Commentary

Important advances in neuroscience and clinical psychiatry have been achieved in recent years, but there are significant gaps in knowledge and much that we don’t understand about the brain and behavior. Further advances depend on cultivating and supporting a new generation of dedicated basic science and clinical investigators. While there is a compelling need to attract, recruit, and encourage talented individuals to pursue scholarly interests, competing life and career demands often prove daunting.

• Participants will learn the steps necessary to prepare a scientific manuscript for publication.
• Participants will review comments by expert referees and learn to incorporate and respond to the peer review process.
• Participants will review the evidence related to the diagnosis and treatment of tardive dyskinesia.
• Participants will be introduced to the spectrum of educational and networking opportunities at the Institute for Psychiatric Services conference.

In the past, this program was very popular and gained national recognition among psychiatric trainees. Numerous submitted papers were accepted for publication in peer-reviewed journals after the competition was completed.

Instructions for manuscript preparation are:

• First author must be a student, resident, or fellow.
• Papers should address specific issues related to the theme of tardive dyskinesia and be no longer than 15 double-spaced typed pages in length (excluding references and illustrations).
• Literature reviews, case reports, or studies that are original and newly developed or recently published are acceptable.
• Reviews and feedback will be provided by a panel of academic psychiatrists.
• Papers will be judged on relevance to tardive dyskinesia, originality, scholarship, scientific rigor, valid methodology, clinical significance, and organization.

To participate, papers and curriculum vitae of the first author must be submitted by July 1, 2018, to Dianne Daugherty by email at [email protected]. Winners will be announced by Aug. 10, 2018. For additional information, write to [email protected] or visit www.mhaus.org/nmsis/about-us/what-is-nmsis.
 

Dr. Caroff, professor of psychiatry, Corporal Michael J. Crescenz VA Medical Center and at the University of Pennsylvania, both in Philadelphia, is director of the NMSIS. He served as consultant to Neurocrine Biosciences and Teva Pharmaceutical Industries, and receives research grant funding from Neurocrine Biosciences.

Important advances in neuroscience and clinical psychiatry have been achieved in recent years, but there are significant gaps in knowledge and much that we don’t understand about the brain and behavior. Further advances depend on cultivating and supporting a new generation of dedicated basic science and clinical investigators. While there is a compelling need to attract, recruit, and encourage talented individuals to pursue scholarly interests, competing life and career demands often prove daunting.

• Participants will learn the steps necessary to prepare a scientific manuscript for publication.
• Participants will review comments by expert referees and learn to incorporate and respond to the peer review process.
• Participants will review the evidence related to the diagnosis and treatment of tardive dyskinesia.
• Participants will be introduced to the spectrum of educational and networking opportunities at the Institute for Psychiatric Services conference.

In the past, this program was very popular and gained national recognition among psychiatric trainees. Numerous submitted papers were accepted for publication in peer-reviewed journals after the competition was completed.

Instructions for manuscript preparation are:

• First author must be a student, resident, or fellow.
• Papers should address specific issues related to the theme of tardive dyskinesia and be no longer than 15 double-spaced typed pages in length (excluding references and illustrations).
• Literature reviews, case reports, or studies that are original and newly developed or recently published are acceptable.
• Reviews and feedback will be provided by a panel of academic psychiatrists.
• Papers will be judged on relevance to tardive dyskinesia, originality, scholarship, scientific rigor, valid methodology, clinical significance, and organization.

To participate, papers and curriculum vitae of the first author must be submitted by July 1, 2018, to Dianne Daugherty by email at [email protected]. Winners will be announced by Aug. 10, 2018. For additional information, write to [email protected] or visit www.mhaus.org/nmsis/about-us/what-is-nmsis.
 

Dr. Caroff, professor of psychiatry, Corporal Michael J. Crescenz VA Medical Center and at the University of Pennsylvania, both in Philadelphia, is director of the NMSIS. He served as consultant to Neurocrine Biosciences and Teva Pharmaceutical Industries, and receives research grant funding from Neurocrine Biosciences.

Important advances in neuroscience and clinical psychiatry have been achieved in recent years, but there are significant gaps in knowledge and much that we don’t understand about the brain and behavior. Further advances depend on cultivating and supporting a new generation of dedicated basic science and clinical investigators. While there is a compelling need to attract, recruit, and encourage talented individuals to pursue scholarly interests, competing life and career demands often prove daunting.

• Participants will learn the steps necessary to prepare a scientific manuscript for publication.
• Participants will review comments by expert referees and learn to incorporate and respond to the peer review process.
• Participants will review the evidence related to the diagnosis and treatment of tardive dyskinesia.
• Participants will be introduced to the spectrum of educational and networking opportunities at the Institute for Psychiatric Services conference.

