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Typhoid isn’t covered??!!
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
When cannabis use becomes another disorder
Despite the justified concern about rising opiate use in the United States, cannabis remains the most commonly used substance in the 12- to 17-year-old population.1 Cannabis use is widespread, particularly in states in which it has been decriminalized or legalized. While use of alcohol and nicotine has fallen among high school students from the years 2010 to 2015, marijuana use has remained relatively constant.2 In addition, the potency of cannabis with regard to tetrahydrocannabinol (THC) content has increased over the years. Despite the common belief among the public that cannabis use is benign, accumulating research is revealing a number of concerning consequences, especially in vulnerable populations and those who use cannabis regularly.
Case summary
Case discussion
Treatment for these adverse effects of cannabis is cessation of the drug. This can be accomplished through hard work with a counselor, who may recommend any of a number of treatments, including contingency management, cognitive behavioral therapy, systematic multidimensional family therapy, and motivational enhancement therapy, among others.5 While common lore is that it is impossible to stop cannabis use, the effect sizes of these treatments is in the moderate to large range. There are viable options to stop cannabis use, especially when it becomes problematic.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].
References
1. “Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings,” Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2013.
2. “Monitoring the Future Survey, 2015,” National Institute on Drug Abuse.
3. Pharmaceuticals (Basel). 2012 Jul;5(7):719-26.
4. Nat Rev Neurosci. 2007 Nov;8(11):885-95.
5. Dtsch Arztebl Int. 2016 Sep;113(39): 653-9.
Despite the justified concern about rising opiate use in the United States, cannabis remains the most commonly used substance in the 12- to 17-year-old population.1 Cannabis use is widespread, particularly in states in which it has been decriminalized or legalized. While use of alcohol and nicotine has fallen among high school students from the years 2010 to 2015, marijuana use has remained relatively constant.2 In addition, the potency of cannabis with regard to tetrahydrocannabinol (THC) content has increased over the years. Despite the common belief among the public that cannabis use is benign, accumulating research is revealing a number of concerning consequences, especially in vulnerable populations and those who use cannabis regularly.
Case summary
Case discussion
Treatment for these adverse effects of cannabis is cessation of the drug. This can be accomplished through hard work with a counselor, who may recommend any of a number of treatments, including contingency management, cognitive behavioral therapy, systematic multidimensional family therapy, and motivational enhancement therapy, among others.5 While common lore is that it is impossible to stop cannabis use, the effect sizes of these treatments is in the moderate to large range. There are viable options to stop cannabis use, especially when it becomes problematic.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].
References
1. “Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings,” Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2013.
2. “Monitoring the Future Survey, 2015,” National Institute on Drug Abuse.
3. Pharmaceuticals (Basel). 2012 Jul;5(7):719-26.
4. Nat Rev Neurosci. 2007 Nov;8(11):885-95.
5. Dtsch Arztebl Int. 2016 Sep;113(39): 653-9.
Despite the justified concern about rising opiate use in the United States, cannabis remains the most commonly used substance in the 12- to 17-year-old population.1 Cannabis use is widespread, particularly in states in which it has been decriminalized or legalized. While use of alcohol and nicotine has fallen among high school students from the years 2010 to 2015, marijuana use has remained relatively constant.2 In addition, the potency of cannabis with regard to tetrahydrocannabinol (THC) content has increased over the years. Despite the common belief among the public that cannabis use is benign, accumulating research is revealing a number of concerning consequences, especially in vulnerable populations and those who use cannabis regularly.
Case summary
Case discussion
Treatment for these adverse effects of cannabis is cessation of the drug. This can be accomplished through hard work with a counselor, who may recommend any of a number of treatments, including contingency management, cognitive behavioral therapy, systematic multidimensional family therapy, and motivational enhancement therapy, among others.5 While common lore is that it is impossible to stop cannabis use, the effect sizes of these treatments is in the moderate to large range. There are viable options to stop cannabis use, especially when it becomes problematic.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].
References
1. “Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings,” Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2013.
2. “Monitoring the Future Survey, 2015,” National Institute on Drug Abuse.
3. Pharmaceuticals (Basel). 2012 Jul;5(7):719-26.
4. Nat Rev Neurosci. 2007 Nov;8(11):885-95.
5. Dtsch Arztebl Int. 2016 Sep;113(39): 653-9.
Sleepless in adolescence
One thing that constantly surprises me about adolescent sleep is that neither the teen nor the parent is as concerned about it as I am. Instead, they complain about irritability, dropping grades, anxiety, depression, obesity, oppositionality, fatigue, and even substance use – all documented effects of sleep debt.
Inadequate sleep changes the brain, resulting in thinner gray matter, less neuroplasticity, poorer higher-level cognitive abilities (attention, working memory, inhibition, judgment, decision-making), lower motivation, and poorer academic functioning. None of these are losses teens can afford!
While sleep problems are more common in those with mental health disorders, poor sleep precedes anxiety and depression more than the reverse. Sleep problems increase the risk of depression, and depression relapses. Insomnia predicts risk behaviors – drinking and driving, smoking, delinquency. Getting less than 8 hours of sleep is associated with a threefold higher risk of suicide attempts.
Despite these pervasive threats to health and development, instead of concern, I find a lot of resistance in families and teens to taking action to improve sleep.
Teens don’t believe in problems from inadequate sleep. After all, they say, their peers are “all” getting the same amount of sleep. And they are largely correct – 75% of U.S. 12th graders get less than 8 hours of sleep. But the data are clear that children aged 12-18 years need 8.25-9.25 hours of sleep.
Parents generally are not aware of how little sleep their teens are getting because they go to bed on their own. If parents do check, any teenagers worth the label can growl their way out of supervision, “promise” to shut off the lights, or feign sleep. Having the house, pantry, and electronics to themselves at night is worth the risk of a consequence, especially for those who would rather avoid interacting.
The social forces keeping teens up at night are their “life”: the hours required for homework can be the reason for inadequate sleep. In subgroups of teens, sports practices, employment, or family responsibilities may extend the day past a bedtime needed for optimal sleep.
But use of electronics – the lifeline of adolescents – is responsible for much of their sleep debt. Electronic devices both delay sleep onset and reduce sleep duration. After 9:00 p.m., 34% of children aged older than 12 years are text messaging, 44% are talking, 55% are online, and 24% are playing computer games. Use of a TV or tablet at bedtime results in reduced sleep, and increased poor quality of sleep. Three or more hours of TV result not only in difficulty falling asleep and frequent awakenings, but also sleep issues later as adults. Shooter video games result in lower sleepiness, longer sleep latency, and shorter REM sleep. Even the low level light from electronic devices alters circadian rhythm and suppresses nocturnal melatonin secretion.
Keep in mind the biological reasons teens go to bed later. One is the typical emotional hyperarousal of being a teen. But other biological forces are at work in adolescence, such as reduction in the accumulation of sleep pressure during wakefulness and delaying the melatonin release that produces sleepiness. Teens (and parents) think sleeping in on weekends takes care of inadequate weekday sleep, but this so-called “recovery sleep” tends to occur at an inappropriate time in the circadian phase and further delays melatonin production, as well as reducing sleep pressure, making it even harder to fall asleep.
In some cases, medications we prescribe – such as stimulants, theophylline, antihistamines, or anticonvulsants – are at fault for delaying or disturbing sleep. But more often it is self-administered substances that are part of the teen’s attempt to stay awake – including nicotine, alcohol, and caffeine – that produce shorter sleep duration, increased latency to sleep, more wake time during sleep, and increased daytime sleepiness; it results in a vicious cycle. Sleep disruption may explain the association of these substances with less memory consolidation, poorer academic performance, and higher rates of risk behaviors.
We adults also are a cause of teen sleep debt. We are the ones allowing the early school start times for teens, primarily to allow for after school sports programs that glorify the school and bring kudos to some at the expense of all the students. A 65-minute earlier start in 10th grade resulted in less than half of students getting 7 hours of sleep or more. The level of resulting sleepiness is equal to that of narcolepsy.
As primary care clinicians, we can and need to detect, educate about, and treat sleep debt and sleep disorders. Sleep questionnaires can help. Treatment of sleep includes coaching for: having a cool, dark room used mainly for sleep; a regular schedule 7 days per week; avoiding exercise within 2 hours of bedtime; avoiding stimulants such as caffeine, tea, nicotine, and medications at least 3 hours before bedtime; keeping to a routine with no daytime naps; and especially no media in the bedroom! For teens already not able to sleep until early morning, you can recommend that they work bedtime back or forward by 1 hour per day until hitting a time that will allow 9 hours of sleep. Alternatively, have them stay up all night to reset their biological clock. Subsequently, the sleep schedule has to stay within 1 hour for sleep and waking 7 days per week. Anxious teens, besides needing therapy, may need a soothing routine, no visible clock, and a plan to get back up for 1 hour every time it takes longer than 10 minutes to fall asleep.
If sleepy teens report adequate time in bed, then we need to understand pathologies such as obstructive sleep apnea, restless legs syndrome, menstruation-related or primary hypersomnias, and narcolepsy to diagnose and resolve the problem.
Parents may have given up protecting their teens from inadequate sleep so we as health providers need to do so.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].
One thing that constantly surprises me about adolescent sleep is that neither the teen nor the parent is as concerned about it as I am. Instead, they complain about irritability, dropping grades, anxiety, depression, obesity, oppositionality, fatigue, and even substance use – all documented effects of sleep debt.
Inadequate sleep changes the brain, resulting in thinner gray matter, less neuroplasticity, poorer higher-level cognitive abilities (attention, working memory, inhibition, judgment, decision-making), lower motivation, and poorer academic functioning. None of these are losses teens can afford!
While sleep problems are more common in those with mental health disorders, poor sleep precedes anxiety and depression more than the reverse. Sleep problems increase the risk of depression, and depression relapses. Insomnia predicts risk behaviors – drinking and driving, smoking, delinquency. Getting less than 8 hours of sleep is associated with a threefold higher risk of suicide attempts.
Despite these pervasive threats to health and development, instead of concern, I find a lot of resistance in families and teens to taking action to improve sleep.
Teens don’t believe in problems from inadequate sleep. After all, they say, their peers are “all” getting the same amount of sleep. And they are largely correct – 75% of U.S. 12th graders get less than 8 hours of sleep. But the data are clear that children aged 12-18 years need 8.25-9.25 hours of sleep.
Parents generally are not aware of how little sleep their teens are getting because they go to bed on their own. If parents do check, any teenagers worth the label can growl their way out of supervision, “promise” to shut off the lights, or feign sleep. Having the house, pantry, and electronics to themselves at night is worth the risk of a consequence, especially for those who would rather avoid interacting.
The social forces keeping teens up at night are their “life”: the hours required for homework can be the reason for inadequate sleep. In subgroups of teens, sports practices, employment, or family responsibilities may extend the day past a bedtime needed for optimal sleep.
But use of electronics – the lifeline of adolescents – is responsible for much of their sleep debt. Electronic devices both delay sleep onset and reduce sleep duration. After 9:00 p.m., 34% of children aged older than 12 years are text messaging, 44% are talking, 55% are online, and 24% are playing computer games. Use of a TV or tablet at bedtime results in reduced sleep, and increased poor quality of sleep. Three or more hours of TV result not only in difficulty falling asleep and frequent awakenings, but also sleep issues later as adults. Shooter video games result in lower sleepiness, longer sleep latency, and shorter REM sleep. Even the low level light from electronic devices alters circadian rhythm and suppresses nocturnal melatonin secretion.
Keep in mind the biological reasons teens go to bed later. One is the typical emotional hyperarousal of being a teen. But other biological forces are at work in adolescence, such as reduction in the accumulation of sleep pressure during wakefulness and delaying the melatonin release that produces sleepiness. Teens (and parents) think sleeping in on weekends takes care of inadequate weekday sleep, but this so-called “recovery sleep” tends to occur at an inappropriate time in the circadian phase and further delays melatonin production, as well as reducing sleep pressure, making it even harder to fall asleep.
In some cases, medications we prescribe – such as stimulants, theophylline, antihistamines, or anticonvulsants – are at fault for delaying or disturbing sleep. But more often it is self-administered substances that are part of the teen’s attempt to stay awake – including nicotine, alcohol, and caffeine – that produce shorter sleep duration, increased latency to sleep, more wake time during sleep, and increased daytime sleepiness; it results in a vicious cycle. Sleep disruption may explain the association of these substances with less memory consolidation, poorer academic performance, and higher rates of risk behaviors.
We adults also are a cause of teen sleep debt. We are the ones allowing the early school start times for teens, primarily to allow for after school sports programs that glorify the school and bring kudos to some at the expense of all the students. A 65-minute earlier start in 10th grade resulted in less than half of students getting 7 hours of sleep or more. The level of resulting sleepiness is equal to that of narcolepsy.
As primary care clinicians, we can and need to detect, educate about, and treat sleep debt and sleep disorders. Sleep questionnaires can help. Treatment of sleep includes coaching for: having a cool, dark room used mainly for sleep; a regular schedule 7 days per week; avoiding exercise within 2 hours of bedtime; avoiding stimulants such as caffeine, tea, nicotine, and medications at least 3 hours before bedtime; keeping to a routine with no daytime naps; and especially no media in the bedroom! For teens already not able to sleep until early morning, you can recommend that they work bedtime back or forward by 1 hour per day until hitting a time that will allow 9 hours of sleep. Alternatively, have them stay up all night to reset their biological clock. Subsequently, the sleep schedule has to stay within 1 hour for sleep and waking 7 days per week. Anxious teens, besides needing therapy, may need a soothing routine, no visible clock, and a plan to get back up for 1 hour every time it takes longer than 10 minutes to fall asleep.
If sleepy teens report adequate time in bed, then we need to understand pathologies such as obstructive sleep apnea, restless legs syndrome, menstruation-related or primary hypersomnias, and narcolepsy to diagnose and resolve the problem.
Parents may have given up protecting their teens from inadequate sleep so we as health providers need to do so.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].
One thing that constantly surprises me about adolescent sleep is that neither the teen nor the parent is as concerned about it as I am. Instead, they complain about irritability, dropping grades, anxiety, depression, obesity, oppositionality, fatigue, and even substance use – all documented effects of sleep debt.
Inadequate sleep changes the brain, resulting in thinner gray matter, less neuroplasticity, poorer higher-level cognitive abilities (attention, working memory, inhibition, judgment, decision-making), lower motivation, and poorer academic functioning. None of these are losses teens can afford!
