 1 chronic disease. In all, chronic disease accounts for roughly 75% of the total healthcare expenditure and 70% of all deaths.^7,14 Recent data suggest that virtual chronic disease management represents an untapped market for telemedicine, given its relative underutilization compared to other services such as telebehavorial health and specialty telemedicine. These patients require frequent visits to the doctor, and targeting this patient population with telemedicine may decrease the number of emergency room visits and hospital admissions.

Another growing area in the field of telemedicine is the “hospital at home” model in which patients who meet the criteria for hospitalization but are otherwise stable are treated at home for diseases such as chronic obstructive pulmonary disease, pneumonia, and heart failure. Studies have shown that the hospital-at-home model, when used appropriately, is not only more cost-effective than hospitalization but results in a shorter treatment duration and lower rates of delirium.^15–17

Finally, in the acute setting, we have seen wide success with telemedicine programs in stroke care, radiology, intensive care, and psychiatry, and several studies have shown mortality rates comparable to those with the traditional model.^18,19 These encounters often require specialized skills and are the focus of multiple ongoing studies.           

Acknowledgment: The authors would like to acknowledge and thank Matthew Faiman, MD, for providing information regarding the Remote Hypertension Program.

Recently, the Association of American Medical Colleges (AAMC) reiterated its projection of a physician shortage in the United States, predicting a shortfall of up to 121,300 physicians by 2030. The shortage would affect primary care as well as medical and surgical specialties. These projections are consistent with prior estimates and, AAMC says, take into account both utilization of NPs and PAs and future changes in how care is delivered.¹

However, other entities have suggested we are misinterpreting the situation. The Institute of Medicine (IOM) has argued that there is no physician shortage. According to their analysis, the health care system isn’t undermanned—rather, it’s inefficient and relies too heavily on physicians and not enough on advanced practice providers. Furthermore, the IOM posits that many of the studies upon which physician workforce projections have been based fail to account for advances in medicine and technology that impact care delivery: telehealth, new medications, and medical devices that give patients a more active role in their health maintenance.²

Who’s right? You might say, “Who cares?” but this isn’t simply a matter of institutional reputation; the data have informed action plans for offsetting the projected shortage. Since 2002, medical schools have increased class sizes by 30% and are working to ensure that the supply of physicians will be sufficient to meet future needs—even though funding for residency training has been frozen since 1997. At the same time, many thought leaders—including the IOM—have recognized NPs and PAs as significant contributors to the health care workforce. In 2007, for example, Cooper called on the NP and PA professions to expand their training capacity, predicting that neither would have a supply of practitioners to meet needs in the event of a physician shortage.³

Both professions took that message to heart. There are now more than 123,000 certified PAs (70% of whom work in specialty practice) and 248,000 licensed NPs (87% in primary care) in the United States.^4,5 There are 239 accredited PA programs (including those with provisional or probationary status), with the number of new graduates per year expected to reach 18,000 by 2026 (compared to 9,000 in 2018).^6,7 There are about 400 academic institutions in the US that have an NP program; in 2016-2017, more than 26,000 new graduates completed their training.^5,8 Overall, the Bureau of Labor Statistics projects that by 2024 the NP profession will have grown by 36%, the PA profession by 37%, and the physician population by 13% (excluding anesthesiologists and surgeons).⁹

There is no argument that NPs and PAs are making an enormous impact on the quality and accessibility of health care in this country. But I am starting to hear rumblings that we may be educating too many NPs and PAs—especially if the physician shortage is not as dire as predicted.

This entire conversation takes me back to the 1970s, when the Graduate Medical Education National Advisory Committee (GMENAC) projected a surplus of physicians, and a moratorium was placed on medical school enrollment. Those projections were validated and repeated through the 1990s; in fact, the aforementioned Cooper was among the first to flip the message around, using new calculations and considerations to project a physician shortage.¹⁰

GMENAC is a classic example of what happens when people and entities overreact to a projection of some kind. If there is a physician shortage today, GMENAC is probably partly responsible because their prediction of an oversupply triggered an arguably over-the-top response. Everyone worked so hard to avoid a surplus that they are creating a deficit!

Continue to: As I listen to...

As I listen to those rumblings of “too many NPs and PAs,” I wonder if this is a mirror to that GMENAC response. Have the NP and PA professions worked so hard to offset the physician shortage (real or imagined) that we may face a glut of NPs and PAs? If so, the concern is that within five to 10 years, we won’t have employment opportunities for all of them. That’s the fear driving these whispers, isn’t it?

As far back as 2000—when this conversation was in its infancy—Dehn and Cawley discussed the consequences of expanding the supply of NPs and PAs. They questioned how the number of, and demand for, NPs and PAs would be balanced in America’s future health care marketplace and wondered if a sharp growth in NP and PA graduates (in conjunction with similar increases in other health professions) could surpass demand and prompt an oversupply, resulting in underemployment and market saturation.¹¹

So, is it time to pause and take another look at the numbers and needs? Maybe. But I believe one of the aspects we must continue to focus on is the quality of our professions. In the wake of the projected physician shortage, the NP profession developed its Doctor of Nursing Practice and the PA profession added postgraduate training opportunities in specific specialties. These not only enhance NPs’ and PAs’ professional credentials—they equip us to provide better patient care. At the end of the day, our ability to care for patients will be the rubric upon which we are judged.

