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Flu shots and persuasion
Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.
At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.
Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:
- The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
- The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
- The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
- The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
- The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.
“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.
At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.
Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:
- The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
- The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
- The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
- The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
- The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.
“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.
At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.
Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:
- The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
- The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
- The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
- The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
- The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.
“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
When is technology ready for mainstream use for mental health care?
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
Good for something, or an American tragedy
The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.
The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.
I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.
I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.
I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.
The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.
I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.
I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.
I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.
The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.
I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.
I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.
I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The cost of conflation: Avoiding loose talk about the duty to warn
The campaign, election, and administration of President Donald Trump have reinvigorated debate over rule 7.3 of the American Psychiatric Association (APA) code of ethics. Known as the Goldwater Rule for its historical roots in a magazine profile and subsequent libel suit by the 1964 Republican presidential nominee,1 this standard deems it unethical for a psychiatrist to offer a professional opinion of a public figure without conducting an examination and obtaining authorization.2 The American Psychological Association similarly provides that assessments must be based on adequate examination of the individual.3
Growing controversy
Shortly after President Trump’s inauguration, a group of 35 mental health professionals penned a letter in the New York Times stating that he was “incapable of serving safely as president.” Importantly, the writers couched their conclusions in professional expertise and specifically criticized the Goldwater Rule as having subjected their colleagues to self-imposed silence.4 A prominent psychiatrist, Allen J. Frances, MD, responded the following day to caution against “psychiatric name-calling” as a substitute for political action.5
Since then, psychiatrists classifying the APA ethics position as a “gag rule” preventing them from performing a public service have garnered considerable press coverage. When the American Psychoanalytic Association (APsaA) reiterated this summer that only APA members are bound by the Goldwater Rule, Boston Globe Media’s STAT news outlet misreported it as a license for psychiatrists to disregard the standard. Amid the ensuing media storm, the APsaA was forced to clarify that it was not countenancing defiance of psychiatry’s flagship organization and that its own longstanding policy remained unchanged.
Among those chafing against the Goldwater Rule in the current political environment, a call to arms has been the profession’s supposed “duty to warn” the public of the president’s mental health. This rationale was made explicit in an eponymous online movement and town hall forum hosted by Bandy X. Lee, MD, MDiv, a member of Yale University’s psychiatry faculty. According to these critics, an inherent tension exists between the Goldwater Rule’s prohibition on volunteering professional opinions from afar and the imperative to warn about the dangers posed by a leader with mental illness.
The duty to warn
Clinicians’ obligation to warn third parties when patients make credible threats or pose a high risk of harm emanates from various state laws, court decisions, and professional ethics rules. In the seminal Tarasoff case, a patient divulged in the course of psychotherapy his plan to murder a fellow student who had rejected his romantic overtures; campus police were alerted, but the intended victim was not. After the plan came to fruition, the California Supreme Court held that therapists must exercise reasonable care to protect “foreseeable victims” where they know or should know that a patient poses a serious danger.6
Although a controversial and massive expansion of tort liability 40 years ago, the basic tenets of Tarasoff have since been adopted by numerous courts, state legislatures, and professional organizations. The American Medical Association (AMA) recognizes an exception to confidentiality to mitigate serious threats of harm to the patient or other identifiable individuals.7 To enable health care professionals to operate in a way that is consistent with these standards, the HIPAA Privacy Rule expressly permits doctors to disclose protected health information, including psychotherapy notes, if the disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”8
In terms of both professional ethics and privacy law, the duty to warn is framed as a limited and enumerated exception to the general rule that patient communications must be kept in confidence. In the absence of a clinician’s being privy to personal details about a patient via interview and examination, the duty to warn loses all coherence. It is precisely the intimacy of the doctor-patient relationship that gives rise to the fiduciary duty of confidentiality, which in turn must yield to public safety in rare situations where a credible threat is issued against an identifiable victim.
Origins of a misconception
Unlike the duty to warn, the Goldwater Rule is neither premised on nor a departure from the dictates of confidentiality. The rule is codified under the section of the APA ethics standards dealing with community and public health activities, not patient privacy. In nearly all cases where the Goldwater Rule could be invoked, the fundamental issue is that no examination has occurred. If it had, informed consent would be required for treatment, and appropriate authorization would be required for disclosure. Moreover, talking with the media – as opposed to alerting law enforcement, family members, or the subject of a threat – would almost never qualify as an appropriate outlet for discharging a physician’s duty to warn.
Whatever its merits, the Goldwater Rule is intended to distinguish between educational activities – in which psychiatrists share their expertise with the public and shed light on mental illness – and professional opinion wherein psychiatrists offer diagnoses or prognoses unsolicited by the individual.9
The APA has since clarified that the Goldwater Rule does not prohibit “psychologically informed leadership studies” so long as they maintain scholarly standards and do not specify a clinical diagnosis. When appropriately conducted as academic research, including acknowledgment of inherent limitations, psychological profiles do not implicate the Goldwater Rule by drawing clinical conclusions outside clinical practice.
Ultimately, the debate over the Goldwater Rule pits concerns over professional standards and respect for persons against the ability of psychiatrists to apply the expertise and language of their profession according to their own best judgment, without running afoul of an ethical norm. The premise that the Tarasoff principle overrides the Goldwater Rule is a red herring that does a disservice to both. There may be valid reasons to reevaluate the Goldwater Rule, but the duty to warn is not one of them.
Lt. Col. Charles G. Kels practices health and disability law in the U.S. Air Force. Dr. Lori H. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.
References
1. Goldwater v. Ginzburg, 414 F2d 324 (2d Cir 1969), cert denied, 396 US 1049 (1970).
2. APA Principles of Medical Ethics, 2013 ed. [7.3].
3. American Psychological Association Ethical Principles of Psychologists and Code of Ethics, 2016 ed. [9.01b].
4. The New York Times. Feb. 14, 2017.
5. The New York Times. Feb. 15, 2017.
6. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal. 1976).
7. AMA Code of Medical Ethics, 2017 ed. [3.2.1(e) Confidentiality].
8. 45 Code of Federal Regulations 164.512(j)
9. JAMA. 2008;300(11):1348-50.
10. Psychiatr Clin North Am. 2002;25(3):A635-A46.
11. APA Opinions of the Ethics Committee, 2017 ed. [Q.7.a].
The campaign, election, and administration of President Donald Trump have reinvigorated debate over rule 7.3 of the American Psychiatric Association (APA) code of ethics. Known as the Goldwater Rule for its historical roots in a magazine profile and subsequent libel suit by the 1964 Republican presidential nominee,1 this standard deems it unethical for a psychiatrist to offer a professional opinion of a public figure without conducting an examination and obtaining authorization.2 The American Psychological Association similarly provides that assessments must be based on adequate examination of the individual.3
Growing controversy
Shortly after President Trump’s inauguration, a group of 35 mental health professionals penned a letter in the New York Times stating that he was “incapable of serving safely as president.” Importantly, the writers couched their conclusions in professional expertise and specifically criticized the Goldwater Rule as having subjected their colleagues to self-imposed silence.4 A prominent psychiatrist, Allen J. Frances, MD, responded the following day to caution against “psychiatric name-calling” as a substitute for political action.5
Since then, psychiatrists classifying the APA ethics position as a “gag rule” preventing them from performing a public service have garnered considerable press coverage. When the American Psychoanalytic Association (APsaA) reiterated this summer that only APA members are bound by the Goldwater Rule, Boston Globe Media’s STAT news outlet misreported it as a license for psychiatrists to disregard the standard. Amid the ensuing media storm, the APsaA was forced to clarify that it was not countenancing defiance of psychiatry’s flagship organization and that its own longstanding policy remained unchanged.
Among those chafing against the Goldwater Rule in the current political environment, a call to arms has been the profession’s supposed “duty to warn” the public of the president’s mental health. This rationale was made explicit in an eponymous online movement and town hall forum hosted by Bandy X. Lee, MD, MDiv, a member of Yale University’s psychiatry faculty. According to these critics, an inherent tension exists between the Goldwater Rule’s prohibition on volunteering professional opinions from afar and the imperative to warn about the dangers posed by a leader with mental illness.
The duty to warn
Clinicians’ obligation to warn third parties when patients make credible threats or pose a high risk of harm emanates from various state laws, court decisions, and professional ethics rules. In the seminal Tarasoff case, a patient divulged in the course of psychotherapy his plan to murder a fellow student who had rejected his romantic overtures; campus police were alerted, but the intended victim was not. After the plan came to fruition, the California Supreme Court held that therapists must exercise reasonable care to protect “foreseeable victims” where they know or should know that a patient poses a serious danger.6
Although a controversial and massive expansion of tort liability 40 years ago, the basic tenets of Tarasoff have since been adopted by numerous courts, state legislatures, and professional organizations. The American Medical Association (AMA) recognizes an exception to confidentiality to mitigate serious threats of harm to the patient or other identifiable individuals.7 To enable health care professionals to operate in a way that is consistent with these standards, the HIPAA Privacy Rule expressly permits doctors to disclose protected health information, including psychotherapy notes, if the disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”8
In terms of both professional ethics and privacy law, the duty to warn is framed as a limited and enumerated exception to the general rule that patient communications must be kept in confidence. In the absence of a clinician’s being privy to personal details about a patient via interview and examination, the duty to warn loses all coherence. It is precisely the intimacy of the doctor-patient relationship that gives rise to the fiduciary duty of confidentiality, which in turn must yield to public safety in rare situations where a credible threat is issued against an identifiable victim.
Origins of a misconception
Unlike the duty to warn, the Goldwater Rule is neither premised on nor a departure from the dictates of confidentiality. The rule is codified under the section of the APA ethics standards dealing with community and public health activities, not patient privacy. In nearly all cases where the Goldwater Rule could be invoked, the fundamental issue is that no examination has occurred. If it had, informed consent would be required for treatment, and appropriate authorization would be required for disclosure. Moreover, talking with the media – as opposed to alerting law enforcement, family members, or the subject of a threat – would almost never qualify as an appropriate outlet for discharging a physician’s duty to warn.
Whatever its merits, the Goldwater Rule is intended to distinguish between educational activities – in which psychiatrists share their expertise with the public and shed light on mental illness – and professional opinion wherein psychiatrists offer diagnoses or prognoses unsolicited by the individual.9
The APA has since clarified that the Goldwater Rule does not prohibit “psychologically informed leadership studies” so long as they maintain scholarly standards and do not specify a clinical diagnosis. When appropriately conducted as academic research, including acknowledgment of inherent limitations, psychological profiles do not implicate the Goldwater Rule by drawing clinical conclusions outside clinical practice.
Ultimately, the debate over the Goldwater Rule pits concerns over professional standards and respect for persons against the ability of psychiatrists to apply the expertise and language of their profession according to their own best judgment, without running afoul of an ethical norm. The premise that the Tarasoff principle overrides the Goldwater Rule is a red herring that does a disservice to both. There may be valid reasons to reevaluate the Goldwater Rule, but the duty to warn is not one of them.
Lt. Col. Charles G. Kels practices health and disability law in the U.S. Air Force. Dr. Lori H. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.
