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How the ADA shapes health care
Question: After many years of diabetes, a 60-year-old office worker develops nephropathy followed by end-stage renal disease, and now requires dialysis. He has opted for peritoneal dialysis rather than hemodialysis, so that he does not have to be away from the workplace for treatment. His diabetes is insulin requiring, and he has occasional hypoglycemic reactions. Although he qualifies for Social Security disability benefits, he prefers to continue working full time. The employer is considering terminating him.
Which of the following is best?
A. The Americans with Disabilities Act prohibits job discrimination against patients with disabilities, so long as they are otherwise qualified for every aspect of the job.
B. Renal insufficiency and diabetes are considered disabilities under the ADA.
C. The employer is obligated to provide full accommodation to enable this employee to continue working.
D. If the accommodations needed for a disabled person are unreasonable, or prove too disruptive or expensive, then the employer is not obligated to provide them.
E. This patient should simply retire and enjoy his SS disability benefits.
Answer: D. Enacted in 1990, the Americans with Disabilities Act seeks to provide clear, strong, consistent, and enforceable standards for ending discrimination against individuals with disabilities.1 The main thrust of the ADA, Title I, is to protect otherwise qualified workers with permanent disabilities from losing their jobs or seeking one, so long as they are qualified to perform the essential (not necessarily all) functions of the job.
In addition, the law prohibits discrimination against people with disabilities from accessing public accommodations (Title III), which include doctors’ offices and health care facilities, as well as restaurants, retail stores, etc. Other areas under the purview of the omnibus ADA include transportation, communications, and access to state and local government programs and services.
The Equal Employment Opportunity Commission (EEOC) enforces Title I of the ADA, the section that deals with job discrimination. Its compliance manual sets out guidelines for determining whether an individual in fact has a disability.
The word “disability” has three components, and the term is not synonymous with “impairment.” However, a disability begins with having an impairment, defined as a physiological disorder affecting one or more of a number of body systems or a mental or psychological disorder.
An example given by the EEOC: If a person cannot find a job because that person has the equivalent of a second-grade education and therefore cannot read, that person does not have an impairment for purposes of the ADA. If, however, that person cannot read because of severe dyslexia, that person has an impairment. Likewise, being overweight is not considered an impairment (unless due to an underlying physical condition, e.g., hypothyroidism), although extreme obesity in excess of 100% ideal body weight is.
Having determined that an impairment exists, the next step in the analysis is to ascertain if the impairment limits one or more “major life activities.” These have classically included activities such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, and breathing.
Third, the limitation must be substantial, meaning sufficiently severe, compared with what an average person is capable of doing. According to the EEOC, a mild type 2 diabetes patient on diet treatment alone and no other restriction has an impairment; but the impairment does not substantially limit any of his major life activities. On the other hand, some impairments are so severe that there is no doubt they substantially limit major life activities, e.g., insulin-dependent diabetes, legal blindness, deafness, manic-depressive syndrome, alcoholism, and HIV infection.
There is litigation aplenty over these issues.
In its seminal 1988 case, the U.S. Supreme Court provided the analytical steps listed above in arriving at its holding that, under the ADA, asymptomatic HIV infection is a disability.2 The case involved a dentist who was sued when he declined to treat an HIV-positive female patient in the office, offering instead to treat her in a hospital without any additional charge. A dental office, like a doctor’s office, is recognized as a place of public accommodations, and therefore falls under the protection of Title III of the ADA.
The court first considered whether HIV infection was a physical impairment. Second, it identified the major life activity upon which the plaintiff relied (reproduction and childbearing) and determined whether it constituted a major life activity under the ADA. Third, it tied the two statutory phrases together, and asked whether the impairment substantially limited these major life activities.
The court held that, in light of the immediacy with which the HIV virus begins to damage the infected person’s white blood cells and the severity of the disease, it is an impairment from the moment of infection, even if the patient was asymptomatic. It also ruled that the HIV infection substantially limited her ability to reproduce in two independent ways. First, a woman infected with HIV who tries to conceive a child imposes on the man a significant risk of becoming infected, and second, an infected woman risks infecting her child during gestation and childbirth, i.e., perinatal transmission.
In 2004, a case reached the U.S. Third Circuit Court of Appeals regarding Cathy Fiscus, an employee at a Walmart Sam’s Club warehouse store in Pittsburgh, who faced being terminated after 12 years at her job. A lower U.S. district court had ruled in favor of the company, agreeing with Walmart that the woman’s end-stage renal disease had not left her significantly limited in a major life activity. Ms. Fiscus sought a reasonable accommodation from her employer during the period of her peritoneal dialysis, which required her to self administer the 45-minute dialysis process at the workplace. Walmart initially agreed, but later declined. The appeals court overturned the lower court’s ruling, writing, “A physical impairment that limits an individual’s ability to cleanse and eliminate body waste does impair a major life activity.”3
Not all conditions are covered by the ADA’s definition of disability. The list includes temporary physical or mental impairments, current illegal drug use, predisposition to illness, personality traits, advanced age, and pregnancy, to name a few.
To avoid running afoul of the ADA, an employer is required to make “reasonable accommodations” for the disabled employee. This refers to practices that allow a disabled person to perform the essential functions of the job.
Examples of reasonable accommodations include making existing facilities readily accessible to and usable by individuals with disabilities, restructuring jobs, modifying work schedules, and providing qualified readers or interpreters.
A “qualified individual with a disability” is an individual with a disability who, “with or without reasonable accommodation,” can perform the essential functions of the employment position in question. A person is not a qualified individual with a disability, however, if he or she cannot satisfy the basic attendance requirements of a position.
Employers are not required to offer any and all accommodations, such as those that are disruptive to the business, overly burdensome, or prohibitively expensive. Providing a clean and private area in the workplace for self-administered peritoneal dialysis fluid exchange would likely qualify as a reasonable accommodation that should be offered, absent some compelling reason not to.
The protection given by the ADA may be suspended if the condition poses a direct threat, defined as “a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures, or by the provision of auxiliary aids or services.”4 The U.S. Supreme Court has noted that this should be assessed by the objective reasonableness of the views of health care professionals.
Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Americans with Disabilities Act of 1990 (ADA), 104 Stat. 327, 42 U. S. C. § 12101 et seq.
2. Bragdon v. Abbott et al. 524 U.S. 624 (1998).
3. Cathy A. Fiscus v. Wal-Mart Stores Inc., 385 F.3d 378 (3d Cir. 2004).
4. 42 U. S. C. § 12182(b)(3).
5. Available at www.kidney.org/atoz/content/employersguide.
Question: After many years of diabetes, a 60-year-old office worker develops nephropathy followed by end-stage renal disease, and now requires dialysis. He has opted for peritoneal dialysis rather than hemodialysis, so that he does not have to be away from the workplace for treatment. His diabetes is insulin requiring, and he has occasional hypoglycemic reactions. Although he qualifies for Social Security disability benefits, he prefers to continue working full time. The employer is considering terminating him.
Which of the following is best?
A. The Americans with Disabilities Act prohibits job discrimination against patients with disabilities, so long as they are otherwise qualified for every aspect of the job.
B. Renal insufficiency and diabetes are considered disabilities under the ADA.
C. The employer is obligated to provide full accommodation to enable this employee to continue working.
D. If the accommodations needed for a disabled person are unreasonable, or prove too disruptive or expensive, then the employer is not obligated to provide them.
E. This patient should simply retire and enjoy his SS disability benefits.
Answer: D. Enacted in 1990, the Americans with Disabilities Act seeks to provide clear, strong, consistent, and enforceable standards for ending discrimination against individuals with disabilities.1 The main thrust of the ADA, Title I, is to protect otherwise qualified workers with permanent disabilities from losing their jobs or seeking one, so long as they are qualified to perform the essential (not necessarily all) functions of the job.
In addition, the law prohibits discrimination against people with disabilities from accessing public accommodations (Title III), which include doctors’ offices and health care facilities, as well as restaurants, retail stores, etc. Other areas under the purview of the omnibus ADA include transportation, communications, and access to state and local government programs and services.
The Equal Employment Opportunity Commission (EEOC) enforces Title I of the ADA, the section that deals with job discrimination. Its compliance manual sets out guidelines for determining whether an individual in fact has a disability.
The word “disability” has three components, and the term is not synonymous with “impairment.” However, a disability begins with having an impairment, defined as a physiological disorder affecting one or more of a number of body systems or a mental or psychological disorder.
An example given by the EEOC: If a person cannot find a job because that person has the equivalent of a second-grade education and therefore cannot read, that person does not have an impairment for purposes of the ADA. If, however, that person cannot read because of severe dyslexia, that person has an impairment. Likewise, being overweight is not considered an impairment (unless due to an underlying physical condition, e.g., hypothyroidism), although extreme obesity in excess of 100% ideal body weight is.
Having determined that an impairment exists, the next step in the analysis is to ascertain if the impairment limits one or more “major life activities.” These have classically included activities such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, and breathing.
Third, the limitation must be substantial, meaning sufficiently severe, compared with what an average person is capable of doing. According to the EEOC, a mild type 2 diabetes patient on diet treatment alone and no other restriction has an impairment; but the impairment does not substantially limit any of his major life activities. On the other hand, some impairments are so severe that there is no doubt they substantially limit major life activities, e.g., insulin-dependent diabetes, legal blindness, deafness, manic-depressive syndrome, alcoholism, and HIV infection.
There is litigation aplenty over these issues.
In its seminal 1988 case, the U.S. Supreme Court provided the analytical steps listed above in arriving at its holding that, under the ADA, asymptomatic HIV infection is a disability.2 The case involved a dentist who was sued when he declined to treat an HIV-positive female patient in the office, offering instead to treat her in a hospital without any additional charge. A dental office, like a doctor’s office, is recognized as a place of public accommodations, and therefore falls under the protection of Title III of the ADA.
