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Letter from the Editor
GI & Hepatology News is one of the most widely read publications focused on the gastroenterology community and is the official newspaper of the AGA. The New Gastroenterologist is the AGA publication targeted to trainees and early career physicians. Recognizing the strength of both digital and print communication, the AGA has consolidated its communication media.
John I. Allen, MD, MBA, AGAF
Editor in Chief of GI & Hepatology News
When The New Gastroenterologist debuted almost 3 years ago, it provided a mechanism for the AGA to condense and disseminate information in a single publication for those of us in training or in the early stages of our careers. Since then, The New Gastroenterologist has become a valuable resource for the AGA community and beyond. It is with great excitement that in 2018, The New Gastroenterologist will switch to a primarily digital format. Content will be distributed in quarterly e-newsletters, which will allow for easier distribution via social media. This will allow for the creation of a website archive of past articles that can be easily queried and accessed. Additionally, The New Gastroenterologist will debut an “In Focus” series of concise updates on pertinent topics in our field. These In Focus articles will be published on a quarterly basis in GI & Hepatology News and will undoubtedly be practical and informative features that will be of interest to all AGA members, regardless of their career stage. The first In Focus article, which appears in this issue of GI & Hepatology News, is written by Nitin Ahuja, MD, and James Reynolds, MD, and provides an enlightening overview of the evaluation and management of chronic constipation. I hope that everyone enjoys this new format of The New Gastroenterologist. As always, if you have any feedback, have interest in contributing, or have ideas that you would like to hear about, please contact me ([email protected]) or Managing Editor Ryan Farrell ([email protected]).
Bryson W. Katona, MD, PhD
Editor in Chief of The New Gastroenterologist
GI & Hepatology News is one of the most widely read publications focused on the gastroenterology community and is the official newspaper of the AGA. The New Gastroenterologist is the AGA publication targeted to trainees and early career physicians. Recognizing the strength of both digital and print communication, the AGA has consolidated its communication media.
John I. Allen, MD, MBA, AGAF
Editor in Chief of GI & Hepatology News
When The New Gastroenterologist debuted almost 3 years ago, it provided a mechanism for the AGA to condense and disseminate information in a single publication for those of us in training or in the early stages of our careers. Since then, The New Gastroenterologist has become a valuable resource for the AGA community and beyond. It is with great excitement that in 2018, The New Gastroenterologist will switch to a primarily digital format. Content will be distributed in quarterly e-newsletters, which will allow for easier distribution via social media. This will allow for the creation of a website archive of past articles that can be easily queried and accessed. Additionally, The New Gastroenterologist will debut an “In Focus” series of concise updates on pertinent topics in our field. These In Focus articles will be published on a quarterly basis in GI & Hepatology News and will undoubtedly be practical and informative features that will be of interest to all AGA members, regardless of their career stage. The first In Focus article, which appears in this issue of GI & Hepatology News, is written by Nitin Ahuja, MD, and James Reynolds, MD, and provides an enlightening overview of the evaluation and management of chronic constipation. I hope that everyone enjoys this new format of The New Gastroenterologist. As always, if you have any feedback, have interest in contributing, or have ideas that you would like to hear about, please contact me ([email protected]) or Managing Editor Ryan Farrell ([email protected]).
Bryson W. Katona, MD, PhD
Editor in Chief of The New Gastroenterologist
GI & Hepatology News is one of the most widely read publications focused on the gastroenterology community and is the official newspaper of the AGA. The New Gastroenterologist is the AGA publication targeted to trainees and early career physicians. Recognizing the strength of both digital and print communication, the AGA has consolidated its communication media.
John I. Allen, MD, MBA, AGAF
Editor in Chief of GI & Hepatology News
When The New Gastroenterologist debuted almost 3 years ago, it provided a mechanism for the AGA to condense and disseminate information in a single publication for those of us in training or in the early stages of our careers. Since then, The New Gastroenterologist has become a valuable resource for the AGA community and beyond. It is with great excitement that in 2018, The New Gastroenterologist will switch to a primarily digital format. Content will be distributed in quarterly e-newsletters, which will allow for easier distribution via social media. This will allow for the creation of a website archive of past articles that can be easily queried and accessed. Additionally, The New Gastroenterologist will debut an “In Focus” series of concise updates on pertinent topics in our field. These In Focus articles will be published on a quarterly basis in GI & Hepatology News and will undoubtedly be practical and informative features that will be of interest to all AGA members, regardless of their career stage. The first In Focus article, which appears in this issue of GI & Hepatology News, is written by Nitin Ahuja, MD, and James Reynolds, MD, and provides an enlightening overview of the evaluation and management of chronic constipation. I hope that everyone enjoys this new format of The New Gastroenterologist. As always, if you have any feedback, have interest in contributing, or have ideas that you would like to hear about, please contact me ([email protected]) or Managing Editor Ryan Farrell ([email protected]).
Bryson W. Katona, MD, PhD
Editor in Chief of The New Gastroenterologist
Handshake
There’s a simple act you’ve done with all your patients that you’ve probably been doing incorrectly. Yes, that is rather a bold assertion, but I’ll bet no one ever taught you the proper way. It’s only recently, after having done it thousands of times, that I came to realize there is a better way to give a handshake.
The first helps establish who you are as a doctor and reassures your patient that you’re both capable and trustworthy. At the end of the visit, it seals the agreement wherein they commit to take your advice (or at least try) and you commit to do whatever necessary to help them.
A poorly executed handshake, or worse, none at all, can erode trust or convey a lack of ability on your part. It’s true that handshakes aren’t always appropriate: For certain patients or disease states, they would be unsuitable. For the majority of patient visits, however, they are key. Here are some secrets to a good handshake:
- As you’ve probably experienced, timing is critical. A handshake requires someone to anticipate your action and to coordinate perfectly with you. When you enter the room, move toward your patient and put your hand forward just as you approach your patient. Too early and you look like an awkward high schooler eager for a Justin Bieber autograph. Too late and you’ll take your patient by surprise. The best position is to have your left foot forward as you reach for their hand. This gives you stability and allows you to convey confidence.
- As you approach your patient, make eye contact. Just a second or two as you cross the room is perfect. Then glance down at their now outstretched hand and connect web to web. Your arm should be tucked in and move straight toward their hand. Swinging out to come back in is great when you’re getting your new NBA jersey from the basketball commissioner, but not for getting patients comfortable with you.
- The grip depends on the patient. For most adults, a firm squeeze with two arm pumps is just right. For the hard-charging, testosterone-replacing ex-Marine, you can reciprocate the extra-firm grasp – let him win the grip contest though, that’s what he wants. For the freezing-in-her-gown great grandmother, an extra long hold, sometimes even double handed, is fine, even appreciated.
- No matter how firm, it is important to convey your enthusiasm and ability to your patient. This is done with a gentle push. As you shake hands, lightly push their arm back into them. This subtle transfer of energy from you to them is a little known tip that will make your handshake much more effective. Never push them off balance or worse, pull them toward you. Your objective is to create trust; making them unsteady will make that impossible.
- Finally, let go after two pumps. If you feel them holding on, then stay until they release. For the majority of patients, that will be a just a couple seconds.
For patients I’ve never met, I often proffer my hand turned slightly upward for our first handshake. This subtle sign of submission shows I’m open and committed to them. For our closing handshake, I have my hand turned slightly downward so that my hand is slightly over theirs. This conveys that I’m confident in what I’ve said and done and that now I want them to uphold their part in our agreement.
I’ve been using the above technique for a few years now with success. It has helped with my patient satisfaction scores, and importantly, has helped me manage difficult patients for whom trust in our relationship is invaluable.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
There’s a simple act you’ve done with all your patients that you’ve probably been doing incorrectly. Yes, that is rather a bold assertion, but I’ll bet no one ever taught you the proper way. It’s only recently, after having done it thousands of times, that I came to realize there is a better way to give a handshake.
The first helps establish who you are as a doctor and reassures your patient that you’re both capable and trustworthy. At the end of the visit, it seals the agreement wherein they commit to take your advice (or at least try) and you commit to do whatever necessary to help them.
A poorly executed handshake, or worse, none at all, can erode trust or convey a lack of ability on your part. It’s true that handshakes aren’t always appropriate: For certain patients or disease states, they would be unsuitable. For the majority of patient visits, however, they are key. Here are some secrets to a good handshake:
- As you’ve probably experienced, timing is critical. A handshake requires someone to anticipate your action and to coordinate perfectly with you. When you enter the room, move toward your patient and put your hand forward just as you approach your patient. Too early and you look like an awkward high schooler eager for a Justin Bieber autograph. Too late and you’ll take your patient by surprise. The best position is to have your left foot forward as you reach for their hand. This gives you stability and allows you to convey confidence.
- As you approach your patient, make eye contact. Just a second or two as you cross the room is perfect. Then glance down at their now outstretched hand and connect web to web. Your arm should be tucked in and move straight toward their hand. Swinging out to come back in is great when you’re getting your new NBA jersey from the basketball commissioner, but not for getting patients comfortable with you.
- The grip depends on the patient. For most adults, a firm squeeze with two arm pumps is just right. For the hard-charging, testosterone-replacing ex-Marine, you can reciprocate the extra-firm grasp – let him win the grip contest though, that’s what he wants. For the freezing-in-her-gown great grandmother, an extra long hold, sometimes even double handed, is fine, even appreciated.
- No matter how firm, it is important to convey your enthusiasm and ability to your patient. This is done with a gentle push. As you shake hands, lightly push their arm back into them. This subtle transfer of energy from you to them is a little known tip that will make your handshake much more effective. Never push them off balance or worse, pull them toward you. Your objective is to create trust; making them unsteady will make that impossible.
- Finally, let go after two pumps. If you feel them holding on, then stay until they release. For the majority of patients, that will be a just a couple seconds.
For patients I’ve never met, I often proffer my hand turned slightly upward for our first handshake. This subtle sign of submission shows I’m open and committed to them. For our closing handshake, I have my hand turned slightly downward so that my hand is slightly over theirs. This conveys that I’m confident in what I’ve said and done and that now I want them to uphold their part in our agreement.
I’ve been using the above technique for a few years now with success. It has helped with my patient satisfaction scores, and importantly, has helped me manage difficult patients for whom trust in our relationship is invaluable.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
There’s a simple act you’ve done with all your patients that you’ve probably been doing incorrectly. Yes, that is rather a bold assertion, but I’ll bet no one ever taught you the proper way. It’s only recently, after having done it thousands of times, that I came to realize there is a better way to give a handshake.
The first helps establish who you are as a doctor and reassures your patient that you’re both capable and trustworthy. At the end of the visit, it seals the agreement wherein they commit to take your advice (or at least try) and you commit to do whatever necessary to help them.
A poorly executed handshake, or worse, none at all, can erode trust or convey a lack of ability on your part. It’s true that handshakes aren’t always appropriate: For certain patients or disease states, they would be unsuitable. For the majority of patient visits, however, they are key. Here are some secrets to a good handshake:
- As you’ve probably experienced, timing is critical. A handshake requires someone to anticipate your action and to coordinate perfectly with you. When you enter the room, move toward your patient and put your hand forward just as you approach your patient. Too early and you look like an awkward high schooler eager for a Justin Bieber autograph. Too late and you’ll take your patient by surprise. The best position is to have your left foot forward as you reach for their hand. This gives you stability and allows you to convey confidence.