We’ve already been making the case for our professions and gaining recognition throughout this process. When Salsberg wrote about the physician shortage in Health Affairs (2015), he reminded us that a critical factor is the supply and availability of clinicians other than physicians (NPs, PAs, midwives) who can make a significant contribution to access and efficiency of health care. He called for NPs and PAs to be fully integrated into the delivery system and to be allowed scope of practice consistent with their education and training.⁷

Continue to: Both NPs and PAs have become...

Both NPs and PAs have become participants in dialogues on health policy and health care reform. Both professions are spending increasing dollars on national advertising to raise awareness of their critical role in expanding access to primary care for millions of Americans. In fact, Princeton University Professor of Economics Uwe E. Reinhardt told the New York Times, “The doctors are fighting a losing battle. The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”¹² Some suggest that PAs need to fight a similar battle.

So, dear reader, what do you think? Should we be concerned that we are educating too many NPs and PAs? Does that argument become somewhat irrelevant if we can firmly establish a substantial role for ourselves in the future of health care? I would love to hear your thoughts; email me at [email protected].

Recently, the Association of American Medical Colleges (AAMC) reiterated its projection of a physician shortage in the United States, predicting a shortfall of up to 121,300 physicians by 2030. The shortage would affect primary care as well as medical and surgical specialties. These projections are consistent with prior estimates and, AAMC says, take into account both utilization of NPs and PAs and future changes in how care is delivered.¹

However, other entities have suggested we are misinterpreting the situation. The Institute of Medicine (IOM) has argued that there is no physician shortage. According to their analysis, the health care system isn’t undermanned—rather, it’s inefficient and relies too heavily on physicians and not enough on advanced practice providers. Furthermore, the IOM posits that many of the studies upon which physician workforce projections have been based fail to account for advances in medicine and technology that impact care delivery: telehealth, new medications, and medical devices that give patients a more active role in their health maintenance.²

Who’s right? You might say, “Who cares?” but this isn’t simply a matter of institutional reputation; the data have informed action plans for offsetting the projected shortage. Since 2002, medical schools have increased class sizes by 30% and are working to ensure that the supply of physicians will be sufficient to meet future needs—even though funding for residency training has been frozen since 1997. At the same time, many thought leaders—including the IOM—have recognized NPs and PAs as significant contributors to the health care workforce. In 2007, for example, Cooper called on the NP and PA professions to expand their training capacity, predicting that neither would have a supply of practitioners to meet needs in the event of a physician shortage.³

Both professions took that message to heart. There are now more than 123,000 certified PAs (70% of whom work in specialty practice) and 248,000 licensed NPs (87% in primary care) in the United States.^4,5 There are 239 accredited PA programs (including those with provisional or probationary status), with the number of new graduates per year expected to reach 18,000 by 2026 (compared to 9,000 in 2018).^6,7 There are about 400 academic institutions in the US that have an NP program; in 2016-2017, more than 26,000 new graduates completed their training.^5,8 Overall, the Bureau of Labor Statistics projects that by 2024 the NP profession will have grown by 36%, the PA profession by 37%, and the physician population by 13% (excluding anesthesiologists and surgeons).⁹

There is no argument that NPs and PAs are making an enormous impact on the quality and accessibility of health care in this country. But I am starting to hear rumblings that we may be educating too many NPs and PAs—especially if the physician shortage is not as dire as predicted.

This entire conversation takes me back to the 1970s, when the Graduate Medical Education National Advisory Committee (GMENAC) projected a surplus of physicians, and a moratorium was placed on medical school enrollment. Those projections were validated and repeated through the 1990s; in fact, the aforementioned Cooper was among the first to flip the message around, using new calculations and considerations to project a physician shortage.¹⁰

GMENAC is a classic example of what happens when people and entities overreact to a projection of some kind. If there is a physician shortage today, GMENAC is probably partly responsible because their prediction of an oversupply triggered an arguably over-the-top response. Everyone worked so hard to avoid a surplus that they are creating a deficit!

Continue to: As I listen to...

As I listen to those rumblings of “too many NPs and PAs,” I wonder if this is a mirror to that GMENAC response. Have the NP and PA professions worked so hard to offset the physician shortage (real or imagined) that we may face a glut of NPs and PAs? If so, the concern is that within five to 10 years, we won’t have employment opportunities for all of them. That’s the fear driving these whispers, isn’t it?

As far back as 2000—when this conversation was in its infancy—Dehn and Cawley discussed the consequences of expanding the supply of NPs and PAs. They questioned how the number of, and demand for, NPs and PAs would be balanced in America’s future health care marketplace and wondered if a sharp growth in NP and PA graduates (in conjunction with similar increases in other health professions) could surpass demand and prompt an oversupply, resulting in underemployment and market saturation.¹¹

So, is it time to pause and take another look at the numbers and needs? Maybe. But I believe one of the aspects we must continue to focus on is the quality of our professions. In the wake of the projected physician shortage, the NP profession developed its Doctor of Nursing Practice and the PA profession added postgraduate training opportunities in specific specialties. These not only enhance NPs’ and PAs’ professional credentials—they equip us to provide better patient care. At the end of the day, our ability to care for patients will be the rubric upon which we are judged.

