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Whose nurse is she/he?
I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?
Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.
However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However,
I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.
When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at [email protected].
I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?
Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.
However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However,
I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.
When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at [email protected].
I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?
Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.
However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However,
I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.
When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.
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].
Oh No, Not Again!
Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.
Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).
On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.
First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.
The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.
To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it.
*As of October 11, 2017, this number rose to 14 deaths.
Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.
Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).
On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.
First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.
The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.
To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it.
*As of October 11, 2017, this number rose to 14 deaths.
Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.
Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).
On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.
First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.
The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.
To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it.
*As of October 11, 2017, this number rose to 14 deaths.
Death by meeting
I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.
I can’t say that I have never attended what I would consider a good meeting. But
Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.
In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.
If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.
If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?
No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.
Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.
I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.
I can’t say that I have never attended what I would consider a good meeting. But
Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.
In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.
If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.
If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?
No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.
Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.
I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.
I can’t say that I have never attended what I would consider a good meeting. But
Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.
In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.
If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.
If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?
No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.
Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.
Rectal temps in the nursery
It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”
However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.
Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.
But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
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.”
It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”
However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.
Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.
But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
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.”
It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”
However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.
Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.
But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
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.”
Now missing in EHR charts: a good impression
I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.
Recently, while on call, I discovered a new problem: the lack of a decent impression.
I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.
Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.
Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.
This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.
In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.
It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.
Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.
Recently, while on call, I discovered a new problem: the lack of a decent impression.
I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.
Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.
Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.
This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.
In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.
It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.
Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.
Recently, while on call, I discovered a new problem: the lack of a decent impression.
I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.
Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.
Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.
This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.
In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.
It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.
Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Teratogenicity may not be a yes or no question
Since thalidomide, the medical community has sought to ensure that we do not miss any safety signal that a drug could cause malformations or developmental delays after in utero exposure.
At the time of a drug’s debut, there are relatively small numbers of exposures in pregnancy, and it’s difficult to decipher teratogenicity. As the number of exposures increases, we are generally able to answer “yes” or “no” to the question of teratogenicity. But in the last decade or so, data on drug exposure in pregnancy has become robust enough – thanks in part to large registries – to provide potentially more useful answers on safety. Specifically, .
Animal studies show us that there is a dose dependent effect in pregnancy, and not every dose causes harm to the fetus. However, that information is not easily translated into clinical practice because of the vast differences between animal and human pharmacokinetics and sensitivity to toxicity.
The first drug that came into focus as having dose dependent teratogenicity in pregnancy is the epilepsy drug valproic acid. In the late 1980s, studies showed that the drug was associated with an increased risk for spina bifida. Later, more congenital malformations were linked to valproic acid, including oral cleft, cardiac and limb defects, developmental delays, lower IQ, and even autism. But in the last few years, an increasing number of studies point to a lower dose that may represent an acceptable risk for some pregnant women.
Looking at data from EURAP, an international registry of antiepileptic drugs and pregnancy, researchers showed that the dose of valproic acid with the greatest risk for harm was 1,500 mg per day or greater, with a 24% frequency of major congenital malformations. But at less than 700 mg per day, the frequency of major malformations dropped to 5.9% (Neurology. 2015 Sep 8;85[10]:866-72).
Another analysis of the EURAP data showed the same dose-dependent relationship with other drugs. The researchers calculated rates of major congenital malformations in 1,402 pregnancies exposed to carbamazepine, 1,280 on lamotrigine, 1,010 on valproic acid, and 217 on phenobarbital, and all showed that the frequency of birth defects increased along with the dose of the drug.
The study identified the dose for each drug with the lowest rates of malformation. For lamotrigine, it was a dose of less than 300 mg per day, with a 2% frequency of malformations. Similarly, the dose was less than 400 mg per day for carbamazepine (3.4% rate of malformations). Overall, risks of malformation were significantly higher in valproic acid and phenobarbital at all tested doses and carbamazepine at doses greater than 400 mg per day, compared with lamotrigine monotherapy at less than 300 mg per day (Lancet Neurol. 2011 Jul;10[7]:609-17).
The study is important because it gives us a benchmark for these drugs, allowing us to see the risks at lower doses.
But not all the data are in agreement. In 2016, a Cochrane review of different antiepileptic drugs in pregnancy found that only with valproic acid could the risk of a malformation be clearly linked to the size of the dose (Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224).
Most recently, a large U.S. database of Medicaid patients, which included more than 1.3 million pregnancies, showed the dose-dependent risk of malformations associated with lithium, still widely used in treating bipolar disorder. The researchers examined the risk of cardiac malformations after first-trimester lithium exposure.