The court first considered whether HIV infection was a physical impairment. Second, it identified the major life activity upon which the plaintiff relied (reproduction and childbearing) and determined whether it constituted a major life activity under the ADA. Third, it tied the two statutory phrases together, and asked whether the impairment substantially limited these major life activities.
The court held that, in light of the immediacy with which the HIV virus begins to damage the infected person’s white blood cells and the severity of the disease, it is an impairment from the moment of infection, even if the patient was asymptomatic. It also ruled that the HIV infection substantially limited her ability to reproduce in two independent ways. First, a woman infected with HIV who tries to conceive a child imposes on the man a significant risk of becoming infected, and second, an infected woman risks infecting her child during gestation and childbirth, i.e., perinatal transmission.
In 2004, a case reached the U.S. Third Circuit Court of Appeals regarding Cathy Fiscus, an employee at a Walmart Sam’s Club warehouse store in Pittsburgh, who faced being terminated after 12 years at her job. A lower U.S. district court had ruled in favor of the company, agreeing with Walmart that the woman’s end-stage renal disease had not left her significantly limited in a major life activity. Ms. Fiscus sought a reasonable accommodation from her employer during the period of her peritoneal dialysis, which required her to self administer the 45-minute dialysis process at the workplace. Walmart initially agreed, but later declined. The appeals court overturned the lower court’s ruling, writing, “A physical impairment that limits an individual’s ability to cleanse and eliminate body waste does impair a major life activity.”3
Not all conditions are covered by the ADA’s definition of disability. The list includes temporary physical or mental impairments, current illegal drug use, predisposition to illness, personality traits, advanced age, and pregnancy, to name a few.
To avoid running afoul of the ADA, an employer is required to make “reasonable accommodations” for the disabled employee. This refers to practices that allow a disabled person to perform the essential functions of the job.
Examples of reasonable accommodations include making existing facilities readily accessible to and usable by individuals with disabilities, restructuring jobs, modifying work schedules, and providing qualified readers or interpreters.
A “qualified individual with a disability” is an individual with a disability who, “with or without reasonable accommodation,” can perform the essential functions of the employment position in question. A person is not a qualified individual with a disability, however, if he or she cannot satisfy the basic attendance requirements of a position.
Employers are not required to offer any and all accommodations, such as those that are disruptive to the business, overly burdensome, or prohibitively expensive. Providing a clean and private area in the workplace for self-administered peritoneal dialysis fluid exchange would likely qualify as a reasonable accommodation that should be offered, absent some compelling reason not to.
The protection given by the ADA may be suspended if the condition poses a direct threat, defined as “a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures, or by the provision of auxiliary aids or services.”4 The U.S. Supreme Court has noted that this should be assessed by the objective reasonableness of the views of health care professionals.
Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Americans with Disabilities Act of 1990 (ADA), 104 Stat. 327, 42 U. S. C. § 12101 et seq.
2. Bragdon v. Abbott et al. 524 U.S. 624 (1998).
3. Cathy A. Fiscus v. Wal-Mart Stores Inc., 385 F.3d 378 (3d Cir. 2004).
4. 42 U. S. C. § 12182(b)(3).
5. Available at www.kidney.org/atoz/content/employersguide.
Question: After many years of diabetes, a 60-year-old office worker develops nephropathy followed by end-stage renal disease, and now requires dialysis. He has opted for peritoneal dialysis rather than hemodialysis, so that he does not have to be away from the workplace for treatment. His diabetes is insulin requiring, and he has occasional hypoglycemic reactions. Although he qualifies for Social Security disability benefits, he prefers to continue working full time. The employer is considering terminating him.
Which of the following is best?
A. The Americans with Disabilities Act prohibits job discrimination against patients with disabilities, so long as they are otherwise qualified for every aspect of the job.
B. Renal insufficiency and diabetes are considered disabilities under the ADA.
C. The employer is obligated to provide full accommodation to enable this employee to continue working.
D. If the accommodations needed for a disabled person are unreasonable, or prove too disruptive or expensive, then the employer is not obligated to provide them.
E. This patient should simply retire and enjoy his SS disability benefits.
Answer: D. Enacted in 1990, the Americans with Disabilities Act seeks to provide clear, strong, consistent, and enforceable standards for ending discrimination against individuals with disabilities.1 The main thrust of the ADA, Title I, is to protect otherwise qualified workers with permanent disabilities from losing their jobs or seeking one, so long as they are qualified to perform the essential (not necessarily all) functions of the job.
In addition, the law prohibits discrimination against people with disabilities from accessing public accommodations (Title III), which include doctors’ offices and health care facilities, as well as restaurants, retail stores, etc. Other areas under the purview of the omnibus ADA include transportation, communications, and access to state and local government programs and services.
The Equal Employment Opportunity Commission (EEOC) enforces Title I of the ADA, the section that deals with job discrimination. Its compliance manual sets out guidelines for determining whether an individual in fact has a disability.
The word “disability” has three components, and the term is not synonymous with “impairment.” However, a disability begins with having an impairment, defined as a physiological disorder affecting one or more of a number of body systems or a mental or psychological disorder.
An example given by the EEOC: If a person cannot find a job because that person has the equivalent of a second-grade education and therefore cannot read, that person does not have an impairment for purposes of the ADA. If, however, that person cannot read because of severe dyslexia, that person has an impairment. Likewise, being overweight is not considered an impairment (unless due to an underlying physical condition, e.g., hypothyroidism), although extreme obesity in excess of 100% ideal body weight is.
Having determined that an impairment exists, the next step in the analysis is to ascertain if the impairment limits one or more “major life activities.” These have classically included activities such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, and breathing.
Third, the limitation must be substantial, meaning sufficiently severe, compared with what an average person is capable of doing. According to the EEOC, a mild type 2 diabetes patient on diet treatment alone and no other restriction has an impairment; but the impairment does not substantially limit any of his major life activities. On the other hand, some impairments are so severe that there is no doubt they substantially limit major life activities, e.g., insulin-dependent diabetes, legal blindness, deafness, manic-depressive syndrome, alcoholism, and HIV infection.
There is litigation aplenty over these issues.
In its seminal 1988 case, the U.S. Supreme Court provided the analytical steps listed above in arriving at its holding that, under the ADA, asymptomatic HIV infection is a disability.2 The case involved a dentist who was sued when he declined to treat an HIV-positive female patient in the office, offering instead to treat her in a hospital without any additional charge. A dental office, like a doctor’s office, is recognized as a place of public accommodations, and therefore falls under the protection of Title III of the ADA.
The court first considered whether HIV infection was a physical impairment. Second, it identified the major life activity upon which the plaintiff relied (reproduction and childbearing) and determined whether it constituted a major life activity under the ADA. Third, it tied the two statutory phrases together, and asked whether the impairment substantially limited these major life activities.
The court held that, in light of the immediacy with which the HIV virus begins to damage the infected person’s white blood cells and the severity of the disease, it is an impairment from the moment of infection, even if the patient was asymptomatic. It also ruled that the HIV infection substantially limited her ability to reproduce in two independent ways. First, a woman infected with HIV who tries to conceive a child imposes on the man a significant risk of becoming infected, and second, an infected woman risks infecting her child during gestation and childbirth, i.e., perinatal transmission.
In 2004, a case reached the U.S. Third Circuit Court of Appeals regarding Cathy Fiscus, an employee at a Walmart Sam’s Club warehouse store in Pittsburgh, who faced being terminated after 12 years at her job. A lower U.S. district court had ruled in favor of the company, agreeing with Walmart that the woman’s end-stage renal disease had not left her significantly limited in a major life activity. Ms. Fiscus sought a reasonable accommodation from her employer during the period of her peritoneal dialysis, which required her to self administer the 45-minute dialysis process at the workplace. Walmart initially agreed, but later declined. The appeals court overturned the lower court’s ruling, writing, “A physical impairment that limits an individual’s ability to cleanse and eliminate body waste does impair a major life activity.”3
Not all conditions are covered by the ADA’s definition of disability. The list includes temporary physical or mental impairments, current illegal drug use, predisposition to illness, personality traits, advanced age, and pregnancy, to name a few.
To avoid running afoul of the ADA, an employer is required to make “reasonable accommodations” for the disabled employee. This refers to practices that allow a disabled person to perform the essential functions of the job.
Examples of reasonable accommodations include making existing facilities readily accessible to and usable by individuals with disabilities, restructuring jobs, modifying work schedules, and providing qualified readers or interpreters.
A “qualified individual with a disability” is an individual with a disability who, “with or without reasonable accommodation,” can perform the essential functions of the employment position in question. A person is not a qualified individual with a disability, however, if he or she cannot satisfy the basic attendance requirements of a position.
Employers are not required to offer any and all accommodations, such as those that are disruptive to the business, overly burdensome, or prohibitively expensive. Providing a clean and private area in the workplace for self-administered peritoneal dialysis fluid exchange would likely qualify as a reasonable accommodation that should be offered, absent some compelling reason not to.
The protection given by the ADA may be suspended if the condition poses a direct threat, defined as “a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures, or by the provision of auxiliary aids or services.”4 The U.S. Supreme Court has noted that this should be assessed by the objective reasonableness of the views of health care professionals.
Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Americans with Disabilities Act of 1990 (ADA), 104 Stat. 327, 42 U. S. C. § 12101 et seq.
2. Bragdon v. Abbott et al. 524 U.S. 624 (1998).
3. Cathy A. Fiscus v. Wal-Mart Stores Inc., 385 F.3d 378 (3d Cir. 2004).
4. 42 U. S. C. § 12182(b)(3).