We’ve already been making the case for our professions and gaining recognition throughout this process. When Salsberg wrote about the physician shortage in Health Affairs (2015), he reminded us that a critical factor is the supply and availability of clinicians other than physicians (NPs, PAs, midwives) who can make a significant contribution to access and efficiency of health care. He called for NPs and PAs to be fully integrated into the delivery system and to be allowed scope of practice consistent with their education and training.⁷

Continue to: Both NPs and PAs have become...

Both NPs and PAs have become participants in dialogues on health policy and health care reform. Both professions are spending increasing dollars on national advertising to raise awareness of their critical role in expanding access to primary care for millions of Americans. In fact, Princeton University Professor of Economics Uwe E. Reinhardt told the New York Times, “The doctors are fighting a losing battle. The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”¹² Some suggest that PAs need to fight a similar battle.

So, dear reader, what do you think? Should we be concerned that we are educating too many NPs and PAs? Does that argument become somewhat irrelevant if we can firmly establish a substantial role for ourselves in the future of health care? I would love to hear your thoughts; email me at [email protected].

Recently, the Association of American Medical Colleges (AAMC) reiterated its projection of a physician shortage in the United States, predicting a shortfall of up to 121,300 physicians by 2030. The shortage would affect primary care as well as medical and surgical specialties. These projections are consistent with prior estimates and, AAMC says, take into account both utilization of NPs and PAs and future changes in how care is delivered.¹

However, other entities have suggested we are misinterpreting the situation. The Institute of Medicine (IOM) has argued that there is no physician shortage. According to their analysis, the health care system isn’t undermanned—rather, it’s inefficient and relies too heavily on physicians and not enough on advanced practice providers. Furthermore, the IOM posits that many of the studies upon which physician workforce projections have been based fail to account for advances in medicine and technology that impact care delivery: telehealth, new medications, and medical devices that give patients a more active role in their health maintenance.²

Who’s right? You might say, “Who cares?” but this isn’t simply a matter of institutional reputation; the data have informed action plans for offsetting the projected shortage. Since 2002, medical schools have increased class sizes by 30% and are working to ensure that the supply of physicians will be sufficient to meet future needs—even though funding for residency training has been frozen since 1997. At the same time, many thought leaders—including the IOM—have recognized NPs and PAs as significant contributors to the health care workforce. In 2007, for example, Cooper called on the NP and PA professions to expand their training capacity, predicting that neither would have a supply of practitioners to meet needs in the event of a physician shortage.³

Both professions took that message to heart. There are now more than 123,000 certified PAs (70% of whom work in specialty practice) and 248,000 licensed NPs (87% in primary care) in the United States.^4,5 There are 239 accredited PA programs (including those with provisional or probationary status), with the number of new graduates per year expected to reach 18,000 by 2026 (compared to 9,000 in 2018).^6,7 There are about 400 academic institutions in the US that have an NP program; in 2016-2017, more than 26,000 new graduates completed their training.^5,8 Overall, the Bureau of Labor Statistics projects that by 2024 the NP profession will have grown by 36%, the PA profession by 37%, and the physician population by 13% (excluding anesthesiologists and surgeons).⁹

There is no argument that NPs and PAs are making an enormous impact on the quality and accessibility of health care in this country. But I am starting to hear rumblings that we may be educating too many NPs and PAs—especially if the physician shortage is not as dire as predicted.

This entire conversation takes me back to the 1970s, when the Graduate Medical Education National Advisory Committee (GMENAC) projected a surplus of physicians, and a moratorium was placed on medical school enrollment. Those projections were validated and repeated through the 1990s; in fact, the aforementioned Cooper was among the first to flip the message around, using new calculations and considerations to project a physician shortage.¹⁰

GMENAC is a classic example of what happens when people and entities overreact to a projection of some kind. If there is a physician shortage today, GMENAC is probably partly responsible because their prediction of an oversupply triggered an arguably over-the-top response. Everyone worked so hard to avoid a surplus that they are creating a deficit!

Continue to: As I listen to...

As I listen to those rumblings of “too many NPs and PAs,” I wonder if this is a mirror to that GMENAC response. Have the NP and PA professions worked so hard to offset the physician shortage (real or imagined) that we may face a glut of NPs and PAs? If so, the concern is that within five to 10 years, we won’t have employment opportunities for all of them. That’s the fear driving these whispers, isn’t it?

As far back as 2000—when this conversation was in its infancy—Dehn and Cawley discussed the consequences of expanding the supply of NPs and PAs. They questioned how the number of, and demand for, NPs and PAs would be balanced in America’s future health care marketplace and wondered if a sharp growth in NP and PA graduates (in conjunction with similar increases in other health professions) could surpass demand and prompt an oversupply, resulting in underemployment and market saturation.¹¹

So, is it time to pause and take another look at the numbers and needs? Maybe. But I believe one of the aspects we must continue to focus on is the quality of our professions. In the wake of the projected physician shortage, the NP profession developed its Doctor of Nursing Practice and the PA profession added postgraduate training opportunities in specific specialties. These not only enhance NPs’ and PAs’ professional credentials—they equip us to provide better patient care. At the end of the day, our ability to care for patients will be the rubric upon which we are judged.