References
1. Goldwater v. Ginzburg, 414 F2d 324 (2d Cir 1969), cert denied, 396 US 1049 (1970).
2. APA Principles of Medical Ethics, 2013 ed. [7.3].
3. American Psychological Association Ethical Principles of Psychologists and Code of Ethics, 2016 ed. [9.01b].
4. The New York Times. Feb. 14, 2017.
5. The New York Times. Feb. 15, 2017.
6. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal. 1976).
7. AMA Code of Medical Ethics, 2017 ed. [3.2.1(e) Confidentiality].
8. 45 Code of Federal Regulations 164.512(j)
9. JAMA. 2008;300(11):1348-50.
10. Psychiatr Clin North Am. 2002;25(3):A635-A46.
11. APA Opinions of the Ethics Committee, 2017 ed. [Q.7.a].
The campaign, election, and administration of President Donald Trump have reinvigorated debate over rule 7.3 of the American Psychiatric Association (APA) code of ethics. Known as the Goldwater Rule for its historical roots in a magazine profile and subsequent libel suit by the 1964 Republican presidential nominee,1 this standard deems it unethical for a psychiatrist to offer a professional opinion of a public figure without conducting an examination and obtaining authorization.2 The American Psychological Association similarly provides that assessments must be based on adequate examination of the individual.3
Growing controversy
Shortly after President Trump’s inauguration, a group of 35 mental health professionals penned a letter in the New York Times stating that he was “incapable of serving safely as president.” Importantly, the writers couched their conclusions in professional expertise and specifically criticized the Goldwater Rule as having subjected their colleagues to self-imposed silence.4 A prominent psychiatrist, Allen J. Frances, MD, responded the following day to caution against “psychiatric name-calling” as a substitute for political action.5
Since then, psychiatrists classifying the APA ethics position as a “gag rule” preventing them from performing a public service have garnered considerable press coverage. When the American Psychoanalytic Association (APsaA) reiterated this summer that only APA members are bound by the Goldwater Rule, Boston Globe Media’s STAT news outlet misreported it as a license for psychiatrists to disregard the standard. Amid the ensuing media storm, the APsaA was forced to clarify that it was not countenancing defiance of psychiatry’s flagship organization and that its own longstanding policy remained unchanged.
Among those chafing against the Goldwater Rule in the current political environment, a call to arms has been the profession’s supposed “duty to warn” the public of the president’s mental health. This rationale was made explicit in an eponymous online movement and town hall forum hosted by Bandy X. Lee, MD, MDiv, a member of Yale University’s psychiatry faculty. According to these critics, an inherent tension exists between the Goldwater Rule’s prohibition on volunteering professional opinions from afar and the imperative to warn about the dangers posed by a leader with mental illness.
The duty to warn
Clinicians’ obligation to warn third parties when patients make credible threats or pose a high risk of harm emanates from various state laws, court decisions, and professional ethics rules. In the seminal Tarasoff case, a patient divulged in the course of psychotherapy his plan to murder a fellow student who had rejected his romantic overtures; campus police were alerted, but the intended victim was not. After the plan came to fruition, the California Supreme Court held that therapists must exercise reasonable care to protect “foreseeable victims” where they know or should know that a patient poses a serious danger.6
Although a controversial and massive expansion of tort liability 40 years ago, the basic tenets of Tarasoff have since been adopted by numerous courts, state legislatures, and professional organizations. The American Medical Association (AMA) recognizes an exception to confidentiality to mitigate serious threats of harm to the patient or other identifiable individuals.7 To enable health care professionals to operate in a way that is consistent with these standards, the HIPAA Privacy Rule expressly permits doctors to disclose protected health information, including psychotherapy notes, if the disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”8
In terms of both professional ethics and privacy law, the duty to warn is framed as a limited and enumerated exception to the general rule that patient communications must be kept in confidence. In the absence of a clinician’s being privy to personal details about a patient via interview and examination, the duty to warn loses all coherence. It is precisely the intimacy of the doctor-patient relationship that gives rise to the fiduciary duty of confidentiality, which in turn must yield to public safety in rare situations where a credible threat is issued against an identifiable victim.
Origins of a misconception
Unlike the duty to warn, the Goldwater Rule is neither premised on nor a departure from the dictates of confidentiality. The rule is codified under the section of the APA ethics standards dealing with community and public health activities, not patient privacy. In nearly all cases where the Goldwater Rule could be invoked, the fundamental issue is that no examination has occurred. If it had, informed consent would be required for treatment, and appropriate authorization would be required for disclosure. Moreover, talking with the media – as opposed to alerting law enforcement, family members, or the subject of a threat – would almost never qualify as an appropriate outlet for discharging a physician’s duty to warn.
Whatever its merits, the Goldwater Rule is intended to distinguish between educational activities – in which psychiatrists share their expertise with the public and shed light on mental illness – and professional opinion wherein psychiatrists offer diagnoses or prognoses unsolicited by the individual.9
The APA has since clarified that the Goldwater Rule does not prohibit “psychologically informed leadership studies” so long as they maintain scholarly standards and do not specify a clinical diagnosis. When appropriately conducted as academic research, including acknowledgment of inherent limitations, psychological profiles do not implicate the Goldwater Rule by drawing clinical conclusions outside clinical practice.
Ultimately, the debate over the Goldwater Rule pits concerns over professional standards and respect for persons against the ability of psychiatrists to apply the expertise and language of their profession according to their own best judgment, without running afoul of an ethical norm. The premise that the Tarasoff principle overrides the Goldwater Rule is a red herring that does a disservice to both. There may be valid reasons to reevaluate the Goldwater Rule, but the duty to warn is not one of them.
Lt. Col. Charles G. Kels practices health and disability law in the U.S. Air Force. Dr. Lori H. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.
References
1. Goldwater v. Ginzburg, 414 F2d 324 (2d Cir 1969), cert denied, 396 US 1049 (1970).
2. APA Principles of Medical Ethics, 2013 ed. [7.3].
3. American Psychological Association Ethical Principles of Psychologists and Code of Ethics, 2016 ed. [9.01b].
4. The New York Times. Feb. 14, 2017.
5. The New York Times. Feb. 15, 2017.
6. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal. 1976).
7. AMA Code of Medical Ethics, 2017 ed. [3.2.1(e) Confidentiality].
8. 45 Code of Federal Regulations 164.512(j)
9. JAMA. 2008;300(11):1348-50.
10. Psychiatr Clin North Am. 2002;25(3):A635-A46.
11. APA Opinions of the Ethics Committee, 2017 ed. [Q.7.a].
The electronic elephant
Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.
Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).
Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?
Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.
Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.
Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at [email protected].
Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.
Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).
Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?
Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.
Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.
Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at [email protected].
Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.
Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).
Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?
Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.
Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.
Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at [email protected].
Contraception coverage rollback is discriminatory
On Oct. 6, the Trump administration rolled back a crucial piece of the Affordable Care Act so that any employer can now claim a moral or religious objection to providing contraception coverage, thus denying their employees access to critical health care – contraception.
Nearly all women – 99% – who have had sex have used some form of contraception at some point during their reproductive lives, regardless of faith or religion (National health statistics reports. 2013 Feb 14[62]). Most women spend the majority of their fertile life span, approximately 35-40 years, avoiding pregnancy, and only a few years actively trying to become pregnant. A desired pregnancy is a gift, but unplanned pregnancies may have a negative impact on women, families, and society.
In the United States, our rising maternal mortality ratio is currently at 26.4 per 100,000 live births (Lancet. 2016 Oct 8;388[10053]:1775-812). Given the risks of pregnancy, especially to those with medical conditions that make pregnancy more dangerous, women need access to methods to avoid pregnancy until they actively seek it. If employers of for-profit businesses now choose to claim a moral or religious objection to providing coverage for contraception, millions of women could become unable to access affordable, effective contraception.
Since the Affordable Care Act mandate that provided coverage for contraceptive methods with no cost-sharing, thousands of women have had improved access to contraception, including IUDs and contraceptive implants, the most effective and longest-lasting reversible methods available. Since President Trump took office, many women have presented to clinics across the country to get long-acting contraception, like an IUD or implant, before the Trump administration could pull the plug on the contraceptive mandate. That scenario has now occurred, leaving millions of women up in the air about the future of their contraceptive coverage.
By allowing employers to deny coverage of contraception, the Trump administration is demonstrating its lack of concern for women’s health and its denial of the most fundamental principles of public health. 
Rolling back the contraceptive mandate is rolling back on vital women’s preventive health services. It is counter to society’s interest in public health and is discriminatory against women.
Dr. Prager is associate professor of obstetrics and gynecology at the University of Washington, Seattle. She is also the director of the family planning division and family planning fellowship. Dr. Prager is an unpaid trainer for Nexplanon (Merck). Dr. Espey is professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Espey reported having no relevant disclosures.
On Oct. 6, the Trump administration rolled back a crucial piece of the Affordable Care Act so that any employer can now claim a moral or religious objection to providing contraception coverage, thus denying their employees access to critical health care – contraception.
Nearly all women – 99% – who have had sex have used some form of contraception at some point during their reproductive lives, regardless of faith or religion (National health statistics reports. 2013 Feb 14[62]). Most women spend the majority of their fertile life span, approximately 35-40 years, avoiding pregnancy, and only a few years actively trying to become pregnant. A desired pregnancy is a gift, but unplanned pregnancies may have a negative impact on women, families, and society.
In the United States, our rising maternal mortality ratio is currently at 26.4 per 100,000 live births (Lancet. 2016 Oct 8;388[10053]:1775-812). Given the risks of pregnancy, especially to those with medical conditions that make pregnancy more dangerous, women need access to methods to avoid pregnancy until they actively seek it. If employers of for-profit businesses now choose to claim a moral or religious objection to providing coverage for contraception, millions of women could become unable to access affordable, effective contraception.
Since the Affordable Care Act mandate that provided coverage for contraceptive methods with no cost-sharing, thousands of women have had improved access to contraception, including IUDs and contraceptive implants, the most effective and longest-lasting reversible methods available. Since President Trump took office, many women have presented to clinics across the country to get long-acting contraception, like an IUD or implant, before the Trump administration could pull the plug on the contraceptive mandate. That scenario has now occurred, leaving millions of women up in the air about the future of their contraceptive coverage.
By allowing employers to deny coverage of contraception, the Trump administration is demonstrating its lack of concern for women’s health and its denial of the most fundamental principles of public health.
Rolling back the contraceptive mandate is rolling back on vital women’s preventive health services. It is counter to society’s interest in public health and is discriminatory against women.
Dr. Prager is associate professor of obstetrics and gynecology at the University of Washington, Seattle. She is also the director of the family planning division and family planning fellowship. Dr. Prager is an unpaid trainer for Nexplanon (Merck). Dr. Espey is professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Espey reported having no relevant disclosures.
On Oct. 6, the Trump administration rolled back a crucial piece of the Affordable Care Act so that any employer can now claim a moral or religious objection to providing contraception coverage, thus denying their employees access to critical health care – contraception.