5. Available at www.kidney.org/atoz/content/employersguide.
Office staff cohesiveness remains important
Recently, a lawyer and I were on the phone about a case, and he mentioned how lucky he was to have had the same staff over the course of a 25-year career, and he was afraid they’d retire before he did.
I feel the same way. My medical assistant has been with me since day one 18 years ago, my secretary since 2004. I hope they keep putting up with me until I hang up my reflex hammer.
It’s impossible to put a great team together just by talent alone. The chemistry and ability to work together are as critical as talent, if not more so, and are far more intangible and unpredictable.
I’ve been lucky that way. The three of us are cohesive. We try to keep some degree of fun in our work routine as each day goes on. My secretary’s 2-year-old daughter, who comes with her every day, adds to the family atmosphere that many patients notice. It’s not uncommon to be asked if the group of us are related. (We’re not.)
Back when I started out, it was with a large group that saw its people as replaceable, and treated them as such. As a result there was a high turnover rate of medical assistants and front office and clerical staff. This led to problems with work-flow and patient care, as there was always someone new being trained.
I can’t imagine having a better team than I have now, and will share this advice with anyone starting a practice: When you get the right people, count yourself lucky and do what you have to do to keep them. They’re worth it.
It’s a lot nicer to work with friends than strangers. It makes the drudgery of the job more interesting, the low points better, and the highs fun.
I wouldn’t have it any other way.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Recently, a lawyer and I were on the phone about a case, and he mentioned how lucky he was to have had the same staff over the course of a 25-year career, and he was afraid they’d retire before he did.
I feel the same way. My medical assistant has been with me since day one 18 years ago, my secretary since 2004. I hope they keep putting up with me until I hang up my reflex hammer.
It’s impossible to put a great team together just by talent alone. The chemistry and ability to work together are as critical as talent, if not more so, and are far more intangible and unpredictable.
I’ve been lucky that way. The three of us are cohesive. We try to keep some degree of fun in our work routine as each day goes on. My secretary’s 2-year-old daughter, who comes with her every day, adds to the family atmosphere that many patients notice. It’s not uncommon to be asked if the group of us are related. (We’re not.)
Back when I started out, it was with a large group that saw its people as replaceable, and treated them as such. As a result there was a high turnover rate of medical assistants and front office and clerical staff. This led to problems with work-flow and patient care, as there was always someone new being trained.
I can’t imagine having a better team than I have now, and will share this advice with anyone starting a practice: When you get the right people, count yourself lucky and do what you have to do to keep them. They’re worth it.
It’s a lot nicer to work with friends than strangers. It makes the drudgery of the job more interesting, the low points better, and the highs fun.
I wouldn’t have it any other way.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Recently, a lawyer and I were on the phone about a case, and he mentioned how lucky he was to have had the same staff over the course of a 25-year career, and he was afraid they’d retire before he did.
I feel the same way. My medical assistant has been with me since day one 18 years ago, my secretary since 2004. I hope they keep putting up with me until I hang up my reflex hammer.
It’s impossible to put a great team together just by talent alone. The chemistry and ability to work together are as critical as talent, if not more so, and are far more intangible and unpredictable.
I’ve been lucky that way. The three of us are cohesive. We try to keep some degree of fun in our work routine as each day goes on. My secretary’s 2-year-old daughter, who comes with her every day, adds to the family atmosphere that many patients notice. It’s not uncommon to be asked if the group of us are related. (We’re not.)
Back when I started out, it was with a large group that saw its people as replaceable, and treated them as such. As a result there was a high turnover rate of medical assistants and front office and clerical staff. This led to problems with work-flow and patient care, as there was always someone new being trained.
I can’t imagine having a better team than I have now, and will share this advice with anyone starting a practice: When you get the right people, count yourself lucky and do what you have to do to keep them. They’re worth it.
It’s a lot nicer to work with friends than strangers. It makes the drudgery of the job more interesting, the low points better, and the highs fun.
I wouldn’t have it any other way.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A Message from the Executive Director: ACS continues to take on the issues of concern to surgeons and their patients
I am pleased to once again submit an annual report for publication in ACS Surgery News. The American College of Surgeons (ACS) had a productive year in 2017 and looks forward to seeing a range of new programs evolve in 2018.
Physician payment
A health policy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services’ efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 was the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates in 2019.
In 2018, the second year of MIPS, the penalty for nonparticipation has increased to 5 percent from 4 percent. Over time, the penalty for nonparticpation or poor performance will continue to rise. The College has created a variety of resources to assist Fellows in their efforts to comply with MIPS, which explain the purpose and structure of the MIPS program and help guide surgeons in choosing and achieving the goal that is right for their individual practice. These tools can be found on the ACS website at facs.org/qpp.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). The College has worked with thought leaders at Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced APM. In 2017, the Secretary of the Department of Health and Human Services reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and entities that may implement the APM model once available.
Education
The College is leading a significant effort to address the needs of surgeons who are looking to update their skills. The Steering Committee for Retraining and Retooling of Practicing Surgeons is working to define standards and establish a national infrastructure to achieve optimal outcomes. The ACS Accredited Education Institutes are at the core of this infrastructure.
At Clinical Congress 2017, we launched the ACS Academy of Master Surgeon Educators. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Also at Clinical Congress, the ACS Committee on Ethics unveiled Ethical Issues in Surgical Care, a landmark resource that defines a framework for the field of surgical ethics as it has evolved over the last decade. The book is organized into four sections that address the broad areas of general consideration, the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Quality
The College released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” in July 2017.This manual provides a guide for surgical quality leaders seeking to improve quality and safety in their institutions, departments, and practices. Efforts are under way to develop adjunctive or integrated resources/standards and to potentially establish a Surgical Quality Verification Program.
The red book was released at the 2017 ACS Quality and Safety Conference, formerly the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference, in New York, NY. The conference, which focused on a broad range of ACS Quality Programs, boasted a record-breaking attendance of more than 1,800 attendees.
The new Surgeon Specific Registry was the first ACS database to launch as part of the College’s integrated registry of the future, which ultimately will allow users to share relevant quality data across individual ACS Quality Programs, such as ACS NSQIP and the Trauma Quality Improvement Program (TQIP®).
Other new quality initiatives include the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR), which the ACS is conducting in collaboration with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. This program supports hospitals in implementing perioperative evidence-based pathways to improve clinical outcomes, reduce hospital length of stay, and improve the patient experience.
The ACS also has become the new home of Strong for Surgery, originally developed by surgeons in Washington State. This program empowers hospitals and clinics to integrate checklists into the preoperative phase of care.
In addition, the ACS was awarded a three-year, multimillion dollar R01 grant from the National Institute on Minority Health and Health Disparities. ACS Past-President L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), is the principal investigator on this award, which is aimed at eliminating variances in access to surgical care.
Trauma
The Committee on Trauma (COT), in collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), hosted a conference in April 2017 to advance the recommendations in the National Academies on Science, Engineering, and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The meeting brought together approximately 170 trauma care professionals with the goal of creating the framework for a National Trauma Care System Action Plan.
In light of recent tragedies and the ongoing public debate over how to stop the continuing violence at our nation’s schools, churches, and other public places, the COT Injury Prevention and Control Committee (IPCC) is advocating for a consensus-based, public health/trauma system approach to firearm injury prevention. Furthermore, at its February 2018 meeting the ACS Board of Regents unanimously approved a plan to expand the College’s focus from the successful Stop the Bleed® program to a broader prevention initiative focused on strategies that include research, advocacy, and strategic collaborations. An action plan was in development at press time.
ACS leadership
The ACS Board of Governors (B/G) continues to implement initiatives through its Pillars and Workgroups. Specific examples from this past year include the release of a white paper on out-of-network billing; production of the biannual e-newsletter, The Cutting Edge; conduct of the 2017 Board of Governors Annual Survey, which focuses on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery; and development of a standardized letter of recommendation for applicants to surgery training programs.
The ACS Board of Regents approved and updated a number of statements in the last 12 months. New statements cover several topics of concern to the Fellowship, including gender salary equity, the use of anesthetics and sedation drugs in children and pregnant women, the opioid abuse epidemic, lithium batteries, opioids and motor vehicle crash prevention, maintaining surgical access with a locum tenens surgeon, social media, the Uniform Emergency Volunteer Health Practitioners Act, credentialing and privileging, and medical students and the electronic health record.
As these few examples demonstrate, the ACS is constantly moving forward to offer surgeons and the other members of the patient care team the tools, resources, and educational opportunities they need to succeed in practice and to provide optimal patient care. As always, you are encouraged to contact the ACS leadership, and let us know how we can best serve you.
Dr. Hoyt is the Executive Director of the ACS, Chicago, IL.
I am pleased to once again submit an annual report for publication in ACS Surgery News. The American College of Surgeons (ACS) had a productive year in 2017 and looks forward to seeing a range of new programs evolve in 2018.
Physician payment
A health policy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services’ efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 was the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates in 2019.
In 2018, the second year of MIPS, the penalty for nonparticipation has increased to 5 percent from 4 percent. Over time, the penalty for nonparticpation or poor performance will continue to rise. The College has created a variety of resources to assist Fellows in their efforts to comply with MIPS, which explain the purpose and structure of the MIPS program and help guide surgeons in choosing and achieving the goal that is right for their individual practice. These tools can be found on the ACS website at facs.org/qpp.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). The College has worked with thought leaders at Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced APM. In 2017, the Secretary of the Department of Health and Human Services reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and entities that may implement the APM model once available.
Education
The College is leading a significant effort to address the needs of surgeons who are looking to update their skills. The Steering Committee for Retraining and Retooling of Practicing Surgeons is working to define standards and establish a national infrastructure to achieve optimal outcomes. The ACS Accredited Education Institutes are at the core of this infrastructure.
