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Missed opportunities: Opioid overdoses and suicide
The current opioid epidemic in the United States has been universally recognized as one of the most important public health issues to date. This crisis has cost nearly $80 billion in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.1 Opioid overdoses have increased by 200% since 2000, with more than 33,000 individuals dying from opioid overdoses in 2015 alone.2,3
Currently, overdoses are considered accidental in origin until proved otherwise, and that assumption has become an acceptable hypothesis for the many parties involved: This hypothesis permits the patient to receive the much-needed overdose treatment, the physicians to discharge the patient from the emergency department after resuscitation and medical stabilization, the hospital to collect reimbursement, the pharmaceutical companies to continue to raise prices – and the health system to ignore recidivism and/or long-term outcomes.
However, while well accepted, the accidental overdose hypothesis might not tell the entire story. A recent, competing etiological hypothesis is that many opioid overdoses may, in fact, be misdiagnosed suicide attempts.7 National suicide prevalence has been increasing since 1999, and both all-cause mortality generally and suicides specifically have been increasing in white, male, and middle-aged patients, which encompass the same demographic groups affected by the opioid epidemic.8,9
Also, more than 50% of patients with opioid use disorder have histories of major depressive disorder,which, when untreated, may further drive suicidal thoughts and behavior.10,11Maria A. Oquendo, MD, PHD, immediate past president of the American Psychiatric Association, wrote in a guest post on the blog of Nora D. Volkow, MD, director of the National Institute on Drug Abuse, about the strong link between opioid use disorders and suicidal thoughts and behavior Furthermore, a 2004 literature review on substance use disorders and suicide found that individuals with opioid use disorders had a 13 times greater risk of completed suicide, compared with the general population.12
Additional associations
A recent study of nearly 5 million veterans enrolled in the Veterans Health Administration demonstrated that, even when adjusted for age and comorbid psychiatric diagnoses, opioid use disorder was associated with an increased risk for suicide; particularly striking was that this risk was doubled in women.13
A survey of 40,000 subjects from the 2014 National Survey on Drug Use and Health demonstrated that prescription opioid misuse was associated with an increased risk of suicidal ideation, and weekly misuse was associated with increased suicide planning and attempts.
The data regarding the prevalence of suicidal ideation in patients who have overdosed are limited, although recent evidence from the National Vital Statistics System on adolescent (aged 15-19 years) drug overdose is concerning, with 772 drug overdoses occurring in this age demographic in 2015 alone. Opioids were involved in the vast majority of fatal drug overdoses among this group, and the prevalence of death from opioid overdoses increased during 1999-2007 (0.8/100,000 to 2.7/100,000), stabilized during 2007-2011, declined during 2012-2014 (down to 2.0/100,000) then increased in 2015 (up to 2.4/100,000). While 80.4% of all drug overdoses in this group (including opioids) were considered unintentional, 13.5% were most likely completed suicides.14
These results suggest that, at the very least, some proportion of opioid overdoses are suicide attempts, and the actual prevalence may be much larger. All of this is difficult to discern as these data come from an epidemiological survey with data input as International Classification of Diseases, 10th revision, codes. Thus, the real-life and real-time quality of the psychiatric and postmortem evaluation that led to the determination of a suicide attempt is unknown. More explicitly, because a thorough evaluation and collateral history may have been lacking, this study may have underestimated the prevalence of overdoses that were actual suicide attempts.
Lessons for physicians
Given the epidemiological evidence linking suicidal thoughts and behavior with opioid use disorders, the frequency of overdoses, demographic factors, and recidivism with naloxone rescue, we should be very concerned that many overdoses are unrecognized suicide attempts. Many physicians can recount giving naloxone to a patient – reversing his or her overdose and simultaneously saving his or her life – only to be confronted with anger and combativeness on the part of the patient. When this response occurs, many physicians may attribute the behavioral dysregulation to the patient’s lack of experience with or tolerance to the drug (especially among naive users) or may disregard the emotional response altogether. The danger in physicians’ reacting like this to such behavior is that substantial ambiguity regarding the patient’s motives still remains: Did the patient intentionally use intravenously thinking he or she would die? Was the patient ambivalent about death? Did the patient wish he or she would die – or not wake up? Or was the patient just was playing a version of “Russian roulette” with needles and lethal quantities of opioids?
When considering logical next steps after naloxone reversal to ensure appropriate diagnosis of and treatment for the patient, a psychiatric consultation and thorough evaluation may be indispensable. This is particularly important given that those who attempt suicide or have active suicidal ideation often are evasive about their behavior and current state of mind.15 Thus, these individuals may be unwilling to disclose active suicidal ideation, intent, and/or plans when interviewed. A psychiatrist, however, has the skill set to evaluate risk and protective factors, assess for other psychiatric comorbidities carefully, and make recommendations for safe disposition and comprehensive treatment. Just as a comprehensive cardiovascular evaluation, formulation of a differential diagnosis, and treatment of chronic cardiovascular disease is the standard of care after a cardiac emergency intervention, we suggest quite similar practice standards for an opioid overdose intervention.