While sleep problems are more common in those with mental health disorders, poor sleep precedes anxiety and depression more than the reverse. Sleep problems increase the risk of depression, and depression relapses. Insomnia predicts risk behaviors – drinking and driving, smoking, delinquency. Getting less than 8 hours of sleep is associated with a threefold higher risk of suicide attempts.
Despite these pervasive threats to health and development, instead of concern, I find a lot of resistance in families and teens to taking action to improve sleep.
Teens don’t believe in problems from inadequate sleep. After all, they say, their peers are “all” getting the same amount of sleep. And they are largely correct – 75% of U.S. 12th graders get less than 8 hours of sleep. But the data are clear that children aged 12-18 years need 8.25-9.25 hours of sleep.
Parents generally are not aware of how little sleep their teens are getting because they go to bed on their own. If parents do check, any teenagers worth the label can growl their way out of supervision, “promise” to shut off the lights, or feign sleep. Having the house, pantry, and electronics to themselves at night is worth the risk of a consequence, especially for those who would rather avoid interacting.
The social forces keeping teens up at night are their “life”: the hours required for homework can be the reason for inadequate sleep. In subgroups of teens, sports practices, employment, or family responsibilities may extend the day past a bedtime needed for optimal sleep.
But use of electronics – the lifeline of adolescents – is responsible for much of their sleep debt. Electronic devices both delay sleep onset and reduce sleep duration. After 9:00 p.m., 34% of children aged older than 12 years are text messaging, 44% are talking, 55% are online, and 24% are playing computer games. Use of a TV or tablet at bedtime results in reduced sleep, and increased poor quality of sleep. Three or more hours of TV result not only in difficulty falling asleep and frequent awakenings, but also sleep issues later as adults. Shooter video games result in lower sleepiness, longer sleep latency, and shorter REM sleep. Even the low level light from electronic devices alters circadian rhythm and suppresses nocturnal melatonin secretion.
Keep in mind the biological reasons teens go to bed later. One is the typical emotional hyperarousal of being a teen. But other biological forces are at work in adolescence, such as reduction in the accumulation of sleep pressure during wakefulness and delaying the melatonin release that produces sleepiness. Teens (and parents) think sleeping in on weekends takes care of inadequate weekday sleep, but this so-called “recovery sleep” tends to occur at an inappropriate time in the circadian phase and further delays melatonin production, as well as reducing sleep pressure, making it even harder to fall asleep.
In some cases, medications we prescribe – such as stimulants, theophylline, antihistamines, or anticonvulsants – are at fault for delaying or disturbing sleep. But more often it is self-administered substances that are part of the teen’s attempt to stay awake – including nicotine, alcohol, and caffeine – that produce shorter sleep duration, increased latency to sleep, more wake time during sleep, and increased daytime sleepiness; it results in a vicious cycle. Sleep disruption may explain the association of these substances with less memory consolidation, poorer academic performance, and higher rates of risk behaviors.
We adults also are a cause of teen sleep debt. We are the ones allowing the early school start times for teens, primarily to allow for after school sports programs that glorify the school and bring kudos to some at the expense of all the students. A 65-minute earlier start in 10th grade resulted in less than half of students getting 7 hours of sleep or more. The level of resulting sleepiness is equal to that of narcolepsy.
As primary care clinicians, we can and need to detect, educate about, and treat sleep debt and sleep disorders. Sleep questionnaires can help. Treatment of sleep includes coaching for: having a cool, dark room used mainly for sleep; a regular schedule 7 days per week; avoiding exercise within 2 hours of bedtime; avoiding stimulants such as caffeine, tea, nicotine, and medications at least 3 hours before bedtime; keeping to a routine with no daytime naps; and especially no media in the bedroom! For teens already not able to sleep until early morning, you can recommend that they work bedtime back or forward by 1 hour per day until hitting a time that will allow 9 hours of sleep. Alternatively, have them stay up all night to reset their biological clock. Subsequently, the sleep schedule has to stay within 1 hour for sleep and waking 7 days per week. Anxious teens, besides needing therapy, may need a soothing routine, no visible clock, and a plan to get back up for 1 hour every time it takes longer than 10 minutes to fall asleep.
If sleepy teens report adequate time in bed, then we need to understand pathologies such as obstructive sleep apnea, restless legs syndrome, menstruation-related or primary hypersomnias, and narcolepsy to diagnose and resolve the problem.
Parents may have given up protecting their teens from inadequate sleep so we as health providers need to do so.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].
Practice changing events of 2017
Members of the Pediatric News Editorial Advisory Board share some of the events and findings of 2017 that they believe have or will have the most impact on pediatric practice.
Francis Rushton Jr., MD, practiced pediatrics in Beaufort, S.C. for 32 years, and currently is the medical director of S.C. Quality through Technology and Innovation in Pediatrics (QTIP), funded by the South Carolina Department of Health and Human Services.
Dropping the human papillomavirus (HPV) regimen to two shots from three shots, as recommended by the Centers for Disease Control and Prevention, appears to have really improved uptake of HPV immunization.
Preventive oral health in the pediatrician’s office is not really a new recommendation from 2017; we have been talking about fluoride varnish for over a decade. What is new is that we gradually are seeing fluoride varnish move into practice, up from 1,000 applications in pediatric offices in 2011 to close to 20,000 applications in South Carolina alone.
Pediatricians are being asked to screen more and more. We’re asked to do developmental screening, postpartum depression screening, autism screening, behavioral health screening, social determinants of health screening, parental concerns screening, etc. As a result, we now have multiple different screens with different schedules. The Survey of Well-Being of Young Children screening tool does it all – one screen at each preschool well visit from birth to age 5 years.
A different approach is to use CHADIS (Child Health and Development Interactive System), a for-profit venture where all the screens are loaded electronically.
Howard Smart, MD, is chairman of pediatrics at Sharp Rees-Stealy Medical Group, San Diego.
The switch to a two-dose schedule for HPV vaccination has improved both acceptance of the vaccine and the likelihood of timely completion of the HPV series.
Kelly Curran, MD, MA, is an assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, practicing adolescent medicine.
The news from Australia is that the older meningitis B vaccine (MeNZB) provides some protection against Neisseria gonorrhoeae, as reported in the Lancet (2017 July 10. doi: 10.1016/S0140-6736[17]31449-6)! The newer version of the meningitis B vaccine Bexsero also contains the same outer membrane vesicle antigen. Given increasing bacterial resistance – and pan-resistant gonorrhea organisms already in some parts of the world – this is exciting news for the future!
The increased use of the reverse screening algorithm for syphilis is exciting. Although this has been “available” for several years, increasingly more physicians/laboratories are using this in practice. Our academic center – in a relatively high prevalence area for syphilis – recently switched to this screening method.
M. Susan Jay, MD, is a professor of pediatrics and section chief of adolescent medicine at the Medical College of Wisconsin and program director of adolescent health and medicine at the Children’s Hospital of Wisconsin, both in Milwaukee.
In adolescent medicine, the addition of long-acting reversible contraceptives has been wonderful as an aid to both menstrual management and contraception. Specifically, Liletta, a new IUD that is smaller in size and remains in place for 5 years as well as being considerably more cost effective, has changed care for adolescent females.
Suzanne C. Boulter, MD, is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H.
I was very impressed with the recent American Academy of Pediatrics policy on human trafficking published in Pediatrics (2017 November. doi: 10.1542/peds.2017-3138), and think this is a new area of knowledge of which pediatricians need to be aware.
With all the news and social media about sexual misconduct by persons in power, I’m a bit concerned that there could be a fallout on pediatricians performing appropriate examinations on their patients that could be interpreted as something else.
Timothy J. Joos, MD, MPH, is a practicing clinician in combined internal medicine/pediatrics in Seattle. For the last decade, he has worked at a federally qualified community health center in Seattle serving a largely low-income and immigrant population.
With regard to practice-changing events for 2017, I don’t wish to downplay the numerous research advances over the year, but the advances cannot be made without funding, and they are not going to be practice-changing if they can’t reach the patients. We can’t ignore the uncertainty that the current political situation in 2017 has caused for our patients and their families, as well as for research and for the health care industry in general.
It is impossible to deny the important role government health care programs play in the health of our own patients and the health of the whole country. According to numbers from the Kaiser Family Foundation website, currently 38% of the estimated 74 million kids in this country are covered by Medicaid and CHIP programs. The numbers of uninsured children are at all-time lows at 5% (adults 10%). The current uncertainty of government funding is felt strongly by safety net providers such as community health centers that have traditionally seen the uninsured patients. The community health center where I work went from 35% of its patients being uninsured before the Affordable Care Act to about 15% now.
Efforts to dismantle the Affordable Care Act and reverse Medicaid expansions, as well as delays on funding to the CHIP program, have created uncertainty and anxiety across health care from the administrators and insurance companies to us – the providers – and the families we take care of. In addition, National Institutes of Health funding is threatened to be cut by 20%. 2017 will go down in history as the year of health care toxic stress (that is, unless 2018 is worse). As we celebrate the end of the year, we all deserve a Xanax and a Zantac.
Members of the Pediatric News Editorial Advisory Board share some of the events and findings of 2017 that they believe have or will have the most impact on pediatric practice.
Francis Rushton Jr., MD, practiced pediatrics in Beaufort, S.C. for 32 years, and currently is the medical director of S.C. Quality through Technology and Innovation in Pediatrics (QTIP), funded by the South Carolina Department of Health and Human Services.
Dropping the human papillomavirus (HPV) regimen to two shots from three shots, as recommended by the Centers for Disease Control and Prevention, appears to have really improved uptake of HPV immunization.
Preventive oral health in the pediatrician’s office is not really a new recommendation from 2017; we have been talking about fluoride varnish for over a decade. What is new is that we gradually are seeing fluoride varnish move into practice, up from 1,000 applications in pediatric offices in 2011 to close to 20,000 applications in South Carolina alone.
Pediatricians are being asked to screen more and more. We’re asked to do developmental screening, postpartum depression screening, autism screening, behavioral health screening, social determinants of health screening, parental concerns screening, etc. As a result, we now have multiple different screens with different schedules. The Survey of Well-Being of Young Children screening tool does it all – one screen at each preschool well visit from birth to age 5 years.
A different approach is to use CHADIS (Child Health and Development Interactive System), a for-profit venture where all the screens are loaded electronically.
Howard Smart, MD, is chairman of pediatrics at Sharp Rees-Stealy Medical Group, San Diego.
The switch to a two-dose schedule for HPV vaccination has improved both acceptance of the vaccine and the likelihood of timely completion of the HPV series.
Kelly Curran, MD, MA, is an assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, practicing adolescent medicine.
The news from Australia is that the older meningitis B vaccine (MeNZB) provides some protection against Neisseria gonorrhoeae, as reported in the Lancet (2017 July 10. doi: 10.1016/S0140-6736[17]31449-6)! The newer version of the meningitis B vaccine Bexsero also contains the same outer membrane vesicle antigen. Given increasing bacterial resistance – and pan-resistant gonorrhea organisms already in some parts of the world – this is exciting news for the future!
The increased use of the reverse screening algorithm for syphilis is exciting. Although this has been “available” for several years, increasingly more physicians/laboratories are using this in practice. Our academic center – in a relatively high prevalence area for syphilis – recently switched to this screening method.
M. Susan Jay, MD, is a professor of pediatrics and section chief of adolescent medicine at the Medical College of Wisconsin and program director of adolescent health and medicine at the Children’s Hospital of Wisconsin, both in Milwaukee.
In adolescent medicine, the addition of long-acting reversible contraceptives has been wonderful as an aid to both menstrual management and contraception. Specifically, Liletta, a new IUD that is smaller in size and remains in place for 5 years as well as being considerably more cost effective, has changed care for adolescent females.
Suzanne C. Boulter, MD, is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H.
I was very impressed with the recent American Academy of Pediatrics policy on human trafficking published in Pediatrics (2017 November. doi: 10.1542/peds.2017-3138), and think this is a new area of knowledge of which pediatricians need to be aware.
With all the news and social media about sexual misconduct by persons in power, I’m a bit concerned that there could be a fallout on pediatricians performing appropriate examinations on their patients that could be interpreted as something else.
Timothy J. Joos, MD, MPH, is a practicing clinician in combined internal medicine/pediatrics in Seattle. For the last decade, he has worked at a federally qualified community health center in Seattle serving a largely low-income and immigrant population.
With regard to practice-changing events for 2017, I don’t wish to downplay the numerous research advances over the year, but the advances cannot be made without funding, and they are not going to be practice-changing if they can’t reach the patients. We can’t ignore the uncertainty that the current political situation in 2017 has caused for our patients and their families, as well as for research and for the health care industry in general.
It is impossible to deny the important role government health care programs play in the health of our own patients and the health of the whole country. According to numbers from the Kaiser Family Foundation website, currently 38% of the estimated 74 million kids in this country are covered by Medicaid and CHIP programs. The numbers of uninsured children are at all-time lows at 5% (adults 10%). The current uncertainty of government funding is felt strongly by safety net providers such as community health centers that have traditionally seen the uninsured patients. The community health center where I work went from 35% of its patients being uninsured before the Affordable Care Act to about 15% now.
Efforts to dismantle the Affordable Care Act and reverse Medicaid expansions, as well as delays on funding to the CHIP program, have created uncertainty and anxiety across health care from the administrators and insurance companies to us – the providers – and the families we take care of. In addition, National Institutes of Health funding is threatened to be cut by 20%. 2017 will go down in history as the year of health care toxic stress (that is, unless 2018 is worse). As we celebrate the end of the year, we all deserve a Xanax and a Zantac.
Members of the Pediatric News Editorial Advisory Board share some of the events and findings of 2017 that they believe have or will have the most impact on pediatric practice.
Francis Rushton Jr., MD, practiced pediatrics in Beaufort, S.C. for 32 years, and currently is the medical director of S.C. Quality through Technology and Innovation in Pediatrics (QTIP), funded by the South Carolina Department of Health and Human Services.
Dropping the human papillomavirus (HPV) regimen to two shots from three shots, as recommended by the Centers for Disease Control and Prevention, appears to have really improved uptake of HPV immunization.
Preventive oral health in the pediatrician’s office is not really a new recommendation from 2017; we have been talking about fluoride varnish for over a decade. What is new is that we gradually are seeing fluoride varnish move into practice, up from 1,000 applications in pediatric offices in 2011 to close to 20,000 applications in South Carolina alone.
Pediatricians are being asked to screen more and more. We’re asked to do developmental screening, postpartum depression screening, autism screening, behavioral health screening, social determinants of health screening, parental concerns screening, etc. As a result, we now have multiple different screens with different schedules. The Survey of Well-Being of Young Children screening tool does it all – one screen at each preschool well visit from birth to age 5 years.