Nearly all women – 99% – who have had sex have used some form of contraception at some point during their reproductive lives, regardless of faith or religion (National health statistics reports. 2013 Feb 14[62]). Most women spend the majority of their fertile life span, approximately 35-40 years, avoiding pregnancy, and only a few years actively trying to become pregnant. A desired pregnancy is a gift, but unplanned pregnancies may have a negative impact on women, families, and society.
In the United States, our rising maternal mortality ratio is currently at 26.4 per 100,000 live births (Lancet. 2016 Oct 8;388[10053]:1775-812). Given the risks of pregnancy, especially to those with medical conditions that make pregnancy more dangerous, women need access to methods to avoid pregnancy until they actively seek it. If employers of for-profit businesses now choose to claim a moral or religious objection to providing coverage for contraception, millions of women could become unable to access affordable, effective contraception.
Since the Affordable Care Act mandate that provided coverage for contraceptive methods with no cost-sharing, thousands of women have had improved access to contraception, including IUDs and contraceptive implants, the most effective and longest-lasting reversible methods available. Since President Trump took office, many women have presented to clinics across the country to get long-acting contraception, like an IUD or implant, before the Trump administration could pull the plug on the contraceptive mandate. That scenario has now occurred, leaving millions of women up in the air about the future of their contraceptive coverage.
By allowing employers to deny coverage of contraception, the Trump administration is demonstrating its lack of concern for women’s health and its denial of the most fundamental principles of public health.
Rolling back the contraceptive mandate is rolling back on vital women’s preventive health services. It is counter to society’s interest in public health and is discriminatory against women.
Dr. Prager is associate professor of obstetrics and gynecology at the University of Washington, Seattle. She is also the director of the family planning division and family planning fellowship. Dr. Prager is an unpaid trainer for Nexplanon (Merck). Dr. Espey is professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Espey reported having no relevant disclosures.
Don't just blame Facebook for fake news: It's us, too
Critics such as Zeynep Tufekci are quite right to take Facebook and Twitter to task for allowing nefarious and hostile actors, likely including the Russian state, to hold sway on social media (“Facebook’s Ad Scandal Isn’t a ‘Fail,’ It’s a Feature,” New York Times, Sept. 23, 2017).
These actors must be reined in online, for the very simple reason that so many of us are immersed in our news feeds and Twitter streams, and thus susceptible to whatever toxins are allowed to proliferate there.
Some have called apps, including social media, “the race to the bottom of the brainstem.” The most primitive parts of our brain, responsible for fight-flight and survival, are always on the lookout for perceived threats. In our restless, clicking and scrolling state, we are often naturally attracted to and activated by tantalizing, titillating, and emotionally charged posts that are lacking in reason, but are inflammatory and viscerally captivating. Viral news, click bait, gossip, rumors, and scandals get a disproportionate share of our attention. And since we become what we do, our reason is overwhelmed by reaction. In fact, a recent 60 Minutes segment demonstrated how President Trump’s political operatives optimized Facebook ads for reaction, not thought. As we engage in social media, we may become less reasonable, and prone to reacting out of our most base and primal fears.
The late neurologist and psychiatrist Viktor E. Frankl pointed out our freedom lies in our ability to put space between stimulus and response. In this space lies our freedom to choose, he wrote. Online, this inner life can shrink. Our wandering minds look for cheap thrills and anything that confirms our biases of threat. We reduce the world to simplistic one-size-fits-all narratives, and heap blame on our usual suspects. I call the Internet the angernet. Anger is the most viral and contagious emotion on social networks, and as we use social media, we deepen the groove of anger – making our anger more likely and the most readily shared.
But we’ve been racing to the bottom of the brainstem, where fear, anger, hatred, and reactivity reside, for decades in this country. Again, we can’t simply blame social media. Trust has been eroding for decades, for many reasons. No matter the generation, only a minority of us trust each other, according to the Pew Research Center’s surveys. Millennials are the least trusting of all: Only 19% of them agree that “generally speaking, people are to be trusted.” Any scroll of the news feed quickly confirms this dangerous bias to mistrust, as we are besieged by a near cataclysmic barrage of traumatic events. We are also more polarized than ever, with a great percentage of partisans believing that the other side aims at the destruction of all they hold dear in America. As we feel more vulnerable, we are more likely to mistrust and become further polarized, and the cycle continues.
More importantly, as we flee real-world relationships and interaction for the ease and seeming reach of the online world, we lose subtle cues and important connections that would normally soothe our reactivity. Humanity has evolved and progressed precisely because of our social connections. We are who happens to us, and what we make of the happening. When we connect in more superficial ways, we endanger our very identities. As a nation, we are having an identity crisis: We have not worked out who we are in relation to one another, and to ourselves. This is expressed politically, and in our confused and fearful opinions and appraisals of each other and government. Without the good graces that come out of shared presence in real-world relationships, we are more likely to think badly of each other. We are more likely to retreat into narrow and tribal identities where we think safety resides, and deemphasize communal identity. In this space of narrow identity, ideological self-righteousness and dogma prevail, and we are less likely to listen and cultivate curiosity, understanding, and empathy for others. One example lies in how representatives and senators spend less time socializing with each other than in years past, and are thus less likely to forge compromise. Online, we are all refugees from the real world, and we fall to building our own personal walls and exiling those with whom we disagree – who then become those we hate, fear, blame, and fight.
We have met the enemy, and it is us.
The antidote to mistrust is in cultivating the top of our nervous systems, where long-term planning and positive emotions reside. We can only do this through real-world relationships. Social media will not ultimately take us to a feeling of society. It might provide a glimmer of connection, but its inherent vectors of disconnection and division are proving deadly, from Internet radicalization, to the increased levels of depression, anxiety, loneliness, and suicidality noted with increasing Internet and social media use.
We each have incredible human possibilities, but to reach them, we have to transcend the biases and reactivity of our habitually and usually unconsciously self-centered egos. We can start with awareness of what the Internet siren is doing to us and steer our ships in a more fruitful direction. Toward home, toward our hearts, and toward each other.
Dr. Chandra is a psychiatrist and writer in San Francisco. He is the author of Facebuddha: Transcendence in the Age of Social Networks (Pacific Heart Books, 2017).
Critics such as Zeynep Tufekci are quite right to take Facebook and Twitter to task for allowing nefarious and hostile actors, likely including the Russian state, to hold sway on social media (“Facebook’s Ad Scandal Isn’t a ‘Fail,’ It’s a Feature,” New York Times, Sept. 23, 2017).
These actors must be reined in online, for the very simple reason that so many of us are immersed in our news feeds and Twitter streams, and thus susceptible to whatever toxins are allowed to proliferate there.
Some have called apps, including social media, “the race to the bottom of the brainstem.” The most primitive parts of our brain, responsible for fight-flight and survival, are always on the lookout for perceived threats. In our restless, clicking and scrolling state, we are often naturally attracted to and activated by tantalizing, titillating, and emotionally charged posts that are lacking in reason, but are inflammatory and viscerally captivating. Viral news, click bait, gossip, rumors, and scandals get a disproportionate share of our attention. And since we become what we do, our reason is overwhelmed by reaction. In fact, a recent 60 Minutes segment demonstrated how President Trump’s political operatives optimized Facebook ads for reaction, not thought. As we engage in social media, we may become less reasonable, and prone to reacting out of our most base and primal fears.
The late neurologist and psychiatrist Viktor E. Frankl pointed out our freedom lies in our ability to put space between stimulus and response. In this space lies our freedom to choose, he wrote. Online, this inner life can shrink. Our wandering minds look for cheap thrills and anything that confirms our biases of threat. We reduce the world to simplistic one-size-fits-all narratives, and heap blame on our usual suspects. I call the Internet the angernet. Anger is the most viral and contagious emotion on social networks, and as we use social media, we deepen the groove of anger – making our anger more likely and the most readily shared.
But we’ve been racing to the bottom of the brainstem, where fear, anger, hatred, and reactivity reside, for decades in this country. Again, we can’t simply blame social media. Trust has been eroding for decades, for many reasons. No matter the generation, only a minority of us trust each other, according to the Pew Research Center’s surveys. Millennials are the least trusting of all: Only 19% of them agree that “generally speaking, people are to be trusted.” Any scroll of the news feed quickly confirms this dangerous bias to mistrust, as we are besieged by a near cataclysmic barrage of traumatic events. We are also more polarized than ever, with a great percentage of partisans believing that the other side aims at the destruction of all they hold dear in America. As we feel more vulnerable, we are more likely to mistrust and become further polarized, and the cycle continues.
More importantly, as we flee real-world relationships and interaction for the ease and seeming reach of the online world, we lose subtle cues and important connections that would normally soothe our reactivity. Humanity has evolved and progressed precisely because of our social connections. We are who happens to us, and what we make of the happening. When we connect in more superficial ways, we endanger our very identities. As a nation, we are having an identity crisis: We have not worked out who we are in relation to one another, and to ourselves. This is expressed politically, and in our confused and fearful opinions and appraisals of each other and government. Without the good graces that come out of shared presence in real-world relationships, we are more likely to think badly of each other. We are more likely to retreat into narrow and tribal identities where we think safety resides, and deemphasize communal identity. In this space of narrow identity, ideological self-righteousness and dogma prevail, and we are less likely to listen and cultivate curiosity, understanding, and empathy for others. One example lies in how representatives and senators spend less time socializing with each other than in years past, and are thus less likely to forge compromise. Online, we are all refugees from the real world, and we fall to building our own personal walls and exiling those with whom we disagree – who then become those we hate, fear, blame, and fight.
We have met the enemy, and it is us.
The antidote to mistrust is in cultivating the top of our nervous systems, where long-term planning and positive emotions reside. We can only do this through real-world relationships. Social media will not ultimately take us to a feeling of society. It might provide a glimmer of connection, but its inherent vectors of disconnection and division are proving deadly, from Internet radicalization, to the increased levels of depression, anxiety, loneliness, and suicidality noted with increasing Internet and social media use.
We each have incredible human possibilities, but to reach them, we have to transcend the biases and reactivity of our habitually and usually unconsciously self-centered egos. We can start with awareness of what the Internet siren is doing to us and steer our ships in a more fruitful direction. Toward home, toward our hearts, and toward each other.
Dr. Chandra is a psychiatrist and writer in San Francisco. He is the author of Facebuddha: Transcendence in the Age of Social Networks (Pacific Heart Books, 2017).
Critics such as Zeynep Tufekci are quite right to take Facebook and Twitter to task for allowing nefarious and hostile actors, likely including the Russian state, to hold sway on social media (“Facebook’s Ad Scandal Isn’t a ‘Fail,’ It’s a Feature,” New York Times, Sept. 23, 2017).
These actors must be reined in online, for the very simple reason that so many of us are immersed in our news feeds and Twitter streams, and thus susceptible to whatever toxins are allowed to proliferate there.
Some have called apps, including social media, “the race to the bottom of the brainstem.” The most primitive parts of our brain, responsible for fight-flight and survival, are always on the lookout for perceived threats. In our restless, clicking and scrolling state, we are often naturally attracted to and activated by tantalizing, titillating, and emotionally charged posts that are lacking in reason, but are inflammatory and viscerally captivating. Viral news, click bait, gossip, rumors, and scandals get a disproportionate share of our attention. And since we become what we do, our reason is overwhelmed by reaction. In fact, a recent 60 Minutes segment demonstrated how President Trump’s political operatives optimized Facebook ads for reaction, not thought. As we engage in social media, we may become less reasonable, and prone to reacting out of our most base and primal fears.