We’ve already been making the case for our professions and gaining recognition throughout this process. When Salsberg wrote about the physician shortage in Health Affairs (2015), he reminded us that a critical factor is the supply and availability of clinicians other than physicians (NPs, PAs, midwives) who can make a significant contribution to access and efficiency of health care. He called for NPs and PAs to be fully integrated into the delivery system and to be allowed scope of practice consistent with their education and training.⁷

Continue to: Both NPs and PAs have become...

Both NPs and PAs have become participants in dialogues on health policy and health care reform. Both professions are spending increasing dollars on national advertising to raise awareness of their critical role in expanding access to primary care for millions of Americans. In fact, Princeton University Professor of Economics Uwe E. Reinhardt told the New York Times, “The doctors are fighting a losing battle. The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”¹² Some suggest that PAs need to fight a similar battle.

So, dear reader, what do you think? Should we be concerned that we are educating too many NPs and PAs? Does that argument become somewhat irrelevant if we can firmly establish a substantial role for ourselves in the future of health care? I would love to hear your thoughts; email me at [email protected].

The September 2018 Practice Alert, “CDC recommendations for the 2018-2019 influenza season” contained an error (J Fam Pract. 2018. 67:550-553). On page 552, under “Available vaccine products,” the article listed “one standard dose IIV4 intradermal option.” This was incorrect. Sanofi Pasteur, the manufacturer of standard dose Intradermal IIV4, discontinued the production and supply of Fluzone Intradermal Quadrivalent vaccine at the conclusion of the 2017-2018 influenza season.

The September 2018 Practice Alert, “CDC recommendations for the 2018-2019 influenza season” contained an error (J Fam Pract. 2018. 67:550-553). On page 552, under “Available vaccine products,” the article listed “one standard dose IIV4 intradermal option.” This was incorrect. Sanofi Pasteur, the manufacturer of standard dose Intradermal IIV4, discontinued the production and supply of Fluzone Intradermal Quadrivalent vaccine at the conclusion of the 2017-2018 influenza season.

The September 2018 Practice Alert, “CDC recommendations for the 2018-2019 influenza season” contained an error (J Fam Pract. 2018. 67:550-553). On page 552, under “Available vaccine products,” the article listed “one standard dose IIV4 intradermal option.” This was incorrect. Sanofi Pasteur, the manufacturer of standard dose Intradermal IIV4, discontinued the production and supply of Fluzone Intradermal Quadrivalent vaccine at the conclusion of the 2017-2018 influenza season.

In the Clinical Inquiry, “Does prophylactic azithromycin reduce the number of COPD exacerbations or hospitalizations?” (J Fam Pract. 2018;67:384-385), Lyon et al state that azithromycin “doesn’t benefit patients ≤65 years, patients with GOLD [Global Initiative for Obstructive Lung Disease] stage IV COPD [chronic obstructive pulmonary disease], current smokers, or patients not using oxygen (strength of recommendation [SOR]: B, randomized controlled trials [RCTs]).” These categorical statements are misleading, and clinicians should ignore most of them when considering azithromycin for their patients with severe COPD.

It would be more accurate to say that there may be a diminished efficacy of azithromycin for patients with GOLD IV COPD and age ≤65 years.

The authors cited groups that were identified in a posthoc analysis¹ of the only large trial involving azithromycin for the treatment of COPD to date.²P values for the interaction of azithromycin with GOLD stage (P=.04), smoking (P=.03), and age (P=.02) were significant, but the mean effects (hazard ratios [HRs]) for GOLD stage IV, smoking, and age ≤65 were .84, .99, and .84, respectively. It would be more accurate to say that there may be a diminished efficacy of azithromycin for patients with GOLD IV COPD and age ≤65 years. Only smokers appear to show no response, although the lower end of the 95% confidence interval was 0.71. The P value for the interaction of azithromycin with no long-term oxygen use (P=.23) was not significant, and it is incorrect to infer that oxygen use or nonuse predicts response.

The authors correctly state that the “significance of the results is limited because the study was not originally powered for this level of subgroup analysis,” but this statement is buried later in the article.

David L. Hahn, MD, MS
Madison, Wis

1. Han MK, Tayob N, Murray S, et al. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med. 2014;189:1503-1508.

2. Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365:689-698.

Continue to: Author's response...

Author’s response:

Your statement that the evidence-based answer regarding the lack of benefit of azithromycin in patients ≤65 years of age, with stage IV COPD, current smokers, and patients not using oxygen is “misleading” is a bit of an overstatement.