A different approach is to use CHADIS (Child Health and Development Interactive System), a for-profit venture where all the screens are loaded electronically.
Howard Smart, MD, is chairman of pediatrics at Sharp Rees-Stealy Medical Group, San Diego.
The switch to a two-dose schedule for HPV vaccination has improved both acceptance of the vaccine and the likelihood of timely completion of the HPV series.
Kelly Curran, MD, MA, is an assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, practicing adolescent medicine.
The news from Australia is that the older meningitis B vaccine (MeNZB) provides some protection against Neisseria gonorrhoeae, as reported in the Lancet (2017 July 10. doi: 10.1016/S0140-6736[17]31449-6)! The newer version of the meningitis B vaccine Bexsero also contains the same outer membrane vesicle antigen. Given increasing bacterial resistance – and pan-resistant gonorrhea organisms already in some parts of the world – this is exciting news for the future!
The increased use of the reverse screening algorithm for syphilis is exciting. Although this has been “available” for several years, increasingly more physicians/laboratories are using this in practice. Our academic center – in a relatively high prevalence area for syphilis – recently switched to this screening method.
M. Susan Jay, MD, is a professor of pediatrics and section chief of adolescent medicine at the Medical College of Wisconsin and program director of adolescent health and medicine at the Children’s Hospital of Wisconsin, both in Milwaukee.
In adolescent medicine, the addition of long-acting reversible contraceptives has been wonderful as an aid to both menstrual management and contraception. Specifically, Liletta, a new IUD that is smaller in size and remains in place for 5 years as well as being considerably more cost effective, has changed care for adolescent females.
Suzanne C. Boulter, MD, is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H.
I was very impressed with the recent American Academy of Pediatrics policy on human trafficking published in Pediatrics (2017 November. doi: 10.1542/peds.2017-3138), and think this is a new area of knowledge of which pediatricians need to be aware.
With all the news and social media about sexual misconduct by persons in power, I’m a bit concerned that there could be a fallout on pediatricians performing appropriate examinations on their patients that could be interpreted as something else.
Timothy J. Joos, MD, MPH, is a practicing clinician in combined internal medicine/pediatrics in Seattle. For the last decade, he has worked at a federally qualified community health center in Seattle serving a largely low-income and immigrant population.
With regard to practice-changing events for 2017, I don’t wish to downplay the numerous research advances over the year, but the advances cannot be made without funding, and they are not going to be practice-changing if they can’t reach the patients. We can’t ignore the uncertainty that the current political situation in 2017 has caused for our patients and their families, as well as for research and for the health care industry in general.
It is impossible to deny the important role government health care programs play in the health of our own patients and the health of the whole country. According to numbers from the Kaiser Family Foundation website, currently 38% of the estimated 74 million kids in this country are covered by Medicaid and CHIP programs. The numbers of uninsured children are at all-time lows at 5% (adults 10%). The current uncertainty of government funding is felt strongly by safety net providers such as community health centers that have traditionally seen the uninsured patients. The community health center where I work went from 35% of its patients being uninsured before the Affordable Care Act to about 15% now.
Efforts to dismantle the Affordable Care Act and reverse Medicaid expansions, as well as delays on funding to the CHIP program, have created uncertainty and anxiety across health care from the administrators and insurance companies to us – the providers – and the families we take care of. In addition, National Institutes of Health funding is threatened to be cut by 20%. 2017 will go down in history as the year of health care toxic stress (that is, unless 2018 is worse). As we celebrate the end of the year, we all deserve a Xanax and a Zantac.
Preexposure prophylaxis among LGBT youth
Every prevention effort or treatment has its own risks. Gynecologists must consider the risk for blood clots from using estrogen-containing oral contraceptives versus the risk of blood clots from pregnancy. Endocrinologists must weigh the risk of decreased bone mineral density versus premature closure of growth plates when starting pubertal blockers for children suffering from precocious puberty. Psychologists and primary care providers must consider the risk for increased suicidal thoughts while on selective serotonin reuptake inhibitors versus the risk of completed suicide if the depression remains untreated.
In the United States alone, 22% of HIV infections occur in people aged 13-24 years. Among those with HIV infection, 81% are young men who have sex with men (MSM).1 Among those new infections, young MSM of color are nearly four times as likely to have HIV, compared with white young MSM.2 Moreover, the incidence of HIV infection among transgender individuals is three times higher than the national average.3
What further hampers public health prevention efforts is the stigma and discrimination LGBT youth face in trying to prevent HIV infections: 84% of those aged 15-24 years report recognizing stigma around HIV in the United States.4 In addition, black MSM were more likely than other MSMs to report this kind of stigma.5 And it isn’t enough that LGBT youth have to face stigma and discrimination. In fact, because of it, they often face serious financial challenges. It is estimated that 50% of homeless youth identify as LGBT, and 40% of them were forced out of their homes because of their sexual orientation or gender identity.6 Also, transgender youth have difficulty finding employment because of their gender identity.7 A combination of homelessness or chronic unemployment has driven many LGBT youth to survival sex or sex for money, which puts them at higher risk for HIV infection.7,8 The risk for HIV infection is so high that we should be using all available resources, including PrEP, to address these profound health disparities.
Studies, however, are forthcoming. One study by Hosek et al. that was published in September suggested that PrEP among adolescents can be safe and well tolerated, may not increase the rate of high-risk sexual behaviors, and may not increase the risk of other STDs such as gonorrhea and chlamydia. It must be noted, however, that incidence of HIV was fairly high – the HIV seroconversion rate was 6.4 per 100 person-years. Nevertheless, researchers found the rate of HIV seroconversion was higher among those with lower levels of Truvada in their bodies, compared with the seroconversion rate in those with higher levels of the medication. This suggests that adherence is key in using PrEP to prevent HIV infection.10 Although far from definitive, this small study provides some solid evidence that PrEP is safe and effective in preventing HIV among LGBT youth. More studies that will eventually support its effectiveness and safety are on the way.11
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
Resource
CDC website on PrEP: https://www.cdc.gov/hiv/risk/prep/index.html, with provider guidelines.
References
1. Centers for Disease Control and Prevention. HIV Among Youth fact sheet, April 2017.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27.
3. Centers for Disease Control and Prevention. HIV Among Transgender People.
4. Kaiser Family Foundation. National survey of teens and young adults on HIV/AIDS, Nov. 1, 2012. .
5. J Acquir Immune Defic Syndr. 2016;73(5):547-55.
6. Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless (The Williams Institute with True Colors and The Palette Fund, 2012).
7. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
8. J Acquir Immune Defic Syndr. 2010 Apr;53(5):661-4.
9. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States: A clinical practice guideline, 2014.
10. JAMA Pediatr. 2017;171(11):1063-71.
11. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.7.21107.
Every prevention effort or treatment has its own risks. Gynecologists must consider the risk for blood clots from using estrogen-containing oral contraceptives versus the risk of blood clots from pregnancy. Endocrinologists must weigh the risk of decreased bone mineral density versus premature closure of growth plates when starting pubertal blockers for children suffering from precocious puberty. Psychologists and primary care providers must consider the risk for increased suicidal thoughts while on selective serotonin reuptake inhibitors versus the risk of completed suicide if the depression remains untreated.
In the United States alone, 22% of HIV infections occur in people aged 13-24 years. Among those with HIV infection, 81% are young men who have sex with men (MSM).1 Among those new infections, young MSM of color are nearly four times as likely to have HIV, compared with white young MSM.2 Moreover, the incidence of HIV infection among transgender individuals is three times higher than the national average.3
What further hampers public health prevention efforts is the stigma and discrimination LGBT youth face in trying to prevent HIV infections: 84% of those aged 15-24 years report recognizing stigma around HIV in the United States.4 In addition, black MSM were more likely than other MSMs to report this kind of stigma.5 And it isn’t enough that LGBT youth have to face stigma and discrimination. In fact, because of it, they often face serious financial challenges. It is estimated that 50% of homeless youth identify as LGBT, and 40% of them were forced out of their homes because of their sexual orientation or gender identity.6 Also, transgender youth have difficulty finding employment because of their gender identity.7 A combination of homelessness or chronic unemployment has driven many LGBT youth to survival sex or sex for money, which puts them at higher risk for HIV infection.7,8 The risk for HIV infection is so high that we should be using all available resources, including PrEP, to address these profound health disparities.
Studies, however, are forthcoming. One study by Hosek et al. that was published in September suggested that PrEP among adolescents can be safe and well tolerated, may not increase the rate of high-risk sexual behaviors, and may not increase the risk of other STDs such as gonorrhea and chlamydia. It must be noted, however, that incidence of HIV was fairly high – the HIV seroconversion rate was 6.4 per 100 person-years. Nevertheless, researchers found the rate of HIV seroconversion was higher among those with lower levels of Truvada in their bodies, compared with the seroconversion rate in those with higher levels of the medication. This suggests that adherence is key in using PrEP to prevent HIV infection.10 Although far from definitive, this small study provides some solid evidence that PrEP is safe and effective in preventing HIV among LGBT youth. More studies that will eventually support its effectiveness and safety are on the way.11
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
Resource
CDC website on PrEP: https://www.cdc.gov/hiv/risk/prep/index.html, with provider guidelines.
References
1. Centers for Disease Control and Prevention. HIV Among Youth fact sheet, April 2017.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27.
3. Centers for Disease Control and Prevention. HIV Among Transgender People.
4. Kaiser Family Foundation. National survey of teens and young adults on HIV/AIDS, Nov. 1, 2012. .
5. J Acquir Immune Defic Syndr. 2016;73(5):547-55.
6. Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless (The Williams Institute with True Colors and The Palette Fund, 2012).
7. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
8. J Acquir Immune Defic Syndr. 2010 Apr;53(5):661-4.
9. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States: A clinical practice guideline, 2014.
10. JAMA Pediatr. 2017;171(11):1063-71.
11. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.7.21107.
Every prevention effort or treatment has its own risks. Gynecologists must consider the risk for blood clots from using estrogen-containing oral contraceptives versus the risk of blood clots from pregnancy. Endocrinologists must weigh the risk of decreased bone mineral density versus premature closure of growth plates when starting pubertal blockers for children suffering from precocious puberty. Psychologists and primary care providers must consider the risk for increased suicidal thoughts while on selective serotonin reuptake inhibitors versus the risk of completed suicide if the depression remains untreated.
In the United States alone, 22% of HIV infections occur in people aged 13-24 years. Among those with HIV infection, 81% are young men who have sex with men (MSM).1 Among those new infections, young MSM of color are nearly four times as likely to have HIV, compared with white young MSM.2 Moreover, the incidence of HIV infection among transgender individuals is three times higher than the national average.3
What further hampers public health prevention efforts is the stigma and discrimination LGBT youth face in trying to prevent HIV infections: 84% of those aged 15-24 years report recognizing stigma around HIV in the United States.4 In addition, black MSM were more likely than other MSMs to report this kind of stigma.5 And it isn’t enough that LGBT youth have to face stigma and discrimination. In fact, because of it, they often face serious financial challenges. It is estimated that 50% of homeless youth identify as LGBT, and 40% of them were forced out of their homes because of their sexual orientation or gender identity.6 Also, transgender youth have difficulty finding employment because of their gender identity.7 A combination of homelessness or chronic unemployment has driven many LGBT youth to survival sex or sex for money, which puts them at higher risk for HIV infection.7,8 The risk for HIV infection is so high that we should be using all available resources, including PrEP, to address these profound health disparities.
Studies, however, are forthcoming. One study by Hosek et al. that was published in September suggested that PrEP among adolescents can be safe and well tolerated, may not increase the rate of high-risk sexual behaviors, and may not increase the risk of other STDs such as gonorrhea and chlamydia. It must be noted, however, that incidence of HIV was fairly high – the HIV seroconversion rate was 6.4 per 100 person-years. Nevertheless, researchers found the rate of HIV seroconversion was higher among those with lower levels of Truvada in their bodies, compared with the seroconversion rate in those with higher levels of the medication. This suggests that adherence is key in using PrEP to prevent HIV infection.10 Although far from definitive, this small study provides some solid evidence that PrEP is safe and effective in preventing HIV among LGBT youth. More studies that will eventually support its effectiveness and safety are on the way.11
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
Resource
CDC website on PrEP: https://www.cdc.gov/hiv/risk/prep/index.html, with provider guidelines.
References
1. Centers for Disease Control and Prevention. HIV Among Youth fact sheet, April 2017.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27.
3. Centers for Disease Control and Prevention. HIV Among Transgender People.
4. Kaiser Family Foundation. National survey of teens and young adults on HIV/AIDS, Nov. 1, 2012. .
5. J Acquir Immune Defic Syndr. 2016;73(5):547-55.
6. Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless (The Williams Institute with True Colors and The Palette Fund, 2012).
7. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
8. J Acquir Immune Defic Syndr. 2010 Apr;53(5):661-4.
9. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States: A clinical practice guideline, 2014.
10. JAMA Pediatr. 2017;171(11):1063-71.
11. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.7.21107.
Toy stethoscopes
Many of my articles are inspired when I observe discordant things juxtaposed. As we move deep into winter, once again I am confronted with the issue of infection control in the office and on the ward. Hospitals have gowns, gloves, masks, and toy stethoscopes. My outpatient offices rarely used more than the sink. In urgent care clinic, each evening I would swab three or four throats for strep, with one or two turning positive. I thought nothing of it, other than being glad when gagging a patient that I wear glasses. In the hospital, I must gown, glove, and mask for a patient with strep throat. The variations in practice between hospitals (I’ve been credentialed in 30) do not make me confident in the evidence base for infection control practices. I mentioned the Red Book to a second-year resident last week. He said he had seen it on a shelf but never actually used it.
In medical school, I was taught that the most important part of a stethoscope is between the ears. I believe that statement is true, but in a similar way to how I choose wines. My palate can’t tell the difference between a $15 and a $50 bottle of wine, so buying more expensive wine is a waste. However, a $3 bottle of wine is clearly inferior, if not undrinkable. There are oenophiles (one a distant cousin in Norway) who have trained their palates to tell the difference in wines, just as there are audiophiles who support the sales of $1,000 stereo speakers. Some fraction of those snobs may have justification. So, if cardiologists have strong opinions on stethoscopes, I won’t begrudge them their choice of a more expensive model. Their tastes do not mean that the average person should spend that much on wine, speakers, or stethoscopes. I will assert that there was a time when I could tell a day or two in advance that my otoscope bulb was going to burn out. The color balance was wrong. I carried a pocket otoscope for a few years when rounding in the hospital, but never found it as accurate as my original one. Every craftsman gets accustomed to their best tools.