With the publication of each of these studies, we are moving toward an era where the question of teratogenicity is no longer just “yes” or “no,” but dose dependent. Soon, I hope we will be able to expand our knowledge by evaluating doses in milligrams per kilogram, rather than just a per day dose, thus addressing body size in evaluating the risk.
As more than half of pregnancies are unplanned, there are often times when women have been exposed to teratogens during early pregnancy and knowing the size of the risk is an invaluable decision-making tool. We don’t have the full risk picture yet, but it is growing clearer.
Dr. Koren is professor of pediatrics at Western University in Ontario and Tel Aviv University in Israel, and is the founder of the Motherisk Program. He reported having no relevant financial disclosures.
Since thalidomide, the medical community has sought to ensure that we do not miss any safety signal that a drug could cause malformations or developmental delays after in utero exposure.
At the time of a drug’s debut, there are relatively small numbers of exposures in pregnancy, and it’s difficult to decipher teratogenicity. As the number of exposures increases, we are generally able to answer “yes” or “no” to the question of teratogenicity. But in the last decade or so, data on drug exposure in pregnancy has become robust enough – thanks in part to large registries – to provide potentially more useful answers on safety. Specifically, .
Animal studies show us that there is a dose dependent effect in pregnancy, and not every dose causes harm to the fetus. However, that information is not easily translated into clinical practice because of the vast differences between animal and human pharmacokinetics and sensitivity to toxicity.
The first drug that came into focus as having dose dependent teratogenicity in pregnancy is the epilepsy drug valproic acid. In the late 1980s, studies showed that the drug was associated with an increased risk for spina bifida. Later, more congenital malformations were linked to valproic acid, including oral cleft, cardiac and limb defects, developmental delays, lower IQ, and even autism. But in the last few years, an increasing number of studies point to a lower dose that may represent an acceptable risk for some pregnant women.
Looking at data from EURAP, an international registry of antiepileptic drugs and pregnancy, researchers showed that the dose of valproic acid with the greatest risk for harm was 1,500 mg per day or greater, with a 24% frequency of major congenital malformations. But at less than 700 mg per day, the frequency of major malformations dropped to 5.9% (Neurology. 2015 Sep 8;85[10]:866-72).
Another analysis of the EURAP data showed the same dose-dependent relationship with other drugs. The researchers calculated rates of major congenital malformations in 1,402 pregnancies exposed to carbamazepine, 1,280 on lamotrigine, 1,010 on valproic acid, and 217 on phenobarbital, and all showed that the frequency of birth defects increased along with the dose of the drug.
The study identified the dose for each drug with the lowest rates of malformation. For lamotrigine, it was a dose of less than 300 mg per day, with a 2% frequency of malformations. Similarly, the dose was less than 400 mg per day for carbamazepine (3.4% rate of malformations). Overall, risks of malformation were significantly higher in valproic acid and phenobarbital at all tested doses and carbamazepine at doses greater than 400 mg per day, compared with lamotrigine monotherapy at less than 300 mg per day (Lancet Neurol. 2011 Jul;10[7]:609-17).
The study is important because it gives us a benchmark for these drugs, allowing us to see the risks at lower doses.
But not all the data are in agreement. In 2016, a Cochrane review of different antiepileptic drugs in pregnancy found that only with valproic acid could the risk of a malformation be clearly linked to the size of the dose (Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224).
Most recently, a large U.S. database of Medicaid patients, which included more than 1.3 million pregnancies, showed the dose-dependent risk of malformations associated with lithium, still widely used in treating bipolar disorder. The researchers examined the risk of cardiac malformations after first-trimester lithium exposure.
With the publication of each of these studies, we are moving toward an era where the question of teratogenicity is no longer just “yes” or “no,” but dose dependent. Soon, I hope we will be able to expand our knowledge by evaluating doses in milligrams per kilogram, rather than just a per day dose, thus addressing body size in evaluating the risk.
As more than half of pregnancies are unplanned, there are often times when women have been exposed to teratogens during early pregnancy and knowing the size of the risk is an invaluable decision-making tool. We don’t have the full risk picture yet, but it is growing clearer.
Dr. Koren is professor of pediatrics at Western University in Ontario and Tel Aviv University in Israel, and is the founder of the Motherisk Program. He reported having no relevant financial disclosures.
Since thalidomide, the medical community has sought to ensure that we do not miss any safety signal that a drug could cause malformations or developmental delays after in utero exposure.