- As you approach your patient, make eye contact. Just a second or two as you cross the room is perfect. Then glance down at their now outstretched hand and connect web to web. Your arm should be tucked in and move straight toward their hand. Swinging out to come back in is great when you’re getting your new NBA jersey from the basketball commissioner, but not for getting patients comfortable with you.
- The grip depends on the patient. For most adults, a firm squeeze with two arm pumps is just right. For the hard-charging, testosterone-replacing ex-Marine, you can reciprocate the extra-firm grasp – let him win the grip contest though, that’s what he wants. For the freezing-in-her-gown great grandmother, an extra long hold, sometimes even double handed, is fine, even appreciated.
- No matter how firm, it is important to convey your enthusiasm and ability to your patient. This is done with a gentle push. As you shake hands, lightly push their arm back into them. This subtle transfer of energy from you to them is a little known tip that will make your handshake much more effective. Never push them off balance or worse, pull them toward you. Your objective is to create trust; making them unsteady will make that impossible.
- Finally, let go after two pumps. If you feel them holding on, then stay until they release. For the majority of patients, that will be a just a couple seconds.
For patients I’ve never met, I often proffer my hand turned slightly upward for our first handshake. This subtle sign of submission shows I’m open and committed to them. For our closing handshake, I have my hand turned slightly downward so that my hand is slightly over theirs. This conveys that I’m confident in what I’ve said and done and that now I want them to uphold their part in our agreement.
I’ve been using the above technique for a few years now with success. It has helped with my patient satisfaction scores, and importantly, has helped me manage difficult patients for whom trust in our relationship is invaluable.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Our fascination with medication compliance
As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.
The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder”1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’ ”2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.
“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.
The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”
My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”
What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. 5
The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.
As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7
A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.
Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.
Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.
References
1. Worcester Patch. Jan. 2, 2018.
2. Rare News. Jan. 4, 2018.
3. WTSP.com. Dec. 31, 2017.
4. Wavy.com, Dec. 20, 2017.
5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.
6. JAMA Psychiatry. 2013 Sep;70(9):913-20.
7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.
8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.
9. Am J Orthopsychiatry. 2016;86(5):477-85.
10. New York Times. Nov. 13, 2017.
As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.
The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder”1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’ ”2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.
“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.
The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”
My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”
What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. 5
The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.
As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7
A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.
Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.
Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.
References
1. Worcester Patch. Jan. 2, 2018.
2. Rare News. Jan. 4, 2018.
3. WTSP.com. Dec. 31, 2017.
4. Wavy.com, Dec. 20, 2017.
5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.
6. JAMA Psychiatry. 2013 Sep;70(9):913-20.
7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.
8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.
9. Am J Orthopsychiatry. 2016;86(5):477-85.
10. New York Times. Nov. 13, 2017.
As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.
The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder”1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’ ”2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.
“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.
The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”
My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”
What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. 5
The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.
As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7
A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.
Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.
Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.
References
1. Worcester Patch. Jan. 2, 2018.
2. Rare News. Jan. 4, 2018.
3. WTSP.com. Dec. 31, 2017.
4. Wavy.com, Dec. 20, 2017.
5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.
6. JAMA Psychiatry. 2013 Sep;70(9):913-20.
7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.
8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.
9. Am J Orthopsychiatry. 2016;86(5):477-85.
10. New York Times. Nov. 13, 2017.
Influenza vaccination of pregnant women needs surveillance
Seasonal influenza vaccine is specifically recommended for women who are or who might become pregnant in the flu season. This special population is targeted for vaccination because pregnant women are at increased risks of serious complications if infected with influenza virus. Despite this recommendation, recent evidence indicates that still fewer than 50% of women in the United States are vaccinated during pregnancy (MMWR Morb Mortal Wkly Rep. 2016 Dec 9;65[48]:1370-3).
Potential reasons for this lack of uptake are concerns about safety of the vaccine for mothers and fetuses (Vaccine. 2012 Dec 17;31[1]:213-8). This has highlighted the need for systematic safety surveillance for influenza vaccination with each subsequent seasonal formulation. To that end, season-specific studies of birth and infant outcomes since the 2009 season have been conducted; findings have been generally reassuring (Vaccine. 2016 Aug 17;34[37]:4443-9; Vaccine. 2016 Aug 17;34[37]:4450-9).
The authors found a doubling of risk for spontaneous abortion within that 28-day exposure window, but no association if the vaccination took place outside that period. This was in contrast to null findings for a similar analysis that the same group had conducted for vaccination in the 2005-2006 and 2006-2007 seasons. Of further interest, the authors noted even higher risks among women who had also been vaccinated for influenza in the previous season (adjusted odds ratio, 7.7; 95% confidence interval, 2.2-27.3). The highest odds ratios were among women who had been vaccinated in the 2010-2011 season and had also been vaccinated with monovalent pandemic H1N1 vaccine in the 2009-2010 season (aOR, 32.5; 95% CI, 2.9-359.0).
The VSD findings raise interesting questions about the biologic plausibility of strain-specific risks for spontaneous abortion, and risks of receiving a second vaccine containing the same strain in a subsequent season. However, this study should be interpreted with caution. With respect to the overall finding of a doubling of risk for spontaneous abortion, this is inconsistent with previous studies. A systematic review of 19 observational studies, 14 of which included exposure to the 2009 monovalent pandemic H1N1 strain, noted hazard ratios or odds ratios for spontaneous abortion ranging from 0.45 to 1.23 and 95% confidence intervals that crossed or were below the null (Vaccine. 2015 Apr 27;33[18]:2108-17). More recently, the Vaccines and Medications in Pregnancy Surveillance System investigators evaluated spontaneous abortion in pregnancies exposed to influenza vaccine over four seasons from 2010 to 2014 and found an overall hazard ratio of 1.09 (95% CI, 0.49-2.40).
However, there are a number of limitations that must be considered. Many previous studies, including the VSD analysis, could have had misclassification of exposure, especially in recent years when vaccines are often received in nontraditional settings. The VSD study findings could have been influenced by unmeasured confounding. For example, there could be differential vaccine uptake in women with comorbidities that are also associated with spontaneous abortion, such as subfertility and psychiatric disorders.
In summary, at present the data viewed as a whole do not support a change to the current recommendation that pregnant women be vaccinated for influenza regardless of trimester. However, these data do call for continued surveillance for the safety of each seasonal formulation of influenza vaccine, and for further exploration of the association between repeat vaccination and spontaneous abortion in other datasets.
Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is also director of MotherToBaby California, a past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no direct conflicts of interest to disclose, but has received grant funding to study influenza vaccine from the Biomedical Advanced Research and Development Authority (BARDA) in the Department of Health and Human Services, and from Seqirus Corporation.
Seasonal influenza vaccine is specifically recommended for women who are or who might become pregnant in the flu season. This special population is targeted for vaccination because pregnant women are at increased risks of serious complications if infected with influenza virus. Despite this recommendation, recent evidence indicates that still fewer than 50% of women in the United States are vaccinated during pregnancy (MMWR Morb Mortal Wkly Rep. 2016 Dec 9;65[48]:1370-3).
Potential reasons for this lack of uptake are concerns about safety of the vaccine for mothers and fetuses (Vaccine. 2012 Dec 17;31[1]:213-8). This has highlighted the need for systematic safety surveillance for influenza vaccination with each subsequent seasonal formulation. To that end, season-specific studies of birth and infant outcomes since the 2009 season have been conducted; findings have been generally reassuring (Vaccine. 2016 Aug 17;34[37]:4443-9; Vaccine. 2016 Aug 17;34[37]:4450-9).
The authors found a doubling of risk for spontaneous abortion within that 28-day exposure window, but no association if the vaccination took place outside that period. This was in contrast to null findings for a similar analysis that the same group had conducted for vaccination in the 2005-2006 and 2006-2007 seasons. Of further interest, the authors noted even higher risks among women who had also been vaccinated for influenza in the previous season (adjusted odds ratio, 7.7; 95% confidence interval, 2.2-27.3). The highest odds ratios were among women who had been vaccinated in the 2010-2011 season and had also been vaccinated with monovalent pandemic H1N1 vaccine in the 2009-2010 season (aOR, 32.5; 95% CI, 2.9-359.0).
The VSD findings raise interesting questions about the biologic plausibility of strain-specific risks for spontaneous abortion, and risks of receiving a second vaccine containing the same strain in a subsequent season. However, this study should be interpreted with caution. With respect to the overall finding of a doubling of risk for spontaneous abortion, this is inconsistent with previous studies. A systematic review of 19 observational studies, 14 of which included exposure to the 2009 monovalent pandemic H1N1 strain, noted hazard ratios or odds ratios for spontaneous abortion ranging from 0.45 to 1.23 and 95% confidence intervals that crossed or were below the null (Vaccine. 2015 Apr 27;33[18]:2108-17). More recently, the Vaccines and Medications in Pregnancy Surveillance System investigators evaluated spontaneous abortion in pregnancies exposed to influenza vaccine over four seasons from 2010 to 2014 and found an overall hazard ratio of 1.09 (95% CI, 0.49-2.40).
However, there are a number of limitations that must be considered. Many previous studies, including the VSD analysis, could have had misclassification of exposure, especially in recent years when vaccines are often received in nontraditional settings. The VSD study findings could have been influenced by unmeasured confounding. For example, there could be differential vaccine uptake in women with comorbidities that are also associated with spontaneous abortion, such as subfertility and psychiatric disorders.
In summary, at present the data viewed as a whole do not support a change to the current recommendation that pregnant women be vaccinated for influenza regardless of trimester. However, these data do call for continued surveillance for the safety of each seasonal formulation of influenza vaccine, and for further exploration of the association between repeat vaccination and spontaneous abortion in other datasets.
Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is also director of MotherToBaby California, a past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no direct conflicts of interest to disclose, but has received grant funding to study influenza vaccine from the Biomedical Advanced Research and Development Authority (BARDA) in the Department of Health and Human Services, and from Seqirus Corporation.
Seasonal influenza vaccine is specifically recommended for women who are or who might become pregnant in the flu season. This special population is targeted for vaccination because pregnant women are at increased risks of serious complications if infected with influenza virus. Despite this recommendation, recent evidence indicates that still fewer than 50% of women in the United States are vaccinated during pregnancy (MMWR Morb Mortal Wkly Rep. 2016 Dec 9;65[48]:1370-3).
Potential reasons for this lack of uptake are concerns about safety of the vaccine for mothers and fetuses (Vaccine. 2012 Dec 17;31[1]:213-8). This has highlighted the need for systematic safety surveillance for influenza vaccination with each subsequent seasonal formulation. To that end, season-specific studies of birth and infant outcomes since the 2009 season have been conducted; findings have been generally reassuring (Vaccine. 2016 Aug 17;34[37]:4443-9; Vaccine. 2016 Aug 17;34[37]:4450-9).