A professional should be aware of the minimum quality of tool needed to get the job done.
Toy isolation stethoscopes ($3 each retail in bulk) add nothing to my discernment of an infant with bronchiolitis who is distressed, so I consider that equipment a waste of money and polluting to the environment. I typically use my stethoscope and foam it on leaving the room. There is evidence that either foam or alcohol pads are effective1 in killing germs, but no proof that this hygiene makes a difference clinically.2 The myriad researchers who have published about stethoscope contamination have stopped at padding their academic portfolios with something easy to publish, which basically is a high school science project using agar plates. They then make insinuations about policy, without any cost-benefit analysis. They really haven’t been bothered enough to advance the science of clinical medicine and actually measure a clinical impact of these policies. It is a corruption of science created by the publish-or-perish environment.
One survey found that 45% of physicians disinfect their stethoscope annually or less. Laundering of white coats follows a similar pattern, which is why the British National Health Service banned lab coats for physicians 10 years ago. No ties or long sleeve shirts either. I am smug knowing that my sartorial sense was ahead of my time in this regard.
The quality-improvement work of Ignaz Semmelweis should be required reading for all physicians. The control chart3 he published on puerperal fever in Vienna in the 1840s is spectacular. Infection control is important. Modern medical science cannot produce a similar control chart to justify the amount of dollars spent annually on gowns, gloves, masks, and toy stethoscopes. Sad.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. Am J Infect Control. 2009 Apr;37(3):241-3.
2. J Hosp Infect. 2015 Sep;91(1):1-7.
3. https://en.wikipedia.org/wiki/Historical_mortality_rates_of_puerperal_fever
Many of my articles are inspired when I observe discordant things juxtaposed. As we move deep into winter, once again I am confronted with the issue of infection control in the office and on the ward. Hospitals have gowns, gloves, masks, and toy stethoscopes. My outpatient offices rarely used more than the sink. In urgent care clinic, each evening I would swab three or four throats for strep, with one or two turning positive. I thought nothing of it, other than being glad when gagging a patient that I wear glasses. In the hospital, I must gown, glove, and mask for a patient with strep throat. The variations in practice between hospitals (I’ve been credentialed in 30) do not make me confident in the evidence base for infection control practices. I mentioned the Red Book to a second-year resident last week. He said he had seen it on a shelf but never actually used it.
In medical school, I was taught that the most important part of a stethoscope is between the ears. I believe that statement is true, but in a similar way to how I choose wines. My palate can’t tell the difference between a $15 and a $50 bottle of wine, so buying more expensive wine is a waste. However, a $3 bottle of wine is clearly inferior, if not undrinkable. There are oenophiles (one a distant cousin in Norway) who have trained their palates to tell the difference in wines, just as there are audiophiles who support the sales of $1,000 stereo speakers. Some fraction of those snobs may have justification. So, if cardiologists have strong opinions on stethoscopes, I won’t begrudge them their choice of a more expensive model. Their tastes do not mean that the average person should spend that much on wine, speakers, or stethoscopes. I will assert that there was a time when I could tell a day or two in advance that my otoscope bulb was going to burn out. The color balance was wrong. I carried a pocket otoscope for a few years when rounding in the hospital, but never found it as accurate as my original one. Every craftsman gets accustomed to their best tools.
A professional should be aware of the minimum quality of tool needed to get the job done.
Toy isolation stethoscopes ($3 each retail in bulk) add nothing to my discernment of an infant with bronchiolitis who is distressed, so I consider that equipment a waste of money and polluting to the environment. I typically use my stethoscope and foam it on leaving the room. There is evidence that either foam or alcohol pads are effective1 in killing germs, but no proof that this hygiene makes a difference clinically.2 The myriad researchers who have published about stethoscope contamination have stopped at padding their academic portfolios with something easy to publish, which basically is a high school science project using agar plates. They then make insinuations about policy, without any cost-benefit analysis. They really haven’t been bothered enough to advance the science of clinical medicine and actually measure a clinical impact of these policies. It is a corruption of science created by the publish-or-perish environment.
One survey found that 45% of physicians disinfect their stethoscope annually or less. Laundering of white coats follows a similar pattern, which is why the British National Health Service banned lab coats for physicians 10 years ago. No ties or long sleeve shirts either. I am smug knowing that my sartorial sense was ahead of my time in this regard.
The quality-improvement work of Ignaz Semmelweis should be required reading for all physicians. The control chart3 he published on puerperal fever in Vienna in the 1840s is spectacular. Infection control is important. Modern medical science cannot produce a similar control chart to justify the amount of dollars spent annually on gowns, gloves, masks, and toy stethoscopes. Sad.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. Am J Infect Control. 2009 Apr;37(3):241-3.
2. J Hosp Infect. 2015 Sep;91(1):1-7.
3. https://en.wikipedia.org/wiki/Historical_mortality_rates_of_puerperal_fever
Many of my articles are inspired when I observe discordant things juxtaposed. As we move deep into winter, once again I am confronted with the issue of infection control in the office and on the ward. Hospitals have gowns, gloves, masks, and toy stethoscopes. My outpatient offices rarely used more than the sink. In urgent care clinic, each evening I would swab three or four throats for strep, with one or two turning positive. I thought nothing of it, other than being glad when gagging a patient that I wear glasses. In the hospital, I must gown, glove, and mask for a patient with strep throat. The variations in practice between hospitals (I’ve been credentialed in 30) do not make me confident in the evidence base for infection control practices. I mentioned the Red Book to a second-year resident last week. He said he had seen it on a shelf but never actually used it.
In medical school, I was taught that the most important part of a stethoscope is between the ears. I believe that statement is true, but in a similar way to how I choose wines. My palate can’t tell the difference between a $15 and a $50 bottle of wine, so buying more expensive wine is a waste. However, a $3 bottle of wine is clearly inferior, if not undrinkable. There are oenophiles (one a distant cousin in Norway) who have trained their palates to tell the difference in wines, just as there are audiophiles who support the sales of $1,000 stereo speakers. Some fraction of those snobs may have justification. So, if cardiologists have strong opinions on stethoscopes, I won’t begrudge them their choice of a more expensive model. Their tastes do not mean that the average person should spend that much on wine, speakers, or stethoscopes. I will assert that there was a time when I could tell a day or two in advance that my otoscope bulb was going to burn out. The color balance was wrong. I carried a pocket otoscope for a few years when rounding in the hospital, but never found it as accurate as my original one. Every craftsman gets accustomed to their best tools.
A professional should be aware of the minimum quality of tool needed to get the job done.
Toy isolation stethoscopes ($3 each retail in bulk) add nothing to my discernment of an infant with bronchiolitis who is distressed, so I consider that equipment a waste of money and polluting to the environment. I typically use my stethoscope and foam it on leaving the room. There is evidence that either foam or alcohol pads are effective1 in killing germs, but no proof that this hygiene makes a difference clinically.2 The myriad researchers who have published about stethoscope contamination have stopped at padding their academic portfolios with something easy to publish, which basically is a high school science project using agar plates. They then make insinuations about policy, without any cost-benefit analysis. They really haven’t been bothered enough to advance the science of clinical medicine and actually measure a clinical impact of these policies. It is a corruption of science created by the publish-or-perish environment.
One survey found that 45% of physicians disinfect their stethoscope annually or less. Laundering of white coats follows a similar pattern, which is why the British National Health Service banned lab coats for physicians 10 years ago. No ties or long sleeve shirts either. I am smug knowing that my sartorial sense was ahead of my time in this regard.
The quality-improvement work of Ignaz Semmelweis should be required reading for all physicians. The control chart3 he published on puerperal fever in Vienna in the 1840s is spectacular. Infection control is important. Modern medical science cannot produce a similar control chart to justify the amount of dollars spent annually on gowns, gloves, masks, and toy stethoscopes. Sad.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. Am J Infect Control. 2009 Apr;37(3):241-3.
2. J Hosp Infect. 2015 Sep;91(1):1-7.
3. https://en.wikipedia.org/wiki/Historical_mortality_rates_of_puerperal_fever
The National Kidney Foundation Names Clinician Reviews® Recipient of the 2018 Nostradamus Award
Frontline Medical Communications today announced that its journal, Clinician Reviews (CR), dedicated to nurse practitioners and physician assistants, has been named recipient of the 2018 Nostradamus Award.
Annually, National Kidney Foundation’s Council of Advanced Practitioners (CAP) presents this award to an individual, group, or organization that, through forethought and vision, recognizes, supports, and promotes the contributions of Advance Practitioners in nephrology. Clinician Reviews is being recognized for its Q&A feature Renal Consult, which provides expert advice to help clinicians address the complexities of renal diseases.
“Clinician Reviews joins a list of outstanding winners, including nephrologists, a United States senator, and others who have recognized CAP’s worth and supported its advancement,” said Karen Clemments, Editorial Director of clinical publications and Editor of Clinician Reviews. She continued, “We are excited to be among an esteemed group of past recipients for our ongoing endeavors to educate advanced practitioners in support of their clinical, professional needs in preventing, diagnosing, and treating kidney diseases.”
In announcing the award, Ms. Clemments noted that Renal Consult aligns with CAP’s goal to improve patient outcomes by enhancing advanced practitioners’ knowledge base and skills that will have a direct impact on clinical practice in a variety of settings. Renal Consult appears quarterly in print and online in CR’s robust, interactive website, digital edition, and mobile app.
The National Kidney Foundation is the leading organization in the United States dedicated to the awareness, prevention, and treatment of kidney disease for hundreds of thousands of healthcare professionals, millions of patients and their families, and tens of millions of Americans at risk. Clinician Reviews will be recognized during an awards luncheon at the NKF 2018 Spring Clinical Meeting in April.
Frontline Medical Communications today announced that its journal, Clinician Reviews (CR), dedicated to nurse practitioners and physician assistants, has been named recipient of the 2018 Nostradamus Award.
Annually, National Kidney Foundation’s Council of Advanced Practitioners (CAP) presents this award to an individual, group, or organization that, through forethought and vision, recognizes, supports, and promotes the contributions of Advance Practitioners in nephrology. Clinician Reviews is being recognized for its Q&A feature Renal Consult, which provides expert advice to help clinicians address the complexities of renal diseases.
“Clinician Reviews joins a list of outstanding winners, including nephrologists, a United States senator, and others who have recognized CAP’s worth and supported its advancement,” said Karen Clemments, Editorial Director of clinical publications and Editor of Clinician Reviews. She continued, “We are excited to be among an esteemed group of past recipients for our ongoing endeavors to educate advanced practitioners in support of their clinical, professional needs in preventing, diagnosing, and treating kidney diseases.”
In announcing the award, Ms. Clemments noted that Renal Consult aligns with CAP’s goal to improve patient outcomes by enhancing advanced practitioners’ knowledge base and skills that will have a direct impact on clinical practice in a variety of settings. Renal Consult appears quarterly in print and online in CR’s robust, interactive website, digital edition, and mobile app.
The National Kidney Foundation is the leading organization in the United States dedicated to the awareness, prevention, and treatment of kidney disease for hundreds of thousands of healthcare professionals, millions of patients and their families, and tens of millions of Americans at risk. Clinician Reviews will be recognized during an awards luncheon at the NKF 2018 Spring Clinical Meeting in April.
Frontline Medical Communications today announced that its journal, Clinician Reviews (CR), dedicated to nurse practitioners and physician assistants, has been named recipient of the 2018 Nostradamus Award.
Annually, National Kidney Foundation’s Council of Advanced Practitioners (CAP) presents this award to an individual, group, or organization that, through forethought and vision, recognizes, supports, and promotes the contributions of Advance Practitioners in nephrology. Clinician Reviews is being recognized for its Q&A feature Renal Consult, which provides expert advice to help clinicians address the complexities of renal diseases.
“Clinician Reviews joins a list of outstanding winners, including nephrologists, a United States senator, and others who have recognized CAP’s worth and supported its advancement,” said Karen Clemments, Editorial Director of clinical publications and Editor of Clinician Reviews. She continued, “We are excited to be among an esteemed group of past recipients for our ongoing endeavors to educate advanced practitioners in support of their clinical, professional needs in preventing, diagnosing, and treating kidney diseases.”
In announcing the award, Ms. Clemments noted that Renal Consult aligns with CAP’s goal to improve patient outcomes by enhancing advanced practitioners’ knowledge base and skills that will have a direct impact on clinical practice in a variety of settings. Renal Consult appears quarterly in print and online in CR’s robust, interactive website, digital edition, and mobile app.
The National Kidney Foundation is the leading organization in the United States dedicated to the awareness, prevention, and treatment of kidney disease for hundreds of thousands of healthcare professionals, millions of patients and their families, and tens of millions of Americans at risk. Clinician Reviews will be recognized during an awards luncheon at the NKF 2018 Spring Clinical Meeting in April.
Complex atypical hyperplasia: When is it appropriate to refer?
Complex atypical hyperplasia (CAH) of the endometrium is considered the precursor for endometrioid endometrial cancer, the most common gynecologic cancer in the United States. This disease is most frequently diagnosed by gynecologists who are evaluating symptoms of abnormal uterine bleeding in premenopausal women or in postmenopausal women who experience new bleeding. Medical therapies, typically progestin-based treatments, can be employed, particularly when fertility preservation is desired or among patients who are poor surgical candidates. However, the most definitive therapy remains surgery with total hysterectomy for two reasons: CAH is associated with a 28% risk for the development of invasive cancer, and occult invasive cancer frequently coexists with CAH.1,2 This raises a question for gynecologists: Given the risk for occult endometrial cancer, should patients be referred to a gynecologic oncologist for their surgery?
What is the risk for cancer?
What is the significance of occult malignancy with CAH?
If surgeons are aware of endometrial cancer preoperatively or intraoperatively, decisions can be made about staging, particularly the need for lymphadenectomy. The virtues of staging in endometrial cancer is a controversial and frequently debated topic. No survival (therapeutic) benefit from lymphadenectomy has been observed in prospective trials when the information from staging results is not used to guide adjuvant therapy.4 However, the administration of adjuvant chemotherapy is associated with improved survival for patients with lymph node metastases.5 Therefore, if there is a benefit to staging with lymphadenectomy, it is its ability to identify patients who most need this life-saving systemic therapy.