In the past, this program was very popular and gained national recognition among psychiatric trainees. Numerous submitted papers were accepted for publication in peer-reviewed journals after the competition was completed.

Instructions for manuscript preparation are:

• First author must be a student, resident, or fellow.
• Papers should address specific issues related to the theme of tardive dyskinesia and be no longer than 15 double-spaced typed pages in length (excluding references and illustrations).
• Literature reviews, case reports, or studies that are original and newly developed or recently published are acceptable.
• Reviews and feedback will be provided by a panel of academic psychiatrists.
• Papers will be judged on relevance to tardive dyskinesia, originality, scholarship, scientific rigor, valid methodology, clinical significance, and organization.

To participate, papers and curriculum vitae of the first author must be submitted by July 1, 2018, to Dianne Daugherty by email at [email protected]. Winners will be announced by Aug. 10, 2018. For additional information, write to [email protected] or visit www.mhaus.org/nmsis/about-us/what-is-nmsis.
 

Dr. Caroff, professor of psychiatry, Corporal Michael J. Crescenz VA Medical Center and at the University of Pennsylvania, both in Philadelphia, is director of the NMSIS. He served as consultant to Neurocrine Biosciences and Teva Pharmaceutical Industries, and receives research grant funding from Neurocrine Biosciences.

Over the last few years, I have spoken to many people about their experiences with involuntary psychiatric hospitalizations. While the stories I’ve heard are anecdotes, often from people who have reached out to me, and not randomized, controlled studies, I’ve taken the liberty of coming to a few conclusions. First, involuntary hospitalizations help people. Most people say that they left the hospital with fewer symptoms than they had when they entered. Second, many of those people, helped though they may have been, are angry about the treatment they received. An unknown percentage feel traumatized by their psychiatric treatment, and years later they dwell on a perception of injustice and injury.

It’s perplexing that this negative residue remains given that involuntary psychiatric care often helps people to escape from the torment of psychosis or from soul-crushing depressions. While many feel it should be easier to involuntarily treat psychiatric disorders, there are no groups of patients asking for easier access to involuntary care. One group, Mad in America – formed by journalist Robert Whitaker – takes the position that psychiatric medications don’t just harm people, but that psychotropic medications actually cause psychiatric disorders in people who would have fared better without them. It now offers CME activities through its conferences and website!

I wanted to know what psychiatrists might learn from his experiences with involuntary care. Weinstein hesitated. “It wasn’t the best experience, and I felt there had to be a better way, but I know everyone was trying to help me, and I want my overall message to be one of hope. I don’t want to complain, because I’ve ended up in a much better place, I’m back at work, enjoying my family, and I feel joy now.”

For psychiatrists, this is the best outcome from a story such as Dr. Weinstein’s. He’s much better, in a scenario where he could have just as easily have died, and he wasn’t traumatized by his care. However, he avoided returning to inpatient care at a precarious time, and he’s left asking if there weren’t a gentler way this could have transpired. These questions are easier to look at from the perspective of a Monday morning quarterback than they are to look at from the perspective of a treatment team dealing with a very sick and combative patient. Still, I hope we all continue to question patients about their experiences and ask if there might be better ways.
 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Care” (Baltimore: Johns Hopkins University Press, 2016).

Over the last few years, I have spoken to many people about their experiences with involuntary psychiatric hospitalizations. While the stories I’ve heard are anecdotes, often from people who have reached out to me, and not randomized, controlled studies, I’ve taken the liberty of coming to a few conclusions. First, involuntary hospitalizations help people. Most people say that they left the hospital with fewer symptoms than they had when they entered. Second, many of those people, helped though they may have been, are angry about the treatment they received. An unknown percentage feel traumatized by their psychiatric treatment, and years later they dwell on a perception of injustice and injury.

It’s perplexing that this negative residue remains given that involuntary psychiatric care often helps people to escape from the torment of psychosis or from soul-crushing depressions. While many feel it should be easier to involuntarily treat psychiatric disorders, there are no groups of patients asking for easier access to involuntary care. One group, Mad in America – formed by journalist Robert Whitaker – takes the position that psychiatric medications don’t just harm people, but that psychotropic medications actually cause psychiatric disorders in people who would have fared better without them. It now offers CME activities through its conferences and website!

I wanted to know what psychiatrists might learn from his experiences with involuntary care. Weinstein hesitated. “It wasn’t the best experience, and I felt there had to be a better way, but I know everyone was trying to help me, and I want my overall message to be one of hope. I don’t want to complain, because I’ve ended up in a much better place, I’m back at work, enjoying my family, and I feel joy now.”