At Clinical Congress 2017, we launched the ACS Academy of Master Surgeon Educators. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Also at Clinical Congress, the ACS Committee on Ethics unveiled Ethical Issues in Surgical Care, a landmark resource that defines a framework for the field of surgical ethics as it has evolved over the last decade. The book is organized into four sections that address the broad areas of general consideration, the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Quality
The College released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” in July 2017.This manual provides a guide for surgical quality leaders seeking to improve quality and safety in their institutions, departments, and practices. Efforts are under way to develop adjunctive or integrated resources/standards and to potentially establish a Surgical Quality Verification Program.
The red book was released at the 2017 ACS Quality and Safety Conference, formerly the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference, in New York, NY. The conference, which focused on a broad range of ACS Quality Programs, boasted a record-breaking attendance of more than 1,800 attendees.
The new Surgeon Specific Registry was the first ACS database to launch as part of the College’s integrated registry of the future, which ultimately will allow users to share relevant quality data across individual ACS Quality Programs, such as ACS NSQIP and the Trauma Quality Improvement Program (TQIP®).
Other new quality initiatives include the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR), which the ACS is conducting in collaboration with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. This program supports hospitals in implementing perioperative evidence-based pathways to improve clinical outcomes, reduce hospital length of stay, and improve the patient experience.
The ACS also has become the new home of Strong for Surgery, originally developed by surgeons in Washington State. This program empowers hospitals and clinics to integrate checklists into the preoperative phase of care.
In addition, the ACS was awarded a three-year, multimillion dollar R01 grant from the National Institute on Minority Health and Health Disparities. ACS Past-President L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), is the principal investigator on this award, which is aimed at eliminating variances in access to surgical care.
Trauma
The Committee on Trauma (COT), in collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), hosted a conference in April 2017 to advance the recommendations in the National Academies on Science, Engineering, and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The meeting brought together approximately 170 trauma care professionals with the goal of creating the framework for a National Trauma Care System Action Plan.
In light of recent tragedies and the ongoing public debate over how to stop the continuing violence at our nation’s schools, churches, and other public places, the COT Injury Prevention and Control Committee (IPCC) is advocating for a consensus-based, public health/trauma system approach to firearm injury prevention. Furthermore, at its February 2018 meeting the ACS Board of Regents unanimously approved a plan to expand the College’s focus from the successful Stop the Bleed® program to a broader prevention initiative focused on strategies that include research, advocacy, and strategic collaborations. An action plan was in development at press time.
ACS leadership
The ACS Board of Governors (B/G) continues to implement initiatives through its Pillars and Workgroups. Specific examples from this past year include the release of a white paper on out-of-network billing; production of the biannual e-newsletter, The Cutting Edge; conduct of the 2017 Board of Governors Annual Survey, which focuses on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery; and development of a standardized letter of recommendation for applicants to surgery training programs.
The ACS Board of Regents approved and updated a number of statements in the last 12 months. New statements cover several topics of concern to the Fellowship, including gender salary equity, the use of anesthetics and sedation drugs in children and pregnant women, the opioid abuse epidemic, lithium batteries, opioids and motor vehicle crash prevention, maintaining surgical access with a locum tenens surgeon, social media, the Uniform Emergency Volunteer Health Practitioners Act, credentialing and privileging, and medical students and the electronic health record.
As these few examples demonstrate, the ACS is constantly moving forward to offer surgeons and the other members of the patient care team the tools, resources, and educational opportunities they need to succeed in practice and to provide optimal patient care. As always, you are encouraged to contact the ACS leadership, and let us know how we can best serve you.
Dr. Hoyt is the Executive Director of the ACS, Chicago, IL.
I am pleased to once again submit an annual report for publication in ACS Surgery News. The American College of Surgeons (ACS) had a productive year in 2017 and looks forward to seeing a range of new programs evolve in 2018.
Physician payment
A health policy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services’ efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 was the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates in 2019.
In 2018, the second year of MIPS, the penalty for nonparticipation has increased to 5 percent from 4 percent. Over time, the penalty for nonparticpation or poor performance will continue to rise. The College has created a variety of resources to assist Fellows in their efforts to comply with MIPS, which explain the purpose and structure of the MIPS program and help guide surgeons in choosing and achieving the goal that is right for their individual practice. These tools can be found on the ACS website at facs.org/qpp.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). The College has worked with thought leaders at Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced APM. In 2017, the Secretary of the Department of Health and Human Services reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and entities that may implement the APM model once available.
Education
The College is leading a significant effort to address the needs of surgeons who are looking to update their skills. The Steering Committee for Retraining and Retooling of Practicing Surgeons is working to define standards and establish a national infrastructure to achieve optimal outcomes. The ACS Accredited Education Institutes are at the core of this infrastructure.
At Clinical Congress 2017, we launched the ACS Academy of Master Surgeon Educators. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Also at Clinical Congress, the ACS Committee on Ethics unveiled Ethical Issues in Surgical Care, a landmark resource that defines a framework for the field of surgical ethics as it has evolved over the last decade. The book is organized into four sections that address the broad areas of general consideration, the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Quality
The College released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” in July 2017.This manual provides a guide for surgical quality leaders seeking to improve quality and safety in their institutions, departments, and practices. Efforts are under way to develop adjunctive or integrated resources/standards and to potentially establish a Surgical Quality Verification Program.
The red book was released at the 2017 ACS Quality and Safety Conference, formerly the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference, in New York, NY. The conference, which focused on a broad range of ACS Quality Programs, boasted a record-breaking attendance of more than 1,800 attendees.
The new Surgeon Specific Registry was the first ACS database to launch as part of the College’s integrated registry of the future, which ultimately will allow users to share relevant quality data across individual ACS Quality Programs, such as ACS NSQIP and the Trauma Quality Improvement Program (TQIP®).
Other new quality initiatives include the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR), which the ACS is conducting in collaboration with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. This program supports hospitals in implementing perioperative evidence-based pathways to improve clinical outcomes, reduce hospital length of stay, and improve the patient experience.
The ACS also has become the new home of Strong for Surgery, originally developed by surgeons in Washington State. This program empowers hospitals and clinics to integrate checklists into the preoperative phase of care.
In addition, the ACS was awarded a three-year, multimillion dollar R01 grant from the National Institute on Minority Health and Health Disparities. ACS Past-President L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), is the principal investigator on this award, which is aimed at eliminating variances in access to surgical care.
Trauma
The Committee on Trauma (COT), in collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), hosted a conference in April 2017 to advance the recommendations in the National Academies on Science, Engineering, and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The meeting brought together approximately 170 trauma care professionals with the goal of creating the framework for a National Trauma Care System Action Plan.
In light of recent tragedies and the ongoing public debate over how to stop the continuing violence at our nation’s schools, churches, and other public places, the COT Injury Prevention and Control Committee (IPCC) is advocating for a consensus-based, public health/trauma system approach to firearm injury prevention. Furthermore, at its February 2018 meeting the ACS Board of Regents unanimously approved a plan to expand the College’s focus from the successful Stop the Bleed® program to a broader prevention initiative focused on strategies that include research, advocacy, and strategic collaborations. An action plan was in development at press time.
ACS leadership
The ACS Board of Governors (B/G) continues to implement initiatives through its Pillars and Workgroups. Specific examples from this past year include the release of a white paper on out-of-network billing; production of the biannual e-newsletter, The Cutting Edge; conduct of the 2017 Board of Governors Annual Survey, which focuses on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery; and development of a standardized letter of recommendation for applicants to surgery training programs.
The ACS Board of Regents approved and updated a number of statements in the last 12 months. New statements cover several topics of concern to the Fellowship, including gender salary equity, the use of anesthetics and sedation drugs in children and pregnant women, the opioid abuse epidemic, lithium batteries, opioids and motor vehicle crash prevention, maintaining surgical access with a locum tenens surgeon, social media, the Uniform Emergency Volunteer Health Practitioners Act, credentialing and privileging, and medical students and the electronic health record.
As these few examples demonstrate, the ACS is constantly moving forward to offer surgeons and the other members of the patient care team the tools, resources, and educational opportunities they need to succeed in practice and to provide optimal patient care. As always, you are encouraged to contact the ACS leadership, and let us know how we can best serve you.
Dr. Hoyt is the Executive Director of the ACS, Chicago, IL.
Beware the con
As I stepped from an exam room one recent busy morning, my office manager pulled me aside. “Someone from the county courthouse is on the phone and needs to talk to you,” she whispered.
“You know better than that,” I said. “While I’m seeing patients, I don’t take calls from anyone except colleagues and immediate family.”
I took the call.
“You failed to appear for jury duty,” the official-sounding voice said. “That’s a violation of state law, as you were warned when you received your summons. You’ll have to come down here and surrender yourself immediately, or else we’ll have to send deputies to your office. I don’t think you’ll want to be led through your waiting room in handcuffs.”
“Wait a minute,” I replied nervously. “I haven’t received a jury summons for 2 years, at least. There must be some mistake.”
“Perhaps we’ve confused you with a citizen with the same or a similar name,” he said. “Let me have your Social Security number and birth date.”
Alarm bells! “You should have that information already,” I replied. “Why don’t you read me what you have?”
A short silence, and then … click.
I immediately called the courthouse. “Citizens who fail to appear receive a warning letter and a new questionnaire, not a phone call,” said the jury manager. “And we use driver license numbers to keep track of jurors.”
The phone company traced the call, which dead-ended at a VoIP circuit, to no one’s surprise. The downside of VoIP (Voice over Internet Protocol) and similar technologies is that unscrupulous individuals can use them to appear to be calling you from a legitimate business when they are not.