Not all patients with endometrial cancer are at equal risk for harboring lymph node metastases and the majority may not benefit from lymphadenectomy. Patients with tumors that are deeply invasive, moderate or high grade, larger than 2 cm, or that have lymphovascular space invasion are at higher risk for lymph node metastases. Women with low grade, minimally invasive tumors that are smaller than 2 cm have extremely low risk for metastases.6 These criteria are commonly employed to stratify women at lowest risk and minimize unnecessary lymphadenectomy procedures. It should be noted that all three of these low risk features must be present to convey that negligible risk profile. The finding of a grade 1 invasive tumor alone is not enough to exclude potential lymph node metastases, particularly in the case of large or deeply invasive cancers.
How can the diagnosis be made preoperatively or intraoperatively?
The gold standard for discriminating between CAH and endometrial cancer is definitive surgical pathology. However, if surgeons wait until these results are available, they have lost the opportunity to stage the patient without subjecting them to a second surgery. The preoperative discovery of cancer may be increased by performing diagnostic curettage rather than relying on office endometrial biopsy sampling.7 This is likely due to the increased volume of tissue removed with dilation and curettage, and a reduction in the risk for sampling error. The addition of hysteroscopy to curettage does not improve upon the detection of cancer. Preoperative MRI to evaluate for depth of myometrial invasion has been described in cases of known endometrial cancer; however, its role in discriminating between CAH and invasive cancer is not well studied.
Intraoperative frozen section is commonly employed to evaluate the hysterectomy specimen for cancer in order to triage patients to staging during that same surgery. However, the accuracy of frozen section with definitive pathology is only approximately 50%.8 This means that at least half of women with CAH will have a false negative frozen section result and will have lost the opportunity for staging at the same procedure. The inaccuracy of frozen section is often overlooked by surgeons who may feel that it is a very straightforward diagnostic procedure. In reality, the characterization of CAH and invasive cancer is technically challenging and relies on multiple sectioning and significant experience in gynecologic pathology.9
Should all patients with CAH be referred and staged?
An alternative to relying on the frozen section process and its inherent inaccuracies would be to routinely stage all women with CAH, knowing that approximately 40% of them have occult cancer, and more than a third of those will have high risk features for lymph node metastases. However, due to the risks associated with lymphadenectomy, particularly lymphedema, most gynecologic oncologists do not routinely stage patients with preoperative CAH with complete lymphadenectomy.
An alternative to the all (complete lymphadenectomy) or none (hysterectomy alone) approach is to perform sentinel lymph node (SLN) biopsy for patients with CAH. SLN biopsy involves removing scant, but high yield lymphatic tissue, and has been shown to be extremely sensitive in detecting metastatic disease.10 This approach is commonly employed by surgeons in the treatment of ductal carcinoma in situ of the breast which, like CAH, is a stage 0 cancer that can be associated with invasive carcinoma on final pathology. In the case of ductal carcinoma in situ, the risk for upstaging is actually substantially lower (25%) than what is observed in CAH.11 Therefore, it would seem even more compelling to apply this approach for endometrial pathologies. The ability to apply the SLN technique is lost after hysterectomy is performed, as there is no longer the target organ into which tracer can be injected; therefore, if SLN biopsy is to be offered to these patients, it needs to be performed using only the preoperative diagnosis of CAH. In this approach, there will be overtreatment of approximately two-thirds of patients, albeit with a less radical and morbid staging procedure.
Making the decision to refer
Ultimately, decisions to refer or not are guided by comprehensive discussions between patient and provider that outline the potential risks and benefits of various approaches. Patients frequently have strong relationships with confidence in their gynecologists who may have cared for them for many years, and may be motivated to have them perform their surgery. For others, the uncertainty and possibility of an unstaged cancer and the potential of a second surgery drives their decision to seek an oncology consultation. Clinicians should discuss the inherent uncertainties in the diagnosis of CAH and the potential for underlying cancer and lymph node metastases, and help patients determine the balance of their underlying competing concerns regarding the risk for inadequate surgery versus the risk of unnecessary surgical procedures.
Summary of recommendations
Invasive endometrial cancer will be identified in the hysterectomy specimens of approximately 40% of women with a preoperative diagnosis of complex endometrial hyperplasia. Preoperative dilation and curettage may reduce the potential for missed occult cancer. Frozen section is an option for determining which patients might benefit from staging but is associated with significant inaccuracies. Failure to diagnose malignancy pre- or intraoperatively handicaps postoperative decision making regarding the necessity of adjuvant chemotherapy, and prevents the ability to offer patients potentially less morbid staging techniques such as SLN biopsy. When gynecologists without oncology training perform these hysterectomies, they should discuss these scenarios to patients and consider referral to gynecologic oncology for patients who desire the potential for comprehensive staging if necessary.
Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina, Chapel Hill. She reports no relevant financial disclosures.
References
1. J Clin Oncol. 2010 Feb;28:788-92.
2. Cancer. 2006 Feb;106:812-9.
3. Int J Gynecol Cancer. 2005 Jan-Feb;15:127-31.
4. Lancet. 2009 Jan;373(9658):125-36.
5. J Clin Oncol. 2006 Jan;24:36-44.
6. Gynecol Oncol 2008 Apr;109:11-8.
7. Am J Obstet Gynecol. 2010 Oct;203(4):349. e1-6.
8. Am J Obstet Gynecol. 2007 May;196(5):e40-2.
9. Obstet Gynecol. 2012 Nov;120(5):1160-75.
10. Lancet Oncol. 2017 Mar;18(3):384-92.
11. Radiology. 2011 Jul;260:119-28.
Complex atypical hyperplasia (CAH) of the endometrium is considered the precursor for endometrioid endometrial cancer, the most common gynecologic cancer in the United States. This disease is most frequently diagnosed by gynecologists who are evaluating symptoms of abnormal uterine bleeding in premenopausal women or in postmenopausal women who experience new bleeding. Medical therapies, typically progestin-based treatments, can be employed, particularly when fertility preservation is desired or among patients who are poor surgical candidates. However, the most definitive therapy remains surgery with total hysterectomy for two reasons: CAH is associated with a 28% risk for the development of invasive cancer, and occult invasive cancer frequently coexists with CAH.1,2 This raises a question for gynecologists: Given the risk for occult endometrial cancer, should patients be referred to a gynecologic oncologist for their surgery?
What is the risk for cancer?
What is the significance of occult malignancy with CAH?
If surgeons are aware of endometrial cancer preoperatively or intraoperatively, decisions can be made about staging, particularly the need for lymphadenectomy. The virtues of staging in endometrial cancer is a controversial and frequently debated topic. No survival (therapeutic) benefit from lymphadenectomy has been observed in prospective trials when the information from staging results is not used to guide adjuvant therapy.4 However, the administration of adjuvant chemotherapy is associated with improved survival for patients with lymph node metastases.5 Therefore, if there is a benefit to staging with lymphadenectomy, it is its ability to identify patients who most need this life-saving systemic therapy.
Not all patients with endometrial cancer are at equal risk for harboring lymph node metastases and the majority may not benefit from lymphadenectomy. Patients with tumors that are deeply invasive, moderate or high grade, larger than 2 cm, or that have lymphovascular space invasion are at higher risk for lymph node metastases. Women with low grade, minimally invasive tumors that are smaller than 2 cm have extremely low risk for metastases.6 These criteria are commonly employed to stratify women at lowest risk and minimize unnecessary lymphadenectomy procedures. It should be noted that all three of these low risk features must be present to convey that negligible risk profile. The finding of a grade 1 invasive tumor alone is not enough to exclude potential lymph node metastases, particularly in the case of large or deeply invasive cancers.
How can the diagnosis be made preoperatively or intraoperatively?
The gold standard for discriminating between CAH and endometrial cancer is definitive surgical pathology. However, if surgeons wait until these results are available, they have lost the opportunity to stage the patient without subjecting them to a second surgery. The preoperative discovery of cancer may be increased by performing diagnostic curettage rather than relying on office endometrial biopsy sampling.7 This is likely due to the increased volume of tissue removed with dilation and curettage, and a reduction in the risk for sampling error. The addition of hysteroscopy to curettage does not improve upon the detection of cancer. Preoperative MRI to evaluate for depth of myometrial invasion has been described in cases of known endometrial cancer; however, its role in discriminating between CAH and invasive cancer is not well studied.
Intraoperative frozen section is commonly employed to evaluate the hysterectomy specimen for cancer in order to triage patients to staging during that same surgery. However, the accuracy of frozen section with definitive pathology is only approximately 50%.8 This means that at least half of women with CAH will have a false negative frozen section result and will have lost the opportunity for staging at the same procedure. The inaccuracy of frozen section is often overlooked by surgeons who may feel that it is a very straightforward diagnostic procedure. In reality, the characterization of CAH and invasive cancer is technically challenging and relies on multiple sectioning and significant experience in gynecologic pathology.9
Should all patients with CAH be referred and staged?
An alternative to relying on the frozen section process and its inherent inaccuracies would be to routinely stage all women with CAH, knowing that approximately 40% of them have occult cancer, and more than a third of those will have high risk features for lymph node metastases. However, due to the risks associated with lymphadenectomy, particularly lymphedema, most gynecologic oncologists do not routinely stage patients with preoperative CAH with complete lymphadenectomy.
An alternative to the all (complete lymphadenectomy) or none (hysterectomy alone) approach is to perform sentinel lymph node (SLN) biopsy for patients with CAH. SLN biopsy involves removing scant, but high yield lymphatic tissue, and has been shown to be extremely sensitive in detecting metastatic disease.10 This approach is commonly employed by surgeons in the treatment of ductal carcinoma in situ of the breast which, like CAH, is a stage 0 cancer that can be associated with invasive carcinoma on final pathology. In the case of ductal carcinoma in situ, the risk for upstaging is actually substantially lower (25%) than what is observed in CAH.11 Therefore, it would seem even more compelling to apply this approach for endometrial pathologies. The ability to apply the SLN technique is lost after hysterectomy is performed, as there is no longer the target organ into which tracer can be injected; therefore, if SLN biopsy is to be offered to these patients, it needs to be performed using only the preoperative diagnosis of CAH. In this approach, there will be overtreatment of approximately two-thirds of patients, albeit with a less radical and morbid staging procedure.
Making the decision to refer
Ultimately, decisions to refer or not are guided by comprehensive discussions between patient and provider that outline the potential risks and benefits of various approaches. Patients frequently have strong relationships with confidence in their gynecologists who may have cared for them for many years, and may be motivated to have them perform their surgery. For others, the uncertainty and possibility of an unstaged cancer and the potential of a second surgery drives their decision to seek an oncology consultation. Clinicians should discuss the inherent uncertainties in the diagnosis of CAH and the potential for underlying cancer and lymph node metastases, and help patients determine the balance of their underlying competing concerns regarding the risk for inadequate surgery versus the risk of unnecessary surgical procedures.
Summary of recommendations
Invasive endometrial cancer will be identified in the hysterectomy specimens of approximately 40% of women with a preoperative diagnosis of complex endometrial hyperplasia. Preoperative dilation and curettage may reduce the potential for missed occult cancer. Frozen section is an option for determining which patients might benefit from staging but is associated with significant inaccuracies. Failure to diagnose malignancy pre- or intraoperatively handicaps postoperative decision making regarding the necessity of adjuvant chemotherapy, and prevents the ability to offer patients potentially less morbid staging techniques such as SLN biopsy. When gynecologists without oncology training perform these hysterectomies, they should discuss these scenarios to patients and consider referral to gynecologic oncology for patients who desire the potential for comprehensive staging if necessary.
Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina, Chapel Hill. She reports no relevant financial disclosures.
References
1. J Clin Oncol. 2010 Feb;28:788-92.
2. Cancer. 2006 Feb;106:812-9.
3. Int J Gynecol Cancer. 2005 Jan-Feb;15:127-31.
4. Lancet. 2009 Jan;373(9658):125-36.
5. J Clin Oncol. 2006 Jan;24:36-44.
6. Gynecol Oncol 2008 Apr;109:11-8.
7. Am J Obstet Gynecol. 2010 Oct;203(4):349. e1-6.
8. Am J Obstet Gynecol. 2007 May;196(5):e40-2.
9. Obstet Gynecol. 2012 Nov;120(5):1160-75.
10. Lancet Oncol. 2017 Mar;18(3):384-92.
11. Radiology. 2011 Jul;260:119-28.
Complex atypical hyperplasia (CAH) of the endometrium is considered the precursor for endometrioid endometrial cancer, the most common gynecologic cancer in the United States. This disease is most frequently diagnosed by gynecologists who are evaluating symptoms of abnormal uterine bleeding in premenopausal women or in postmenopausal women who experience new bleeding. Medical therapies, typically progestin-based treatments, can be employed, particularly when fertility preservation is desired or among patients who are poor surgical candidates. However, the most definitive therapy remains surgery with total hysterectomy for two reasons: CAH is associated with a 28% risk for the development of invasive cancer, and occult invasive cancer frequently coexists with CAH.1,2 This raises a question for gynecologists: Given the risk for occult endometrial cancer, should patients be referred to a gynecologic oncologist for their surgery?
What is the risk for cancer?
What is the significance of occult malignancy with CAH?
If surgeons are aware of endometrial cancer preoperatively or intraoperatively, decisions can be made about staging, particularly the need for lymphadenectomy. The virtues of staging in endometrial cancer is a controversial and frequently debated topic. No survival (therapeutic) benefit from lymphadenectomy has been observed in prospective trials when the information from staging results is not used to guide adjuvant therapy.4 However, the administration of adjuvant chemotherapy is associated with improved survival for patients with lymph node metastases.5 Therefore, if there is a benefit to staging with lymphadenectomy, it is its ability to identify patients who most need this life-saving systemic therapy.
Not all patients with endometrial cancer are at equal risk for harboring lymph node metastases and the majority may not benefit from lymphadenectomy. Patients with tumors that are deeply invasive, moderate or high grade, larger than 2 cm, or that have lymphovascular space invasion are at higher risk for lymph node metastases. Women with low grade, minimally invasive tumors that are smaller than 2 cm have extremely low risk for metastases.6 These criteria are commonly employed to stratify women at lowest risk and minimize unnecessary lymphadenectomy procedures. It should be noted that all three of these low risk features must be present to convey that negligible risk profile. The finding of a grade 1 invasive tumor alone is not enough to exclude potential lymph node metastases, particularly in the case of large or deeply invasive cancers.
How can the diagnosis be made preoperatively or intraoperatively?