The authors found a doubling of risk for spontaneous abortion within that 28-day exposure window, but no association if the vaccination took place outside that period. This was in contrast to null findings for a similar analysis that the same group had conducted for vaccination in the 2005-2006 and 2006-2007 seasons. Of further interest, the authors noted even higher risks among women who had also been vaccinated for influenza in the previous season (adjusted odds ratio, 7.7; 95% confidence interval, 2.2-27.3). The highest odds ratios were among women who had been vaccinated in the 2010-2011 season and had also been vaccinated with monovalent pandemic H1N1 vaccine in the 2009-2010 season (aOR, 32.5; 95% CI, 2.9-359.0).
The VSD findings raise interesting questions about the biologic plausibility of strain-specific risks for spontaneous abortion, and risks of receiving a second vaccine containing the same strain in a subsequent season. However, this study should be interpreted with caution. With respect to the overall finding of a doubling of risk for spontaneous abortion, this is inconsistent with previous studies. A systematic review of 19 observational studies, 14 of which included exposure to the 2009 monovalent pandemic H1N1 strain, noted hazard ratios or odds ratios for spontaneous abortion ranging from 0.45 to 1.23 and 95% confidence intervals that crossed or were below the null (Vaccine. 2015 Apr 27;33[18]:2108-17). More recently, the Vaccines and Medications in Pregnancy Surveillance System investigators evaluated spontaneous abortion in pregnancies exposed to influenza vaccine over four seasons from 2010 to 2014 and found an overall hazard ratio of 1.09 (95% CI, 0.49-2.40).
However, there are a number of limitations that must be considered. Many previous studies, including the VSD analysis, could have had misclassification of exposure, especially in recent years when vaccines are often received in nontraditional settings. The VSD study findings could have been influenced by unmeasured confounding. For example, there could be differential vaccine uptake in women with comorbidities that are also associated with spontaneous abortion, such as subfertility and psychiatric disorders.
In summary, at present the data viewed as a whole do not support a change to the current recommendation that pregnant women be vaccinated for influenza regardless of trimester. However, these data do call for continued surveillance for the safety of each seasonal formulation of influenza vaccine, and for further exploration of the association between repeat vaccination and spontaneous abortion in other datasets.
Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is also director of MotherToBaby California, a past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no direct conflicts of interest to disclose, but has received grant funding to study influenza vaccine from the Biomedical Advanced Research and Development Authority (BARDA) in the Department of Health and Human Services, and from Seqirus Corporation.
How to set up your own RSS feed
In my last column, I reviewed the reasons why RSS news feeds can be a useful tool for keeping abreast on frequently updated information, including blog entries, news headlines, audio, and video, without having to check multiple Web pages every day.
This can help increase readership on your website, publicize a podcast, or keep your patients up to date on the latest treatments and procedures in your practice. And if your name appears in news or gossip sites, you will be alerted immediately.
Alternatively, many organizations that publish their own articles and news stories use a content management system (CMS) to organize, store, and publish their material, including RSS feeds. Examples include Drupal and Plone, which are both free, open source programs. Stand-alone RSS creation programs also exist; one popular example is RSS Builder, also a free and open source.
Disadvantages of free systems include advertisements (which can sometimes be removed for a monthly fee) and little or no technical support – and you will probably be limited to a single feed. You’ll also have to add and update headlines, links, and descriptive text manually. Your free feed can become quite expensive if you or staffers are forced to spend an inordinate amount of time maintaining it. Paid RSS editors like FeedForAll and NewzAlert Composer allow easier and less time-consuming content creation and maintenance.
Once you have picked a service or application, you can create your first feed, a process that will be different from program to program. But all feeds will need some basic data: a name (which should be the same as your practice or website); the URL for your website, to help viewers link back to your home page; and a description – a sentence or two describing the general content on the feed.
The next step is to populate the feed with content. Enter the title of each article, blog post, podcast episode, etc.; the URL that links directly to that content; and the publishing date. Each entry should have its own short, interesting description, which is what potential readers will see before they choose to click your entry in their RSS readers, and a global unique identifier (GUID), which the RSS readers use to detect changes or updates.
When all of your content is entered, all that remains is to export your feed to an extensible markup language (XML) file, which will allow visitors to subscribe to it. Upload the XML file to your website, place it on your home page, and click the “publish feed” button.
Once your feed is live, you’ll want to list it on some of the many RSS feed directories to maximize its visibility on search engines. There are literally hundreds of such directories; look for medically oriented ones that do not charge fees, and do not require a reciprocal link back to their website. Add each directory’s URL to your XML file.
Addendum: In my December 2017 column (“Your Online Reputation”), I suggested encouraging your most devoted patients to post favorable reviews about you on the “rating” websites. Several readers (including a practice consultant) have suggested making a laptop or tablet available in your office for that purpose. While that sounds like a great idea, most rating portals track incoming IP addresses, and automatically reject multiple reviews originating from the same computer.
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.
In my last column, I reviewed the reasons why RSS news feeds can be a useful tool for keeping abreast on frequently updated information, including blog entries, news headlines, audio, and video, without having to check multiple Web pages every day.
This can help increase readership on your website, publicize a podcast, or keep your patients up to date on the latest treatments and procedures in your practice. And if your name appears in news or gossip sites, you will be alerted immediately.
Alternatively, many organizations that publish their own articles and news stories use a content management system (CMS) to organize, store, and publish their material, including RSS feeds. Examples include Drupal and Plone, which are both free, open source programs. Stand-alone RSS creation programs also exist; one popular example is RSS Builder, also a free and open source.
Disadvantages of free systems include advertisements (which can sometimes be removed for a monthly fee) and little or no technical support – and you will probably be limited to a single feed. You’ll also have to add and update headlines, links, and descriptive text manually. Your free feed can become quite expensive if you or staffers are forced to spend an inordinate amount of time maintaining it. Paid RSS editors like FeedForAll and NewzAlert Composer allow easier and less time-consuming content creation and maintenance.
Once you have picked a service or application, you can create your first feed, a process that will be different from program to program. But all feeds will need some basic data: a name (which should be the same as your practice or website); the URL for your website, to help viewers link back to your home page; and a description – a sentence or two describing the general content on the feed.
The next step is to populate the feed with content. Enter the title of each article, blog post, podcast episode, etc.; the URL that links directly to that content; and the publishing date. Each entry should have its own short, interesting description, which is what potential readers will see before they choose to click your entry in their RSS readers, and a global unique identifier (GUID), which the RSS readers use to detect changes or updates.
When all of your content is entered, all that remains is to export your feed to an extensible markup language (XML) file, which will allow visitors to subscribe to it. Upload the XML file to your website, place it on your home page, and click the “publish feed” button.
Once your feed is live, you’ll want to list it on some of the many RSS feed directories to maximize its visibility on search engines. There are literally hundreds of such directories; look for medically oriented ones that do not charge fees, and do not require a reciprocal link back to their website. Add each directory’s URL to your XML file.
Addendum: In my December 2017 column (“Your Online Reputation”), I suggested encouraging your most devoted patients to post favorable reviews about you on the “rating” websites. Several readers (including a practice consultant) have suggested making a laptop or tablet available in your office for that purpose. While that sounds like a great idea, most rating portals track incoming IP addresses, and automatically reject multiple reviews originating from the same computer.
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.
In my last column, I reviewed the reasons why RSS news feeds can be a useful tool for keeping abreast on frequently updated information, including blog entries, news headlines, audio, and video, without having to check multiple Web pages every day.
This can help increase readership on your website, publicize a podcast, or keep your patients up to date on the latest treatments and procedures in your practice. And if your name appears in news or gossip sites, you will be alerted immediately.
Alternatively, many organizations that publish their own articles and news stories use a content management system (CMS) to organize, store, and publish their material, including RSS feeds. Examples include Drupal and Plone, which are both free, open source programs. Stand-alone RSS creation programs also exist; one popular example is RSS Builder, also a free and open source.
Disadvantages of free systems include advertisements (which can sometimes be removed for a monthly fee) and little or no technical support – and you will probably be limited to a single feed. You’ll also have to add and update headlines, links, and descriptive text manually. Your free feed can become quite expensive if you or staffers are forced to spend an inordinate amount of time maintaining it. Paid RSS editors like FeedForAll and NewzAlert Composer allow easier and less time-consuming content creation and maintenance.
Once you have picked a service or application, you can create your first feed, a process that will be different from program to program. But all feeds will need some basic data: a name (which should be the same as your practice or website); the URL for your website, to help viewers link back to your home page; and a description – a sentence or two describing the general content on the feed.
The next step is to populate the feed with content. Enter the title of each article, blog post, podcast episode, etc.; the URL that links directly to that content; and the publishing date. Each entry should have its own short, interesting description, which is what potential readers will see before they choose to click your entry in their RSS readers, and a global unique identifier (GUID), which the RSS readers use to detect changes or updates.
When all of your content is entered, all that remains is to export your feed to an extensible markup language (XML) file, which will allow visitors to subscribe to it. Upload the XML file to your website, place it on your home page, and click the “publish feed” button.
Once your feed is live, you’ll want to list it on some of the many RSS feed directories to maximize its visibility on search engines. There are literally hundreds of such directories; look for medically oriented ones that do not charge fees, and do not require a reciprocal link back to their website. Add each directory’s URL to your XML file.
Addendum: In my December 2017 column (“Your Online Reputation”), I suggested encouraging your most devoted patients to post favorable reviews about you on the “rating” websites. Several readers (including a practice consultant) have suggested making a laptop or tablet available in your office for that purpose. While that sounds like a great idea, most rating portals track incoming IP addresses, and automatically reject multiple reviews originating from the same computer.
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.
Experience may not always the best teacher
“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?
He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).
Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.
Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.
The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.
After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
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.”
“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?
He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).
Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.
Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.
The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.
After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
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.”
“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?
He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).
Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.
Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.
The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.
After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
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.”
Sexual harassment
Question: A medical assistant alleged that Dr. Y sexually harassed her by sending anonymous gifts and messages such as, “you’re gorgeous,” and “I love your figure.” It was a repeat of Dr. Y’s previous behavior pattern directed at a different worker, who had lodged a complaint with the human resources department. The medical assistant now files a sexual harassment action under Title VII of the federal Civil Rights Act of 1964 against the health care institution, alleging a hostile work environment.
Which of the following is false?
A. Sexual harassment is a form of sexual misconduct regulated by state medical boards.
B. Mere words, without physical action, may suffice to be deemed sexual harassment.
C. A hostile environment arises when offensive conduct is so severe and pervasive as to amount to job discrimination.
D. Sexual harassment is a civil rights violation unique to the workplace.
E. Liability may attach to the supervisor, institution, or the harasser.
Answer: D. This hypothetical is modified from an actual Connecticut case that was recently decided in favor of the plaintiff.1 In that case, which involved a dentist, the federal Second Circuit unanimously rejected the University of Connecticut Health Center’s appeal against a jury’s verdict holding it responsible for its employee’s sexual harassment of a coworker, who was awarded $125,000. It ruled that the health center should have known of its employee’s harassing behavior.