Those of us of a certain age remember phony office calls offering great deals on supplies or waiting room magazine subscriptions. Those capers eventually disappeared; but scam artists are endlessly creative. This is especially true since the Internet took over, well, everything. There’s a real dark side to the information age.
The jury duty scheme, I learned, is an increasingly popular one. Others involve calls or e-mails from the “fraud department” of your bank, claiming to be investigating a breach of your account, or one of your credit or debit cards. Another purports to be a “Customs official” informing you that you owe a big duty payment on an overseas shipment. Victims of power outages due to natural disasters are hearing from crooks claiming to be from the local power company; the power won’t be restored, they say, without an advance payment.
In most cases, the common denominator – and the biggest red flag – is a request for a social security number, a birth date, a credit card number, or other private information that could be used to steal your identity or empty your accounts.
Here’s a summary of what my recent experience taught (or reminded) me:
- Never give out a bank account, social security, or credit card number online or over the telephone if you didn’t initiate the contact, no matter how legitimate the caller sounds. This is true of anyone claiming to be from a bank, a service company, or a government office, as well as anyone trying to sell you anything.
- No federal or state court will call to say you’ve missed jury duty – or that they are assembling jury pools and need to “prescreen” those who might be selected to serve on them. The jury manager I spoke with said she knew of no reason why anyone in my state would ever be called about jury service before mailing back a completed questionnaire, and even then, such a call would be extraordinary.
- Never send anyone a “commission” or “finder’s fee” as a condition of receiving funds. In legitimate transactions, such fees are merely deducted from the money being paid out.
- Examine your credit card and bank account statements each month. Immediately challenge any charges you don’t recognize.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
As I stepped from an exam room one recent busy morning, my office manager pulled me aside. “Someone from the county courthouse is on the phone and needs to talk to you,” she whispered.
“You know better than that,” I said. “While I’m seeing patients, I don’t take calls from anyone except colleagues and immediate family.”
I took the call.
“You failed to appear for jury duty,” the official-sounding voice said. “That’s a violation of state law, as you were warned when you received your summons. You’ll have to come down here and surrender yourself immediately, or else we’ll have to send deputies to your office. I don’t think you’ll want to be led through your waiting room in handcuffs.”
“Wait a minute,” I replied nervously. “I haven’t received a jury summons for 2 years, at least. There must be some mistake.”
“Perhaps we’ve confused you with a citizen with the same or a similar name,” he said. “Let me have your Social Security number and birth date.”
Alarm bells! “You should have that information already,” I replied. “Why don’t you read me what you have?”
A short silence, and then … click.
I immediately called the courthouse. “Citizens who fail to appear receive a warning letter and a new questionnaire, not a phone call,” said the jury manager. “And we use driver license numbers to keep track of jurors.”
The phone company traced the call, which dead-ended at a VoIP circuit, to no one’s surprise. The downside of VoIP (Voice over Internet Protocol) and similar technologies is that unscrupulous individuals can use them to appear to be calling you from a legitimate business when they are not.
Those of us of a certain age remember phony office calls offering great deals on supplies or waiting room magazine subscriptions. Those capers eventually disappeared; but scam artists are endlessly creative. This is especially true since the Internet took over, well, everything. There’s a real dark side to the information age.
The jury duty scheme, I learned, is an increasingly popular one. Others involve calls or e-mails from the “fraud department” of your bank, claiming to be investigating a breach of your account, or one of your credit or debit cards. Another purports to be a “Customs official” informing you that you owe a big duty payment on an overseas shipment. Victims of power outages due to natural disasters are hearing from crooks claiming to be from the local power company; the power won’t be restored, they say, without an advance payment.
In most cases, the common denominator – and the biggest red flag – is a request for a social security number, a birth date, a credit card number, or other private information that could be used to steal your identity or empty your accounts.
Here’s a summary of what my recent experience taught (or reminded) me:
- Never give out a bank account, social security, or credit card number online or over the telephone if you didn’t initiate the contact, no matter how legitimate the caller sounds. This is true of anyone claiming to be from a bank, a service company, or a government office, as well as anyone trying to sell you anything.
- No federal or state court will call to say you’ve missed jury duty – or that they are assembling jury pools and need to “prescreen” those who might be selected to serve on them. The jury manager I spoke with said she knew of no reason why anyone in my state would ever be called about jury service before mailing back a completed questionnaire, and even then, such a call would be extraordinary.
- Never send anyone a “commission” or “finder’s fee” as a condition of receiving funds. In legitimate transactions, such fees are merely deducted from the money being paid out.
- Examine your credit card and bank account statements each month. Immediately challenge any charges you don’t recognize.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
As I stepped from an exam room one recent busy morning, my office manager pulled me aside. “Someone from the county courthouse is on the phone and needs to talk to you,” she whispered.
“You know better than that,” I said. “While I’m seeing patients, I don’t take calls from anyone except colleagues and immediate family.”
I took the call.
“You failed to appear for jury duty,” the official-sounding voice said. “That’s a violation of state law, as you were warned when you received your summons. You’ll have to come down here and surrender yourself immediately, or else we’ll have to send deputies to your office. I don’t think you’ll want to be led through your waiting room in handcuffs.”
“Wait a minute,” I replied nervously. “I haven’t received a jury summons for 2 years, at least. There must be some mistake.”
“Perhaps we’ve confused you with a citizen with the same or a similar name,” he said. “Let me have your Social Security number and birth date.”
Alarm bells! “You should have that information already,” I replied. “Why don’t you read me what you have?”
A short silence, and then … click.
I immediately called the courthouse. “Citizens who fail to appear receive a warning letter and a new questionnaire, not a phone call,” said the jury manager. “And we use driver license numbers to keep track of jurors.”
The phone company traced the call, which dead-ended at a VoIP circuit, to no one’s surprise. The downside of VoIP (Voice over Internet Protocol) and similar technologies is that unscrupulous individuals can use them to appear to be calling you from a legitimate business when they are not.
Those of us of a certain age remember phony office calls offering great deals on supplies or waiting room magazine subscriptions. Those capers eventually disappeared; but scam artists are endlessly creative. This is especially true since the Internet took over, well, everything. There’s a real dark side to the information age.
The jury duty scheme, I learned, is an increasingly popular one. Others involve calls or e-mails from the “fraud department” of your bank, claiming to be investigating a breach of your account, or one of your credit or debit cards. Another purports to be a “Customs official” informing you that you owe a big duty payment on an overseas shipment. Victims of power outages due to natural disasters are hearing from crooks claiming to be from the local power company; the power won’t be restored, they say, without an advance payment.
In most cases, the common denominator – and the biggest red flag – is a request for a social security number, a birth date, a credit card number, or other private information that could be used to steal your identity or empty your accounts.
Here’s a summary of what my recent experience taught (or reminded) me:
- Never give out a bank account, social security, or credit card number online or over the telephone if you didn’t initiate the contact, no matter how legitimate the caller sounds. This is true of anyone claiming to be from a bank, a service company, or a government office, as well as anyone trying to sell you anything.
- No federal or state court will call to say you’ve missed jury duty – or that they are assembling jury pools and need to “prescreen” those who might be selected to serve on them. The jury manager I spoke with said she knew of no reason why anyone in my state would ever be called about jury service before mailing back a completed questionnaire, and even then, such a call would be extraordinary.
- Never send anyone a “commission” or “finder’s fee” as a condition of receiving funds. In legitimate transactions, such fees are merely deducted from the money being paid out.
- Examine your credit card and bank account statements each month. Immediately challenge any charges you don’t recognize.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Jump-starting the day
I’ve never been a fan of delayed school start times for high school students. The data just don’t impress me. But mostly I think delayed start times should be just one component of a broad community-wide initiative to address sleep hygiene that includes discussions about bedtimes, after-school schedules, and overuse of electronic devices. And I don’t see those discussions happening.
In most communities, delaying start times for adolescents will mean that younger children will be starting their school days earlier. Buses and drivers are finite and expensive resources that must be shared. Although I have heard it used as an argument against delayed school starts for high schoolers, an earlier start time for grade-school age children is not one of the downsides I include on my list of negatives. In fact, from my perspective, getting youngsters to school early is one of the few advantages of a delayed school start program for high school.
Underwritten by the Reebok athletic footwear manufacturer, the BOKS (Build Our Kids’ Success) program began in 2009 when a group of mothers in Massachusetts organized a before-school activity program in their local grade school (“A before-school exercise program may help children thrive,” by Gretchen Reynolds, New York Times, Feb. 14, 2018). They may have been motivated primarily by the need to survive those difficult morning hours, but clearly they weren’t alone in their concerns, and the concept has spread to include 3,000 schools worldwide.
Hoping to document the anecdotal observations of the program’s success, researchers from Harvard and the Massachusetts General Hospital surveyed children in 24 schools (“Effects of Before-School Physical Activity on Obesity Prevention and Wellness,” Am J Prev Med. 2018. Feb 12. doi: 10.1016/j.amepre.2018.01.017). Participation in the program was voluntary, and the control group consisted of children whose families chose not to participate. Those children in the before-school activity program 3 mornings per week were more likely to have lower body mass index z scores and “demonstrated improvement in their student engagement scores.” The children who participated only 2 days per week had no significant changes in their body mass index scores. However, they did demonstrate “significant improvements in positive affect and vitality/energy.”
The early-morning energy of youth is a given. The problem is that many children find themselves in home environments in which that energy is squandered or at least misdirected. School can be the environment in which that physical exuberance is allowed to run its natural course. We simply need the will to invest in what needs to be done to make it happen.
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].
I’ve never been a fan of delayed school start times for high school students. The data just don’t impress me. But mostly I think delayed start times should be just one component of a broad community-wide initiative to address sleep hygiene that includes discussions about bedtimes, after-school schedules, and overuse of electronic devices. And I don’t see those discussions happening.