At the time of a drug’s debut, there are relatively small numbers of exposures in pregnancy, and it’s difficult to decipher teratogenicity. As the number of exposures increases, we are generally able to answer “yes” or “no” to the question of teratogenicity. But in the last decade or so, data on drug exposure in pregnancy has become robust enough – thanks in part to large registries – to provide potentially more useful answers on safety. Specifically, .
Animal studies show us that there is a dose dependent effect in pregnancy, and not every dose causes harm to the fetus. However, that information is not easily translated into clinical practice because of the vast differences between animal and human pharmacokinetics and sensitivity to toxicity.
The first drug that came into focus as having dose dependent teratogenicity in pregnancy is the epilepsy drug valproic acid. In the late 1980s, studies showed that the drug was associated with an increased risk for spina bifida. Later, more congenital malformations were linked to valproic acid, including oral cleft, cardiac and limb defects, developmental delays, lower IQ, and even autism. But in the last few years, an increasing number of studies point to a lower dose that may represent an acceptable risk for some pregnant women.
Looking at data from EURAP, an international registry of antiepileptic drugs and pregnancy, researchers showed that the dose of valproic acid with the greatest risk for harm was 1,500 mg per day or greater, with a 24% frequency of major congenital malformations. But at less than 700 mg per day, the frequency of major malformations dropped to 5.9% (Neurology. 2015 Sep 8;85[10]:866-72).
Another analysis of the EURAP data showed the same dose-dependent relationship with other drugs. The researchers calculated rates of major congenital malformations in 1,402 pregnancies exposed to carbamazepine, 1,280 on lamotrigine, 1,010 on valproic acid, and 217 on phenobarbital, and all showed that the frequency of birth defects increased along with the dose of the drug.
The study identified the dose for each drug with the lowest rates of malformation. For lamotrigine, it was a dose of less than 300 mg per day, with a 2% frequency of malformations. Similarly, the dose was less than 400 mg per day for carbamazepine (3.4% rate of malformations). Overall, risks of malformation were significantly higher in valproic acid and phenobarbital at all tested doses and carbamazepine at doses greater than 400 mg per day, compared with lamotrigine monotherapy at less than 300 mg per day (Lancet Neurol. 2011 Jul;10[7]:609-17).
The study is important because it gives us a benchmark for these drugs, allowing us to see the risks at lower doses.
But not all the data are in agreement. In 2016, a Cochrane review of different antiepileptic drugs in pregnancy found that only with valproic acid could the risk of a malformation be clearly linked to the size of the dose (Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224).
Most recently, a large U.S. database of Medicaid patients, which included more than 1.3 million pregnancies, showed the dose-dependent risk of malformations associated with lithium, still widely used in treating bipolar disorder. The researchers examined the risk of cardiac malformations after first-trimester lithium exposure.
With the publication of each of these studies, we are moving toward an era where the question of teratogenicity is no longer just “yes” or “no,” but dose dependent. Soon, I hope we will be able to expand our knowledge by evaluating doses in milligrams per kilogram, rather than just a per day dose, thus addressing body size in evaluating the risk.
As more than half of pregnancies are unplanned, there are often times when women have been exposed to teratogens during early pregnancy and knowing the size of the risk is an invaluable decision-making tool. We don’t have the full risk picture yet, but it is growing clearer.
Dr. Koren is professor of pediatrics at Western University in Ontario and Tel Aviv University in Israel, and is the founder of the Motherisk Program. He reported having no relevant financial disclosures.
Bearing the Standard
An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.1 Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.
The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”1
The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.
It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.2 All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.
Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.
There is a shortage of addiction and pain specialists in and outside the federal system.3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.
Critics of the VA have in many cases rightly made accountability the watchword of their campaigns. To its credit, the VA has embraced the cause in the I CARE value of integrity. “Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.”
But that sense of responsibility must extend to all those who provide care to veterans—especially those who prescribe medications that have the immense double-edged potential to relieve pain and disability but at the same time also cause suffering and death.
While this inability to enforce VA/DoD responsible prescribing requirements in the community is likely more urgent and life threatening, there still are many other federal clinical and organizational policies and regulations to which the community is not required to adhere. I will discuss some of these and their potentially negative implications in future columns. For the promise of Choice to be realized, we all must work together to bear the highest possible standard of care for those who serve and have served.