Sexual harassment, a current hot topic, is pervasive, affecting a diversity of individuals in the fields of media, sports, politics, judiciary, education, entertainment, and others. The medical profession is no exception, and studies indicate that sexual harassment affects patients and physicians alike, occurring in hospitals, private offices, and academic centers.
In a large questionnaire study involving 4,501 female physicians, the authors found a prevalence rate of 47.7%. Harassment was more common while in medical school or during internship, residency, or fellowship than in practice.2 Patients may be the harassers. In 599 of the 1,064 licensed female family physicians in Ontario, more than 75% reported sexual harassment by patients at some time during their careers, either in their own offices by their own patients, or in settings such as emergency departments and clinics, where unknown patients presented an even higher risk.3
When physicians sexually harass fellow workers such as nurses, they distract their victims from providing attentive and competent care. In a review of the subject, researchers cited a study of 188 critical care nurses in hospitals, where nearly half (46%) reported experiencing sexual harassment that included “offensive sexual remarks, unwanted physical contact, unwanted nonverbal attention, requests for unwanted dates, sexual propositions, and physical assault.”4 To this list must now be added misconduct via the use of social media. In the study, physicians (82%), coworkers (20%), and immediate supervisors (7%) accounted for most of the incidents.
Neglecting to look seriously into complaints or to monitor and remedy the situation may create a hostile environment and trigger liability.
An example is the recent well-publicized case of Olympics team physician Dr. Larry Nassar, who was also a faculty member at Michigan State University. Olympic gold medalist McKayla Maroney named both the university and the U.S. Olympic Committee as codefendants in a lawsuit alleging that the institutions failed to properly investigate the team doctor’s criminal sexual conduct.
In Anania v. Daubenspeck Chiropractic, two employees of a chiropractor alleged that his patients sexually harassed them, but he did not remedy the situation.5 The trial court initially dismissed their lawsuit, holding that Ohio law did not recognize a cause of action for sexual harassment by a nonemployee patient, and that liability for sexual harassment can only exist in the context of respondeat superior (employer-employee) liability.
However, the court of appeals held that so long as the chiropractor knew or should have known of the harassment, and failed to take corrective action, he could be liable for allowing a hostile environment to exist.
Negligent supervision is another favorite plaintiff’s cause of action. In Doe v. Borromeo, a patient sought to hold the hospital liable for sexual assault by a physician during a medical exam.6 The lower state court had summarily dismissed the case, which was based on vicarious liability, but the state court of appeals reversed, finding the patient’s complaint against the hospital included a negligent supervision claim.
The appeals court reasoned that this was distinguishable from one based upon vicarious liability, so long as the supervising entity had a duty to protect the victim – and such a duty can only be established if the supervising entity knew or should have known of the existence of the harasser’s propensities, if any, to commit criminal and tortious acts.
Sexual harassment is a form of sex discrimination under Title VII of the Civil Rights Act of 1964, which is enforced by the Equal Employment Opportunity Commission. The commission’s website explains the law in clear and simple language:
“It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include ‘sexual harassment’ or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex.
“For example, it is illegal to harass a woman by making offensive comments about women in general. Both victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex.
“Although the law doesn’t prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim’s supervisor, a supervisor in another area, a coworker, or someone who is not an employee of the employer, such as a client or customer.”7
For sexual harassment to occur, the aggrieved party must either show a “hostile environment” or “quid pro quo” situation.
In a hostile environment case, the harassment is serious and persistent, creating unacceptable and offensive work conditions. The plaintiff has to show that the employer knew or should have known of the situation but failed to remedy it.
The “quid pro quo” type of case requires a showing that a person in authority conditioned some aspect of the employee’s employment, such as promotion or retention, upon a sexual favor or relationship.
The U.S. Supreme Court has both clarified and muddied the law’s position on these two previously distinct types of sexual harassment.
In the landmark case of Burlington Industries v. Ellerth, the plaintiff, who was a salesperson, alleged that a supervisor made advances to her and threatened to deny her certain job benefits if she did not cooperate.8 The threats were never carried out, and she was in fact promoted; but her lawsuit alleged that the harassment caused her resignation and amounted to a “constructive” discharge.
Likewise, in Faragher v. City of Boca Raton, the plaintiff, employed as a lifeguard, alleged that her work environment was riddled with crude remarks and obscenities.9 One of the two supervisors reportedly once said to Faragher, “Date me or clean toilets for a year.” Another lifeguard had previously lodged similar complaints. The plaintiff ultimately resigned and brought suit.
The U.S. Supreme Court characterized both of these as “hostile environment” rather than “quid pro quo” cases, because the plaintiffs did not suffer any direct adverse job action. In its decisions, the court defined the scope of liability and affirmative defenses, holding that employers can be subject to vicarious liability when supervisors create actionable hostile work environments.
In other cases, the Supreme Court has ruled for the use of “the reasonable person in the plaintiff’s position” standard in judging the severity of sexual harassment. The court has also held that the genders of the harasser and the harassed employee are not material in determining whether sexual harassment has occurred.
A physician can be accused of harassing an employee, a nurse, an assistant, a fellow worker, a third party, or a patient. Focusing on misconduct within the doctor-patient relationship, the Federation of State Medical Boards adopted in May 2006 a policy entitled “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”10
Although it did not use the term sexual harassment, the policy emphasized that physician sexual misconduct may include behavior that is verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual. It used the term “sexual impropriety” to denote behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. Together with “sexual violation,” a term the FSMB used when referring to physical sexual contact, they form the basis for disciplinary action by a state medical board.
Caveat: When performing a physical exam, physicians should always use good judgment and sensitivity, relying on the presence of a medical assistant to ensure patient comfort and to alleviate possible embarrassment or anxiety.
Under the federal EEOC rules, the employer rather than the harasser is the defendant. But there are other legal recourses, including tort and criminal actions, that directly target the harasser. Successful plaintiffs may be awarded lost wages, as well as damages for emotional distress, medical expenses, and punitive damages. They may also recover attorney fees.
In one case, a psychiatric nurse was awarded $1.2 million (later reduced to $850,000); in another, a nurse successfully sued a physician’s medical practice and received $150,000 in damages.4 And in an unusual case, a plaintiff was awarded only $1 in damages, but her counsel was paid $41,598 in fees.11 For the practicing doctor, medical board sanction, notoriety, and loss of professional standing and privileges constitute additional costs.
The medical profession is as susceptible as any other – perhaps more so – to allegations of sexual harassment. The magic words for actionable sexual harassment are severe, pervasive, and unwelcome. Although laws in the workplace generally do not prohibit simple teasing, offhand comments, or minor isolated incidents, the line separating these behaviors from bona fide sexual harassment is thin.
Erring on the side of strict and sober professional propriety seems prudent, given the current climate of zero tolerance.
References
1. MacCluskey v. University of Connecticut Health Center, United States Court of Appeals, Second Circuit, No. 17-0807-cv, Dec. 19, 2017.
2. Arch Intern Med. 1998 Feb 23;158(4):352-8.
3. N Engl J Med. 1993 Dec 23;329(26):1936-9.
4. J Nurs Care Qual. 2004 Jul-Sep;19(3):234-41.
5. Anania v. Daubenspeck Chiropractic, 718 N.E. 2d 480 (Ohio 1998).
6. Doe v. Borromeo, Nos. 305162, 305163 (Mich. Ct. App. Sept. 20, 2012).
7. Available at https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
8. Burlington Industries, Inc. v. Ellerth, 524 US 742 (1998).
9. Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
10. Federation of State Medical Boards, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”
11. J Healthc Risk Manag. 1999 Summer;19(3):14-25.
Question: A medical assistant alleged that Dr. Y sexually harassed her by sending anonymous gifts and messages such as, “you’re gorgeous,” and “I love your figure.” It was a repeat of Dr. Y’s previous behavior pattern directed at a different worker, who had lodged a complaint with the human resources department. The medical assistant now files a sexual harassment action under Title VII of the federal Civil Rights Act of 1964 against the health care institution, alleging a hostile work environment.
Which of the following is false?
A. Sexual harassment is a form of sexual misconduct regulated by state medical boards.
B. Mere words, without physical action, may suffice to be deemed sexual harassment.
C. A hostile environment arises when offensive conduct is so severe and pervasive as to amount to job discrimination.
D. Sexual harassment is a civil rights violation unique to the workplace.
E. Liability may attach to the supervisor, institution, or the harasser.
Answer: D. This hypothetical is modified from an actual Connecticut case that was recently decided in favor of the plaintiff.1 In that case, which involved a dentist, the federal Second Circuit unanimously rejected the University of Connecticut Health Center’s appeal against a jury’s verdict holding it responsible for its employee’s sexual harassment of a coworker, who was awarded $125,000. It ruled that the health center should have known of its employee’s harassing behavior.
Sexual harassment, a current hot topic, is pervasive, affecting a diversity of individuals in the fields of media, sports, politics, judiciary, education, entertainment, and others. The medical profession is no exception, and studies indicate that sexual harassment affects patients and physicians alike, occurring in hospitals, private offices, and academic centers.
In a large questionnaire study involving 4,501 female physicians, the authors found a prevalence rate of 47.7%. Harassment was more common while in medical school or during internship, residency, or fellowship than in practice.2 Patients may be the harassers. In 599 of the 1,064 licensed female family physicians in Ontario, more than 75% reported sexual harassment by patients at some time during their careers, either in their own offices by their own patients, or in settings such as emergency departments and clinics, where unknown patients presented an even higher risk.3
When physicians sexually harass fellow workers such as nurses, they distract their victims from providing attentive and competent care. In a review of the subject, researchers cited a study of 188 critical care nurses in hospitals, where nearly half (46%) reported experiencing sexual harassment that included “offensive sexual remarks, unwanted physical contact, unwanted nonverbal attention, requests for unwanted dates, sexual propositions, and physical assault.”4 To this list must now be added misconduct via the use of social media. In the study, physicians (82%), coworkers (20%), and immediate supervisors (7%) accounted for most of the incidents.
Neglecting to look seriously into complaints or to monitor and remedy the situation may create a hostile environment and trigger liability.
An example is the recent well-publicized case of Olympics team physician Dr. Larry Nassar, who was also a faculty member at Michigan State University. Olympic gold medalist McKayla Maroney named both the university and the U.S. Olympic Committee as codefendants in a lawsuit alleging that the institutions failed to properly investigate the team doctor’s criminal sexual conduct.
In Anania v. Daubenspeck Chiropractic, two employees of a chiropractor alleged that his patients sexually harassed them, but he did not remedy the situation.5 The trial court initially dismissed their lawsuit, holding that Ohio law did not recognize a cause of action for sexual harassment by a nonemployee patient, and that liability for sexual harassment can only exist in the context of respondeat superior (employer-employee) liability.
However, the court of appeals held that so long as the chiropractor knew or should have known of the harassment, and failed to take corrective action, he could be liable for allowing a hostile environment to exist.
Negligent supervision is another favorite plaintiff’s cause of action. In Doe v. Borromeo, a patient sought to hold the hospital liable for sexual assault by a physician during a medical exam.6 The lower state court had summarily dismissed the case, which was based on vicarious liability, but the state court of appeals reversed, finding the patient’s complaint against the hospital included a negligent supervision claim.