The late neurologist and psychiatrist Viktor E. Frankl pointed out our freedom lies in our ability to put space between stimulus and response. In this space lies our freedom to choose, he wrote. Online, this inner life can shrink. Our wandering minds look for cheap thrills and anything that confirms our biases of threat. We reduce the world to simplistic one-size-fits-all narratives, and heap blame on our usual suspects. I call the Internet the angernet. Anger is the most viral and contagious emotion on social networks, and as we use social media, we deepen the groove of anger – making our anger more likely and the most readily shared.
But we’ve been racing to the bottom of the brainstem, where fear, anger, hatred, and reactivity reside, for decades in this country. Again, we can’t simply blame social media. Trust has been eroding for decades, for many reasons. No matter the generation, only a minority of us trust each other, according to the Pew Research Center’s surveys. Millennials are the least trusting of all: Only 19% of them agree that “generally speaking, people are to be trusted.” Any scroll of the news feed quickly confirms this dangerous bias to mistrust, as we are besieged by a near cataclysmic barrage of traumatic events. We are also more polarized than ever, with a great percentage of partisans believing that the other side aims at the destruction of all they hold dear in America. As we feel more vulnerable, we are more likely to mistrust and become further polarized, and the cycle continues.
More importantly, as we flee real-world relationships and interaction for the ease and seeming reach of the online world, we lose subtle cues and important connections that would normally soothe our reactivity. Humanity has evolved and progressed precisely because of our social connections. We are who happens to us, and what we make of the happening. When we connect in more superficial ways, we endanger our very identities. As a nation, we are having an identity crisis: We have not worked out who we are in relation to one another, and to ourselves. This is expressed politically, and in our confused and fearful opinions and appraisals of each other and government. Without the good graces that come out of shared presence in real-world relationships, we are more likely to think badly of each other. We are more likely to retreat into narrow and tribal identities where we think safety resides, and deemphasize communal identity. In this space of narrow identity, ideological self-righteousness and dogma prevail, and we are less likely to listen and cultivate curiosity, understanding, and empathy for others. One example lies in how representatives and senators spend less time socializing with each other than in years past, and are thus less likely to forge compromise. Online, we are all refugees from the real world, and we fall to building our own personal walls and exiling those with whom we disagree – who then become those we hate, fear, blame, and fight.
We have met the enemy, and it is us.
The antidote to mistrust is in cultivating the top of our nervous systems, where long-term planning and positive emotions reside. We can only do this through real-world relationships. Social media will not ultimately take us to a feeling of society. It might provide a glimmer of connection, but its inherent vectors of disconnection and division are proving deadly, from Internet radicalization, to the increased levels of depression, anxiety, loneliness, and suicidality noted with increasing Internet and social media use.
We each have incredible human possibilities, but to reach them, we have to transcend the biases and reactivity of our habitually and usually unconsciously self-centered egos. We can start with awareness of what the Internet siren is doing to us and steer our ships in a more fruitful direction. Toward home, toward our hearts, and toward each other.
Dr. Chandra is a psychiatrist and writer in San Francisco. He is the author of Facebuddha: Transcendence in the Age of Social Networks (Pacific Heart Books, 2017).
If You Were Surgeon General ...
This past August, President Trump, with the advice and consent of the United States Senate, nominated Indiana Health Commissioner Jerome M. Adams, MD, MPH, as the nation’s 20th Surgeon General (SG). As the country’s “doctor,” the SG has access to the best available scientific information to advise Americans of ways to improve their health and decrease risk for illness and injury. Overseen by the Office of the Assistant Secretary for Health, the Office of the Surgeon General has no budget or line authority. As a political appointee, the SG ranks three levels below a presidential cabinet member and reports to an assistant health secretary.1
The SG nominally oversees the US Public Health Service Commissioned Corps, an exclusive group of more than 6,700 public health professionals working throughout the federal government with the mission to protect, promote, and advance the health of our nation.2 In 2010, under the Affordable Care Act, the SG was designated as Chair of the National Prevention Council, which coordinates and leads 20 executive departments encouraging prevention, wellness, and health promotion activities.
Past SGs, during their time in office, have quietly gone about their duties, although some have used their platform to raise awareness of specific public health concerns. C. Everett Koop (a Reagan appointee) is among the most-remembered SGs, thanks in part to his use of the media to promote his causes, specifically smoking cessation and AIDS prevention. Newly appointed Dr. Adams, an anesthesiologist by training, is known for his focus on the opioid epidemic, tobacco use, and infant mortality.
As we’ve seen over the years, the limitations of the SG’s role equate to a mixed bag of “results.” For every C. Everett Koop (whether you agree with his views or not, he was prolific!), there are several SGs who came and went from office without making a blip on the public’s radar. Since health care remains at the forefront of our national conversation, the burning question is: If you were a consultant to the SG, which health issues would you prioritize?
I posed this question to 30 of my PA and NP colleagues. While certainly not an official survey—rather, a straw poll—I was nonetheless surprised by the overlap in responses. Here are some of the highlights.
Substance abuse/opioid crisis. Globally, one in every eight deaths result from the use of tobacco, alcohol, and other drugs. According to Humphreys et al, the implications of addiction are clear: It will do massive and increasing damage to humanity if not addressed emergently and at the source.3 But to do so, we must understand the root cause. Neuroscientific research has shown that repeated addictive drug use can rewire the brain’s motivational and reward circuits and influence decision-making.3
This is evidenced by the startling fact that every day, an average of 91 Americans die of opioid overdose.3 In March, the Director-General of the World Health Organization called for more scientifically informed public policies regarding addiction.4 The President’s Commission on Combating Drug Addiction and the Opioid Crisis released a preliminary report in August recommending next steps, which included the declaration of a federal state of emergency.5
Mental health. As you may recall from my December 2016 editorial, mental health is a forgotten facet of primary care—and one that is imperative to address.6 Only 43% of family physicians in this country provide mental health care; furthermore, half of Americans with mental health conditions go without essential care, and those with intellectual and developmental disabilities are significantly underserved.6 Perhaps increased efforts to attend to mental health in primary care will subsequently reduce addiction and substance abuse rates, resulting in a physically and mentally healthier America.
Oral health. Dr. Koop was known for his quote, “You can’t be healthy without good oral health.” Unfortunately, the major challenge expressed in Oral Health in America: A Report of the Surgeon General—“not all Americans have achieved the same level of oral health and well-being”—is as relevant today as it was when the report was released in 2000.7 We must therefore accelerate efforts toward achieving this goal. We must also address the need for a more diverse and well-distributed oral health workforce.
The CDC Division of Oral Health has made oral health an integral component of public health programs, with a goal of eliminating disparities and improving oral health for all. Continued investment in research, such as that undertaken by the National Institute of Dental and Craniofacial Research Centers for Research to Reduce Disparities in Oral Health, is critical.8 Lastly, we must continue to expand initiatives to prevent tobacco use and promote better dietary choices.
Obesity. Literature on the health consequences of obesity in both adults and children has increased exponentially in recent decades, due to the condition’s alarming prevalence in the US and other industrialized countries. The CDC reports significant racial and ethnic disparities in obesity, specifically among Hispanics/Latinos compared to non-Hispanic whites. Because obesity significantly contributes to acute and chronic diseases and has a direct relationship to morbidity and mortality, public health officials should target health prevention messages and interventions to those populations with the greatest need.9
Kidney disease. An estimated 31 million people in the US have chronic kidney disease (CKD), and it is the eighth leading cause of death in this country. Shockingly, 9 out of 10 people who have stage 3 CKD are not even aware they have it.10 The cost of CKD in the US is extortionate; research in this area is horrifically underfunded compared to that for other chronic diseases. The entire NIH budget for CKD is $31 billion, while the expense to the patient population is $32 billion—and every five minutes, someone’s kidneys fail.11
The seemingly obvious question is, what can we do to prevent CKD? As far back as 1948, SG Thomas Parran Jr. advocated for preventive and curative services.12 Alas, I recently came across an excellent poem by Joseph Malins (circa 1855) that speaks volumes about prevention versus cure (see box).
Environmental threats/emerging viruses. Particular attention should be paid to newly identified infectious agents, both locally and internationally, to prevent public health problems—for example, the Zika virus epidemic. In 1896, William Osler said, “Humanity has but three great enemies: infection, famine, and war; of these, by far the greatest, by far the most terrible is infection.”13 We know the factors that contribute to the emergence of new infections: the evolution of pathogenic infectious agents (microbial adaptation and change), development of drug resistance, and vector resistance to pesticides. Other important factors include climate and changing ecosystems, economic development and land use (eg, urbanization, deforestation), and technology and industry (eg, food processing and handling).14
Access to health care. Last but certainly not least, every respondent emphasized that we need to prioritize access to health care and eliminate socioeconomic disparities. But when we recognize that these disparities exist across all populations, we see that this is not an easy task. Lack of health insurance, lack of financial resources, irregular sources of care, legal obstacles, structural barriers, lack of health care providers, language barriers, socioeconomic disparity, and age are all contributing factors that are also obstacles.15 But in order for any of the previously discussed changes in health care to be influential, they must be accessible.
And so I open the floor to you, colleagues: What do you think should be done to improve access to health care? What are your pressing public health issues? Share your thoughts with me at [email protected].
1. Scutti S. Dr. Jerome Adams confirmed as Surgeon General. www.cnn.com/2017/08/04/health/jerome-adams-surgeon-general-confirmation/index.html. Accessed September 1, 2017.
2. U.S. Department of Health and Human Services. About the Office of the Surgeon General. www.surgeongeneral.gov/about/index.html. Accessed September 1, 2017.
3. Humphreys K, Malenka RC, Knutson B, MacCoun RJ. Brains, environments, and policy responses to addiction. Science. 2017;356(6344):1237-1238.
4. Chan M. Opening remarks at the 60th session of the Commission on Narcotic Drugs. www.who.int/dg/speeches/2017/commission-narcotic-drugs/en/. Accessed September 1, 2017.
5. Burns J. Opioid Task Force recommends state of emergency and (sort of) bold treatment agenda. www.forbes.com/sites/janetwburns/2017/08/02/opioid-task-force-recommends-state-of-emergency-and-sort-of-bold-treatment-agenda/#378810163956. Accessed September 1, 2017.
6. Danielsen RD. Mental health: a forgotten facet of primary care. Clinician Reviews. 2016;26(12):7,46.
7. NIH National Institute of Dental and Craniofacial Research. Oral health in America: report of the Surgeon General (executive summary). Rockville, MD: National Institute of Dental and Craniofacial Research; 2000. Page 287.
8. Satcher D, Nottingham JH. Revisiting oral health in America: a report of the Surgeon General. AJPH. 2017;107(suppl 1):S32-S33.
9. Hu F. Obesity Epidemiology. 2008; New York: Oxford University Press. 5-7.
10. American Kidney Fund. 2015 kidney disease statistics. www.kidneyfund.org/assets/pdf/kidney-disease-statistics.pdf. Accessed September 7, 2017.