1. Davidson J. Veterans’ health-care gap creates ‘greater risk’ for opioid use [news release]. Washington Post. August 7, 2017. https://www.washingtonpost.com/news/powerpost/wp/2017/08/07/veterans-health-care-gap-creates-greater-risk-for -opioid-abuse/?utm_term=.e4ec9596db6b. Accessed September 18, 2017.
2. Department of Veterans Affairs Office of Inspector General. Office of Healthcare Inspections. Report No. 17-01846-316. Opioid prescribing to high-risk veterans receiving VA purchased care. https://www.va.gov/oig/pubs/VAOIG-17-01846-316.pdf. Published July 31, 2017. Accessed September 18, 2017.
3. Vestal C. How severe is the shortage of substance abuse specialists? http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/01/how-severe-is-the-shortage-of-substance-abuse -specialists. Published April 1, 2015. Accessed September 28, 2017.
4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.
5. U.S. Department of Veterans Affairs. I care quick reference core values. https://www.va.gov/icare/docs/core_values_quick_reference.pdf. Accessed September 18, 2017.
An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.1 Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.
The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”1
The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.
It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.2 All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.
Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.
There is a shortage of addiction and pain specialists in and outside the federal system.3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.
Critics of the VA have in many cases rightly made accountability the watchword of their campaigns. To its credit, the VA has embraced the cause in the I CARE value of integrity. “Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.”
But that sense of responsibility must extend to all those who provide care to veterans—especially those who prescribe medications that have the immense double-edged potential to relieve pain and disability but at the same time also cause suffering and death.
While this inability to enforce VA/DoD responsible prescribing requirements in the community is likely more urgent and life threatening, there still are many other federal clinical and organizational policies and regulations to which the community is not required to adhere. I will discuss some of these and their potentially negative implications in future columns. For the promise of Choice to be realized, we all must work together to bear the highest possible standard of care for those who serve and have served.
An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.1 Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.
The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”1
The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.
It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.2 All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.
Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.
There is a shortage of addiction and pain specialists in and outside the federal system.3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.
Critics of the VA have in many cases rightly made accountability the watchword of their campaigns. To its credit, the VA has embraced the cause in the I CARE value of integrity. “Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.”
But that sense of responsibility must extend to all those who provide care to veterans—especially those who prescribe medications that have the immense double-edged potential to relieve pain and disability but at the same time also cause suffering and death.
While this inability to enforce VA/DoD responsible prescribing requirements in the community is likely more urgent and life threatening, there still are many other federal clinical and organizational policies and regulations to which the community is not required to adhere. I will discuss some of these and their potentially negative implications in future columns. For the promise of Choice to be realized, we all must work together to bear the highest possible standard of care for those who serve and have served.
1. Davidson J. Veterans’ health-care gap creates ‘greater risk’ for opioid use [news release]. Washington Post. August 7, 2017. https://www.washingtonpost.com/news/powerpost/wp/2017/08/07/veterans-health-care-gap-creates-greater-risk-for -opioid-abuse/?utm_term=.e4ec9596db6b. Accessed September 18, 2017.
2. Department of Veterans Affairs Office of Inspector General. Office of Healthcare Inspections. Report No. 17-01846-316. Opioid prescribing to high-risk veterans receiving VA purchased care. https://www.va.gov/oig/pubs/VAOIG-17-01846-316.pdf. Published July 31, 2017. Accessed September 18, 2017.
3. Vestal C. How severe is the shortage of substance abuse specialists? http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/01/how-severe-is-the-shortage-of-substance-abuse -specialists. Published April 1, 2015. Accessed September 28, 2017.
4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.
5. U.S. Department of Veterans Affairs. I care quick reference core values. https://www.va.gov/icare/docs/core_values_quick_reference.pdf. Accessed September 18, 2017.
1. Davidson J. Veterans’ health-care gap creates ‘greater risk’ for opioid use [news release]. Washington Post. August 7, 2017. https://www.washingtonpost.com/news/powerpost/wp/2017/08/07/veterans-health-care-gap-creates-greater-risk-for -opioid-abuse/?utm_term=.e4ec9596db6b. Accessed September 18, 2017.
2. Department of Veterans Affairs Office of Inspector General. Office of Healthcare Inspections. Report No. 17-01846-316. Opioid prescribing to high-risk veterans receiving VA purchased care. https://www.va.gov/oig/pubs/VAOIG-17-01846-316.pdf. Published July 31, 2017. Accessed September 18, 2017.
3. Vestal C. How severe is the shortage of substance abuse specialists? http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/01/how-severe-is-the-shortage-of-substance-abuse -specialists. Published April 1, 2015. Accessed September 28, 2017.