The appeals court reasoned that this was distinguishable from one based upon vicarious liability, so long as the supervising entity had a duty to protect the victim – and such a duty can only be established if the supervising entity knew or should have known of the existence of the harasser’s propensities, if any, to commit criminal and tortious acts.
Sexual harassment is a form of sex discrimination under Title VII of the Civil Rights Act of 1964, which is enforced by the Equal Employment Opportunity Commission. The commission’s website explains the law in clear and simple language:
“It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include ‘sexual harassment’ or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex.
“For example, it is illegal to harass a woman by making offensive comments about women in general. Both victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex.
“Although the law doesn’t prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim’s supervisor, a supervisor in another area, a coworker, or someone who is not an employee of the employer, such as a client or customer.”7
For sexual harassment to occur, the aggrieved party must either show a “hostile environment” or “quid pro quo” situation.
In a hostile environment case, the harassment is serious and persistent, creating unacceptable and offensive work conditions. The plaintiff has to show that the employer knew or should have known of the situation but failed to remedy it.
The “quid pro quo” type of case requires a showing that a person in authority conditioned some aspect of the employee’s employment, such as promotion or retention, upon a sexual favor or relationship.
The U.S. Supreme Court has both clarified and muddied the law’s position on these two previously distinct types of sexual harassment.
In the landmark case of Burlington Industries v. Ellerth, the plaintiff, who was a salesperson, alleged that a supervisor made advances to her and threatened to deny her certain job benefits if she did not cooperate.8 The threats were never carried out, and she was in fact promoted; but her lawsuit alleged that the harassment caused her resignation and amounted to a “constructive” discharge.
Likewise, in Faragher v. City of Boca Raton, the plaintiff, employed as a lifeguard, alleged that her work environment was riddled with crude remarks and obscenities.9 One of the two supervisors reportedly once said to Faragher, “Date me or clean toilets for a year.” Another lifeguard had previously lodged similar complaints. The plaintiff ultimately resigned and brought suit.
The U.S. Supreme Court characterized both of these as “hostile environment” rather than “quid pro quo” cases, because the plaintiffs did not suffer any direct adverse job action. In its decisions, the court defined the scope of liability and affirmative defenses, holding that employers can be subject to vicarious liability when supervisors create actionable hostile work environments.
In other cases, the Supreme Court has ruled for the use of “the reasonable person in the plaintiff’s position” standard in judging the severity of sexual harassment. The court has also held that the genders of the harasser and the harassed employee are not material in determining whether sexual harassment has occurred.
A physician can be accused of harassing an employee, a nurse, an assistant, a fellow worker, a third party, or a patient. Focusing on misconduct within the doctor-patient relationship, the Federation of State Medical Boards adopted in May 2006 a policy entitled “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”10
Although it did not use the term sexual harassment, the policy emphasized that physician sexual misconduct may include behavior that is verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual. It used the term “sexual impropriety” to denote behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. Together with “sexual violation,” a term the FSMB used when referring to physical sexual contact, they form the basis for disciplinary action by a state medical board.
Caveat: When performing a physical exam, physicians should always use good judgment and sensitivity, relying on the presence of a medical assistant to ensure patient comfort and to alleviate possible embarrassment or anxiety.
Under the federal EEOC rules, the employer rather than the harasser is the defendant. But there are other legal recourses, including tort and criminal actions, that directly target the harasser. Successful plaintiffs may be awarded lost wages, as well as damages for emotional distress, medical expenses, and punitive damages. They may also recover attorney fees.
In one case, a psychiatric nurse was awarded $1.2 million (later reduced to $850,000); in another, a nurse successfully sued a physician’s medical practice and received $150,000 in damages.4 And in an unusual case, a plaintiff was awarded only $1 in damages, but her counsel was paid $41,598 in fees.11 For the practicing doctor, medical board sanction, notoriety, and loss of professional standing and privileges constitute additional costs.
The medical profession is as susceptible as any other – perhaps more so – to allegations of sexual harassment. The magic words for actionable sexual harassment are severe, pervasive, and unwelcome. Although laws in the workplace generally do not prohibit simple teasing, offhand comments, or minor isolated incidents, the line separating these behaviors from bona fide sexual harassment is thin.
Erring on the side of strict and sober professional propriety seems prudent, given the current climate of zero tolerance.
References
1. MacCluskey v. University of Connecticut Health Center, United States Court of Appeals, Second Circuit, No. 17-0807-cv, Dec. 19, 2017.
2. Arch Intern Med. 1998 Feb 23;158(4):352-8.
3. N Engl J Med. 1993 Dec 23;329(26):1936-9.
4. J Nurs Care Qual. 2004 Jul-Sep;19(3):234-41.
5. Anania v. Daubenspeck Chiropractic, 718 N.E. 2d 480 (Ohio 1998).
6. Doe v. Borromeo, Nos. 305162, 305163 (Mich. Ct. App. Sept. 20, 2012).
7. Available at https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
8. Burlington Industries, Inc. v. Ellerth, 524 US 742 (1998).
9. Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
10. Federation of State Medical Boards, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”
11. J Healthc Risk Manag. 1999 Summer;19(3):14-25.
Question: A medical assistant alleged that Dr. Y sexually harassed her by sending anonymous gifts and messages such as, “you’re gorgeous,” and “I love your figure.” It was a repeat of Dr. Y’s previous behavior pattern directed at a different worker, who had lodged a complaint with the human resources department. The medical assistant now files a sexual harassment action under Title VII of the federal Civil Rights Act of 1964 against the health care institution, alleging a hostile work environment.
Which of the following is false?
A. Sexual harassment is a form of sexual misconduct regulated by state medical boards.
B. Mere words, without physical action, may suffice to be deemed sexual harassment.
C. A hostile environment arises when offensive conduct is so severe and pervasive as to amount to job discrimination.
D. Sexual harassment is a civil rights violation unique to the workplace.
E. Liability may attach to the supervisor, institution, or the harasser.
Answer: D. This hypothetical is modified from an actual Connecticut case that was recently decided in favor of the plaintiff.1 In that case, which involved a dentist, the federal Second Circuit unanimously rejected the University of Connecticut Health Center’s appeal against a jury’s verdict holding it responsible for its employee’s sexual harassment of a coworker, who was awarded $125,000. It ruled that the health center should have known of its employee’s harassing behavior.
Sexual harassment, a current hot topic, is pervasive, affecting a diversity of individuals in the fields of media, sports, politics, judiciary, education, entertainment, and others. The medical profession is no exception, and studies indicate that sexual harassment affects patients and physicians alike, occurring in hospitals, private offices, and academic centers.
In a large questionnaire study involving 4,501 female physicians, the authors found a prevalence rate of 47.7%. Harassment was more common while in medical school or during internship, residency, or fellowship than in practice.2 Patients may be the harassers. In 599 of the 1,064 licensed female family physicians in Ontario, more than 75% reported sexual harassment by patients at some time during their careers, either in their own offices by their own patients, or in settings such as emergency departments and clinics, where unknown patients presented an even higher risk.3
When physicians sexually harass fellow workers such as nurses, they distract their victims from providing attentive and competent care. In a review of the subject, researchers cited a study of 188 critical care nurses in hospitals, where nearly half (46%) reported experiencing sexual harassment that included “offensive sexual remarks, unwanted physical contact, unwanted nonverbal attention, requests for unwanted dates, sexual propositions, and physical assault.”4 To this list must now be added misconduct via the use of social media. In the study, physicians (82%), coworkers (20%), and immediate supervisors (7%) accounted for most of the incidents.
Neglecting to look seriously into complaints or to monitor and remedy the situation may create a hostile environment and trigger liability.
An example is the recent well-publicized case of Olympics team physician Dr. Larry Nassar, who was also a faculty member at Michigan State University. Olympic gold medalist McKayla Maroney named both the university and the U.S. Olympic Committee as codefendants in a lawsuit alleging that the institutions failed to properly investigate the team doctor’s criminal sexual conduct.
In Anania v. Daubenspeck Chiropractic, two employees of a chiropractor alleged that his patients sexually harassed them, but he did not remedy the situation.5 The trial court initially dismissed their lawsuit, holding that Ohio law did not recognize a cause of action for sexual harassment by a nonemployee patient, and that liability for sexual harassment can only exist in the context of respondeat superior (employer-employee) liability.
However, the court of appeals held that so long as the chiropractor knew or should have known of the harassment, and failed to take corrective action, he could be liable for allowing a hostile environment to exist.
Negligent supervision is another favorite plaintiff’s cause of action. In Doe v. Borromeo, a patient sought to hold the hospital liable for sexual assault by a physician during a medical exam.6 The lower state court had summarily dismissed the case, which was based on vicarious liability, but the state court of appeals reversed, finding the patient’s complaint against the hospital included a negligent supervision claim.
The appeals court reasoned that this was distinguishable from one based upon vicarious liability, so long as the supervising entity had a duty to protect the victim – and such a duty can only be established if the supervising entity knew or should have known of the existence of the harasser’s propensities, if any, to commit criminal and tortious acts.
Sexual harassment is a form of sex discrimination under Title VII of the Civil Rights Act of 1964, which is enforced by the Equal Employment Opportunity Commission. The commission’s website explains the law in clear and simple language:
“It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include ‘sexual harassment’ or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex.
“For example, it is illegal to harass a woman by making offensive comments about women in general. Both victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex.
“Although the law doesn’t prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim’s supervisor, a supervisor in another area, a coworker, or someone who is not an employee of the employer, such as a client or customer.”7
For sexual harassment to occur, the aggrieved party must either show a “hostile environment” or “quid pro quo” situation.
In a hostile environment case, the harassment is serious and persistent, creating unacceptable and offensive work conditions. The plaintiff has to show that the employer knew or should have known of the situation but failed to remedy it.
The “quid pro quo” type of case requires a showing that a person in authority conditioned some aspect of the employee’s employment, such as promotion or retention, upon a sexual favor or relationship.
The U.S. Supreme Court has both clarified and muddied the law’s position on these two previously distinct types of sexual harassment.
In the landmark case of Burlington Industries v. Ellerth, the plaintiff, who was a salesperson, alleged that a supervisor made advances to her and threatened to deny her certain job benefits if she did not cooperate.8 The threats were never carried out, and she was in fact promoted; but her lawsuit alleged that the harassment caused her resignation and amounted to a “constructive” discharge.
Likewise, in Faragher v. City of Boca Raton, the plaintiff, employed as a lifeguard, alleged that her work environment was riddled with crude remarks and obscenities.9 One of the two supervisors reportedly once said to Faragher, “Date me or clean toilets for a year.” Another lifeguard had previously lodged similar complaints. The plaintiff ultimately resigned and brought suit.
The U.S. Supreme Court characterized both of these as “hostile environment” rather than “quid pro quo” cases, because the plaintiffs did not suffer any direct adverse job action. In its decisions, the court defined the scope of liability and affirmative defenses, holding that employers can be subject to vicarious liability when supervisors create actionable hostile work environments.