It is fair to say, however, that our statement regarding lack of efficacy among these subgroups of patients should be softened a bit since the data are from subgroup analyses, which should never be the source of definitive conclusions. And you point out that the 95% confidence intervals [CIs] of the HRs for these subgroups of patients do not include a potentially significant effect (0.68, 0.71, 0.61, and 0.65, respectively), so it is possible there is a Type II error, which would lead one to conclude there is no effect for these subgroups when there is one.

Regarding oxygen therapy, in this Clinical Inquiry, we presented data from the direct subgroup analysis, which revealed no difference in COPD exacerbations between the azithromycin and placebo groups for patients not receiving long-term supplemental oxygen (HR=0.80; 95% CI, 0.62-1.03); however, you are correct to point out that the oxygen use subgroup interaction (patients on oxygen vs patients not on oxygen), which we did not include in this Clinical Inquiry, did not reach significance (P=.23), casting some doubt on the authors’ conclusion of no effect for patients not on oxygen.

On the whole, I feel this Clinical Inquiry accurately summarized the existing evidence and that additional research is needed to better define the utility of azithromycin in these subgroups of patients.

Corey Lyon, DO
Denver, Colo

In the Clinical Inquiry, “Does prophylactic azithromycin reduce the number of COPD exacerbations or hospitalizations?” (J Fam Pract. 2018;67:384-385), Lyon et al state that azithromycin “doesn’t benefit patients ≤65 years, patients with GOLD [Global Initiative for Obstructive Lung Disease] stage IV COPD [chronic obstructive pulmonary disease], current smokers, or patients not using oxygen (strength of recommendation [SOR]: B, randomized controlled trials [RCTs]).” These categorical statements are misleading, and clinicians should ignore most of them when considering azithromycin for their patients with severe COPD.

It would be more accurate to say that there may be a diminished efficacy of azithromycin for patients with GOLD IV COPD and age ≤65 years.

The authors cited groups that were identified in a posthoc analysis¹ of the only large trial involving azithromycin for the treatment of COPD to date.²P values for the interaction of azithromycin with GOLD stage (P=.04), smoking (P=.03), and age (P=.02) were significant, but the mean effects (hazard ratios [HRs]) for GOLD stage IV, smoking, and age ≤65 were .84, .99, and .84, respectively. It would be more accurate to say that there may be a diminished efficacy of azithromycin for patients with GOLD IV COPD and age ≤65 years. Only smokers appear to show no response, although the lower end of the 95% confidence interval was 0.71. The P value for the interaction of azithromycin with no long-term oxygen use (P=.23) was not significant, and it is incorrect to infer that oxygen use or nonuse predicts response.

The authors correctly state that the “significance of the results is limited because the study was not originally powered for this level of subgroup analysis,” but this statement is buried later in the article.

David L. Hahn, MD, MS
Madison, Wis

1. Han MK, Tayob N, Murray S, et al. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med. 2014;189:1503-1508.

2. Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365:689-698.

Continue to: Author's response...

Author’s response:

Your statement that the evidence-based answer regarding the lack of benefit of azithromycin in patients ≤65 years of age, with stage IV COPD, current smokers, and patients not using oxygen is “misleading” is a bit of an overstatement.

It is fair to say, however, that our statement regarding lack of efficacy among these subgroups of patients should be softened a bit since the data are from subgroup analyses, which should never be the source of definitive conclusions. And you point out that the 95% confidence intervals [CIs] of the HRs for these subgroups of patients do not include a potentially significant effect (0.68, 0.71, 0.61, and 0.65, respectively), so it is possible there is a Type II error, which would lead one to conclude there is no effect for these subgroups when there is one.

Regarding oxygen therapy, in this Clinical Inquiry, we presented data from the direct subgroup analysis, which revealed no difference in COPD exacerbations between the azithromycin and placebo groups for patients not receiving long-term supplemental oxygen (HR=0.80; 95% CI, 0.62-1.03); however, you are correct to point out that the oxygen use subgroup interaction (patients on oxygen vs patients not on oxygen), which we did not include in this Clinical Inquiry, did not reach significance (P=.23), casting some doubt on the authors’ conclusion of no effect for patients not on oxygen.

On the whole, I feel this Clinical Inquiry accurately summarized the existing evidence and that additional research is needed to better define the utility of azithromycin in these subgroups of patients.

Corey Lyon, DO
Denver, Colo

In the Clinical Inquiry, “Does prophylactic azithromycin reduce the number of COPD exacerbations or hospitalizations?” (J Fam Pract. 2018;67:384-385), Lyon et al state that azithromycin “doesn’t benefit patients ≤65 years, patients with GOLD [Global Initiative for Obstructive Lung Disease] stage IV COPD [chronic obstructive pulmonary disease], current smokers, or patients not using oxygen (strength of recommendation [SOR]: B, randomized controlled trials [RCTs]).” These categorical statements are misleading, and clinicians should ignore most of them when considering azithromycin for their patients with severe COPD.

It would be more accurate to say that there may be a diminished efficacy of azithromycin for patients with GOLD IV COPD and age ≤65 years.