4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.
5. U.S. Department of Veterans Affairs. I care quick reference core values. https://www.va.gov/icare/docs/core_values_quick_reference.pdf. Accessed September 18, 2017.
Do Infants Fed Rice and Rice Products Have an Increased Risk for Skin Cancer?
To the Editor:
Rice and rice products, such as rice cereal and rice snacks, contain inorganic arsenic. Exposure to arsenicin utero and during early life may be associated with adverse fetal growth, adverse infant and child immune response, and adverse neurodevelopmental outcomes. Therefore, the World Health Organization, the Food and Agriculture Organization of the United Nations, the European Union, and the US Food and Drug Administration have suggested maximum arsenic ingestion recommendations for infants: 100 ng/g for inorganic arsenic in products geared toward infants. However, infants consuming only a few servings of rice products may exceed the weekly tolerable intake of arsenic.
Karagas et al1 obtained dietary data on 759 infants who were enrolled in the New Hampshire Birth Cohort Study from 2011 to 2014. They noted that 80% of the infants had been introduced to rice cereal during the first year. Additional data on diet and total urinary arsenic at 12 months was available for 129 infants: 32.6% of these infants were fed rice snacks. In addition, the total urinary arsenic concentration was higher among infants who ate rice cereal or rice snacks as compared to infants who did not eat rice or rice products.
Chronic arsenic exposure can result in patchy dark brown hyperpigmentation with scattered pale spots referred to as “raindrops on a dusty road.” The axilla, eyelids, groin, neck, nipples, and temples often are affected. However, the hyperpigmentation can extend across the chest, abdomen, and back in severe cases.
Horizontal white lines across the nails (Mees lines) may develop. Keratoses, often on the palms (arsenic keratoses), may appear; they persist and may progress to skin cancers. In addition, patients with arsenic exposure are more susceptible to developing nonmelanoma skin cancers.2
It is unknown if exposure to inorganic arsenic in infancy predisposes these individuals to skin cancer when they become adults. Long-term longitudinal follow-up of the participants in this study may provide additional insight. Perhaps infants should not receive rice cereals and rice snacks or their parents should more carefully monitor the amount of rice and rice products that they ingest.
- Karagas MR, Punshon T, Sayarath V, et al. Association of rice and rice-product consumption with arsenic exposure early in life. JAMA Pediatr. 2016;170:609-616.
- Mayer JE, Goldman RH. Arsenic and skin cancer in the USA: the current evidence regarding arsenic-contaminated drinking water. Int J Dermatol. 2016;55;e585-e591.
To the Editor:
Rice and rice products, such as rice cereal and rice snacks, contain inorganic arsenic. Exposure to arsenicin utero and during early life may be associated with adverse fetal growth, adverse infant and child immune response, and adverse neurodevelopmental outcomes. Therefore, the World Health Organization, the Food and Agriculture Organization of the United Nations, the European Union, and the US Food and Drug Administration have suggested maximum arsenic ingestion recommendations for infants: 100 ng/g for inorganic arsenic in products geared toward infants. However, infants consuming only a few servings of rice products may exceed the weekly tolerable intake of arsenic.
Karagas et al1 obtained dietary data on 759 infants who were enrolled in the New Hampshire Birth Cohort Study from 2011 to 2014. They noted that 80% of the infants had been introduced to rice cereal during the first year. Additional data on diet and total urinary arsenic at 12 months was available for 129 infants: 32.6% of these infants were fed rice snacks. In addition, the total urinary arsenic concentration was higher among infants who ate rice cereal or rice snacks as compared to infants who did not eat rice or rice products.
Chronic arsenic exposure can result in patchy dark brown hyperpigmentation with scattered pale spots referred to as “raindrops on a dusty road.” The axilla, eyelids, groin, neck, nipples, and temples often are affected. However, the hyperpigmentation can extend across the chest, abdomen, and back in severe cases.
Horizontal white lines across the nails (Mees lines) may develop. Keratoses, often on the palms (arsenic keratoses), may appear; they persist and may progress to skin cancers. In addition, patients with arsenic exposure are more susceptible to developing nonmelanoma skin cancers.2
It is unknown if exposure to inorganic arsenic in infancy predisposes these individuals to skin cancer when they become adults. Long-term longitudinal follow-up of the participants in this study may provide additional insight. Perhaps infants should not receive rice cereals and rice snacks or their parents should more carefully monitor the amount of rice and rice products that they ingest.