11. Tyler. Statistics on chronic kidney disease (CKD) that may shock you. www.dietitiansathome.com/post/statistics-on-chronic-kidney-disease-ckd.
12. Sledge D. Linking public health and individual medicine: the health policy approach of Surgeon General Thomas Parran. Am J Public Health. 2017;107(4):509-516.
13. Osler W. The study of the fevers of the south. JAMA. 1896;XXVI(21):999-1004.
14. Fauci AS, Touchette NA, Folkers GK. Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerging Infectious Diseases. 2005;11(4):519-525.
15. Mandal A. Disparities in access to health care. www.news-medical.net/health/Disparities-in-Access-to-Health-Care.aspx. Accessed September 1, 2017.
This past August, President Trump, with the advice and consent of the United States Senate, nominated Indiana Health Commissioner Jerome M. Adams, MD, MPH, as the nation’s 20th Surgeon General (SG). As the country’s “doctor,” the SG has access to the best available scientific information to advise Americans of ways to improve their health and decrease risk for illness and injury. Overseen by the Office of the Assistant Secretary for Health, the Office of the Surgeon General has no budget or line authority. As a political appointee, the SG ranks three levels below a presidential cabinet member and reports to an assistant health secretary.1
The SG nominally oversees the US Public Health Service Commissioned Corps, an exclusive group of more than 6,700 public health professionals working throughout the federal government with the mission to protect, promote, and advance the health of our nation.2 In 2010, under the Affordable Care Act, the SG was designated as Chair of the National Prevention Council, which coordinates and leads 20 executive departments encouraging prevention, wellness, and health promotion activities.
Past SGs, during their time in office, have quietly gone about their duties, although some have used their platform to raise awareness of specific public health concerns. C. Everett Koop (a Reagan appointee) is among the most-remembered SGs, thanks in part to his use of the media to promote his causes, specifically smoking cessation and AIDS prevention. Newly appointed Dr. Adams, an anesthesiologist by training, is known for his focus on the opioid epidemic, tobacco use, and infant mortality.
As we’ve seen over the years, the limitations of the SG’s role equate to a mixed bag of “results.” For every C. Everett Koop (whether you agree with his views or not, he was prolific!), there are several SGs who came and went from office without making a blip on the public’s radar. Since health care remains at the forefront of our national conversation, the burning question is: If you were a consultant to the SG, which health issues would you prioritize?
I posed this question to 30 of my PA and NP colleagues. While certainly not an official survey—rather, a straw poll—I was nonetheless surprised by the overlap in responses. Here are some of the highlights.
Substance abuse/opioid crisis. Globally, one in every eight deaths result from the use of tobacco, alcohol, and other drugs. According to Humphreys et al, the implications of addiction are clear: It will do massive and increasing damage to humanity if not addressed emergently and at the source.3 But to do so, we must understand the root cause. Neuroscientific research has shown that repeated addictive drug use can rewire the brain’s motivational and reward circuits and influence decision-making.3
This is evidenced by the startling fact that every day, an average of 91 Americans die of opioid overdose.3 In March, the Director-General of the World Health Organization called for more scientifically informed public policies regarding addiction.4 The President’s Commission on Combating Drug Addiction and the Opioid Crisis released a preliminary report in August recommending next steps, which included the declaration of a federal state of emergency.5
Mental health. As you may recall from my December 2016 editorial, mental health is a forgotten facet of primary care—and one that is imperative to address.6 Only 43% of family physicians in this country provide mental health care; furthermore, half of Americans with mental health conditions go without essential care, and those with intellectual and developmental disabilities are significantly underserved.6 Perhaps increased efforts to attend to mental health in primary care will subsequently reduce addiction and substance abuse rates, resulting in a physically and mentally healthier America.
Oral health. Dr. Koop was known for his quote, “You can’t be healthy without good oral health.” Unfortunately, the major challenge expressed in Oral Health in America: A Report of the Surgeon General—“not all Americans have achieved the same level of oral health and well-being”—is as relevant today as it was when the report was released in 2000.7 We must therefore accelerate efforts toward achieving this goal. We must also address the need for a more diverse and well-distributed oral health workforce.
The CDC Division of Oral Health has made oral health an integral component of public health programs, with a goal of eliminating disparities and improving oral health for all. Continued investment in research, such as that undertaken by the National Institute of Dental and Craniofacial Research Centers for Research to Reduce Disparities in Oral Health, is critical.8 Lastly, we must continue to expand initiatives to prevent tobacco use and promote better dietary choices.
Obesity. Literature on the health consequences of obesity in both adults and children has increased exponentially in recent decades, due to the condition’s alarming prevalence in the US and other industrialized countries. The CDC reports significant racial and ethnic disparities in obesity, specifically among Hispanics/Latinos compared to non-Hispanic whites. Because obesity significantly contributes to acute and chronic diseases and has a direct relationship to morbidity and mortality, public health officials should target health prevention messages and interventions to those populations with the greatest need.9
Kidney disease. An estimated 31 million people in the US have chronic kidney disease (CKD), and it is the eighth leading cause of death in this country. Shockingly, 9 out of 10 people who have stage 3 CKD are not even aware they have it.10 The cost of CKD in the US is extortionate; research in this area is horrifically underfunded compared to that for other chronic diseases. The entire NIH budget for CKD is $31 billion, while the expense to the patient population is $32 billion—and every five minutes, someone’s kidneys fail.11
The seemingly obvious question is, what can we do to prevent CKD? As far back as 1948, SG Thomas Parran Jr. advocated for preventive and curative services.12 Alas, I recently came across an excellent poem by Joseph Malins (circa 1855) that speaks volumes about prevention versus cure (see box).
Environmental threats/emerging viruses. Particular attention should be paid to newly identified infectious agents, both locally and internationally, to prevent public health problems—for example, the Zika virus epidemic. In 1896, William Osler said, “Humanity has but three great enemies: infection, famine, and war; of these, by far the greatest, by far the most terrible is infection.”13 We know the factors that contribute to the emergence of new infections: the evolution of pathogenic infectious agents (microbial adaptation and change), development of drug resistance, and vector resistance to pesticides. Other important factors include climate and changing ecosystems, economic development and land use (eg, urbanization, deforestation), and technology and industry (eg, food processing and handling).14
Access to health care. Last but certainly not least, every respondent emphasized that we need to prioritize access to health care and eliminate socioeconomic disparities. But when we recognize that these disparities exist across all populations, we see that this is not an easy task. Lack of health insurance, lack of financial resources, irregular sources of care, legal obstacles, structural barriers, lack of health care providers, language barriers, socioeconomic disparity, and age are all contributing factors that are also obstacles.15 But in order for any of the previously discussed changes in health care to be influential, they must be accessible.
And so I open the floor to you, colleagues: What do you think should be done to improve access to health care? What are your pressing public health issues? Share your thoughts with me at [email protected].
This past August, President Trump, with the advice and consent of the United States Senate, nominated Indiana Health Commissioner Jerome M. Adams, MD, MPH, as the nation’s 20th Surgeon General (SG). As the country’s “doctor,” the SG has access to the best available scientific information to advise Americans of ways to improve their health and decrease risk for illness and injury. Overseen by the Office of the Assistant Secretary for Health, the Office of the Surgeon General has no budget or line authority. As a political appointee, the SG ranks three levels below a presidential cabinet member and reports to an assistant health secretary.1
The SG nominally oversees the US Public Health Service Commissioned Corps, an exclusive group of more than 6,700 public health professionals working throughout the federal government with the mission to protect, promote, and advance the health of our nation.2 In 2010, under the Affordable Care Act, the SG was designated as Chair of the National Prevention Council, which coordinates and leads 20 executive departments encouraging prevention, wellness, and health promotion activities.
Past SGs, during their time in office, have quietly gone about their duties, although some have used their platform to raise awareness of specific public health concerns. C. Everett Koop (a Reagan appointee) is among the most-remembered SGs, thanks in part to his use of the media to promote his causes, specifically smoking cessation and AIDS prevention. Newly appointed Dr. Adams, an anesthesiologist by training, is known for his focus on the opioid epidemic, tobacco use, and infant mortality.
As we’ve seen over the years, the limitations of the SG’s role equate to a mixed bag of “results.” For every C. Everett Koop (whether you agree with his views or not, he was prolific!), there are several SGs who came and went from office without making a blip on the public’s radar. Since health care remains at the forefront of our national conversation, the burning question is: If you were a consultant to the SG, which health issues would you prioritize?
I posed this question to 30 of my PA and NP colleagues. While certainly not an official survey—rather, a straw poll—I was nonetheless surprised by the overlap in responses. Here are some of the highlights.
Substance abuse/opioid crisis. Globally, one in every eight deaths result from the use of tobacco, alcohol, and other drugs. According to Humphreys et al, the implications of addiction are clear: It will do massive and increasing damage to humanity if not addressed emergently and at the source.3 But to do so, we must understand the root cause. Neuroscientific research has shown that repeated addictive drug use can rewire the brain’s motivational and reward circuits and influence decision-making.3
This is evidenced by the startling fact that every day, an average of 91 Americans die of opioid overdose.3 In March, the Director-General of the World Health Organization called for more scientifically informed public policies regarding addiction.4 The President’s Commission on Combating Drug Addiction and the Opioid Crisis released a preliminary report in August recommending next steps, which included the declaration of a federal state of emergency.5
Mental health. As you may recall from my December 2016 editorial, mental health is a forgotten facet of primary care—and one that is imperative to address.6 Only 43% of family physicians in this country provide mental health care; furthermore, half of Americans with mental health conditions go without essential care, and those with intellectual and developmental disabilities are significantly underserved.6 Perhaps increased efforts to attend to mental health in primary care will subsequently reduce addiction and substance abuse rates, resulting in a physically and mentally healthier America.
Oral health. Dr. Koop was known for his quote, “You can’t be healthy without good oral health.” Unfortunately, the major challenge expressed in Oral Health in America: A Report of the Surgeon General—“not all Americans have achieved the same level of oral health and well-being”—is as relevant today as it was when the report was released in 2000.7 We must therefore accelerate efforts toward achieving this goal. We must also address the need for a more diverse and well-distributed oral health workforce.
The CDC Division of Oral Health has made oral health an integral component of public health programs, with a goal of eliminating disparities and improving oral health for all. Continued investment in research, such as that undertaken by the National Institute of Dental and Craniofacial Research Centers for Research to Reduce Disparities in Oral Health, is critical.8 Lastly, we must continue to expand initiatives to prevent tobacco use and promote better dietary choices.