The authors cited groups that were identified in a posthoc analysis¹ of the only large trial involving azithromycin for the treatment of COPD to date.²P values for the interaction of azithromycin with GOLD stage (P=.04), smoking (P=.03), and age (P=.02) were significant, but the mean effects (hazard ratios [HRs]) for GOLD stage IV, smoking, and age ≤65 were .84, .99, and .84, respectively. It would be more accurate to say that there may be a diminished efficacy of azithromycin for patients with GOLD IV COPD and age ≤65 years. Only smokers appear to show no response, although the lower end of the 95% confidence interval was 0.71. The P value for the interaction of azithromycin with no long-term oxygen use (P=.23) was not significant, and it is incorrect to infer that oxygen use or nonuse predicts response.

The authors correctly state that the “significance of the results is limited because the study was not originally powered for this level of subgroup analysis,” but this statement is buried later in the article.

David L. Hahn, MD, MS
Madison, Wis

1. Han MK, Tayob N, Murray S, et al. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med. 2014;189:1503-1508.

2. Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365:689-698.

Continue to: Author's response...

Author’s response:

Your statement that the evidence-based answer regarding the lack of benefit of azithromycin in patients ≤65 years of age, with stage IV COPD, current smokers, and patients not using oxygen is “misleading” is a bit of an overstatement.

It is fair to say, however, that our statement regarding lack of efficacy among these subgroups of patients should be softened a bit since the data are from subgroup analyses, which should never be the source of definitive conclusions. And you point out that the 95% confidence intervals [CIs] of the HRs for these subgroups of patients do not include a potentially significant effect (0.68, 0.71, 0.61, and 0.65, respectively), so it is possible there is a Type II error, which would lead one to conclude there is no effect for these subgroups when there is one.

Regarding oxygen therapy, in this Clinical Inquiry, we presented data from the direct subgroup analysis, which revealed no difference in COPD exacerbations between the azithromycin and placebo groups for patients not receiving long-term supplemental oxygen (HR=0.80; 95% CI, 0.62-1.03); however, you are correct to point out that the oxygen use subgroup interaction (patients on oxygen vs patients not on oxygen), which we did not include in this Clinical Inquiry, did not reach significance (P=.23), casting some doubt on the authors’ conclusion of no effect for patients not on oxygen.

On the whole, I feel this Clinical Inquiry accurately summarized the existing evidence and that additional research is needed to better define the utility of azithromycin in these subgroups of patients.

Corey Lyon, DO
Denver, Colo

In these first decades of the 21st century, the United States is the richest, strongest, most innovative nation on the planet. Americans like to chant “We’re Number 1”—and by many measures, they’re right. But in one crucial area of human endeavor—keeping people healthy—the mighty United States is a third-rate power.

All the other industrialized democracies have significantly better health outcomes than the United States—longer life expectancy, better recovery rates from illness or injury, less infant mortality.¹ Yet these nations spend, on average, half as much as the United States does for health care.¹ And these other rich democracies guarantee health care for everyone—while the United States leaves 29 million people ages <65 years with no health insurance, and another 50 million with deductibles so high that they are effectively uninsured.^2,3

This disgraceful state of affairs is not the fault of the nation’s physicians. Rather, the problems with health care in the United States stem from the system that American providers have to work in.

Health care has become big business. As the physician-turned-reporter Dr. Elisabeth Rosenthal notes in An American Sickness: How Healthcare Became Big Business, profits have come to matter more than patients for much of the $3.3 trillion US health care industry.^4,5 And the financial winners in our system—notably the “Big Four” health insurance giants, the for-profit hospital chains, and “Big Pharma”—fight hard to protect their profits. When the Affordable Care Act (“ObamaCare”) was first proposed, one of its main goals was to cut the administrative costs of health insurance, to force the private insurers to run their business as efficiently as Medicare. The insurance industry didn’t like that; its lobbyists fought back, successfully. As passed, the law allows the insurers to add up to 20% in administrative fees to every doctor and hospital bill—which adds hundreds of billions of dollars to the nation’s total health care spending every year.

Primary care doctors earn significantly less than specialists. But it doesn’t have to be that way.

Then there’s the problem that health-care economists call “specialty distribution imbalance.” In plain English, this means that the United States has too many doctors working in narrow (but highly compensated) subspecialties and not enough in the primary care fields of family medicine, internal medicine, and pediatrics. This is one more area where our country is out of sync with other industrialized democracies.

When I traveled the world studying health care systems, economists and government health ministers regularly told me that an efficient system should have 2 primary care providers for every 1 specialist. That is, primary care should make up about 66% of the overall physician work force.

If a 2:1 ratio of primary care providers to specialists is right, then the United States is upside down.

Most rich countries come close to this desired ratio. In the United Kingdom, family doctors working out of their own offices (it’s called a “surgery”) and treating patients on the local High Street (that is, Main Street), control 70% of the National Health Service (NHS) budget.⁶ “That’s the framework of the NHS, and of course we want to keep it,” John Reid, the UK’s former Minister of Health, told me. “If you just pop into your doctor’s surgery on the high street, that’s often just as effective, but never as expensive, as waiting to see a specialist.”

Continue to: If that 2:1 ratio is the right proportion...