To the Editor:
Rice and rice products, such as rice cereal and rice snacks, contain inorganic arsenic. Exposure to arsenicin utero and during early life may be associated with adverse fetal growth, adverse infant and child immune response, and adverse neurodevelopmental outcomes. Therefore, the World Health Organization, the Food and Agriculture Organization of the United Nations, the European Union, and the US Food and Drug Administration have suggested maximum arsenic ingestion recommendations for infants: 100 ng/g for inorganic arsenic in products geared toward infants. However, infants consuming only a few servings of rice products may exceed the weekly tolerable intake of arsenic.
Karagas et al1 obtained dietary data on 759 infants who were enrolled in the New Hampshire Birth Cohort Study from 2011 to 2014. They noted that 80% of the infants had been introduced to rice cereal during the first year. Additional data on diet and total urinary arsenic at 12 months was available for 129 infants: 32.6% of these infants were fed rice snacks. In addition, the total urinary arsenic concentration was higher among infants who ate rice cereal or rice snacks as compared to infants who did not eat rice or rice products.
Chronic arsenic exposure can result in patchy dark brown hyperpigmentation with scattered pale spots referred to as “raindrops on a dusty road.” The axilla, eyelids, groin, neck, nipples, and temples often are affected. However, the hyperpigmentation can extend across the chest, abdomen, and back in severe cases.
Horizontal white lines across the nails (Mees lines) may develop. Keratoses, often on the palms (arsenic keratoses), may appear; they persist and may progress to skin cancers. In addition, patients with arsenic exposure are more susceptible to developing nonmelanoma skin cancers.2
It is unknown if exposure to inorganic arsenic in infancy predisposes these individuals to skin cancer when they become adults. Long-term longitudinal follow-up of the participants in this study may provide additional insight. Perhaps infants should not receive rice cereals and rice snacks or their parents should more carefully monitor the amount of rice and rice products that they ingest.
- Karagas MR, Punshon T, Sayarath V, et al. Association of rice and rice-product consumption with arsenic exposure early in life. JAMA Pediatr. 2016;170:609-616.
- Mayer JE, Goldman RH. Arsenic and skin cancer in the USA: the current evidence regarding arsenic-contaminated drinking water. Int J Dermatol. 2016;55;e585-e591.
- Karagas MR, Punshon T, Sayarath V, et al. Association of rice and rice-product consumption with arsenic exposure early in life. JAMA Pediatr. 2016;170:609-616.
- Mayer JE, Goldman RH. Arsenic and skin cancer in the USA: the current evidence regarding arsenic-contaminated drinking water. Int J Dermatol. 2016;55;e585-e591.
Major Changes in the American Board of Dermatology’s Certification Examination
Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.
Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.
Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.
In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.
The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:
- BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
- CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
- APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations
These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.
The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.1 Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.
The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification
The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.
Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.
An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.
It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.2
- Exam of the Future: content outline and blueprint for BASIC exam. American Board of Dermatology website. https://dlpgnf31z4a6s.cloudfront.net/media/151102/basic-exam-content-outline-08132017.pdf. Updated August 13, 2017. Accessed September 12, 2017.
- Exam of the Future information center. American Board of Dermatology website. https://www.abderm.org/residents-and-fellows/exam-of-the-future-information-center.aspx. Accessed September 12, 2017.
Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.
Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.
Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.
In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.
The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:
- BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
- CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
- APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations
These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.
The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.1 Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.
The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification
The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.
Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.
An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.
It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.2
Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.
Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.
Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.
In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.
The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:
- BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
- CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
- APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations
These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.
The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.1 Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.
The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification
The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.
Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.
An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.
It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.2
- Exam of the Future: content outline and blueprint for BASIC exam. American Board of Dermatology website. https://dlpgnf31z4a6s.cloudfront.net/media/151102/basic-exam-content-outline-08132017.pdf. Updated August 13, 2017. Accessed September 12, 2017.
- Exam of the Future information center. American Board of Dermatology website. https://www.abderm.org/residents-and-fellows/exam-of-the-future-information-center.aspx. Accessed September 12, 2017.
- Exam of the Future: content outline and blueprint for BASIC exam. American Board of Dermatology website. https://dlpgnf31z4a6s.cloudfront.net/media/151102/basic-exam-content-outline-08132017.pdf. Updated August 13, 2017. Accessed September 12, 2017.
- Exam of the Future information center. American Board of Dermatology website. https://www.abderm.org/residents-and-fellows/exam-of-the-future-information-center.aspx. Accessed September 12, 2017.