In most communities, delaying start times for adolescents will mean that younger children will be starting their school days earlier. Buses and drivers are finite and expensive resources that must be shared. Although I have heard it used as an argument against delayed school starts for high schoolers, an earlier start time for grade-school age children is not one of the downsides I include on my list of negatives. In fact, from my perspective, getting youngsters to school early is one of the few advantages of a delayed school start program for high school.
Underwritten by the Reebok athletic footwear manufacturer, the BOKS (Build Our Kids’ Success) program began in 2009 when a group of mothers in Massachusetts organized a before-school activity program in their local grade school (“A before-school exercise program may help children thrive,” by Gretchen Reynolds, New York Times, Feb. 14, 2018). They may have been motivated primarily by the need to survive those difficult morning hours, but clearly they weren’t alone in their concerns, and the concept has spread to include 3,000 schools worldwide.
Hoping to document the anecdotal observations of the program’s success, researchers from Harvard and the Massachusetts General Hospital surveyed children in 24 schools (“Effects of Before-School Physical Activity on Obesity Prevention and Wellness,” Am J Prev Med. 2018. Feb 12. doi: 10.1016/j.amepre.2018.01.017). Participation in the program was voluntary, and the control group consisted of children whose families chose not to participate. Those children in the before-school activity program 3 mornings per week were more likely to have lower body mass index z scores and “demonstrated improvement in their student engagement scores.” The children who participated only 2 days per week had no significant changes in their body mass index scores. However, they did demonstrate “significant improvements in positive affect and vitality/energy.”
The early-morning energy of youth is a given. The problem is that many children find themselves in home environments in which that energy is squandered or at least misdirected. School can be the environment in which that physical exuberance is allowed to run its natural course. We simply need the will to invest in what needs to be done to make it happen.
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].
I’ve never been a fan of delayed school start times for high school students. The data just don’t impress me. But mostly I think delayed start times should be just one component of a broad community-wide initiative to address sleep hygiene that includes discussions about bedtimes, after-school schedules, and overuse of electronic devices. And I don’t see those discussions happening.
In most communities, delaying start times for adolescents will mean that younger children will be starting their school days earlier. Buses and drivers are finite and expensive resources that must be shared. Although I have heard it used as an argument against delayed school starts for high schoolers, an earlier start time for grade-school age children is not one of the downsides I include on my list of negatives. In fact, from my perspective, getting youngsters to school early is one of the few advantages of a delayed school start program for high school.
Underwritten by the Reebok athletic footwear manufacturer, the BOKS (Build Our Kids’ Success) program began in 2009 when a group of mothers in Massachusetts organized a before-school activity program in their local grade school (“A before-school exercise program may help children thrive,” by Gretchen Reynolds, New York Times, Feb. 14, 2018). They may have been motivated primarily by the need to survive those difficult morning hours, but clearly they weren’t alone in their concerns, and the concept has spread to include 3,000 schools worldwide.
Hoping to document the anecdotal observations of the program’s success, researchers from Harvard and the Massachusetts General Hospital surveyed children in 24 schools (“Effects of Before-School Physical Activity on Obesity Prevention and Wellness,” Am J Prev Med. 2018. Feb 12. doi: 10.1016/j.amepre.2018.01.017). Participation in the program was voluntary, and the control group consisted of children whose families chose not to participate. Those children in the before-school activity program 3 mornings per week were more likely to have lower body mass index z scores and “demonstrated improvement in their student engagement scores.” The children who participated only 2 days per week had no significant changes in their body mass index scores. However, they did demonstrate “significant improvements in positive affect and vitality/energy.”
The early-morning energy of youth is a given. The problem is that many children find themselves in home environments in which that energy is squandered or at least misdirected. School can be the environment in which that physical exuberance is allowed to run its natural course. We simply need the will to invest in what needs to be done to make it happen.
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].
Commonality
I grew up in a diversity-free zone. The bubble surrounding Pleasantville, New York, in the 1950s and 1960s didn’t include people of color. We were all middle-class, some upper, some lower, some blue collar, some white collar – but, all of us comfortably in the middle. The children with disabilities must have been hidden in their homes or housed in institutions. They certainly weren’t our classmates. We were spread across the broad Judeo-Christian spectrum. Who knew there were other religions?
Of course, when I left for college I entered another even less inclusive bubble that didn’t admit women.
For many years, the process that brought about this dramatic change was a fortuitous conglomeration of brush wars fought by courageous individuals and minority groups. However, in the last decade or two, the struggle for inclusion has broadened under the banner of diversity, a term once primarily used to describe evolving ecologic populations. In light of this expanding definition, it is not surprising that the American Academy of Pediatrics has begun to consider its role in promoting diversity. As reported in AAP News (Anne Hegland, March 2018) the American Academy of Pediatrics board of directors recently discussed a plan for implementing at “all levels of the Academy” the suggestions of its Task Force on Diversity and Inclusion.
The academy is in the enviable positive of having a membership that agrees in general terms where its priorities should be – the health and welfare of children. It can afford to invest some of its energies in being more inclusive. However, the United States currently is struggling to rediscover a set of priorities that its citizens can agree on. We have politicians who would rather win a battle over their adversaries than address the obvious needs of the country. And, we have journalists who prefer to feast on these battles rather than search for evidence of cooperation. This is not a time to sharpen our focus on how different we are from one another. It is time to raise another flag along side the “diversity” banner. It should read “commonality,” and remind us that while we are celebrating our differences, we must work harder to uncover the core values that we share.
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].
I grew up in a diversity-free zone. The bubble surrounding Pleasantville, New York, in the 1950s and 1960s didn’t include people of color. We were all middle-class, some upper, some lower, some blue collar, some white collar – but, all of us comfortably in the middle. The children with disabilities must have been hidden in their homes or housed in institutions. They certainly weren’t our classmates. We were spread across the broad Judeo-Christian spectrum. Who knew there were other religions?
Of course, when I left for college I entered another even less inclusive bubble that didn’t admit women.
For many years, the process that brought about this dramatic change was a fortuitous conglomeration of brush wars fought by courageous individuals and minority groups. However, in the last decade or two, the struggle for inclusion has broadened under the banner of diversity, a term once primarily used to describe evolving ecologic populations. In light of this expanding definition, it is not surprising that the American Academy of Pediatrics has begun to consider its role in promoting diversity. As reported in AAP News (Anne Hegland, March 2018) the American Academy of Pediatrics board of directors recently discussed a plan for implementing at “all levels of the Academy” the suggestions of its Task Force on Diversity and Inclusion.
The academy is in the enviable positive of having a membership that agrees in general terms where its priorities should be – the health and welfare of children. It can afford to invest some of its energies in being more inclusive. However, the United States currently is struggling to rediscover a set of priorities that its citizens can agree on. We have politicians who would rather win a battle over their adversaries than address the obvious needs of the country. And, we have journalists who prefer to feast on these battles rather than search for evidence of cooperation. This is not a time to sharpen our focus on how different we are from one another. It is time to raise another flag along side the “diversity” banner. It should read “commonality,” and remind us that while we are celebrating our differences, we must work harder to uncover the core values that we share.
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].
I grew up in a diversity-free zone. The bubble surrounding Pleasantville, New York, in the 1950s and 1960s didn’t include people of color. We were all middle-class, some upper, some lower, some blue collar, some white collar – but, all of us comfortably in the middle. The children with disabilities must have been hidden in their homes or housed in institutions. They certainly weren’t our classmates. We were spread across the broad Judeo-Christian spectrum. Who knew there were other religions?
Of course, when I left for college I entered another even less inclusive bubble that didn’t admit women.
For many years, the process that brought about this dramatic change was a fortuitous conglomeration of brush wars fought by courageous individuals and minority groups. However, in the last decade or two, the struggle for inclusion has broadened under the banner of diversity, a term once primarily used to describe evolving ecologic populations. In light of this expanding definition, it is not surprising that the American Academy of Pediatrics has begun to consider its role in promoting diversity. As reported in AAP News (Anne Hegland, March 2018) the American Academy of Pediatrics board of directors recently discussed a plan for implementing at “all levels of the Academy” the suggestions of its Task Force on Diversity and Inclusion.
The academy is in the enviable positive of having a membership that agrees in general terms where its priorities should be – the health and welfare of children. It can afford to invest some of its energies in being more inclusive. However, the United States currently is struggling to rediscover a set of priorities that its citizens can agree on. We have politicians who would rather win a battle over their adversaries than address the obvious needs of the country. And, we have journalists who prefer to feast on these battles rather than search for evidence of cooperation. This is not a time to sharpen our focus on how different we are from one another. It is time to raise another flag along side the “diversity” banner. It should read “commonality,” and remind us that while we are celebrating our differences, we must work harder to uncover the core values that we share.
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].
Is there a resilience deficit?
Even if you have never experienced a symptom of burnout, you probably have at least one colleague who has. In the last decade, collateral damage from physician burnout has earned it a place on the agenda of the American Academy of Pediatrics and most other physician organizations.
When one steps back and takes a longer view, burnout is simply a poor fit between physicians and their roles. An increasing number of physicians are finding themselves in jobs in which – for a variety of reasons – they feel uncomfortable. Eventually, the discomfort resulting from that poor fit becomes so unbearable the only solution is to change jobs or retire.
However, an article in Pediatrics entitled “Seeking professional resilience” addresses burnout from the perspective that physician vulnerability is a major contributor to the problem (Pediatrics. 2018, Feb 1. doi: 10.1542/peds.2017-2388). The author, Abby R. Rosenberg, MD, suggests that one solution to burnout is helping physicians learn how “to maintain physical and emotional well-being in the face of adversity,” that is, “resilience.”