Obesity. Literature on the health consequences of obesity in both adults and children has increased exponentially in recent decades, due to the condition’s alarming prevalence in the US and other industrialized countries. The CDC reports significant racial and ethnic disparities in obesity, specifically among Hispanics/Latinos compared to non-Hispanic whites. Because obesity significantly contributes to acute and chronic diseases and has a direct relationship to morbidity and mortality, public health officials should target health prevention messages and interventions to those populations with the greatest need.9
Kidney disease. An estimated 31 million people in the US have chronic kidney disease (CKD), and it is the eighth leading cause of death in this country. Shockingly, 9 out of 10 people who have stage 3 CKD are not even aware they have it.10 The cost of CKD in the US is extortionate; research in this area is horrifically underfunded compared to that for other chronic diseases. The entire NIH budget for CKD is $31 billion, while the expense to the patient population is $32 billion—and every five minutes, someone’s kidneys fail.11
The seemingly obvious question is, what can we do to prevent CKD? As far back as 1948, SG Thomas Parran Jr. advocated for preventive and curative services.12 Alas, I recently came across an excellent poem by Joseph Malins (circa 1855) that speaks volumes about prevention versus cure (see box).
Environmental threats/emerging viruses. Particular attention should be paid to newly identified infectious agents, both locally and internationally, to prevent public health problems—for example, the Zika virus epidemic. In 1896, William Osler said, “Humanity has but three great enemies: infection, famine, and war; of these, by far the greatest, by far the most terrible is infection.”13 We know the factors that contribute to the emergence of new infections: the evolution of pathogenic infectious agents (microbial adaptation and change), development of drug resistance, and vector resistance to pesticides. Other important factors include climate and changing ecosystems, economic development and land use (eg, urbanization, deforestation), and technology and industry (eg, food processing and handling).14
Access to health care. Last but certainly not least, every respondent emphasized that we need to prioritize access to health care and eliminate socioeconomic disparities. But when we recognize that these disparities exist across all populations, we see that this is not an easy task. Lack of health insurance, lack of financial resources, irregular sources of care, legal obstacles, structural barriers, lack of health care providers, language barriers, socioeconomic disparity, and age are all contributing factors that are also obstacles.15 But in order for any of the previously discussed changes in health care to be influential, they must be accessible.
And so I open the floor to you, colleagues: What do you think should be done to improve access to health care? What are your pressing public health issues? Share your thoughts with me at [email protected].
1. Scutti S. Dr. Jerome Adams confirmed as Surgeon General. www.cnn.com/2017/08/04/health/jerome-adams-surgeon-general-confirmation/index.html. Accessed September 1, 2017.
2. U.S. Department of Health and Human Services. About the Office of the Surgeon General. www.surgeongeneral.gov/about/index.html. Accessed September 1, 2017.
3. Humphreys K, Malenka RC, Knutson B, MacCoun RJ. Brains, environments, and policy responses to addiction. Science. 2017;356(6344):1237-1238.
4. Chan M. Opening remarks at the 60th session of the Commission on Narcotic Drugs. www.who.int/dg/speeches/2017/commission-narcotic-drugs/en/. Accessed September 1, 2017.
5. Burns J. Opioid Task Force recommends state of emergency and (sort of) bold treatment agenda. www.forbes.com/sites/janetwburns/2017/08/02/opioid-task-force-recommends-state-of-emergency-and-sort-of-bold-treatment-agenda/#378810163956. Accessed September 1, 2017.
6. Danielsen RD. Mental health: a forgotten facet of primary care. Clinician Reviews. 2016;26(12):7,46.
7. NIH National Institute of Dental and Craniofacial Research. Oral health in America: report of the Surgeon General (executive summary). Rockville, MD: National Institute of Dental and Craniofacial Research; 2000. Page 287.
8. Satcher D, Nottingham JH. Revisiting oral health in America: a report of the Surgeon General. AJPH. 2017;107(suppl 1):S32-S33.
9. Hu F. Obesity Epidemiology. 2008; New York: Oxford University Press. 5-7.
10. American Kidney Fund. 2015 kidney disease statistics. www.kidneyfund.org/assets/pdf/kidney-disease-statistics.pdf. Accessed September 7, 2017.
11. Tyler. Statistics on chronic kidney disease (CKD) that may shock you. www.dietitiansathome.com/post/statistics-on-chronic-kidney-disease-ckd.
12. Sledge D. Linking public health and individual medicine: the health policy approach of Surgeon General Thomas Parran. Am J Public Health. 2017;107(4):509-516.
13. Osler W. The study of the fevers of the south. JAMA. 1896;XXVI(21):999-1004.
14. Fauci AS, Touchette NA, Folkers GK. Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerging Infectious Diseases. 2005;11(4):519-525.
15. Mandal A. Disparities in access to health care. www.news-medical.net/health/Disparities-in-Access-to-Health-Care.aspx. Accessed September 1, 2017.
1. Scutti S. Dr. Jerome Adams confirmed as Surgeon General. www.cnn.com/2017/08/04/health/jerome-adams-surgeon-general-confirmation/index.html. Accessed September 1, 2017.
2. U.S. Department of Health and Human Services. About the Office of the Surgeon General. www.surgeongeneral.gov/about/index.html. Accessed September 1, 2017.
3. Humphreys K, Malenka RC, Knutson B, MacCoun RJ. Brains, environments, and policy responses to addiction. Science. 2017;356(6344):1237-1238.
4. Chan M. Opening remarks at the 60th session of the Commission on Narcotic Drugs. www.who.int/dg/speeches/2017/commission-narcotic-drugs/en/. Accessed September 1, 2017.
5. Burns J. Opioid Task Force recommends state of emergency and (sort of) bold treatment agenda. www.forbes.com/sites/janetwburns/2017/08/02/opioid-task-force-recommends-state-of-emergency-and-sort-of-bold-treatment-agenda/#378810163956. Accessed September 1, 2017.
6. Danielsen RD. Mental health: a forgotten facet of primary care. Clinician Reviews. 2016;26(12):7,46.
7. NIH National Institute of Dental and Craniofacial Research. Oral health in America: report of the Surgeon General (executive summary). Rockville, MD: National Institute of Dental and Craniofacial Research; 2000. Page 287.
8. Satcher D, Nottingham JH. Revisiting oral health in America: a report of the Surgeon General. AJPH. 2017;107(suppl 1):S32-S33.
9. Hu F. Obesity Epidemiology. 2008; New York: Oxford University Press. 5-7.
10. American Kidney Fund. 2015 kidney disease statistics. www.kidneyfund.org/assets/pdf/kidney-disease-statistics.pdf. Accessed September 7, 2017.
11. Tyler. Statistics on chronic kidney disease (CKD) that may shock you. www.dietitiansathome.com/post/statistics-on-chronic-kidney-disease-ckd.
12. Sledge D. Linking public health and individual medicine: the health policy approach of Surgeon General Thomas Parran. Am J Public Health. 2017;107(4):509-516.
13. Osler W. The study of the fevers of the south. JAMA. 1896;XXVI(21):999-1004.
14. Fauci AS, Touchette NA, Folkers GK. Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerging Infectious Diseases. 2005;11(4):519-525.
15. Mandal A. Disparities in access to health care. www.news-medical.net/health/Disparities-in-Access-to-Health-Care.aspx. Accessed September 1, 2017.
Duty vs. confidentiality
Question: During an office visit, a patient confided in his primary care provider his intention to go on a shooting spree. When pressed, he admitted he owned a firearm, but did not truly intend to carry out the act. He denied having a specific target location or victim in mind. The primary care provider (PCP) opted to counsel the patient, and continued him on his antidepressant medication. The PCP did not make a referral to a psychiatrist. Several weeks later, the patient put his threat into action, shooting and injuring several innocent shoppers at a mall.
In a lawsuit against the PCP, which of the following is best?
A. It is unethical for the PCP to report this threat, because it violates the principle of confidentiality.
B. Failure to warn under the circumstances definitely makes the physician liable.
C. The PCP is liable under the Tarasoff doctrine.
D. Without a named victim, there is no one to warn.
E. Whether the PCP is liable may turn on the issue of foreseeability, and an immediate referral to a psychiatrist would have been a more prudent course of action.
Answer: E. One of the physician’s sacred promises is to maintain patient confidentiality. It is more than an unspoken contractual agreement; it’s a central component of trust, without which the doctor-patient relationship cannot exist. Indeed, Hippocrates had cautioned, “whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge as reckoning that all should be kept secret.”
Thus, the recent expansive decision handed down by the Washington state Supreme Court stunned many mental health professionals.1 In Volk v. DeMeerleer, a clinic patient had confided in his psychiatrist over 9 years of therapy his suicidal and homicidal ideations. He eventually went on to kill his former girlfriend and one of her sons, and then committed suicide. The psychiatrist did not have full control of this clinic patient, nor had the patient named a specific victim. Nevertheless, the Volk court held that the doctor’s duty extended to any foreseeable harm by the patient, leaving it up to the jury to decide on the issue of foreseeability.
The court held that the psychiatrist had a “special relationship” with the victims, because he had a duty to exercise reasonable care to act, consistent with the standards of the mental health profession, in order to protect the foreseeable victims.
The court reasoned that some ability to control the patient’s conduct is sufficient for the “special relationship” and the consequent duty of care to exist, writing: “We find that absolute control is unnecessary, and the actions available to mental health professionals, even in the outpatient setting, weigh in favor of imposing a duty.” The court also noted that a psychiatrist’s obligation to protect third parties against patients’ violence would normally set aside confidentiality and yield to greater societal interests.
The vexing issue of compromising confidentiality in the name of protecting public safety had its genesis in the famous Tarasoff v. Regents of University of California case.2
In Tarasoff, the California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, whom the patient stabbed to death 2 months later.
The court reasoned that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship, pointing out: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
Following Tarasoff, it is generally accepted that there is no affirmative duty to warn where there is no readily identifiable victim. In a subsequent case, the same court explained that “the duty to warn depends upon and arises from the existence of a prior threat to a specific identifiable victim. In those instances in which the released offender poses a predictable threat of harm to a named or readily identifiable victim or group of victims who can be effectively warned of the danger, a releasing agent may well be liable for failure to warn such persons. Despite the tragic events underlying the present complaint, plaintiffs’ decedent was not a known, identifiable victim, but rather a member of a large, amorphous public group of potential targets. Under these circumstances, we hold that County had no affirmative duty to warn plaintiffs, the police, the mother of the juvenile offender, or other local parents.”3
Commentators have suggested that such post-Tarasoff cases, coupled with the advent of state statutes that codify Tarasoff, have witnessed a retreat from imposing on clinicians a duty to warn.4 By dispensing with the control and “readily identifiable victim” elements, Volk appears to contradict this perceived trend. Foreseeability may turn out to be the dispositive issue.
Some have speculated whether Volk’s expanded view will apply to other professionals such as a family practitioner or even a school counselor. Physicians who are not experienced in treating mental health patients will do well to promptly refer their unstable patients to a specialist psychiatrist.
Volk can also be read as offering judicial insight into patients who pose a health hazard by insisting on operating a vehicle against medical advice. In its 2012 Code of Medical Ethics, the American Medical Association had this to say: “In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”5
That is now replaced in the AMA code with a broader version covering the duty to disclose: “Physicians may disclose personal health information without the specific consent of the patient ... to other third parties situated to mitigate the threat when in the physician’s judgment there is a reasonable probability that: (i) the patient will seriously harm him/herself; or (ii) the patient will inflict serious physical harm on an identifiable individual or individuals.”6
Under Volk, physicians are now more likely to forsake confidentiality in the name of public safety – even in the absence of a readily identifiable potential victim.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials have been taken from earlier columns in Internal Medicine News. For additional information, readers may contact the author at [email protected].