The gold standard for discriminating between CAH and endometrial cancer is definitive surgical pathology. However, if surgeons wait until these results are available, they have lost the opportunity to stage the patient without subjecting them to a second surgery. The preoperative discovery of cancer may be increased by performing diagnostic curettage rather than relying on office endometrial biopsy sampling.7 This is likely due to the increased volume of tissue removed with dilation and curettage, and a reduction in the risk for sampling error. The addition of hysteroscopy to curettage does not improve upon the detection of cancer. Preoperative MRI to evaluate for depth of myometrial invasion has been described in cases of known endometrial cancer; however, its role in discriminating between CAH and invasive cancer is not well studied.
Intraoperative frozen section is commonly employed to evaluate the hysterectomy specimen for cancer in order to triage patients to staging during that same surgery. However, the accuracy of frozen section with definitive pathology is only approximately 50%.8 This means that at least half of women with CAH will have a false negative frozen section result and will have lost the opportunity for staging at the same procedure. The inaccuracy of frozen section is often overlooked by surgeons who may feel that it is a very straightforward diagnostic procedure. In reality, the characterization of CAH and invasive cancer is technically challenging and relies on multiple sectioning and significant experience in gynecologic pathology.9
Should all patients with CAH be referred and staged?
An alternative to relying on the frozen section process and its inherent inaccuracies would be to routinely stage all women with CAH, knowing that approximately 40% of them have occult cancer, and more than a third of those will have high risk features for lymph node metastases. However, due to the risks associated with lymphadenectomy, particularly lymphedema, most gynecologic oncologists do not routinely stage patients with preoperative CAH with complete lymphadenectomy.
An alternative to the all (complete lymphadenectomy) or none (hysterectomy alone) approach is to perform sentinel lymph node (SLN) biopsy for patients with CAH. SLN biopsy involves removing scant, but high yield lymphatic tissue, and has been shown to be extremely sensitive in detecting metastatic disease.10 This approach is commonly employed by surgeons in the treatment of ductal carcinoma in situ of the breast which, like CAH, is a stage 0 cancer that can be associated with invasive carcinoma on final pathology. In the case of ductal carcinoma in situ, the risk for upstaging is actually substantially lower (25%) than what is observed in CAH.11 Therefore, it would seem even more compelling to apply this approach for endometrial pathologies. The ability to apply the SLN technique is lost after hysterectomy is performed, as there is no longer the target organ into which tracer can be injected; therefore, if SLN biopsy is to be offered to these patients, it needs to be performed using only the preoperative diagnosis of CAH. In this approach, there will be overtreatment of approximately two-thirds of patients, albeit with a less radical and morbid staging procedure.
Making the decision to refer
Ultimately, decisions to refer or not are guided by comprehensive discussions between patient and provider that outline the potential risks and benefits of various approaches. Patients frequently have strong relationships with confidence in their gynecologists who may have cared for them for many years, and may be motivated to have them perform their surgery. For others, the uncertainty and possibility of an unstaged cancer and the potential of a second surgery drives their decision to seek an oncology consultation. Clinicians should discuss the inherent uncertainties in the diagnosis of CAH and the potential for underlying cancer and lymph node metastases, and help patients determine the balance of their underlying competing concerns regarding the risk for inadequate surgery versus the risk of unnecessary surgical procedures.
Summary of recommendations
Invasive endometrial cancer will be identified in the hysterectomy specimens of approximately 40% of women with a preoperative diagnosis of complex endometrial hyperplasia. Preoperative dilation and curettage may reduce the potential for missed occult cancer. Frozen section is an option for determining which patients might benefit from staging but is associated with significant inaccuracies. Failure to diagnose malignancy pre- or intraoperatively handicaps postoperative decision making regarding the necessity of adjuvant chemotherapy, and prevents the ability to offer patients potentially less morbid staging techniques such as SLN biopsy. When gynecologists without oncology training perform these hysterectomies, they should discuss these scenarios to patients and consider referral to gynecologic oncology for patients who desire the potential for comprehensive staging if necessary.
Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina, Chapel Hill. She reports no relevant financial disclosures.
References
1. J Clin Oncol. 2010 Feb;28:788-92.
2. Cancer. 2006 Feb;106:812-9.
3. Int J Gynecol Cancer. 2005 Jan-Feb;15:127-31.
4. Lancet. 2009 Jan;373(9658):125-36.
5. J Clin Oncol. 2006 Jan;24:36-44.
6. Gynecol Oncol 2008 Apr;109:11-8.
7. Am J Obstet Gynecol. 2010 Oct;203(4):349. e1-6.
8. Am J Obstet Gynecol. 2007 May;196(5):e40-2.
9. Obstet Gynecol. 2012 Nov;120(5):1160-75.
10. Lancet Oncol. 2017 Mar;18(3):384-92.
11. Radiology. 2011 Jul;260:119-28.
Physician-assisted suicide – an update
Question: Choose the best answer regarding physician-assisted suicide in the United States:
A. It is now legal in most states.
B. Under California law, assisting or causing one to commit suicide, including physician-assisted suicide, still remains a felony.
C. Both the U.S. Supreme Court and the New York Court of Appeals have held there is no constitutional right to physician-assisted suicide.
D. The American Medical Association is neutral on the issue.
E. Pain relief is the overriding reason for patients who request physician-assisted suicide.
Answer: C. We reviewed this topic in one of our regular columns in 2013.1 At that time, efforts to legalize physician-assisted suicide (PAS) appeared to be gathering momentum across the country, with four jurisdictions having legalized the practice, beginning with Oregon in 1994. The other states were Washington, Vermont, and Montana, whose Supreme Court held that there was no public interest reason against the practice.2
Since that time, California, Colorado, and the District of Columbia have joined the group. Currently, PAS – but not euthanasia – is legally available in these jurisdictions and in Switzerland, but both can be legally practiced in Belgium, Canada, Colombia, Luxembourg, and the Netherlands.
All state statutes permitting PAS provide similar provisions and safeguards. Only competent individuals who are terminally ill, i.e., death expected within 6 months, can make a request for a lethal dose of medication to carry out the suicidal act. The request to the doctor is first made verbally, then in writing, and a second opinion must be obtained to confirm the patient’s intent, understanding, and free choice. There is also a waiting period.
Public support for euthanasia and PAS in the United States is said to have plateaued since the 1990s. But a significant number of Americans, 67%, still favor PAS, up from 56% a decade ago.3 However, not many patients resort to PAS – usually those with terminal cancers or neuromuscular conditions – and only a minority of physicians are participants.
For example, 61 physicians in Oregon wrote a total of 115 prescriptions in 2012; there were 77 known Death With Dignity Act deaths in Oregon that year.4 In Oregon and Washington State, less than 1% of licensed physicians write prescriptions for physician-assisted suicide each year. In contrast, about half or more of physicians in the Netherlands and Belgium reported ever having received a request, and 60% of Dutch physicians have granted such requests.
The California Department of Public Health reported that 111 terminally ill patients availed themselves of California’s End of Life Option Act in the 7 months after it became effective on June 9, 2016.
In a recent review on euthanasia and PAS for the period 1947-2016, Ezekiel Emanuel, MD, and colleagues noted that typical patients were older, white, and well educated, and pain was mostly not reported as the primary motivation.5 A large portion of patients receiving PAS in Oregon and Washington were enrolled in hospice or palliative care. Abuses have not been apparent.
In the vast majority of jurisdictions, assisting or causing one to commit suicide, including PAS, still remains a crime; for example, it is considered manslaughter under Hawaii state law §707-702.
In distinguishing between assisting suicide and withdrawing life-sustaining treatment, the U.S. Supreme Court’s landmark 1997 Vacco v. Quill decision emphasized issues of causation and intent.6 On causation, the court reasoned that when a patient refuses life-sustaining treatment, he dies from an underlying fatal disease; but if a patient ingests a lethal medication, he is killed by that medication. As to intent, a physician who honors a patient’s refusal of treatment purposefully intends only to respect his patient’s wishes and to cease doing futile or degrading things. On the other hand, a doctor who assists a suicide “must, necessarily and indubitably, intend primarily that the patient be made dead.”
In its companion case Washington v. Glucksberg, the Supreme Court held that the asserted “right” to assistance in committing suicide is not a fundamental liberty interest protected by the due process clause.7
State supreme courts in Florida, New Mexico, and elsewhere have likewise rebuffed claims of any constitutional right to PAS. The latest court to so rule is in New York, which has a long history of criminalizing assisted suicide.8 The New York Court of Appeals recently addressed claims brought by three terminally ill individuals, several medical providers, and a nonprofit entity seeking a declaration that New York’s “assisted suicide” statutes exclude physicians from prescribing a lethal dose of drugs to terminally ill, competent patients.
The court unequivocally rejected such claims and affirmed that a physician who assists a suicide by prescribing lethal doses of drugs is subject to criminal prosecution for second-degree manslaughter. It refused to regard PAS as being different from assisted suicide in general, and it rejected the constitutional claim to assisted suicide by a terminally ill person. The state appeals court reiterated the U.S. Supreme Court’s distinction between refusing life-sustaining treatment and assisted suicide, the former being “at least partially rooted in notions of bodily integrity, as the right to refuse treatment is a consequence of a person’s right to resist unwanted bodily invasions.” The New York Court of Appeals also noted that the state has a legitimate purpose and a rational basis for guarding against the risks of mistake and abuse.
These developments may signal a shift away from the legalization of PAS, as recently suggested in a Washington Post article.9 According to the end-of-life advocacy organization Compassion and Choices, none of the 27 states where such measures were introduced in 2017 passed them into law, including states such as Connecticut, Hawaii, and Rhode Island. In Central and Eastern Europe, support is decreasing, whereas the opposite is true in Western Europe.
U.S. federal lawmakers also appear to be pushing back. On July 13, 2017, the U.S. House Committee on Appropriations voted to block implementation of a “death with dignity” statute passed by the District of Columbia. Further, 11 House members – including 6 Democrats – have introduced a resolution asserting that PAS undermines a key safeguard that protects our nation’s most vulnerable citizens, including the elderly, people with disabilities, and people experiencing psychiatric diagnoses.10
The American Medical Association is steadfast in its opposition to PAS and euthanasia. In its latest Code of Ethics, the AMA reaffirmed its long-held position that “allowing physicians to engage in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. … Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.”11
References
1. “Physician-assisted suicide,” Internal Medicine News, Oct. 14, 2013.
2. Baxter v. State of Montana, 224 P. 3d 1211 (2010).
3. “Majority of Americans Remain Supportive of Euthanasia,” Gallup News, June 12, 2017.
4. Statistics available at public.health.oregon.gov under Oregon Death with Dignity Act.
5. JAMA. 2016 Jul 5;316(1):79-90.
6. Vacco v. Quill, 117 S. Ct. 2293 (1997).
7. Washington v. Glucksberg, 521 U.S. 702 (1997).
8. Myers v. Schneiderman, New York Court of Appeals, 2017.
9. “Legalizing assisted suicide has stalled at every level,” Washington Post, Oct. 24, 2017.
10. H. Con. Res. 80, 115th Congress (2017-2018).
11. AMA Code of Medical Ethics §5.7 (2017).
Question: Choose the best answer regarding physician-assisted suicide in the United States:
A. It is now legal in most states.
B. Under California law, assisting or causing one to commit suicide, including physician-assisted suicide, still remains a felony.
C. Both the U.S. Supreme Court and the New York Court of Appeals have held there is no constitutional right to physician-assisted suicide.
D. The American Medical Association is neutral on the issue.
E. Pain relief is the overriding reason for patients who request physician-assisted suicide.
Answer: C. We reviewed this topic in one of our regular columns in 2013.1 At that time, efforts to legalize physician-assisted suicide (PAS) appeared to be gathering momentum across the country, with four jurisdictions having legalized the practice, beginning with Oregon in 1994. The other states were Washington, Vermont, and Montana, whose Supreme Court held that there was no public interest reason against the practice.2
Since that time, California, Colorado, and the District of Columbia have joined the group. Currently, PAS – but not euthanasia – is legally available in these jurisdictions and in Switzerland, but both can be legally practiced in Belgium, Canada, Colombia, Luxembourg, and the Netherlands.
All state statutes permitting PAS provide similar provisions and safeguards. Only competent individuals who are terminally ill, i.e., death expected within 6 months, can make a request for a lethal dose of medication to carry out the suicidal act. The request to the doctor is first made verbally, then in writing, and a second opinion must be obtained to confirm the patient’s intent, understanding, and free choice. There is also a waiting period.
Public support for euthanasia and PAS in the United States is said to have plateaued since the 1990s. But a significant number of Americans, 67%, still favor PAS, up from 56% a decade ago.3 However, not many patients resort to PAS – usually those with terminal cancers or neuromuscular conditions – and only a minority of physicians are participants.
For example, 61 physicians in Oregon wrote a total of 115 prescriptions in 2012; there were 77 known Death With Dignity Act deaths in Oregon that year.4 In Oregon and Washington State, less than 1% of licensed physicians write prescriptions for physician-assisted suicide each year. In contrast, about half or more of physicians in the Netherlands and Belgium reported ever having received a request, and 60% of Dutch physicians have granted such requests.
The California Department of Public Health reported that 111 terminally ill patients availed themselves of California’s End of Life Option Act in the 7 months after it became effective on June 9, 2016.
In a recent review on euthanasia and PAS for the period 1947-2016, Ezekiel Emanuel, MD, and colleagues noted that typical patients were older, white, and well educated, and pain was mostly not reported as the primary motivation.5 A large portion of patients receiving PAS in Oregon and Washington were enrolled in hospice or palliative care. Abuses have not been apparent.
In the vast majority of jurisdictions, assisting or causing one to commit suicide, including PAS, still remains a crime; for example, it is considered manslaughter under Hawaii state law §707-702.
In distinguishing between assisting suicide and withdrawing life-sustaining treatment, the U.S. Supreme Court’s landmark 1997 Vacco v. Quill decision emphasized issues of causation and intent.6 On causation, the court reasoned that when a patient refuses life-sustaining treatment, he dies from an underlying fatal disease; but if a patient ingests a lethal medication, he is killed by that medication. As to intent, a physician who honors a patient’s refusal of treatment purposefully intends only to respect his patient’s wishes and to cease doing futile or degrading things. On the other hand, a doctor who assists a suicide “must, necessarily and indubitably, intend primarily that the patient be made dead.”
In its companion case Washington v. Glucksberg, the Supreme Court held that the asserted “right” to assistance in committing suicide is not a fundamental liberty interest protected by the due process clause.7
State supreme courts in Florida, New Mexico, and elsewhere have likewise rebuffed claims of any constitutional right to PAS. The latest court to so rule is in New York, which has a long history of criminalizing assisted suicide.8 The New York Court of Appeals recently addressed claims brought by three terminally ill individuals, several medical providers, and a nonprofit entity seeking a declaration that New York’s “assisted suicide” statutes exclude physicians from prescribing a lethal dose of drugs to terminally ill, competent patients.