For psychiatrists, this is the best outcome from a story such as Dr. Weinstein’s. He’s much better, in a scenario where he could have just as easily have died, and he wasn’t traumatized by his care. However, he avoided returning to inpatient care at a precarious time, and he’s left asking if there weren’t a gentler way this could have transpired. These questions are easier to look at from the perspective of a Monday morning quarterback than they are to look at from the perspective of a treatment team dealing with a very sick and combative patient. Still, I hope we all continue to question patients about their experiences and ask if there might be better ways.
 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Care” (Baltimore: Johns Hopkins University Press, 2016).

Over the last few years, I have spoken to many people about their experiences with involuntary psychiatric hospitalizations. While the stories I’ve heard are anecdotes, often from people who have reached out to me, and not randomized, controlled studies, I’ve taken the liberty of coming to a few conclusions. First, involuntary hospitalizations help people. Most people say that they left the hospital with fewer symptoms than they had when they entered. Second, many of those people, helped though they may have been, are angry about the treatment they received. An unknown percentage feel traumatized by their psychiatric treatment, and years later they dwell on a perception of injustice and injury.

It’s perplexing that this negative residue remains given that involuntary psychiatric care often helps people to escape from the torment of psychosis or from soul-crushing depressions. While many feel it should be easier to involuntarily treat psychiatric disorders, there are no groups of patients asking for easier access to involuntary care. One group, Mad in America – formed by journalist Robert Whitaker – takes the position that psychiatric medications don’t just harm people, but that psychotropic medications actually cause psychiatric disorders in people who would have fared better without them. It now offers CME activities through its conferences and website!

I wanted to know what psychiatrists might learn from his experiences with involuntary care. Weinstein hesitated. “It wasn’t the best experience, and I felt there had to be a better way, but I know everyone was trying to help me, and I want my overall message to be one of hope. I don’t want to complain, because I’ve ended up in a much better place, I’m back at work, enjoying my family, and I feel joy now.”

For psychiatrists, this is the best outcome from a story such as Dr. Weinstein’s. He’s much better, in a scenario where he could have just as easily have died, and he wasn’t traumatized by his care. However, he avoided returning to inpatient care at a precarious time, and he’s left asking if there weren’t a gentler way this could have transpired. These questions are easier to look at from the perspective of a Monday morning quarterback than they are to look at from the perspective of a treatment team dealing with a very sick and combative patient. Still, I hope we all continue to question patients about their experiences and ask if there might be better ways.
 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Care” (Baltimore: Johns Hopkins University Press, 2016).

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.

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.

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.

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.

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.

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.

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.

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.

Nick Youngson/thebluediamondgallery.com/CC BY SA 3.0 nyphotographic.com/thebluediamondgallery.com/CC BY-SA 3.0

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.

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.

Nick Youngson/thebluediamondgallery.com/CC BY SA 3.0 nyphotographic.com/thebluediamondgallery.com/CC BY-SA 3.0

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.

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.

Nick Youngson/thebluediamondgallery.com/CC BY SA 3.0 nyphotographic.com/thebluediamondgallery.com/CC BY-SA 3.0

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.

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

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.

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.

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.

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.”

artisteer/Thinkstock

“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.

Like most other supposedly affluent professionals, doctors have always been popular targets for scam artists and con men. 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.

• 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.”

artisteer/Thinkstock

“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.

Like most other supposedly affluent professionals, doctors have always been popular targets for scam artists and con men. 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.

• 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.”

artisteer/Thinkstock

“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.

Like most other supposedly affluent professionals, doctors have always been popular targets for scam artists and con men. 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.

• 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].

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.

DGLimages/Thinkstock

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.

DGLimages/Thinkstock

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.

DGLimages/Thinkstock

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.

diego_cervo/Thinkstock

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.

diego_cervo/Thinkstock

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.

diego_cervo/Thinkstock

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.

monkeybusinessimages/Thinkstock

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.

monkeybusinessimages/Thinkstock

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.

monkeybusinessimages/Thinkstock

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

There 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 make decisions to modify treatment plans based on marijuana use on a case-by-case basis, such decisions need to be made in partnership with the Veteran and must be based on concerns regarding Veteran health and safety.”⁵

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 make decisions to modify treatment plans based on marijuana use on a case-by-case basis, such decisions need to be made in partnership with the Veteran and must be based on concerns regarding Veteran health and safety.”⁵

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 make decisions to modify treatment plans based on marijuana use on a case-by-case basis, such decisions need to be made in partnership with the Veteran and must be based on concerns regarding Veteran health and safety.”⁵

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.