It turns out that the recent buzz surrounding “resilience” has drawn a throng of theorists. I guess if we can have chaos theory, we can have resilience theories. Dr. Rosenberg sorts these theories into three categories based on whether they consider resilience an intrinsic trait, a process of adaptation, or an outcome. She offers an alternative description in which resilience is conceived as “a process of harnessing the resources we need to sustain well-being.” Dr. Rosenberg’s suggestions of how this harnessing process can be achieved are certainly worth reading, but I fear that most physicians threatened with burnout won’t have the time or the composure to follow her recommendations. Fifty years of watching physicians both thrive and flame out has convinced me that in most cases, resilience is an intrinsic trait gifted to the recipient at birth.
I am sure there are older physicians who believe that burnout is just another case of “they-don’t-make-’em-like-they-used-to” and would claim that young physicians just don’t have the same grit that we had a generation ago. I guess it is possible that the shift away from the owner/operator model toward one in which a physician has become a cog in the wheel of a large corporation has selected for physicians who are less resilient by nature. But I suspect that the number of resilient physicians is unchanged over the last hundred years. It is more likely that even those blessed with a resilient nature enter their training challenged by a burden of debt significantly greater than my peers and I faced 50 years ago.
The problem isn’t the resiliency deficit. Burnout is the result of a job that has evolved into one with challenges that even the more resilient physicians struggle to tolerate. Under a litigious cloud, hunched over a computer for half the day, the modern physician must struggle to find relevance in a situation in which he has relinquished control to a system that may not share his values.
Refining the selection process to find even more resilient candidates for medical school might lower the burnout rate by a point or two. However, the real answer requires a major overhaul of medical delivery system so that providers can once again feel that every hour they invest is meaningful. The privilege to practice medicine always has required sacrifices on the part of the physician. However, without a sense of purpose, these sacrifices can become intolerable.
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].
Even if you have never experienced a symptom of burnout, you probably have at least one colleague who has. In the last decade, collateral damage from physician burnout has earned it a place on the agenda of the American Academy of Pediatrics and most other physician organizations.
When one steps back and takes a longer view, burnout is simply a poor fit between physicians and their roles. An increasing number of physicians are finding themselves in jobs in which – for a variety of reasons – they feel uncomfortable. Eventually, the discomfort resulting from that poor fit becomes so unbearable the only solution is to change jobs or retire.
However, an article in Pediatrics entitled “Seeking professional resilience” addresses burnout from the perspective that physician vulnerability is a major contributor to the problem (Pediatrics. 2018, Feb 1. doi: 10.1542/peds.2017-2388). The author, Abby R. Rosenberg, MD, suggests that one solution to burnout is helping physicians learn how “to maintain physical and emotional well-being in the face of adversity,” that is, “resilience.”
It turns out that the recent buzz surrounding “resilience” has drawn a throng of theorists. I guess if we can have chaos theory, we can have resilience theories. Dr. Rosenberg sorts these theories into three categories based on whether they consider resilience an intrinsic trait, a process of adaptation, or an outcome. She offers an alternative description in which resilience is conceived as “a process of harnessing the resources we need to sustain well-being.” Dr. Rosenberg’s suggestions of how this harnessing process can be achieved are certainly worth reading, but I fear that most physicians threatened with burnout won’t have the time or the composure to follow her recommendations. Fifty years of watching physicians both thrive and flame out has convinced me that in most cases, resilience is an intrinsic trait gifted to the recipient at birth.
I am sure there are older physicians who believe that burnout is just another case of “they-don’t-make-’em-like-they-used-to” and would claim that young physicians just don’t have the same grit that we had a generation ago. I guess it is possible that the shift away from the owner/operator model toward one in which a physician has become a cog in the wheel of a large corporation has selected for physicians who are less resilient by nature. But I suspect that the number of resilient physicians is unchanged over the last hundred years. It is more likely that even those blessed with a resilient nature enter their training challenged by a burden of debt significantly greater than my peers and I faced 50 years ago.
The problem isn’t the resiliency deficit. Burnout is the result of a job that has evolved into one with challenges that even the more resilient physicians struggle to tolerate. Under a litigious cloud, hunched over a computer for half the day, the modern physician must struggle to find relevance in a situation in which he has relinquished control to a system that may not share his values.
Refining the selection process to find even more resilient candidates for medical school might lower the burnout rate by a point or two. However, the real answer requires a major overhaul of medical delivery system so that providers can once again feel that every hour they invest is meaningful. The privilege to practice medicine always has required sacrifices on the part of the physician. However, without a sense of purpose, these sacrifices can become intolerable.
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].
Even if you have never experienced a symptom of burnout, you probably have at least one colleague who has. In the last decade, collateral damage from physician burnout has earned it a place on the agenda of the American Academy of Pediatrics and most other physician organizations.
When one steps back and takes a longer view, burnout is simply a poor fit between physicians and their roles. An increasing number of physicians are finding themselves in jobs in which – for a variety of reasons – they feel uncomfortable. Eventually, the discomfort resulting from that poor fit becomes so unbearable the only solution is to change jobs or retire.
However, an article in Pediatrics entitled “Seeking professional resilience” addresses burnout from the perspective that physician vulnerability is a major contributor to the problem (Pediatrics. 2018, Feb 1. doi: 10.1542/peds.2017-2388). The author, Abby R. Rosenberg, MD, suggests that one solution to burnout is helping physicians learn how “to maintain physical and emotional well-being in the face of adversity,” that is, “resilience.”
It turns out that the recent buzz surrounding “resilience” has drawn a throng of theorists. I guess if we can have chaos theory, we can have resilience theories. Dr. Rosenberg sorts these theories into three categories based on whether they consider resilience an intrinsic trait, a process of adaptation, or an outcome. She offers an alternative description in which resilience is conceived as “a process of harnessing the resources we need to sustain well-being.” Dr. Rosenberg’s suggestions of how this harnessing process can be achieved are certainly worth reading, but I fear that most physicians threatened with burnout won’t have the time or the composure to follow her recommendations. Fifty years of watching physicians both thrive and flame out has convinced me that in most cases, resilience is an intrinsic trait gifted to the recipient at birth.
I am sure there are older physicians who believe that burnout is just another case of “they-don’t-make-’em-like-they-used-to” and would claim that young physicians just don’t have the same grit that we had a generation ago. I guess it is possible that the shift away from the owner/operator model toward one in which a physician has become a cog in the wheel of a large corporation has selected for physicians who are less resilient by nature. But I suspect that the number of resilient physicians is unchanged over the last hundred years. It is more likely that even those blessed with a resilient nature enter their training challenged by a burden of debt significantly greater than my peers and I faced 50 years ago.
The problem isn’t the resiliency deficit. Burnout is the result of a job that has evolved into one with challenges that even the more resilient physicians struggle to tolerate. Under a litigious cloud, hunched over a computer for half the day, the modern physician must struggle to find relevance in a situation in which he has relinquished control to a system that may not share his values.
Refining the selection process to find even more resilient candidates for medical school might lower the burnout rate by a point or two. However, the real answer requires a major overhaul of medical delivery system so that providers can once again feel that every hour they invest is meaningful. The privilege to practice medicine always has required sacrifices on the part of the physician. However, without a sense of purpose, these sacrifices can become intolerable.
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].
Medical Marijuana Redux
There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.
In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.2 The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.
Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.3 Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.4
VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.5 In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.6 According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.7
Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.
The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.
But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”8 Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.
Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.
The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.9,10
The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.
Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”5 The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.11
Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”5
Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to
Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.
1. Curie M. Pierre Curie With Autobiographical Notes. Kellogg C, Kellogg V, trans. New York: Macmillan; 1923.
2. Geppert CMA. Legal and clinical evolution of Veterans Health Administration policy on medical marijuana. Fed Pract. 2014;31(3):6-12.
3. National Conference of State Legislators. State Medical Marijuana Laws. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx Updated February 15, 2018. Accessed March 2, 2018.
4. Shane L. VA refutes rumors of new policy on medical marijuana. https://www.militarytimes.com/veterans/2017/12/19/va-refutes-rumors-of-a-new-policy-on-medical-marijuana. Published December 19, 2017. Accessed March 2, 2018.
5. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs. December 8, 2017.
6. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, dated January 31, 2011 (rescinded).
7. U.S. Department of Veterans Affairs, Veterans Health Administration. Clinical considerations regarding veteran patients who participate in state-approved medical marijuana programs. Washington, DC; 2010. [Nonpublic document.]
8. 21 U.S.C. 801 et al, the Controlled Substances Act.
9. Welch SA. The pharmacology of cannabinoids. In: Principles of Addiction Medicine: The Essentials. Cavacuiti CA, ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2011:62.
10. U.S. Department of Veterans Affairs. VA Handbook 5383.2, VA drug-free workplace plan. https://www.va.gov/vapubs/search_action.cfm?dType=2. Published April 11, 1997. Accessed March 2, 2018.
11. Zezima K. VA says it won’t study medical marijuana’s effect on veterans. The Washington Post. https://www.washingtonpost.com/news/post-nation/wp/2018/01/16/va-says-it-wont-study-medical-marijuanas-effect-on-veterans/?utm_term=.9d554109d135. Published January 16, 2018. Accessed March 2, 2018.
There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.
In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.2 The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.
Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.3 Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.4
VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.5 In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.6 According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.7
Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.
The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.
But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”8 Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.
Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.
The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.9,10
The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.
Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”5 The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.11
Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”5
Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to
Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.
There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.
In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.2 The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.
Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.3 Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.4
VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.5 In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.6 According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.7
Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.
The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.
But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”8 Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.
Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.
The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.9,10
The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.
Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”5 The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.11
Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”5
Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to
Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.