In other cases, the Supreme Court has ruled for the use of “the reasonable person in the plaintiff’s position” standard in judging the severity of sexual harassment. The court has also held that the genders of the harasser and the harassed employee are not material in determining whether sexual harassment has occurred.
A physician can be accused of harassing an employee, a nurse, an assistant, a fellow worker, a third party, or a patient. Focusing on misconduct within the doctor-patient relationship, the Federation of State Medical Boards adopted in May 2006 a policy entitled “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”10
Although it did not use the term sexual harassment, the policy emphasized that physician sexual misconduct may include behavior that is verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual. It used the term “sexual impropriety” to denote behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. Together with “sexual violation,” a term the FSMB used when referring to physical sexual contact, they form the basis for disciplinary action by a state medical board.
Caveat: When performing a physical exam, physicians should always use good judgment and sensitivity, relying on the presence of a medical assistant to ensure patient comfort and to alleviate possible embarrassment or anxiety.
Under the federal EEOC rules, the employer rather than the harasser is the defendant. But there are other legal recourses, including tort and criminal actions, that directly target the harasser. Successful plaintiffs may be awarded lost wages, as well as damages for emotional distress, medical expenses, and punitive damages. They may also recover attorney fees.
In one case, a psychiatric nurse was awarded $1.2 million (later reduced to $850,000); in another, a nurse successfully sued a physician’s medical practice and received $150,000 in damages.4 And in an unusual case, a plaintiff was awarded only $1 in damages, but her counsel was paid $41,598 in fees.11 For the practicing doctor, medical board sanction, notoriety, and loss of professional standing and privileges constitute additional costs.
The medical profession is as susceptible as any other – perhaps more so – to allegations of sexual harassment. The magic words for actionable sexual harassment are severe, pervasive, and unwelcome. Although laws in the workplace generally do not prohibit simple teasing, offhand comments, or minor isolated incidents, the line separating these behaviors from bona fide sexual harassment is thin.
Erring on the side of strict and sober professional propriety seems prudent, given the current climate of zero tolerance.
References
1. MacCluskey v. University of Connecticut Health Center, United States Court of Appeals, Second Circuit, No. 17-0807-cv, Dec. 19, 2017.
2. Arch Intern Med. 1998 Feb 23;158(4):352-8.
3. N Engl J Med. 1993 Dec 23;329(26):1936-9.
4. J Nurs Care Qual. 2004 Jul-Sep;19(3):234-41.
5. Anania v. Daubenspeck Chiropractic, 718 N.E. 2d 480 (Ohio 1998).
6. Doe v. Borromeo, Nos. 305162, 305163 (Mich. Ct. App. Sept. 20, 2012).
7. Available at https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
8. Burlington Industries, Inc. v. Ellerth, 524 US 742 (1998).
9. Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
10. Federation of State Medical Boards, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”
11. J Healthc Risk Manag. 1999 Summer;19(3):14-25.
The Right, and Now the Wrong of 2017
In my December 2017 editorial, I presented a values-based roundup of the year. That column explained the criteria for the selections of the most right and most wrong in 2017 in terms of 3 ethical theories: utilitarianism, deontology, and virtue ethics. December featured the good in federal practice. This month, the editorial turns to the bad in federal practice.
Sadly, there were far more candidates for the ethical worst of 2017 in the DoD, VA, and PHS than those of us dedicated to federal service would wish to see. Unfortunately, this reflects both the current state of our society and the nature of the human condition.
On Sunday morning, November 5, 2017, near my hometown of San Antonio, Texas, a gunman in military gear and firearms murdered 26 people who were worshipping at a rural Baptist church. The context of this horrific offense simultaneously mocked the fidelity of our armed forces and a religious faith that in many forms has been a foundation of our nation. Leading forensic mental health experts advise against using the name of mass murderers to avoid perversely glorifying them, and I will adopt that wise convention here.1
Soon after the massacre, news organizations reported that the perpetrator had served in the Air Force, stationed in my adopted home of New Mexico. The shooter had been given a bad conduct discharge after a court-martial in 2012 found him guilty of brutally assaulting his then current wife and their child.2 More than 1 military law expert has opined that perhaps the discharge should have been dishonorable, given the brutality of the conduct, although whether that verdict would have made it more likely, the crime was reported is not certain.
The day following the mass shooting, the Air Force euphemistically acknowledged that it had made an “error,” “mistake,” in not reporting the attacker’s violent history to the federal database, which tracks such offenders to prevent them from lawfully purchasing a weapon. These words and others, such as blunder and failure, used in the media do an injustice to the worshippers’ lives lost that ill-fated morning.3
I must stop here and emphasize as strongly as possible that the selection of this attack is in no way meant to demonize the Air Force as an agency or any individual serving in it. In fact, further investigation suggested that all branches of the armed forces did not fulfill their reporting obligations under the law. Nor am I making the unprovable claim, as some politicians have hinted, that if the Air Force had followed its procedure and policy, the shooter would never have taken 26 innocent lives. Although I note that this is exactly the assumption driving a number of lawsuits brought by the victims’ families against the Air Force for its failure to follow its rules.
Rather, I chose this terrible incident because of its universality and generalizability as a paradigm of what philosopher Hannah Arendt called the banality of evil. As she wrote in her book Eichmann in Jerusalem, “There is a strange interdependence between thoughtlessness and evil.”4 Although the law must deem the attack a capital crime, ethics should see it as a the ripple effect of hundreds of small moral failures of dozens of individuals and the system that neither inspired nor held them accountable for taking routine tasks as morally serious. An Office of Special Investigations officer told CNN, “The system as it is now is personality dependent, which is obviously irresponsible and broken,” noting that accurate recording of case details depends on the discretion of individual case workers.5
Those federal workers are no better or worse than any of us. This bloody tragedy that might be dismissed as an administrative oversight powerfully demonstrates that even the smallest task matters greatly. It is the systemic, long-standing, repeated nature of the DoD’s improper reporting of servicemen and women that makes this action ethically problematic and warrants my selection as the worst event of 2018.
Major newspapers on November 7 carried a report from the Associated Press with a damning headline, “Pentagon has known of crime reporting lapses for 20 years.”6 National Public Radio reported that several Inspector General investigations had documented that over this period the DoD was not regularly reporting violent offenses to the National Criminal Information Center database as mandated. A Fordham law professor and gun regulation specialist quoted on the program zeroed in on an absence of accountability as the leadership flaw that permitted rank and file staff to ignore their protocols. “It’s a ‘who’s watching the watchers’ kind of issue,” he said. “There is no oversight over the Air Force or over the FBI that demands that these regulatory obligations are actually followed through with.”7
Finally, after the tragedy, it was discovered that the Air Force had not just 1 but 2 chances to prevent the gunman from future firearm purchases. The shooter had escaped from a psychiatric facility—his status in the psychiatric hospital was unclear—but it is known that he was admitted after he had smuggled weapons onto the base and threatened to kill his commanders. His hospitalization should have been reported to the national database, which would have raised a red flag when he tried to buy guns.8
Each of the hundreds of prosaic decisions that indirectly contributed to the Texas shooting was borne of a juggernaut of small compromises from procrustean bureaucratic leadership at the top to mindless conformity at the bottom: a breach all 3 ethical theories. Even if 1 unfiled report leads to no untoward outcome, it is clear that for utilitarianism, it is safer and sounder public policy to take lawful steps to prevent individuals with violent pasts and the potential to kill others from purchasing firearms. Deontologically, whether by omission or commission, not reporting such individuals violates the duty of veracity, as it withholds the truth from those who have a right to possess it. Finally, for this horror to be possible, many people had to not act with integrity, accountability, and trustworthiness.
Many may criticize my a choice to begin the new year so inauspiciously drawing attention to ethical failures and such a malicious crime. I would counter this criticism with the contention that a sober analysis of serious moral lapses in terms of the ethical theory introduced last month is a most salutatory welcome to 2018. So as we embark upon a new year in federal practice, let us strive not only for clinical expertise and administrative efficiency, but also for moral excellence.
1. Pies RW. After Las Vegas, the danger of copy-cat murders. Psychiatric Times. November 14, 2017. http://www.psychiatrictimes.com/blogs/couch-crisis/after-las-vegas-danger -copy-cat-killers. Accessed December 16, 2017.
2. Horton A. The Air Force says it failed to follow procedures, allowing Texas church shooter to obtain firearms. The Washington Post. November 7, 2017. https://www.washingtonpost .com/news/checkpoint/wp/2017/11/06/the-air-force-says-it -failed-to-follow-procedures-allowing-texas-church-shooter -to-obtain-firearms/. Accessed December 17, 2017.
3. Montgomery D, Mele C, Fernandez M. Gunman kills at least 26 in attack on rural Texas church. The New York Times. November 5, 2017. https://www.nytimes.com/2017/11/05/us/church-shooting-texas.html Accessed December 16, 2017.
4. Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. London: Penguin;1977.
5. Cohen Z, Devine C. Failure to report Texas gunman’s record reflects systemic problem, sources say.” CNN Politics. November 10, 2017. http://www.cnn.com/2017/11/10/politics/us-military-crime-database-flaws-texas-church-shooting/index.html Accessed December 17, 20
6. Burns R. Pentagon has known of crime reporting lapses for 20 years. Chicago Tribune/Associated Press. November 7, 2017. http://www.chicagotribune.com/news/nationworld/ct -texas-church-shooter-air-force-mattis-20171107-story.html. Accessed December 17, 2017.
7. Domonoske C. Oversight groups have repeatedly identified flaws in military crime reporting. NPR. November 19, 2017. https://www.npr.org/sections/thetwo-way/2017/11/19/564792784/oversight-groups-have-repeatedly-identified-flaws-in-military-crime-reporting. Accessed December 16, 2017
8. Romero S, Blinder A, Pérez-Pena R. Texas gunman once escaped from mental health facility. The New York Times. November 7, 2017. https://www.nytimes.com/2017/11/07/us /texas-shooting-church.html. Accessed December 17, 2017.
In my December 2017 editorial, I presented a values-based roundup of the year. That column explained the criteria for the selections of the most right and most wrong in 2017 in terms of 3 ethical theories: utilitarianism, deontology, and virtue ethics. December featured the good in federal practice. This month, the editorial turns to the bad in federal practice.
Sadly, there were far more candidates for the ethical worst of 2017 in the DoD, VA, and PHS than those of us dedicated to federal service would wish to see. Unfortunately, this reflects both the current state of our society and the nature of the human condition.
On Sunday morning, November 5, 2017, near my hometown of San Antonio, Texas, a gunman in military gear and firearms murdered 26 people who were worshipping at a rural Baptist church. The context of this horrific offense simultaneously mocked the fidelity of our armed forces and a religious faith that in many forms has been a foundation of our nation. Leading forensic mental health experts advise against using the name of mass murderers to avoid perversely glorifying them, and I will adopt that wise convention here.1
Soon after the massacre, news organizations reported that the perpetrator had served in the Air Force, stationed in my adopted home of New Mexico. The shooter had been given a bad conduct discharge after a court-martial in 2012 found him guilty of brutally assaulting his then current wife and their child.2 More than 1 military law expert has opined that perhaps the discharge should have been dishonorable, given the brutality of the conduct, although whether that verdict would have made it more likely, the crime was reported is not certain.