If that 2:1 ratio is the right proportion for an effective health care system, the United States is upside down. For decades now, some two-thirds of new medical graduates have gone into narrower specialties, leaving our country with a serious shortage of primary care physicians.⁷ This situation helps to explain the higher cost and poorer overall outcomes that characterize American health care.

“Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care,” a report from the World Health Organization noted.⁸ “The results are...higher overall costs, and exclusion of people who cannot pay.” The report concluded that an emphasis on primary care leads to better outcomes for the same level of investment. This simple truth has been called the “Iron Law” of health care systems.

How can the United States get more primary care physicians? One answer is compensation. American primary care doctors routinely earn significantly less than specialists. But it doesn’t have to be that way. When I asked my family doctor in London, Dr. Ahmed Badat, why it is that 62% of British physicians are in family care, he was blunt: “Under the NHS, I make twice as much as a cardiac surgeon.”

If the big payers—government programs and private insurers—beef up fees for primary care (and pay for it by reducing compensation for specialists), more young American med students are likely to choose that route. Repayment plans that forgive the student loans of those in primary care fields also would attract more newly-minted physicians; these programs already are in place in several states.⁹

Continue to: Medical schools also have a role...

Medical schools also have a role to play. It’s no secret that the schools have emphasized specialties, with faculty members often steering their best students into narrow fields. But schools could promote an atmosphere in which primary care is treated as the most desirable destination for new doctors. Actively seeking out, and accepting, applicants who say they want to practice primary care is another key tool the medical schools could employ to deal with this national problem.

More doctors in primary care would mean better health care at lower cost for American patients. It’s long past time to take the steps needed to reach that goal.

In these first decades of the 21st century, the United States is the richest, strongest, most innovative nation on the planet. Americans like to chant “We’re Number 1”—and by many measures, they’re right. But in one crucial area of human endeavor—keeping people healthy—the mighty United States is a third-rate power.

All the other industrialized democracies have significantly better health outcomes than the United States—longer life expectancy, better recovery rates from illness or injury, less infant mortality.¹ Yet these nations spend, on average, half as much as the United States does for health care.¹ And these other rich democracies guarantee health care for everyone—while the United States leaves 29 million people ages <65 years with no health insurance, and another 50 million with deductibles so high that they are effectively uninsured.^2,3

This disgraceful state of affairs is not the fault of the nation’s physicians. Rather, the problems with health care in the United States stem from the system that American providers have to work in.

Health care has become big business. As the physician-turned-reporter Dr. Elisabeth Rosenthal notes in An American Sickness: How Healthcare Became Big Business, profits have come to matter more than patients for much of the $3.3 trillion US health care industry.^4,5 And the financial winners in our system—notably the “Big Four” health insurance giants, the for-profit hospital chains, and “Big Pharma”—fight hard to protect their profits. When the Affordable Care Act (“ObamaCare”) was first proposed, one of its main goals was to cut the administrative costs of health insurance, to force the private insurers to run their business as efficiently as Medicare. The insurance industry didn’t like that; its lobbyists fought back, successfully. As passed, the law allows the insurers to add up to 20% in administrative fees to every doctor and hospital bill—which adds hundreds of billions of dollars to the nation’s total health care spending every year.

Primary care doctors earn significantly less than specialists. But it doesn’t have to be that way.

Then there’s the problem that health-care economists call “specialty distribution imbalance.” In plain English, this means that the United States has too many doctors working in narrow (but highly compensated) subspecialties and not enough in the primary care fields of family medicine, internal medicine, and pediatrics. This is one more area where our country is out of sync with other industrialized democracies.

When I traveled the world studying health care systems, economists and government health ministers regularly told me that an efficient system should have 2 primary care providers for every 1 specialist. That is, primary care should make up about 66% of the overall physician work force.

If a 2:1 ratio of primary care providers to specialists is right, then the United States is upside down.

Most rich countries come close to this desired ratio. In the United Kingdom, family doctors working out of their own offices (it’s called a “surgery”) and treating patients on the local High Street (that is, Main Street), control 70% of the National Health Service (NHS) budget.⁶ “That’s the framework of the NHS, and of course we want to keep it,” John Reid, the UK’s former Minister of Health, told me. “If you just pop into your doctor’s surgery on the high street, that’s often just as effective, but never as expensive, as waiting to see a specialist.”

Continue to: If that 2:1 ratio is the right proportion...

If that 2:1 ratio is the right proportion for an effective health care system, the United States is upside down. For decades now, some two-thirds of new medical graduates have gone into narrower specialties, leaving our country with a serious shortage of primary care physicians.⁷ This situation helps to explain the higher cost and poorer overall outcomes that characterize American health care.

“Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care,” a report from the World Health Organization noted.⁸ “The results are...higher overall costs, and exclusion of people who cannot pay.” The report concluded that an emphasis on primary care leads to better outcomes for the same level of investment. This simple truth has been called the “Iron Law” of health care systems.

How can the United States get more primary care physicians? One answer is compensation. American primary care doctors routinely earn significantly less than specialists. But it doesn’t have to be that way. When I asked my family doctor in London, Dr. Ahmed Badat, why it is that 62% of British physicians are in family care, he was blunt: “Under the NHS, I make twice as much as a cardiac surgeon.”