References
1. Volk v. DeMeerleer, 386 P.3d 254 (Wa. 2016).
2. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
3. Thompson v. County of Alameda, 167 Cal. Rptr. 70, 76 (1980).
4. Behav Sci Law. 2001;19(3):325-43.
5. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed].
6. AMA Code of Medical Ethics, 2017 ed. [3.2.1 Confidentiality].
Question: During an office visit, a patient confided in his primary care provider his intention to go on a shooting spree. When pressed, he admitted he owned a firearm, but did not truly intend to carry out the act. He denied having a specific target location or victim in mind. The primary care provider (PCP) opted to counsel the patient, and continued him on his antidepressant medication. The PCP did not make a referral to a psychiatrist. Several weeks later, the patient put his threat into action, shooting and injuring several innocent shoppers at a mall.
In a lawsuit against the PCP, which of the following is best?
A. It is unethical for the PCP to report this threat, because it violates the principle of confidentiality.
B. Failure to warn under the circumstances definitely makes the physician liable.
C. The PCP is liable under the Tarasoff doctrine.
D. Without a named victim, there is no one to warn.
E. Whether the PCP is liable may turn on the issue of foreseeability, and an immediate referral to a psychiatrist would have been a more prudent course of action.
Answer: E. One of the physician’s sacred promises is to maintain patient confidentiality. It is more than an unspoken contractual agreement; it’s a central component of trust, without which the doctor-patient relationship cannot exist. Indeed, Hippocrates had cautioned, “whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge as reckoning that all should be kept secret.”
Thus, the recent expansive decision handed down by the Washington state Supreme Court stunned many mental health professionals.1 In Volk v. DeMeerleer, a clinic patient had confided in his psychiatrist over 9 years of therapy his suicidal and homicidal ideations. He eventually went on to kill his former girlfriend and one of her sons, and then committed suicide. The psychiatrist did not have full control of this clinic patient, nor had the patient named a specific victim. Nevertheless, the Volk court held that the doctor’s duty extended to any foreseeable harm by the patient, leaving it up to the jury to decide on the issue of foreseeability.
The court held that the psychiatrist had a “special relationship” with the victims, because he had a duty to exercise reasonable care to act, consistent with the standards of the mental health profession, in order to protect the foreseeable victims.
The court reasoned that some ability to control the patient’s conduct is sufficient for the “special relationship” and the consequent duty of care to exist, writing: “We find that absolute control is unnecessary, and the actions available to mental health professionals, even in the outpatient setting, weigh in favor of imposing a duty.” The court also noted that a psychiatrist’s obligation to protect third parties against patients’ violence would normally set aside confidentiality and yield to greater societal interests.
The vexing issue of compromising confidentiality in the name of protecting public safety had its genesis in the famous Tarasoff v. Regents of University of California case.2
In Tarasoff, the California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, whom the patient stabbed to death 2 months later.
The court reasoned that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship, pointing out: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
Following Tarasoff, it is generally accepted that there is no affirmative duty to warn where there is no readily identifiable victim. In a subsequent case, the same court explained that “the duty to warn depends upon and arises from the existence of a prior threat to a specific identifiable victim. In those instances in which the released offender poses a predictable threat of harm to a named or readily identifiable victim or group of victims who can be effectively warned of the danger, a releasing agent may well be liable for failure to warn such persons. Despite the tragic events underlying the present complaint, plaintiffs’ decedent was not a known, identifiable victim, but rather a member of a large, amorphous public group of potential targets. Under these circumstances, we hold that County had no affirmative duty to warn plaintiffs, the police, the mother of the juvenile offender, or other local parents.”3
Commentators have suggested that such post-Tarasoff cases, coupled with the advent of state statutes that codify Tarasoff, have witnessed a retreat from imposing on clinicians a duty to warn.4 By dispensing with the control and “readily identifiable victim” elements, Volk appears to contradict this perceived trend. Foreseeability may turn out to be the dispositive issue.
Some have speculated whether Volk’s expanded view will apply to other professionals such as a family practitioner or even a school counselor. Physicians who are not experienced in treating mental health patients will do well to promptly refer their unstable patients to a specialist psychiatrist.
Volk can also be read as offering judicial insight into patients who pose a health hazard by insisting on operating a vehicle against medical advice. In its 2012 Code of Medical Ethics, the American Medical Association had this to say: “In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”5
That is now replaced in the AMA code with a broader version covering the duty to disclose: “Physicians may disclose personal health information without the specific consent of the patient ... to other third parties situated to mitigate the threat when in the physician’s judgment there is a reasonable probability that: (i) the patient will seriously harm him/herself; or (ii) the patient will inflict serious physical harm on an identifiable individual or individuals.”6
Under Volk, physicians are now more likely to forsake confidentiality in the name of public safety – even in the absence of a readily identifiable potential victim.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials have been taken from earlier columns in Internal Medicine News. For additional information, readers may contact the author at [email protected].
References
1. Volk v. DeMeerleer, 386 P.3d 254 (Wa. 2016).
2. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
3. Thompson v. County of Alameda, 167 Cal. Rptr. 70, 76 (1980).
4. Behav Sci Law. 2001;19(3):325-43.
5. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed].
6. AMA Code of Medical Ethics, 2017 ed. [3.2.1 Confidentiality].
Question: During an office visit, a patient confided in his primary care provider his intention to go on a shooting spree. When pressed, he admitted he owned a firearm, but did not truly intend to carry out the act. He denied having a specific target location or victim in mind. The primary care provider (PCP) opted to counsel the patient, and continued him on his antidepressant medication. The PCP did not make a referral to a psychiatrist. Several weeks later, the patient put his threat into action, shooting and injuring several innocent shoppers at a mall.
In a lawsuit against the PCP, which of the following is best?
A. It is unethical for the PCP to report this threat, because it violates the principle of confidentiality.
B. Failure to warn under the circumstances definitely makes the physician liable.
C. The PCP is liable under the Tarasoff doctrine.
D. Without a named victim, there is no one to warn.
E. Whether the PCP is liable may turn on the issue of foreseeability, and an immediate referral to a psychiatrist would have been a more prudent course of action.
Answer: E. One of the physician’s sacred promises is to maintain patient confidentiality. It is more than an unspoken contractual agreement; it’s a central component of trust, without which the doctor-patient relationship cannot exist. Indeed, Hippocrates had cautioned, “whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge as reckoning that all should be kept secret.”
Thus, the recent expansive decision handed down by the Washington state Supreme Court stunned many mental health professionals.1 In Volk v. DeMeerleer, a clinic patient had confided in his psychiatrist over 9 years of therapy his suicidal and homicidal ideations. He eventually went on to kill his former girlfriend and one of her sons, and then committed suicide. The psychiatrist did not have full control of this clinic patient, nor had the patient named a specific victim. Nevertheless, the Volk court held that the doctor’s duty extended to any foreseeable harm by the patient, leaving it up to the jury to decide on the issue of foreseeability.
The court held that the psychiatrist had a “special relationship” with the victims, because he had a duty to exercise reasonable care to act, consistent with the standards of the mental health profession, in order to protect the foreseeable victims.
The court reasoned that some ability to control the patient’s conduct is sufficient for the “special relationship” and the consequent duty of care to exist, writing: “We find that absolute control is unnecessary, and the actions available to mental health professionals, even in the outpatient setting, weigh in favor of imposing a duty.” The court also noted that a psychiatrist’s obligation to protect third parties against patients’ violence would normally set aside confidentiality and yield to greater societal interests.
The vexing issue of compromising confidentiality in the name of protecting public safety had its genesis in the famous Tarasoff v. Regents of University of California case.2
In Tarasoff, the California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, whom the patient stabbed to death 2 months later.
The court reasoned that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship, pointing out: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
Following Tarasoff, it is generally accepted that there is no affirmative duty to warn where there is no readily identifiable victim. In a subsequent case, the same court explained that “the duty to warn depends upon and arises from the existence of a prior threat to a specific identifiable victim. In those instances in which the released offender poses a predictable threat of harm to a named or readily identifiable victim or group of victims who can be effectively warned of the danger, a releasing agent may well be liable for failure to warn such persons. Despite the tragic events underlying the present complaint, plaintiffs’ decedent was not a known, identifiable victim, but rather a member of a large, amorphous public group of potential targets. Under these circumstances, we hold that County had no affirmative duty to warn plaintiffs, the police, the mother of the juvenile offender, or other local parents.”3
Commentators have suggested that such post-Tarasoff cases, coupled with the advent of state statutes that codify Tarasoff, have witnessed a retreat from imposing on clinicians a duty to warn.4 By dispensing with the control and “readily identifiable victim” elements, Volk appears to contradict this perceived trend. Foreseeability may turn out to be the dispositive issue.
Some have speculated whether Volk’s expanded view will apply to other professionals such as a family practitioner or even a school counselor. Physicians who are not experienced in treating mental health patients will do well to promptly refer their unstable patients to a specialist psychiatrist.
Volk can also be read as offering judicial insight into patients who pose a health hazard by insisting on operating a vehicle against medical advice. In its 2012 Code of Medical Ethics, the American Medical Association had this to say: “In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”5
That is now replaced in the AMA code with a broader version covering the duty to disclose: “Physicians may disclose personal health information without the specific consent of the patient ... to other third parties situated to mitigate the threat when in the physician’s judgment there is a reasonable probability that: (i) the patient will seriously harm him/herself; or (ii) the patient will inflict serious physical harm on an identifiable individual or individuals.”6
Under Volk, physicians are now more likely to forsake confidentiality in the name of public safety – even in the absence of a readily identifiable potential victim.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials have been taken from earlier columns in Internal Medicine News. For additional information, readers may contact the author at [email protected].
References
1. Volk v. DeMeerleer, 386 P.3d 254 (Wa. 2016).
2. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
3. Thompson v. County of Alameda, 167 Cal. Rptr. 70, 76 (1980).
4. Behav Sci Law. 2001;19(3):325-43.
5. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed].
6. AMA Code of Medical Ethics, 2017 ed. [3.2.1 Confidentiality].
It’s too soon to discard cotesting in cervical cancer
In their new cervical cancer screening draft recommendation statement, the U.S. Preventive Services Task Force recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21-29 years, and either continuing 3-year cytology screening or 5-year high-risk human papillomavirus (HPV) screening in women aged 30-65 years.1 They arrived at the conclusion primarily based on an analysis of benefits and harms of each of the currently used screening modalities. Cytology plus HPV cotesting was considered but rejected based on the benefits versus harms calculations. However, some of the assumptions in their modeling are wrong and this has led them to faulty conclusions.
The USPSTF correctly identified CIN-2/3 and CIN-3+ detected and cervical cancer cases and deaths prevented as benefits. But they used the number of colposcopies and the number of tests conducted as their proxy for harms, primarily because these were more easily measured. They identified other harms, such as greater psychological distress related to being told of a positive HPV result (compared with being told of an abnormal cytology or cotest result), but these harms were not numerical and so they could not be incorporated into their modeling. They also did not measure the psychological distress associated with an extended screening interval or HPV-only screening.