The day following the mass shooting, the Air Force euphemistically acknowledged that it had made an “error,” “mistake,” in not reporting the attacker’s violent history to the federal database, which tracks such offenders to prevent them from lawfully purchasing a weapon. These words and others, such as blunder and failure, used in the media do an injustice to the worshippers’ lives lost that ill-fated morning.3
I must stop here and emphasize as strongly as possible that the selection of this attack is in no way meant to demonize the Air Force as an agency or any individual serving in it. In fact, further investigation suggested that all branches of the armed forces did not fulfill their reporting obligations under the law. Nor am I making the unprovable claim, as some politicians have hinted, that if the Air Force had followed its procedure and policy, the shooter would never have taken 26 innocent lives. Although I note that this is exactly the assumption driving a number of lawsuits brought by the victims’ families against the Air Force for its failure to follow its rules.
Rather, I chose this terrible incident because of its universality and generalizability as a paradigm of what philosopher Hannah Arendt called the banality of evil. As she wrote in her book Eichmann in Jerusalem, “There is a strange interdependence between thoughtlessness and evil.”4 Although the law must deem the attack a capital crime, ethics should see it as a the ripple effect of hundreds of small moral failures of dozens of individuals and the system that neither inspired nor held them accountable for taking routine tasks as morally serious. An Office of Special Investigations officer told CNN, “The system as it is now is personality dependent, which is obviously irresponsible and broken,” noting that accurate recording of case details depends on the discretion of individual case workers.5
Those federal workers are no better or worse than any of us. This bloody tragedy that might be dismissed as an administrative oversight powerfully demonstrates that even the smallest task matters greatly. It is the systemic, long-standing, repeated nature of the DoD’s improper reporting of servicemen and women that makes this action ethically problematic and warrants my selection as the worst event of 2018.
Major newspapers on November 7 carried a report from the Associated Press with a damning headline, “Pentagon has known of crime reporting lapses for 20 years.”6 National Public Radio reported that several Inspector General investigations had documented that over this period the DoD was not regularly reporting violent offenses to the National Criminal Information Center database as mandated. A Fordham law professor and gun regulation specialist quoted on the program zeroed in on an absence of accountability as the leadership flaw that permitted rank and file staff to ignore their protocols. “It’s a ‘who’s watching the watchers’ kind of issue,” he said. “There is no oversight over the Air Force or over the FBI that demands that these regulatory obligations are actually followed through with.”7
Finally, after the tragedy, it was discovered that the Air Force had not just 1 but 2 chances to prevent the gunman from future firearm purchases. The shooter had escaped from a psychiatric facility—his status in the psychiatric hospital was unclear—but it is known that he was admitted after he had smuggled weapons onto the base and threatened to kill his commanders. His hospitalization should have been reported to the national database, which would have raised a red flag when he tried to buy guns.8
Each of the hundreds of prosaic decisions that indirectly contributed to the Texas shooting was borne of a juggernaut of small compromises from procrustean bureaucratic leadership at the top to mindless conformity at the bottom: a breach all 3 ethical theories. Even if 1 unfiled report leads to no untoward outcome, it is clear that for utilitarianism, it is safer and sounder public policy to take lawful steps to prevent individuals with violent pasts and the potential to kill others from purchasing firearms. Deontologically, whether by omission or commission, not reporting such individuals violates the duty of veracity, as it withholds the truth from those who have a right to possess it. Finally, for this horror to be possible, many people had to not act with integrity, accountability, and trustworthiness.
Many may criticize my a choice to begin the new year so inauspiciously drawing attention to ethical failures and such a malicious crime. I would counter this criticism with the contention that a sober analysis of serious moral lapses in terms of the ethical theory introduced last month is a most salutatory welcome to 2018. So as we embark upon a new year in federal practice, let us strive not only for clinical expertise and administrative efficiency, but also for moral excellence.
In my December 2017 editorial, I presented a values-based roundup of the year. That column explained the criteria for the selections of the most right and most wrong in 2017 in terms of 3 ethical theories: utilitarianism, deontology, and virtue ethics. December featured the good in federal practice. This month, the editorial turns to the bad in federal practice.
Sadly, there were far more candidates for the ethical worst of 2017 in the DoD, VA, and PHS than those of us dedicated to federal service would wish to see. Unfortunately, this reflects both the current state of our society and the nature of the human condition.
On Sunday morning, November 5, 2017, near my hometown of San Antonio, Texas, a gunman in military gear and firearms murdered 26 people who were worshipping at a rural Baptist church. The context of this horrific offense simultaneously mocked the fidelity of our armed forces and a religious faith that in many forms has been a foundation of our nation. Leading forensic mental health experts advise against using the name of mass murderers to avoid perversely glorifying them, and I will adopt that wise convention here.1
Soon after the massacre, news organizations reported that the perpetrator had served in the Air Force, stationed in my adopted home of New Mexico. The shooter had been given a bad conduct discharge after a court-martial in 2012 found him guilty of brutally assaulting his then current wife and their child.2 More than 1 military law expert has opined that perhaps the discharge should have been dishonorable, given the brutality of the conduct, although whether that verdict would have made it more likely, the crime was reported is not certain.
The day following the mass shooting, the Air Force euphemistically acknowledged that it had made an “error,” “mistake,” in not reporting the attacker’s violent history to the federal database, which tracks such offenders to prevent them from lawfully purchasing a weapon. These words and others, such as blunder and failure, used in the media do an injustice to the worshippers’ lives lost that ill-fated morning.3
I must stop here and emphasize as strongly as possible that the selection of this attack is in no way meant to demonize the Air Force as an agency or any individual serving in it. In fact, further investigation suggested that all branches of the armed forces did not fulfill their reporting obligations under the law. Nor am I making the unprovable claim, as some politicians have hinted, that if the Air Force had followed its procedure and policy, the shooter would never have taken 26 innocent lives. Although I note that this is exactly the assumption driving a number of lawsuits brought by the victims’ families against the Air Force for its failure to follow its rules.
Rather, I chose this terrible incident because of its universality and generalizability as a paradigm of what philosopher Hannah Arendt called the banality of evil. As she wrote in her book Eichmann in Jerusalem, “There is a strange interdependence between thoughtlessness and evil.”4 Although the law must deem the attack a capital crime, ethics should see it as a the ripple effect of hundreds of small moral failures of dozens of individuals and the system that neither inspired nor held them accountable for taking routine tasks as morally serious. An Office of Special Investigations officer told CNN, “The system as it is now is personality dependent, which is obviously irresponsible and broken,” noting that accurate recording of case details depends on the discretion of individual case workers.5
Those federal workers are no better or worse than any of us. This bloody tragedy that might be dismissed as an administrative oversight powerfully demonstrates that even the smallest task matters greatly. It is the systemic, long-standing, repeated nature of the DoD’s improper reporting of servicemen and women that makes this action ethically problematic and warrants my selection as the worst event of 2018.
Major newspapers on November 7 carried a report from the Associated Press with a damning headline, “Pentagon has known of crime reporting lapses for 20 years.”6 National Public Radio reported that several Inspector General investigations had documented that over this period the DoD was not regularly reporting violent offenses to the National Criminal Information Center database as mandated. A Fordham law professor and gun regulation specialist quoted on the program zeroed in on an absence of accountability as the leadership flaw that permitted rank and file staff to ignore their protocols. “It’s a ‘who’s watching the watchers’ kind of issue,” he said. “There is no oversight over the Air Force or over the FBI that demands that these regulatory obligations are actually followed through with.”7
Finally, after the tragedy, it was discovered that the Air Force had not just 1 but 2 chances to prevent the gunman from future firearm purchases. The shooter had escaped from a psychiatric facility—his status in the psychiatric hospital was unclear—but it is known that he was admitted after he had smuggled weapons onto the base and threatened to kill his commanders. His hospitalization should have been reported to the national database, which would have raised a red flag when he tried to buy guns.8
Each of the hundreds of prosaic decisions that indirectly contributed to the Texas shooting was borne of a juggernaut of small compromises from procrustean bureaucratic leadership at the top to mindless conformity at the bottom: a breach all 3 ethical theories. Even if 1 unfiled report leads to no untoward outcome, it is clear that for utilitarianism, it is safer and sounder public policy to take lawful steps to prevent individuals with violent pasts and the potential to kill others from purchasing firearms. Deontologically, whether by omission or commission, not reporting such individuals violates the duty of veracity, as it withholds the truth from those who have a right to possess it. Finally, for this horror to be possible, many people had to not act with integrity, accountability, and trustworthiness.
Many may criticize my a choice to begin the new year so inauspiciously drawing attention to ethical failures and such a malicious crime. I would counter this criticism with the contention that a sober analysis of serious moral lapses in terms of the ethical theory introduced last month is a most salutatory welcome to 2018. So as we embark upon a new year in federal practice, let us strive not only for clinical expertise and administrative efficiency, but also for moral excellence.
1. Pies RW. After Las Vegas, the danger of copy-cat murders. Psychiatric Times. November 14, 2017. http://www.psychiatrictimes.com/blogs/couch-crisis/after-las-vegas-danger -copy-cat-killers. Accessed December 16, 2017.
2. Horton A. The Air Force says it failed to follow procedures, allowing Texas church shooter to obtain firearms. The Washington Post. November 7, 2017. https://www.washingtonpost .com/news/checkpoint/wp/2017/11/06/the-air-force-says-it -failed-to-follow-procedures-allowing-texas-church-shooter -to-obtain-firearms/. Accessed December 17, 2017.
3. Montgomery D, Mele C, Fernandez M. Gunman kills at least 26 in attack on rural Texas church. The New York Times. November 5, 2017. https://www.nytimes.com/2017/11/05/us/church-shooting-texas.html Accessed December 16, 2017.
4. Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. London: Penguin;1977.
5. Cohen Z, Devine C. Failure to report Texas gunman’s record reflects systemic problem, sources say.” CNN Politics. November 10, 2017. http://www.cnn.com/2017/11/10/politics/us-military-crime-database-flaws-texas-church-shooting/index.html Accessed December 17, 20
6. Burns R. Pentagon has known of crime reporting lapses for 20 years. Chicago Tribune/Associated Press. November 7, 2017. http://www.chicagotribune.com/news/nationworld/ct -texas-church-shooter-air-force-mattis-20171107-story.html. Accessed December 17, 2017.
7. Domonoske C. Oversight groups have repeatedly identified flaws in military crime reporting. NPR. November 19, 2017. https://www.npr.org/sections/thetwo-way/2017/11/19/564792784/oversight-groups-have-repeatedly-identified-flaws-in-military-crime-reporting. Accessed December 16, 2017
8. Romero S, Blinder A, Pérez-Pena R. Texas gunman once escaped from mental health facility. The New York Times. November 7, 2017. https://www.nytimes.com/2017/11/07/us /texas-shooting-church.html. Accessed December 17, 2017.