1. Curie M. Pierre Curie With Autobiographical Notes. Kellogg C, Kellogg V, trans. New York: Macmillan; 1923.
2. Geppert CMA. Legal and clinical evolution of Veterans Health Administration policy on medical marijuana. Fed Pract. 2014;31(3):6-12.
3. National Conference of State Legislators. State Medical Marijuana Laws. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx Updated February 15, 2018. Accessed March 2, 2018.
4. Shane L. VA refutes rumors of new policy on medical marijuana. https://www.militarytimes.com/veterans/2017/12/19/va-refutes-rumors-of-a-new-policy-on-medical-marijuana. Published December 19, 2017. Accessed March 2, 2018.
5. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs. December 8, 2017.
6. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, dated January 31, 2011 (rescinded).
7. U.S. Department of Veterans Affairs, Veterans Health Administration. Clinical considerations regarding veteran patients who participate in state-approved medical marijuana programs. Washington, DC; 2010. [Nonpublic document.]
8. 21 U.S.C. 801 et al, the Controlled Substances Act.
9. Welch SA. The pharmacology of cannabinoids. In: Principles of Addiction Medicine: The Essentials. Cavacuiti CA, ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2011:62.
10. U.S. Department of Veterans Affairs. VA Handbook 5383.2, VA drug-free workplace plan. https://www.va.gov/vapubs/search_action.cfm?dType=2. Published April 11, 1997. Accessed March 2, 2018.
11. Zezima K. VA says it won’t study medical marijuana’s effect on veterans. The Washington Post. https://www.washingtonpost.com/news/post-nation/wp/2018/01/16/va-says-it-wont-study-medical-marijuanas-effect-on-veterans/?utm_term=.9d554109d135. Published January 16, 2018. Accessed March 2, 2018.
1. Curie M. Pierre Curie With Autobiographical Notes. Kellogg C, Kellogg V, trans. New York: Macmillan; 1923.
2. Geppert CMA. Legal and clinical evolution of Veterans Health Administration policy on medical marijuana. Fed Pract. 2014;31(3):6-12.
3. National Conference of State Legislators. State Medical Marijuana Laws. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx Updated February 15, 2018. Accessed March 2, 2018.
4. Shane L. VA refutes rumors of new policy on medical marijuana. https://www.militarytimes.com/veterans/2017/12/19/va-refutes-rumors-of-a-new-policy-on-medical-marijuana. Published December 19, 2017. Accessed March 2, 2018.
5. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs. December 8, 2017.
6. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, dated January 31, 2011 (rescinded).
7. U.S. Department of Veterans Affairs, Veterans Health Administration. Clinical considerations regarding veteran patients who participate in state-approved medical marijuana programs. Washington, DC; 2010. [Nonpublic document.]
8. 21 U.S.C. 801 et al, the Controlled Substances Act.
9. Welch SA. The pharmacology of cannabinoids. In: Principles of Addiction Medicine: The Essentials. Cavacuiti CA, ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2011:62.
10. U.S. Department of Veterans Affairs. VA Handbook 5383.2, VA drug-free workplace plan. https://www.va.gov/vapubs/search_action.cfm?dType=2. Published April 11, 1997. Accessed March 2, 2018.
11. Zezima K. VA says it won’t study medical marijuana’s effect on veterans. The Washington Post. https://www.washingtonpost.com/news/post-nation/wp/2018/01/16/va-says-it-wont-study-medical-marijuanas-effect-on-veterans/?utm_term=.9d554109d135. Published January 16, 2018. Accessed March 2, 2018.
AHRQ Practice Toolbox: Practice transformation
This is the seventh in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Thus far, this series has discussed topics such as shared decision making, team-based care, and integrating behavioral health and primary care. All of these are important topics, but this raises the question, “How do I make the changes to my practice?” This month’s article discusses AHRQ’s resources for transforming your practice to be able to better introduce these advances.
Building capacity for quality improvement in primary care. Primary care practices often benefit from external support and assistance while they develop the capacity to carry out quality improvement activities as an integral part of their work. These resources describe approaches and supports that are needed to build QI capacity in primary care.
Care coordination. The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people, which results in safe, appropriate, and effective care. AHRQ’s resources in this area offer examples of care coordination approaches and activities, as well as guidance and models for understanding and measuring patients’ perceptions of care coordination.
Improvement approaches related to patient engagement and support. Several different types of resources related to patient engagement are available. These include the what, why, and how of self-management support, implementing health literacy universal precautions, and engaging patients and families in patient safety efforts.
AHRQ’s Primary Care YouTube channel offers videos from clinical staff, researchers, and others describing their work in many of these areas.
While the goal of practice transformation is the improvement of patient care and patient outcomes, patient and staff satisfaction (including issues regarding provider burnout) must not be lost in the process. The Clinician & Group Survey of the Consumer Assessment of Healthcare Providers and Systems assesses patient experiences with health care providers and staff in doctors’ offices. Survey results can be used to improve care provided by individual providers, sites of care, medical groups, or provider networks, as well as equip consumers with information they can use to choose physicians and other health care providers, physician practices, or medical groups. The survey includes standardized questionnaires for adults and children. The adult questionnaire can be used in both primary care and specialty care settings; the child questionnaire is designed for primary care settings but could be adapted for specialty care. Users can also add supplemental items to customize their questionnaires.
For many practices, working with a practice facilitator will be a big part of the transformation. Practice facilitation is an evidence-based approach to quality improvement in primary care practices. It will be discussed at length next month. In addition, in July and August, we will discuss optimizing health information technology and workflow in your practice.
Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is the director of the National Center for Excellence in Primary Care Research at AHRQ.
This is the seventh in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Thus far, this series has discussed topics such as shared decision making, team-based care, and integrating behavioral health and primary care. All of these are important topics, but this raises the question, “How do I make the changes to my practice?” This month’s article discusses AHRQ’s resources for transforming your practice to be able to better introduce these advances.
Building capacity for quality improvement in primary care. Primary care practices often benefit from external support and assistance while they develop the capacity to carry out quality improvement activities as an integral part of their work. These resources describe approaches and supports that are needed to build QI capacity in primary care.
Care coordination. The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people, which results in safe, appropriate, and effective care. AHRQ’s resources in this area offer examples of care coordination approaches and activities, as well as guidance and models for understanding and measuring patients’ perceptions of care coordination.
Improvement approaches related to patient engagement and support. Several different types of resources related to patient engagement are available. These include the what, why, and how of self-management support, implementing health literacy universal precautions, and engaging patients and families in patient safety efforts.
AHRQ’s Primary Care YouTube channel offers videos from clinical staff, researchers, and others describing their work in many of these areas.
While the goal of practice transformation is the improvement of patient care and patient outcomes, patient and staff satisfaction (including issues regarding provider burnout) must not be lost in the process. The Clinician & Group Survey of the Consumer Assessment of Healthcare Providers and Systems assesses patient experiences with health care providers and staff in doctors’ offices. Survey results can be used to improve care provided by individual providers, sites of care, medical groups, or provider networks, as well as equip consumers with information they can use to choose physicians and other health care providers, physician practices, or medical groups. The survey includes standardized questionnaires for adults and children. The adult questionnaire can be used in both primary care and specialty care settings; the child questionnaire is designed for primary care settings but could be adapted for specialty care. Users can also add supplemental items to customize their questionnaires.
For many practices, working with a practice facilitator will be a big part of the transformation. Practice facilitation is an evidence-based approach to quality improvement in primary care practices. It will be discussed at length next month. In addition, in July and August, we will discuss optimizing health information technology and workflow in your practice.
Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is the director of the National Center for Excellence in Primary Care Research at AHRQ.
This is the seventh in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Thus far, this series has discussed topics such as shared decision making, team-based care, and integrating behavioral health and primary care. All of these are important topics, but this raises the question, “How do I make the changes to my practice?” This month’s article discusses AHRQ’s resources for transforming your practice to be able to better introduce these advances.
Building capacity for quality improvement in primary care. Primary care practices often benefit from external support and assistance while they develop the capacity to carry out quality improvement activities as an integral part of their work. These resources describe approaches and supports that are needed to build QI capacity in primary care.
Care coordination. The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people, which results in safe, appropriate, and effective care. AHRQ’s resources in this area offer examples of care coordination approaches and activities, as well as guidance and models for understanding and measuring patients’ perceptions of care coordination.
Improvement approaches related to patient engagement and support. Several different types of resources related to patient engagement are available. These include the what, why, and how of self-management support, implementing health literacy universal precautions, and engaging patients and families in patient safety efforts.
AHRQ’s Primary Care YouTube channel offers videos from clinical staff, researchers, and others describing their work in many of these areas.
While the goal of practice transformation is the improvement of patient care and patient outcomes, patient and staff satisfaction (including issues regarding provider burnout) must not be lost in the process. The Clinician & Group Survey of the Consumer Assessment of Healthcare Providers and Systems assesses patient experiences with health care providers and staff in doctors’ offices. Survey results can be used to improve care provided by individual providers, sites of care, medical groups, or provider networks, as well as equip consumers with information they can use to choose physicians and other health care providers, physician practices, or medical groups. The survey includes standardized questionnaires for adults and children. The adult questionnaire can be used in both primary care and specialty care settings; the child questionnaire is designed for primary care settings but could be adapted for specialty care. Users can also add supplemental items to customize their questionnaires.
For many practices, working with a practice facilitator will be a big part of the transformation. Practice facilitation is an evidence-based approach to quality improvement in primary care practices. It will be discussed at length next month. In addition, in July and August, we will discuss optimizing health information technology and workflow in your practice.
Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is the director of the National Center for Excellence in Primary Care Research at AHRQ.
Hidden costs
By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.
I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.
Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?
Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.
Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.
And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.
Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.
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].
By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.
I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.
Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?
Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.
Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.
And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.
Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.
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].
By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.
I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.
Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?
Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.
Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.
And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.
Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.
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].