If the big payers—government programs and private insurers—beef up fees for primary care (and pay for it by reducing compensation for specialists), more young American med students are likely to choose that route. Repayment plans that forgive the student loans of those in primary care fields also would attract more newly-minted physicians; these programs already are in place in several states.⁹

Continue to: Medical schools also have a role...

Medical schools also have a role to play. It’s no secret that the schools have emphasized specialties, with faculty members often steering their best students into narrow fields. But schools could promote an atmosphere in which primary care is treated as the most desirable destination for new doctors. Actively seeking out, and accepting, applicants who say they want to practice primary care is another key tool the medical schools could employ to deal with this national problem.

More doctors in primary care would mean better health care at lower cost for American patients. It’s long past time to take the steps needed to reach that goal.

In these first decades of the 21st century, the United States is the richest, strongest, most innovative nation on the planet. Americans like to chant “We’re Number 1”—and by many measures, they’re right. But in one crucial area of human endeavor—keeping people healthy—the mighty United States is a third-rate power.

All the other industrialized democracies have significantly better health outcomes than the United States—longer life expectancy, better recovery rates from illness or injury, less infant mortality.¹ Yet these nations spend, on average, half as much as the United States does for health care.¹ And these other rich democracies guarantee health care for everyone—while the United States leaves 29 million people ages <65 years with no health insurance, and another 50 million with deductibles so high that they are effectively uninsured.^2,3

This disgraceful state of affairs is not the fault of the nation’s physicians. Rather, the problems with health care in the United States stem from the system that American providers have to work in.

Health care has become big business. As the physician-turned-reporter Dr. Elisabeth Rosenthal notes in An American Sickness: How Healthcare Became Big Business, profits have come to matter more than patients for much of the $3.3 trillion US health care industry.^4,5 And the financial winners in our system—notably the “Big Four” health insurance giants, the for-profit hospital chains, and “Big Pharma”—fight hard to protect their profits. When the Affordable Care Act (“ObamaCare”) was first proposed, one of its main goals was to cut the administrative costs of health insurance, to force the private insurers to run their business as efficiently as Medicare. The insurance industry didn’t like that; its lobbyists fought back, successfully. As passed, the law allows the insurers to add up to 20% in administrative fees to every doctor and hospital bill—which adds hundreds of billions of dollars to the nation’s total health care spending every year.

Primary care doctors earn significantly less than specialists. But it doesn’t have to be that way.

Then there’s the problem that health-care economists call “specialty distribution imbalance.” In plain English, this means that the United States has too many doctors working in narrow (but highly compensated) subspecialties and not enough in the primary care fields of family medicine, internal medicine, and pediatrics. This is one more area where our country is out of sync with other industrialized democracies.

When I traveled the world studying health care systems, economists and government health ministers regularly told me that an efficient system should have 2 primary care providers for every 1 specialist. That is, primary care should make up about 66% of the overall physician work force.

If a 2:1 ratio of primary care providers to specialists is right, then the United States is upside down.

Most rich countries come close to this desired ratio. In the United Kingdom, family doctors working out of their own offices (it’s called a “surgery”) and treating patients on the local High Street (that is, Main Street), control 70% of the National Health Service (NHS) budget.⁶ “That’s the framework of the NHS, and of course we want to keep it,” John Reid, the UK’s former Minister of Health, told me. “If you just pop into your doctor’s surgery on the high street, that’s often just as effective, but never as expensive, as waiting to see a specialist.”

Continue to: If that 2:1 ratio is the right proportion...

If that 2:1 ratio is the right proportion for an effective health care system, the United States is upside down. For decades now, some two-thirds of new medical graduates have gone into narrower specialties, leaving our country with a serious shortage of primary care physicians.⁷ This situation helps to explain the higher cost and poorer overall outcomes that characterize American health care.

“Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care,” a report from the World Health Organization noted.⁸ “The results are...higher overall costs, and exclusion of people who cannot pay.” The report concluded that an emphasis on primary care leads to better outcomes for the same level of investment. This simple truth has been called the “Iron Law” of health care systems.

How can the United States get more primary care physicians? One answer is compensation. American primary care doctors routinely earn significantly less than specialists. But it doesn’t have to be that way. When I asked my family doctor in London, Dr. Ahmed Badat, why it is that 62% of British physicians are in family care, he was blunt: “Under the NHS, I make twice as much as a cardiac surgeon.”

If the big payers—government programs and private insurers—beef up fees for primary care (and pay for it by reducing compensation for specialists), more young American med students are likely to choose that route. Repayment plans that forgive the student loans of those in primary care fields also would attract more newly-minted physicians; these programs already are in place in several states.⁹

Continue to: Medical schools also have a role...

Medical schools also have a role to play. It’s no secret that the schools have emphasized specialties, with faculty members often steering their best students into narrow fields. But schools could promote an atmosphere in which primary care is treated as the most desirable destination for new doctors. Actively seeking out, and accepting, applicants who say they want to practice primary care is another key tool the medical schools could employ to deal with this national problem.

More doctors in primary care would mean better health care at lower cost for American patients. It’s long past time to take the steps needed to reach that goal.