The USPSTF also primarily relied on evidence from seven large, randomly controlled trials of primary screening, mostly conducted in Europe.3 Of the seven trials, two of them (SWEDESCREEN and POBASCAM) used HPV testing by a polymerase chain reaction methodology that is not approved by the U.S. Food and Drug Administration, not commercially available in the United States, and has different sensitivity and specificity does than FDA-approved tests.
Most of the studies also were done with conventional cytology that is, for the most part, no longer used in the United States. The age range in some of the studies was also very narrow (SWEDESCREEN evaluated women aged 32-38 years only) while extending to very young ages in others (ARTISTIC evaluated women as young as age 20 years). It may not be possible to extrapolate from these results to the U.S. experience. On the other hand, the USPSTF elected not to use data from very large retrospective U.S. trials, such as the data from more than 1 million women from Kaiser Permanente Northern California, which helped form the foundation of current guidelines.4
Although screening has dramatically reduced the incidence of cervical cancer in the United States, most screening in this country is opportunistic and lacks population-based registries or regular invitations to screening. The USPSTF notes that a sizable proportion of the U.S.-based female population is not routinely screened. In fact, 11.4% of 21- to 65-year-old women have not been screened in the previous 5 years and the percentages are higher among minority and disadvantaged populations. Although the numbers seem relatively small, more than half of women with cervical cancer are found in this population. These women also are at greater risk of being lost to follow-up. Unlike the patients in the European trials, there is no current mechanism in the United States to assure that patients will return in 5 years. In fact, the USPSTF notes this limitation in their evidence, but doesn’t provide a remedy. These women may not get rescreened for many years after the 5-year interval has passed, and there is no evidence that this interval is safe.
Finally, the USPSTF recommendations for HPV primary screening relied in whole or in part on cytology triage of positive results. There is no U.S. experience for the use of cytology within this context, and many experts have argued that the test performance of cytology in a triage setting would be different than in a screening setting and would further be different in a vaccinated population. Since the modeling on which these draft recommendations are based did not account for these changed performance characteristics, their assumptions must be wrong.
Five years have not yet passed since publication of the last set of guidelines, and we have no idea how this extended screening interval functions in our opportunistic screening system. Stated simply, these draft recommendations have gone too far and too fast and should be reconsidered.
Dr. Spitzer is a professor of obstetrics and gynecology at Hofstra Northwell School of Medicine, Hempstead, N.Y., and a past president of the American Society for Colposcopy and Cervical Pathology. He reported receiving royalties from Elsevier, and consulting fees from Hologic, Biop Medical, Illumigen, and Merck.
References
1. Draft Recommendation Statement: Cervical Cancer: Screening. U.S. Preventive Services Task Force. September 2017.
2. Screening for Cervical Cancer in Primary Care: A Decision Analysis for the U.S. Preventive Services Task Force. 2017.
3. Screening for Cervical Cancer With High-Risk Human Papillomavirus Testing: A Systematic Evidence Review for the U.S. Preventive Services Task Force. 2017.
4. J Natl Cancer Inst. 2014 Jul 18;106(8). pii: dju153.
In their new cervical cancer screening draft recommendation statement, the U.S. Preventive Services Task Force recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21-29 years, and either continuing 3-year cytology screening or 5-year high-risk human papillomavirus (HPV) screening in women aged 30-65 years.1 They arrived at the conclusion primarily based on an analysis of benefits and harms of each of the currently used screening modalities. Cytology plus HPV cotesting was considered but rejected based on the benefits versus harms calculations. However, some of the assumptions in their modeling are wrong and this has led them to faulty conclusions.
The USPSTF correctly identified CIN-2/3 and CIN-3+ detected and cervical cancer cases and deaths prevented as benefits. But they used the number of colposcopies and the number of tests conducted as their proxy for harms, primarily because these were more easily measured. They identified other harms, such as greater psychological distress related to being told of a positive HPV result (compared with being told of an abnormal cytology or cotest result), but these harms were not numerical and so they could not be incorporated into their modeling. They also did not measure the psychological distress associated with an extended screening interval or HPV-only screening.
The USPSTF also primarily relied on evidence from seven large, randomly controlled trials of primary screening, mostly conducted in Europe.3 Of the seven trials, two of them (SWEDESCREEN and POBASCAM) used HPV testing by a polymerase chain reaction methodology that is not approved by the U.S. Food and Drug Administration, not commercially available in the United States, and has different sensitivity and specificity does than FDA-approved tests.
Most of the studies also were done with conventional cytology that is, for the most part, no longer used in the United States. The age range in some of the studies was also very narrow (SWEDESCREEN evaluated women aged 32-38 years only) while extending to very young ages in others (ARTISTIC evaluated women as young as age 20 years). It may not be possible to extrapolate from these results to the U.S. experience. On the other hand, the USPSTF elected not to use data from very large retrospective U.S. trials, such as the data from more than 1 million women from Kaiser Permanente Northern California, which helped form the foundation of current guidelines.4
Although screening has dramatically reduced the incidence of cervical cancer in the United States, most screening in this country is opportunistic and lacks population-based registries or regular invitations to screening. The USPSTF notes that a sizable proportion of the U.S.-based female population is not routinely screened. In fact, 11.4% of 21- to 65-year-old women have not been screened in the previous 5 years and the percentages are higher among minority and disadvantaged populations. Although the numbers seem relatively small, more than half of women with cervical cancer are found in this population. These women also are at greater risk of being lost to follow-up. Unlike the patients in the European trials, there is no current mechanism in the United States to assure that patients will return in 5 years. In fact, the USPSTF notes this limitation in their evidence, but doesn’t provide a remedy. These women may not get rescreened for many years after the 5-year interval has passed, and there is no evidence that this interval is safe.
Finally, the USPSTF recommendations for HPV primary screening relied in whole or in part on cytology triage of positive results. There is no U.S. experience for the use of cytology within this context, and many experts have argued that the test performance of cytology in a triage setting would be different than in a screening setting and would further be different in a vaccinated population. Since the modeling on which these draft recommendations are based did not account for these changed performance characteristics, their assumptions must be wrong.
Five years have not yet passed since publication of the last set of guidelines, and we have no idea how this extended screening interval functions in our opportunistic screening system. Stated simply, these draft recommendations have gone too far and too fast and should be reconsidered.
Dr. Spitzer is a professor of obstetrics and gynecology at Hofstra Northwell School of Medicine, Hempstead, N.Y., and a past president of the American Society for Colposcopy and Cervical Pathology. He reported receiving royalties from Elsevier, and consulting fees from Hologic, Biop Medical, Illumigen, and Merck.
References
1. Draft Recommendation Statement: Cervical Cancer: Screening. U.S. Preventive Services Task Force. September 2017.
2. Screening for Cervical Cancer in Primary Care: A Decision Analysis for the U.S. Preventive Services Task Force. 2017.
3. Screening for Cervical Cancer With High-Risk Human Papillomavirus Testing: A Systematic Evidence Review for the U.S. Preventive Services Task Force. 2017.
4. J Natl Cancer Inst. 2014 Jul 18;106(8). pii: dju153.
In their new cervical cancer screening draft recommendation statement, the U.S. Preventive Services Task Force recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21-29 years, and either continuing 3-year cytology screening or 5-year high-risk human papillomavirus (HPV) screening in women aged 30-65 years.1 They arrived at the conclusion primarily based on an analysis of benefits and harms of each of the currently used screening modalities. Cytology plus HPV cotesting was considered but rejected based on the benefits versus harms calculations. However, some of the assumptions in their modeling are wrong and this has led them to faulty conclusions.
The USPSTF correctly identified CIN-2/3 and CIN-3+ detected and cervical cancer cases and deaths prevented as benefits. But they used the number of colposcopies and the number of tests conducted as their proxy for harms, primarily because these were more easily measured. They identified other harms, such as greater psychological distress related to being told of a positive HPV result (compared with being told of an abnormal cytology or cotest result), but these harms were not numerical and so they could not be incorporated into their modeling. They also did not measure the psychological distress associated with an extended screening interval or HPV-only screening.
The USPSTF also primarily relied on evidence from seven large, randomly controlled trials of primary screening, mostly conducted in Europe.3 Of the seven trials, two of them (SWEDESCREEN and POBASCAM) used HPV testing by a polymerase chain reaction methodology that is not approved by the U.S. Food and Drug Administration, not commercially available in the United States, and has different sensitivity and specificity does than FDA-approved tests.
Most of the studies also were done with conventional cytology that is, for the most part, no longer used in the United States. The age range in some of the studies was also very narrow (SWEDESCREEN evaluated women aged 32-38 years only) while extending to very young ages in others (ARTISTIC evaluated women as young as age 20 years). It may not be possible to extrapolate from these results to the U.S. experience. On the other hand, the USPSTF elected not to use data from very large retrospective U.S. trials, such as the data from more than 1 million women from Kaiser Permanente Northern California, which helped form the foundation of current guidelines.4
Although screening has dramatically reduced the incidence of cervical cancer in the United States, most screening in this country is opportunistic and lacks population-based registries or regular invitations to screening. The USPSTF notes that a sizable proportion of the U.S.-based female population is not routinely screened. In fact, 11.4% of 21- to 65-year-old women have not been screened in the previous 5 years and the percentages are higher among minority and disadvantaged populations. Although the numbers seem relatively small, more than half of women with cervical cancer are found in this population. These women also are at greater risk of being lost to follow-up. Unlike the patients in the European trials, there is no current mechanism in the United States to assure that patients will return in 5 years. In fact, the USPSTF notes this limitation in their evidence, but doesn’t provide a remedy. These women may not get rescreened for many years after the 5-year interval has passed, and there is no evidence that this interval is safe.
Finally, the USPSTF recommendations for HPV primary screening relied in whole or in part on cytology triage of positive results. There is no U.S. experience for the use of cytology within this context, and many experts have argued that the test performance of cytology in a triage setting would be different than in a screening setting and would further be different in a vaccinated population. Since the modeling on which these draft recommendations are based did not account for these changed performance characteristics, their assumptions must be wrong.
Five years have not yet passed since publication of the last set of guidelines, and we have no idea how this extended screening interval functions in our opportunistic screening system. Stated simply, these draft recommendations have gone too far and too fast and should be reconsidered.
Dr. Spitzer is a professor of obstetrics and gynecology at Hofstra Northwell School of Medicine, Hempstead, N.Y., and a past president of the American Society for Colposcopy and Cervical Pathology. He reported receiving royalties from Elsevier, and consulting fees from Hologic, Biop Medical, Illumigen, and Merck.
References
1. Draft Recommendation Statement: Cervical Cancer: Screening. U.S. Preventive Services Task Force. September 2017.
2. Screening for Cervical Cancer in Primary Care: A Decision Analysis for the U.S. Preventive Services Task Force. 2017.
3. Screening for Cervical Cancer With High-Risk Human Papillomavirus Testing: A Systematic Evidence Review for the U.S. Preventive Services Task Force. 2017.
4. J Natl Cancer Inst. 2014 Jul 18;106(8). pii: dju153.