The court unequivocally rejected such claims and affirmed that a physician who assists a suicide by prescribing lethal doses of drugs is subject to criminal prosecution for second-degree manslaughter. It refused to regard PAS as being different from assisted suicide in general, and it rejected the constitutional claim to assisted suicide by a terminally ill person. The state appeals court reiterated the U.S. Supreme Court’s distinction between refusing life-sustaining treatment and assisted suicide, the former being “at least partially rooted in notions of bodily integrity, as the right to refuse treatment is a consequence of a person’s right to resist unwanted bodily invasions.” The New York Court of Appeals also noted that the state has a legitimate purpose and a rational basis for guarding against the risks of mistake and abuse.
These developments may signal a shift away from the legalization of PAS, as recently suggested in a Washington Post article.9 According to the end-of-life advocacy organization Compassion and Choices, none of the 27 states where such measures were introduced in 2017 passed them into law, including states such as Connecticut, Hawaii, and Rhode Island. In Central and Eastern Europe, support is decreasing, whereas the opposite is true in Western Europe.
U.S. federal lawmakers also appear to be pushing back. On July 13, 2017, the U.S. House Committee on Appropriations voted to block implementation of a “death with dignity” statute passed by the District of Columbia. Further, 11 House members – including 6 Democrats – have introduced a resolution asserting that PAS undermines a key safeguard that protects our nation’s most vulnerable citizens, including the elderly, people with disabilities, and people experiencing psychiatric diagnoses.10
The American Medical Association is steadfast in its opposition to PAS and euthanasia. In its latest Code of Ethics, the AMA reaffirmed its long-held position that “allowing physicians to engage in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. … Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.”11
References
1. “Physician-assisted suicide,” Internal Medicine News, Oct. 14, 2013.
2. Baxter v. State of Montana, 224 P. 3d 1211 (2010).
3. “Majority of Americans Remain Supportive of Euthanasia,” Gallup News, June 12, 2017.
4. Statistics available at public.health.oregon.gov under Oregon Death with Dignity Act.
5. JAMA. 2016 Jul 5;316(1):79-90.
6. Vacco v. Quill, 117 S. Ct. 2293 (1997).
7. Washington v. Glucksberg, 521 U.S. 702 (1997).
8. Myers v. Schneiderman, New York Court of Appeals, 2017.
9. “Legalizing assisted suicide has stalled at every level,” Washington Post, Oct. 24, 2017.
10. H. Con. Res. 80, 115th Congress (2017-2018).
11. AMA Code of Medical Ethics §5.7 (2017).
Question: Choose the best answer regarding physician-assisted suicide in the United States:
A. It is now legal in most states.
B. Under California law, assisting or causing one to commit suicide, including physician-assisted suicide, still remains a felony.
C. Both the U.S. Supreme Court and the New York Court of Appeals have held there is no constitutional right to physician-assisted suicide.
D. The American Medical Association is neutral on the issue.
E. Pain relief is the overriding reason for patients who request physician-assisted suicide.
Answer: C. We reviewed this topic in one of our regular columns in 2013.1 At that time, efforts to legalize physician-assisted suicide (PAS) appeared to be gathering momentum across the country, with four jurisdictions having legalized the practice, beginning with Oregon in 1994. The other states were Washington, Vermont, and Montana, whose Supreme Court held that there was no public interest reason against the practice.2
Since that time, California, Colorado, and the District of Columbia have joined the group. Currently, PAS – but not euthanasia – is legally available in these jurisdictions and in Switzerland, but both can be legally practiced in Belgium, Canada, Colombia, Luxembourg, and the Netherlands.
All state statutes permitting PAS provide similar provisions and safeguards. Only competent individuals who are terminally ill, i.e., death expected within 6 months, can make a request for a lethal dose of medication to carry out the suicidal act. The request to the doctor is first made verbally, then in writing, and a second opinion must be obtained to confirm the patient’s intent, understanding, and free choice. There is also a waiting period.
Public support for euthanasia and PAS in the United States is said to have plateaued since the 1990s. But a significant number of Americans, 67%, still favor PAS, up from 56% a decade ago.3 However, not many patients resort to PAS – usually those with terminal cancers or neuromuscular conditions – and only a minority of physicians are participants.
For example, 61 physicians in Oregon wrote a total of 115 prescriptions in 2012; there were 77 known Death With Dignity Act deaths in Oregon that year.4 In Oregon and Washington State, less than 1% of licensed physicians write prescriptions for physician-assisted suicide each year. In contrast, about half or more of physicians in the Netherlands and Belgium reported ever having received a request, and 60% of Dutch physicians have granted such requests.
The California Department of Public Health reported that 111 terminally ill patients availed themselves of California’s End of Life Option Act in the 7 months after it became effective on June 9, 2016.
In a recent review on euthanasia and PAS for the period 1947-2016, Ezekiel Emanuel, MD, and colleagues noted that typical patients were older, white, and well educated, and pain was mostly not reported as the primary motivation.5 A large portion of patients receiving PAS in Oregon and Washington were enrolled in hospice or palliative care. Abuses have not been apparent.
In the vast majority of jurisdictions, assisting or causing one to commit suicide, including PAS, still remains a crime; for example, it is considered manslaughter under Hawaii state law §707-702.
In distinguishing between assisting suicide and withdrawing life-sustaining treatment, the U.S. Supreme Court’s landmark 1997 Vacco v. Quill decision emphasized issues of causation and intent.6 On causation, the court reasoned that when a patient refuses life-sustaining treatment, he dies from an underlying fatal disease; but if a patient ingests a lethal medication, he is killed by that medication. As to intent, a physician who honors a patient’s refusal of treatment purposefully intends only to respect his patient’s wishes and to cease doing futile or degrading things. On the other hand, a doctor who assists a suicide “must, necessarily and indubitably, intend primarily that the patient be made dead.”
In its companion case Washington v. Glucksberg, the Supreme Court held that the asserted “right” to assistance in committing suicide is not a fundamental liberty interest protected by the due process clause.7
State supreme courts in Florida, New Mexico, and elsewhere have likewise rebuffed claims of any constitutional right to PAS. The latest court to so rule is in New York, which has a long history of criminalizing assisted suicide.8 The New York Court of Appeals recently addressed claims brought by three terminally ill individuals, several medical providers, and a nonprofit entity seeking a declaration that New York’s “assisted suicide” statutes exclude physicians from prescribing a lethal dose of drugs to terminally ill, competent patients.
The court unequivocally rejected such claims and affirmed that a physician who assists a suicide by prescribing lethal doses of drugs is subject to criminal prosecution for second-degree manslaughter. It refused to regard PAS as being different from assisted suicide in general, and it rejected the constitutional claim to assisted suicide by a terminally ill person. The state appeals court reiterated the U.S. Supreme Court’s distinction between refusing life-sustaining treatment and assisted suicide, the former being “at least partially rooted in notions of bodily integrity, as the right to refuse treatment is a consequence of a person’s right to resist unwanted bodily invasions.” The New York Court of Appeals also noted that the state has a legitimate purpose and a rational basis for guarding against the risks of mistake and abuse.
These developments may signal a shift away from the legalization of PAS, as recently suggested in a Washington Post article.9 According to the end-of-life advocacy organization Compassion and Choices, none of the 27 states where such measures were introduced in 2017 passed them into law, including states such as Connecticut, Hawaii, and Rhode Island. In Central and Eastern Europe, support is decreasing, whereas the opposite is true in Western Europe.
U.S. federal lawmakers also appear to be pushing back. On July 13, 2017, the U.S. House Committee on Appropriations voted to block implementation of a “death with dignity” statute passed by the District of Columbia. Further, 11 House members – including 6 Democrats – have introduced a resolution asserting that PAS undermines a key safeguard that protects our nation’s most vulnerable citizens, including the elderly, people with disabilities, and people experiencing psychiatric diagnoses.10
The American Medical Association is steadfast in its opposition to PAS and euthanasia. In its latest Code of Ethics, the AMA reaffirmed its long-held position that “allowing physicians to engage in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. … Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.”11
References
1. “Physician-assisted suicide,” Internal Medicine News, Oct. 14, 2013.
2. Baxter v. State of Montana, 224 P. 3d 1211 (2010).
3. “Majority of Americans Remain Supportive of Euthanasia,” Gallup News, June 12, 2017.
4. Statistics available at public.health.oregon.gov under Oregon Death with Dignity Act.
5. JAMA. 2016 Jul 5;316(1):79-90.
6. Vacco v. Quill, 117 S. Ct. 2293 (1997).
7. Washington v. Glucksberg, 521 U.S. 702 (1997).
8. Myers v. Schneiderman, New York Court of Appeals, 2017.
9. “Legalizing assisted suicide has stalled at every level,” Washington Post, Oct. 24, 2017.
10. H. Con. Res. 80, 115th Congress (2017-2018).
11. AMA Code of Medical Ethics §5.7 (2017).
The (Friendly) Ghosts of Emergency Medicine Past, Present, and Yet to Come
Past…
Almost 40 years have elapsed since the American Board of Medical Specialties recognized emergency medicine (EM) as the 23rd medical specialty. Though the fundamental principles of patient care, medical education, and certification established by the American Board of Emergency Medicine (ABEM) have stood the test of time, the ED of today is a very different place than the “ER” of 1979. So too, today’s emergency physicians (EPs) are not only better trained and more capable of providing the highest quality of care in the ED, but are also increasingly doing so in venues outside of the traditional hospital-based ED.
Present...
In 1996, The New York Hospital – Cornell University Medical Center recruited me to be their first emergency physician-in-chief and EMS medical director, and to establish a first-rate academic ED and EM residency program. Starting with an “ER” staff of eight full-time and part-time non-EM-boarded attending physicians and a varying number of medical and surgical residents, over the next 20 years I expanded the complement of board-certified attending EPs to over 50, added attending-supervised nurse practitioners (NPs) and physician assistants (PAs), recruited a residency director, and helped him start a 4-year EM residency on both our Cornell and Columbia campuses. I also supported the initiation of 1-year ED nurse, PA, and NP residency programs. In corroboration with the chair of radiology, we added 24-hour dedicated sonography technologists to supplement the bedside emergency sonography that we had just been credentialed to perform, and established one of the very first divisions of emergency radiology, headed by EM board member and columnist, Keith Hentel, MD. Keith staffed his division with 24/7 attending radiologists to interpret all ED radiographic studies and provide imaging advice. More recently, I was able to arrange for dedicated 24/7 ED pharmacists, 24/7 ED social workers, and a patient safety/quality assurance division.
When I arrived at New York – Cornell, I supported the expansion of the ED patient services already in place, headed by an incredibly skilled and compassionate director, Constance Peterson, MA, who always insisted that her small office open directly off of the ED waiting room. Constance recruited and supervised a group of dedicated patient greeters and facilitators to ensure that no patient would get lost or fall through the “cracks” of our ever-expanding ED.
The plans for a new ED located at the front entrance to the hospital had literally been “carved in stone” by the time I arrived, but a decade later a magnificent gift from a donor gave me the opportunity to design a fourth patient-care area that expanded our ED to two full city blocks. I designed the new addition to serve the specific needs of a rapidly aging population and to provide a secure unit capable of managing patients with new or emerging infectious diseases and those with compromised immune systems. I also included in the new unit a large, state-of-the-art gynecologic (GYN) examination suite for conducting sexual assault exams and other GYN exams while providing the patient with a maximum level of comfort.
To coordinate activities throughout the ED and to provide a rapid expansion of staff when needed to manage surges in patient volume, I divided the ED into three acute areas and one urgent care area, each headed by an attending physician 24/7. One of the attendings was designated as the “administrative attending” or “AA.” Among other responsibilities, the AA was required to e-mail me and Associate Director Jeremy Sperling, MD, (now chair of EM at Einstein/Jacobi) a detailed note on patient volume, rate of new registrations, and any problems, at the end of every 8-hour shift—or more frequently when the need arose. Whenever patient volume was in danger of exceeding capacity, Jeremy immediately sent an urgent e-mail to all of our attending EPs, PAs, and NPs, offering double the hourly rate for 4 to 8 hours of patient care, while adhering to all relevant work-hour requirements. To cover the cost of these additional emergency clinical hours, I made a small portion of our fee-for-service revenues available. Two years ago, I initiated a physician scribe program to restore the physician-patient relationship during patient evaluations and treatments.
With the successful establishment of our EM residency program by Wallace Carter, MD, in 2003, I started 1- and 2-year fellowships in new disciplines for a 21st century ED—using a portion of our fee-for-service revenues designated for research and development to supplement the part-time attending base salaries of non-ACGME fellows. Beginning in 2005, I established the nation’s first geriatric EM fellowship, supported our newly established global EM program, recruited one of our attending EPs, Jay Lemery, MD, to start a wilderness medicine program in the Adirondack Mountains with Cornell (University) Outdoor Education, and appointed a director of EM/critical care. The ED expansion in 2009 enabled me to hire five attending EPs who were also board eligible/certified in medical toxicology, creating a “tox” group for bedside guidance and care in the ED and consultations throughout the hospital. The tox group also provided invaluable assistance to our secure psychiatric ED, headed by renowned emergency psychiatrists Lisa Sombrotto, MD, and Sharon Hird, MD. I also supported the activities of the pediatric EM fellowship, which had been established and nurtured by our extremely capable chief of pediatric EM, Shari Platt, MD. Most recently, I began to develop a new program in women’s health emergencies.
To expedite emergently needed care for an increasing number of oncology patients, I created a special “fast-track” to ensure that febrile cancer-treatment patients received needed antibiotics within an hour of arrival. I created a second fast-track to expedite the diagnosis and treatment (ie, transfer to the OR) of patients with surgical abdomens, and a third track to expedite the care of patients with community-acquired pneumonia.
And Yet to Come…
The programs and divisions described were developed over a 20-year period, always mindful of the standards and quality measures first promulgated by ABEM in 1979. New hospital-based ED initiatives will undoubtedly continue to be created in the future by EPs who are challenged to develop new and effective ways of caring for the ever-increasing numbers of patients in the face of continued hospital and ED closings.