1. Pies RW. After Las Vegas, the danger of copy-cat murders. Psychiatric Times. November 14, 2017. http://www.psychiatrictimes.com/blogs/couch-crisis/after-las-vegas-danger -copy-cat-killers. Accessed December 16, 2017.
2. Horton A. The Air Force says it failed to follow procedures, allowing Texas church shooter to obtain firearms. The Washington Post. November 7, 2017. https://www.washingtonpost .com/news/checkpoint/wp/2017/11/06/the-air-force-says-it -failed-to-follow-procedures-allowing-texas-church-shooter -to-obtain-firearms/. Accessed December 17, 2017.
3. Montgomery D, Mele C, Fernandez M. Gunman kills at least 26 in attack on rural Texas church. The New York Times. November 5, 2017. https://www.nytimes.com/2017/11/05/us/church-shooting-texas.html Accessed December 16, 2017.
4. Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. London: Penguin;1977.
5. Cohen Z, Devine C. Failure to report Texas gunman’s record reflects systemic problem, sources say.” CNN Politics. November 10, 2017. http://www.cnn.com/2017/11/10/politics/us-military-crime-database-flaws-texas-church-shooting/index.html Accessed December 17, 20
6. Burns R. Pentagon has known of crime reporting lapses for 20 years. Chicago Tribune/Associated Press. November 7, 2017. http://www.chicagotribune.com/news/nationworld/ct -texas-church-shooter-air-force-mattis-20171107-story.html. Accessed December 17, 2017.
7. Domonoske C. Oversight groups have repeatedly identified flaws in military crime reporting. NPR. November 19, 2017. https://www.npr.org/sections/thetwo-way/2017/11/19/564792784/oversight-groups-have-repeatedly-identified-flaws-in-military-crime-reporting. Accessed December 16, 2017
8. Romero S, Blinder A, Pérez-Pena R. Texas gunman once escaped from mental health facility. The New York Times. November 7, 2017. https://www.nytimes.com/2017/11/07/us /texas-shooting-church.html. Accessed December 17, 2017.
The Clock Is Ticking
Over the last decade we have come to understand the nature of psoriasis as a systemic inflammatory condition rather than as simply a skin disease. With this concept, we have continued to identify systemic comorbidities associated with psoriasis, including cardiovascular risk, diabetes mellitus, and metabolic syndrome. As dermatologists, we must serve as the gatekeeper for our patients with psoriasis and help to screen for comorbidities as well as provide appropriate counseling and referral.
Of the potential benefits of novel systemic therapies for psoriasis, the potential for addressing comorbid conditions with these treatments is critically important. Therefore, when I discuss psoriasis treatments, I always review and emphasize the anti-inflammatory effects of these agents. Although we know that psoriasis increases the risk for vascular inflammation and major adverse cardiovascular events (MACEs), it has been unclear if psoriasis duration affects these risks.
Egeberg et al1 utilized 2 resources to understand the effect of psoriasis duration on vascular disease and cardiovascular events: a human imaging study and a population-based study of cardiovascular disease events. In the first part of the study, patients with psoriasis (N=190) underwent fludeoxyglucose F 18 positron emission tomography/computed tomography. Next, MACE risk was examined using nationwide registries (adjusted hazard ratio in patients with psoriasis [n=87,161] vs the general population [n=4,234,793]). In the imaging study, participants had low cardiovascular risk by traditional risk scores. The authors found that vascular inflammation as demonstrated by the imaging system was significantly associated with disease duration (β=.171; P=.002). In the population-based study, psoriasis duration had a strong relationship with MACE risk (1.0% per additional year of psoriasis duration [hazard ratio, 1.010; 95% confidence interval, 1.007-1.013]). The researchers reported that every standard deviation increase in disease duration increased the target-to-background ratio by 2.5%, which translated into an absolute increase of approximately 10% in future adverse events.1
Therefore, the authors concluded that there were negative effects of psoriasis duration on vascular inflammation and MACEs,1 which suggests that the cumulative duration of low-grade chronic inflammation may accelerate vascular disease development and MACEs. The authors therefore noted that providers should consider inquiring about duration of disease to counsel for heightened cardiovascular disease risk in psoriasis patients.1
We have some evidence that therapeutic intervention may be useful. Wu et al2 compared MACE risk in psoriasis patients receiving methotrexate or tumor necrosis factor α (TNF-α) inhibitors.
The findings of these studies are poignant and help to further emphasize the importance of proper identification and treatment of psoriasis and its comorbidities. This information also adds an element of urgency to the way we look at this disease and demonstrates that we must intervene as soon as possible in this process.
- Egeberg A, Skov L, Joshi AA, et al. The relationship between duration of psoriasis, vascular inflammation, and cardiovascular events [published online August 18, 2017]. J Am Acad Dermatol. 2017;77:650.e3-656.e3.
- Wu JJ, Guerin AD, Sundaram M, et al. Cardiovascular event risk assessment in psoriasis patients treated with tumor necrosis factor-α inhibitors versus methotrexate [published online October 26, 2016]. J Am Acad Dermatol. 2017;76:81-90.
Over the last decade we have come to understand the nature of psoriasis as a systemic inflammatory condition rather than as simply a skin disease. With this concept, we have continued to identify systemic comorbidities associated with psoriasis, including cardiovascular risk, diabetes mellitus, and metabolic syndrome. As dermatologists, we must serve as the gatekeeper for our patients with psoriasis and help to screen for comorbidities as well as provide appropriate counseling and referral.
Of the potential benefits of novel systemic therapies for psoriasis, the potential for addressing comorbid conditions with these treatments is critically important. Therefore, when I discuss psoriasis treatments, I always review and emphasize the anti-inflammatory effects of these agents. Although we know that psoriasis increases the risk for vascular inflammation and major adverse cardiovascular events (MACEs), it has been unclear if psoriasis duration affects these risks.
Egeberg et al1 utilized 2 resources to understand the effect of psoriasis duration on vascular disease and cardiovascular events: a human imaging study and a population-based study of cardiovascular disease events. In the first part of the study, patients with psoriasis (N=190) underwent fludeoxyglucose F 18 positron emission tomography/computed tomography. Next, MACE risk was examined using nationwide registries (adjusted hazard ratio in patients with psoriasis [n=87,161] vs the general population [n=4,234,793]). In the imaging study, participants had low cardiovascular risk by traditional risk scores. The authors found that vascular inflammation as demonstrated by the imaging system was significantly associated with disease duration (β=.171; P=.002). In the population-based study, psoriasis duration had a strong relationship with MACE risk (1.0% per additional year of psoriasis duration [hazard ratio, 1.010; 95% confidence interval, 1.007-1.013]). The researchers reported that every standard deviation increase in disease duration increased the target-to-background ratio by 2.5%, which translated into an absolute increase of approximately 10% in future adverse events.1
Therefore, the authors concluded that there were negative effects of psoriasis duration on vascular inflammation and MACEs,1 which suggests that the cumulative duration of low-grade chronic inflammation may accelerate vascular disease development and MACEs. The authors therefore noted that providers should consider inquiring about duration of disease to counsel for heightened cardiovascular disease risk in psoriasis patients.1
We have some evidence that therapeutic intervention may be useful. Wu et al2 compared MACE risk in psoriasis patients receiving methotrexate or tumor necrosis factor α (TNF-α) inhibitors.
The findings of these studies are poignant and help to further emphasize the importance of proper identification and treatment of psoriasis and its comorbidities. This information also adds an element of urgency to the way we look at this disease and demonstrates that we must intervene as soon as possible in this process.
Over the last decade we have come to understand the nature of psoriasis as a systemic inflammatory condition rather than as simply a skin disease. With this concept, we have continued to identify systemic comorbidities associated with psoriasis, including cardiovascular risk, diabetes mellitus, and metabolic syndrome. As dermatologists, we must serve as the gatekeeper for our patients with psoriasis and help to screen for comorbidities as well as provide appropriate counseling and referral.
Of the potential benefits of novel systemic therapies for psoriasis, the potential for addressing comorbid conditions with these treatments is critically important. Therefore, when I discuss psoriasis treatments, I always review and emphasize the anti-inflammatory effects of these agents. Although we know that psoriasis increases the risk for vascular inflammation and major adverse cardiovascular events (MACEs), it has been unclear if psoriasis duration affects these risks.
Egeberg et al1 utilized 2 resources to understand the effect of psoriasis duration on vascular disease and cardiovascular events: a human imaging study and a population-based study of cardiovascular disease events. In the first part of the study, patients with psoriasis (N=190) underwent fludeoxyglucose F 18 positron emission tomography/computed tomography. Next, MACE risk was examined using nationwide registries (adjusted hazard ratio in patients with psoriasis [n=87,161] vs the general population [n=4,234,793]). In the imaging study, participants had low cardiovascular risk by traditional risk scores. The authors found that vascular inflammation as demonstrated by the imaging system was significantly associated with disease duration (β=.171; P=.002). In the population-based study, psoriasis duration had a strong relationship with MACE risk (1.0% per additional year of psoriasis duration [hazard ratio, 1.010; 95% confidence interval, 1.007-1.013]). The researchers reported that every standard deviation increase in disease duration increased the target-to-background ratio by 2.5%, which translated into an absolute increase of approximately 10% in future adverse events.1
Therefore, the authors concluded that there were negative effects of psoriasis duration on vascular inflammation and MACEs,1 which suggests that the cumulative duration of low-grade chronic inflammation may accelerate vascular disease development and MACEs. The authors therefore noted that providers should consider inquiring about duration of disease to counsel for heightened cardiovascular disease risk in psoriasis patients.1
We have some evidence that therapeutic intervention may be useful. Wu et al2 compared MACE risk in psoriasis patients receiving methotrexate or tumor necrosis factor α (TNF-α) inhibitors.
The findings of these studies are poignant and help to further emphasize the importance of proper identification and treatment of psoriasis and its comorbidities. This information also adds an element of urgency to the way we look at this disease and demonstrates that we must intervene as soon as possible in this process.
- Egeberg A, Skov L, Joshi AA, et al. The relationship between duration of psoriasis, vascular inflammation, and cardiovascular events [published online August 18, 2017]. J Am Acad Dermatol. 2017;77:650.e3-656.e3.
- Wu JJ, Guerin AD, Sundaram M, et al. Cardiovascular event risk assessment in psoriasis patients treated with tumor necrosis factor-α inhibitors versus methotrexate [published online October 26, 2016]. J Am Acad Dermatol. 2017;76:81-90.
- Egeberg A, Skov L, Joshi AA, et al. The relationship between duration of psoriasis, vascular inflammation, and cardiovascular events [published online August 18, 2017]. J Am Acad Dermatol. 2017;77:650.e3-656.e3.
- Wu JJ, Guerin AD, Sundaram M, et al. Cardiovascular event risk assessment in psoriasis patients treated with tumor necrosis factor-α inhibitors versus methotrexate [published online October 26, 2016]. J Am Acad Dermatol. 2017;76:81-90.
Related Content Online
The Role of Biologic Therapy for Psoriasis in Cardiovascular Risk Reduction
The price of protection
It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.
With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.
However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”
Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.
There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.
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].
It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.
With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.
However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”
Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.
There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.
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].
It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.
With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.
However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”
Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.
There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.
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].