At the same time, the increased numbers of patients seeking care in EDs, most recently created by the Affordable Care Act of 2010, is leading many EPs to apply the skills they learned as residents and their hospital-based ED experiences in new venues for emergency care. In recent years, there has been a virtual explosion in the number of urgent care centers, freestanding EDs, “convenient-care” centers, and even remote patient care in the form of “telehealth” or “telemedicine.” In 2014, when the National Hockey League mandated the presence of EPs at all games, I negotiated a contract that also enables our attending EPs to have senior residents accompany them and observe the practice of EM outside hospital walls. Prehospital and “interhospital” care also continues to expand with an increasing need for critical care and long-distance patient transfers to and from hospitals, and with a growing interest in community para-medicine programs.
In an October 2012 editorial (Emerg Med. 2012;44[10]:4), I wrote about French high-wire acrobat Philippe Petit who had rigged a cable between the two towers of the World Trade Center in August 1974, and then “aided only by a long, custom-made balancing pole, crossed, re-crossed, and danced on the wire without a safety net, for 45 minutes.” Most observers that day were certain he would fall to his death, and no one imagined that he would survive and outlast the 110-story towers he had anchored his cable to. So too, with EM: Hospital-based EDs will certainly remain an essential part of EM in the years to come, but EPs will also have increasing opportunities to practice their specialty in other important venues as well. The EP of the future will not be bound to a particular location to practice EM.
As I have this time of year for the past 11 years, I wish all of our readers, and all EPs everywhere, a joyous and safe holiday season and many happy and healthy new years to come.
Past…
Almost 40 years have elapsed since the American Board of Medical Specialties recognized emergency medicine (EM) as the 23rd medical specialty. Though the fundamental principles of patient care, medical education, and certification established by the American Board of Emergency Medicine (ABEM) have stood the test of time, the ED of today is a very different place than the “ER” of 1979. So too, today’s emergency physicians (EPs) are not only better trained and more capable of providing the highest quality of care in the ED, but are also increasingly doing so in venues outside of the traditional hospital-based ED.
Present...
In 1996, The New York Hospital – Cornell University Medical Center recruited me to be their first emergency physician-in-chief and EMS medical director, and to establish a first-rate academic ED and EM residency program. Starting with an “ER” staff of eight full-time and part-time non-EM-boarded attending physicians and a varying number of medical and surgical residents, over the next 20 years I expanded the complement of board-certified attending EPs to over 50, added attending-supervised nurse practitioners (NPs) and physician assistants (PAs), recruited a residency director, and helped him start a 4-year EM residency on both our Cornell and Columbia campuses. I also supported the initiation of 1-year ED nurse, PA, and NP residency programs. In corroboration with the chair of radiology, we added 24-hour dedicated sonography technologists to supplement the bedside emergency sonography that we had just been credentialed to perform, and established one of the very first divisions of emergency radiology, headed by EM board member and columnist, Keith Hentel, MD. Keith staffed his division with 24/7 attending radiologists to interpret all ED radiographic studies and provide imaging advice. More recently, I was able to arrange for dedicated 24/7 ED pharmacists, 24/7 ED social workers, and a patient safety/quality assurance division.
When I arrived at New York – Cornell, I supported the expansion of the ED patient services already in place, headed by an incredibly skilled and compassionate director, Constance Peterson, MA, who always insisted that her small office open directly off of the ED waiting room. Constance recruited and supervised a group of dedicated patient greeters and facilitators to ensure that no patient would get lost or fall through the “cracks” of our ever-expanding ED.
The plans for a new ED located at the front entrance to the hospital had literally been “carved in stone” by the time I arrived, but a decade later a magnificent gift from a donor gave me the opportunity to design a fourth patient-care area that expanded our ED to two full city blocks. I designed the new addition to serve the specific needs of a rapidly aging population and to provide a secure unit capable of managing patients with new or emerging infectious diseases and those with compromised immune systems. I also included in the new unit a large, state-of-the-art gynecologic (GYN) examination suite for conducting sexual assault exams and other GYN exams while providing the patient with a maximum level of comfort.
To coordinate activities throughout the ED and to provide a rapid expansion of staff when needed to manage surges in patient volume, I divided the ED into three acute areas and one urgent care area, each headed by an attending physician 24/7. One of the attendings was designated as the “administrative attending” or “AA.” Among other responsibilities, the AA was required to e-mail me and Associate Director Jeremy Sperling, MD, (now chair of EM at Einstein/Jacobi) a detailed note on patient volume, rate of new registrations, and any problems, at the end of every 8-hour shift—or more frequently when the need arose. Whenever patient volume was in danger of exceeding capacity, Jeremy immediately sent an urgent e-mail to all of our attending EPs, PAs, and NPs, offering double the hourly rate for 4 to 8 hours of patient care, while adhering to all relevant work-hour requirements. To cover the cost of these additional emergency clinical hours, I made a small portion of our fee-for-service revenues available. Two years ago, I initiated a physician scribe program to restore the physician-patient relationship during patient evaluations and treatments.
With the successful establishment of our EM residency program by Wallace Carter, MD, in 2003, I started 1- and 2-year fellowships in new disciplines for a 21st century ED—using a portion of our fee-for-service revenues designated for research and development to supplement the part-time attending base salaries of non-ACGME fellows. Beginning in 2005, I established the nation’s first geriatric EM fellowship, supported our newly established global EM program, recruited one of our attending EPs, Jay Lemery, MD, to start a wilderness medicine program in the Adirondack Mountains with Cornell (University) Outdoor Education, and appointed a director of EM/critical care. The ED expansion in 2009 enabled me to hire five attending EPs who were also board eligible/certified in medical toxicology, creating a “tox” group for bedside guidance and care in the ED and consultations throughout the hospital. The tox group also provided invaluable assistance to our secure psychiatric ED, headed by renowned emergency psychiatrists Lisa Sombrotto, MD, and Sharon Hird, MD. I also supported the activities of the pediatric EM fellowship, which had been established and nurtured by our extremely capable chief of pediatric EM, Shari Platt, MD. Most recently, I began to develop a new program in women’s health emergencies.
To expedite emergently needed care for an increasing number of oncology patients, I created a special “fast-track” to ensure that febrile cancer-treatment patients received needed antibiotics within an hour of arrival. I created a second fast-track to expedite the diagnosis and treatment (ie, transfer to the OR) of patients with surgical abdomens, and a third track to expedite the care of patients with community-acquired pneumonia.
And Yet to Come…
The programs and divisions described were developed over a 20-year period, always mindful of the standards and quality measures first promulgated by ABEM in 1979. New hospital-based ED initiatives will undoubtedly continue to be created in the future by EPs who are challenged to develop new and effective ways of caring for the ever-increasing numbers of patients in the face of continued hospital and ED closings.
At the same time, the increased numbers of patients seeking care in EDs, most recently created by the Affordable Care Act of 2010, is leading many EPs to apply the skills they learned as residents and their hospital-based ED experiences in new venues for emergency care. In recent years, there has been a virtual explosion in the number of urgent care centers, freestanding EDs, “convenient-care” centers, and even remote patient care in the form of “telehealth” or “telemedicine.” In 2014, when the National Hockey League mandated the presence of EPs at all games, I negotiated a contract that also enables our attending EPs to have senior residents accompany them and observe the practice of EM outside hospital walls. Prehospital and “interhospital” care also continues to expand with an increasing need for critical care and long-distance patient transfers to and from hospitals, and with a growing interest in community para-medicine programs.
In an October 2012 editorial (Emerg Med. 2012;44[10]:4), I wrote about French high-wire acrobat Philippe Petit who had rigged a cable between the two towers of the World Trade Center in August 1974, and then “aided only by a long, custom-made balancing pole, crossed, re-crossed, and danced on the wire without a safety net, for 45 minutes.” Most observers that day were certain he would fall to his death, and no one imagined that he would survive and outlast the 110-story towers he had anchored his cable to. So too, with EM: Hospital-based EDs will certainly remain an essential part of EM in the years to come, but EPs will also have increasing opportunities to practice their specialty in other important venues as well. The EP of the future will not be bound to a particular location to practice EM.
As I have this time of year for the past 11 years, I wish all of our readers, and all EPs everywhere, a joyous and safe holiday season and many happy and healthy new years to come.
Past…
Almost 40 years have elapsed since the American Board of Medical Specialties recognized emergency medicine (EM) as the 23rd medical specialty. Though the fundamental principles of patient care, medical education, and certification established by the American Board of Emergency Medicine (ABEM) have stood the test of time, the ED of today is a very different place than the “ER” of 1979. So too, today’s emergency physicians (EPs) are not only better trained and more capable of providing the highest quality of care in the ED, but are also increasingly doing so in venues outside of the traditional hospital-based ED.
Present...
In 1996, The New York Hospital – Cornell University Medical Center recruited me to be their first emergency physician-in-chief and EMS medical director, and to establish a first-rate academic ED and EM residency program. Starting with an “ER” staff of eight full-time and part-time non-EM-boarded attending physicians and a varying number of medical and surgical residents, over the next 20 years I expanded the complement of board-certified attending EPs to over 50, added attending-supervised nurse practitioners (NPs) and physician assistants (PAs), recruited a residency director, and helped him start a 4-year EM residency on both our Cornell and Columbia campuses. I also supported the initiation of 1-year ED nurse, PA, and NP residency programs. In corroboration with the chair of radiology, we added 24-hour dedicated sonography technologists to supplement the bedside emergency sonography that we had just been credentialed to perform, and established one of the very first divisions of emergency radiology, headed by EM board member and columnist, Keith Hentel, MD. Keith staffed his division with 24/7 attending radiologists to interpret all ED radiographic studies and provide imaging advice. More recently, I was able to arrange for dedicated 24/7 ED pharmacists, 24/7 ED social workers, and a patient safety/quality assurance division.
When I arrived at New York – Cornell, I supported the expansion of the ED patient services already in place, headed by an incredibly skilled and compassionate director, Constance Peterson, MA, who always insisted that her small office open directly off of the ED waiting room. Constance recruited and supervised a group of dedicated patient greeters and facilitators to ensure that no patient would get lost or fall through the “cracks” of our ever-expanding ED.
The plans for a new ED located at the front entrance to the hospital had literally been “carved in stone” by the time I arrived, but a decade later a magnificent gift from a donor gave me the opportunity to design a fourth patient-care area that expanded our ED to two full city blocks. I designed the new addition to serve the specific needs of a rapidly aging population and to provide a secure unit capable of managing patients with new or emerging infectious diseases and those with compromised immune systems. I also included in the new unit a large, state-of-the-art gynecologic (GYN) examination suite for conducting sexual assault exams and other GYN exams while providing the patient with a maximum level of comfort.
To coordinate activities throughout the ED and to provide a rapid expansion of staff when needed to manage surges in patient volume, I divided the ED into three acute areas and one urgent care area, each headed by an attending physician 24/7. One of the attendings was designated as the “administrative attending” or “AA.” Among other responsibilities, the AA was required to e-mail me and Associate Director Jeremy Sperling, MD, (now chair of EM at Einstein/Jacobi) a detailed note on patient volume, rate of new registrations, and any problems, at the end of every 8-hour shift—or more frequently when the need arose. Whenever patient volume was in danger of exceeding capacity, Jeremy immediately sent an urgent e-mail to all of our attending EPs, PAs, and NPs, offering double the hourly rate for 4 to 8 hours of patient care, while adhering to all relevant work-hour requirements. To cover the cost of these additional emergency clinical hours, I made a small portion of our fee-for-service revenues available. Two years ago, I initiated a physician scribe program to restore the physician-patient relationship during patient evaluations and treatments.
With the successful establishment of our EM residency program by Wallace Carter, MD, in 2003, I started 1- and 2-year fellowships in new disciplines for a 21st century ED—using a portion of our fee-for-service revenues designated for research and development to supplement the part-time attending base salaries of non-ACGME fellows. Beginning in 2005, I established the nation’s first geriatric EM fellowship, supported our newly established global EM program, recruited one of our attending EPs, Jay Lemery, MD, to start a wilderness medicine program in the Adirondack Mountains with Cornell (University) Outdoor Education, and appointed a director of EM/critical care. The ED expansion in 2009 enabled me to hire five attending EPs who were also board eligible/certified in medical toxicology, creating a “tox” group for bedside guidance and care in the ED and consultations throughout the hospital. The tox group also provided invaluable assistance to our secure psychiatric ED, headed by renowned emergency psychiatrists Lisa Sombrotto, MD, and Sharon Hird, MD. I also supported the activities of the pediatric EM fellowship, which had been established and nurtured by our extremely capable chief of pediatric EM, Shari Platt, MD. Most recently, I began to develop a new program in women’s health emergencies.
To expedite emergently needed care for an increasing number of oncology patients, I created a special “fast-track” to ensure that febrile cancer-treatment patients received needed antibiotics within an hour of arrival. I created a second fast-track to expedite the diagnosis and treatment (ie, transfer to the OR) of patients with surgical abdomens, and a third track to expedite the care of patients with community-acquired pneumonia.
And Yet to Come…
The programs and divisions described were developed over a 20-year period, always mindful of the standards and quality measures first promulgated by ABEM in 1979. New hospital-based ED initiatives will undoubtedly continue to be created in the future by EPs who are challenged to develop new and effective ways of caring for the ever-increasing numbers of patients in the face of continued hospital and ED closings.
At the same time, the increased numbers of patients seeking care in EDs, most recently created by the Affordable Care Act of 2010, is leading many EPs to apply the skills they learned as residents and their hospital-based ED experiences in new venues for emergency care. In recent years, there has been a virtual explosion in the number of urgent care centers, freestanding EDs, “convenient-care” centers, and even remote patient care in the form of “telehealth” or “telemedicine.” In 2014, when the National Hockey League mandated the presence of EPs at all games, I negotiated a contract that also enables our attending EPs to have senior residents accompany them and observe the practice of EM outside hospital walls. Prehospital and “interhospital” care also continues to expand with an increasing need for critical care and long-distance patient transfers to and from hospitals, and with a growing interest in community para-medicine programs.
In an October 2012 editorial (Emerg Med. 2012;44[10]:4), I wrote about French high-wire acrobat Philippe Petit who had rigged a cable between the two towers of the World Trade Center in August 1974, and then “aided only by a long, custom-made balancing pole, crossed, re-crossed, and danced on the wire without a safety net, for 45 minutes.” Most observers that day were certain he would fall to his death, and no one imagined that he would survive and outlast the 110-story towers he had anchored his cable to. So too, with EM: Hospital-based EDs will certainly remain an essential part of EM in the years to come, but EPs will also have increasing opportunities to practice their specialty in other important venues as well. The EP of the future will not be bound to a particular location to practice EM.
As I have this time of year for the past 11 years, I wish all of our readers, and all EPs everywhere, a joyous and safe holiday season and many happy and healthy new years to come.