Dr. Srivastava is a fourth-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University. He also serves as chairman of the scientific advisory boards for RiverMend Health.
References
1. Med Care. 2016 Oct;54:901-6.
2. MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1445-52.
3. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82.
4. N Engl J Med. 2016 Dec 8;375(23):2213-15.
5. Drug Alcohol Depend. 2017 Sep 1;178:176-87.
6. BMJ. 2013 Jan 30;346:f174.
7. Nora’s Blog. 2017 Apr 20. https://www.drugabuse.gov/about-nida/noras-blog/2017/04/opioid-use-disorders-suicide-hidden-tragedy-guest-blog
8. NCHS Data Brief. 2016 Apr;(241):1-8.
9. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83.
10. Addict Behav. 2009 Jun-Jul;34(6-7):498-504.
11. J Affect Disord. 2013 May;147(1-3):17-28.
12. Drug Alcohol Depend. 2004 Dec 7;76 Suppl:S11-9.
13. Addiction. 2017 Jul;112(7):1193-1201.
14. NCHS Data Brief. 2017 Aug;282:1-7.
15. Am J Psychiatry. 2003 Nov;160(11 Suppl):1-60.
The current opioid epidemic in the United States has been universally recognized as one of the most important public health issues to date. This crisis has cost nearly $80 billion in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.1 Opioid overdoses have increased by 200% since 2000, with more than 33,000 individuals dying from opioid overdoses in 2015 alone.2,3
Currently, overdoses are considered accidental in origin until proved otherwise, and that assumption has become an acceptable hypothesis for the many parties involved: This hypothesis permits the patient to receive the much-needed overdose treatment, the physicians to discharge the patient from the emergency department after resuscitation and medical stabilization, the hospital to collect reimbursement, the pharmaceutical companies to continue to raise prices – and the health system to ignore recidivism and/or long-term outcomes.
However, while well accepted, the accidental overdose hypothesis might not tell the entire story. A recent, competing etiological hypothesis is that many opioid overdoses may, in fact, be misdiagnosed suicide attempts.7 National suicide prevalence has been increasing since 1999, and both all-cause mortality generally and suicides specifically have been increasing in white, male, and middle-aged patients, which encompass the same demographic groups affected by the opioid epidemic.8,9
Also, more than 50% of patients with opioid use disorder have histories of major depressive disorder,which, when untreated, may further drive suicidal thoughts and behavior.10,11Maria A. Oquendo, MD, PHD, immediate past president of the American Psychiatric Association, wrote in a guest post on the blog of Nora D. Volkow, MD, director of the National Institute on Drug Abuse, about the strong link between opioid use disorders and suicidal thoughts and behavior Furthermore, a 2004 literature review on substance use disorders and suicide found that individuals with opioid use disorders had a 13 times greater risk of completed suicide, compared with the general population.12
Additional associations
A recent study of nearly 5 million veterans enrolled in the Veterans Health Administration demonstrated that, even when adjusted for age and comorbid psychiatric diagnoses, opioid use disorder was associated with an increased risk for suicide; particularly striking was that this risk was doubled in women.13
A survey of 40,000 subjects from the 2014 National Survey on Drug Use and Health demonstrated that prescription opioid misuse was associated with an increased risk of suicidal ideation, and weekly misuse was associated with increased suicide planning and attempts.
The data regarding the prevalence of suicidal ideation in patients who have overdosed are limited, although recent evidence from the National Vital Statistics System on adolescent (aged 15-19 years) drug overdose is concerning, with 772 drug overdoses occurring in this age demographic in 2015 alone. Opioids were involved in the vast majority of fatal drug overdoses among this group, and the prevalence of death from opioid overdoses increased during 1999-2007 (0.8/100,000 to 2.7/100,000), stabilized during 2007-2011, declined during 2012-2014 (down to 2.0/100,000) then increased in 2015 (up to 2.4/100,000). While 80.4% of all drug overdoses in this group (including opioids) were considered unintentional, 13.5% were most likely completed suicides.14
These results suggest that, at the very least, some proportion of opioid overdoses are suicide attempts, and the actual prevalence may be much larger. All of this is difficult to discern as these data come from an epidemiological survey with data input as International Classification of Diseases, 10th revision, codes. Thus, the real-life and real-time quality of the psychiatric and postmortem evaluation that led to the determination of a suicide attempt is unknown. More explicitly, because a thorough evaluation and collateral history may have been lacking, this study may have underestimated the prevalence of overdoses that were actual suicide attempts.
Lessons for physicians
Given the epidemiological evidence linking suicidal thoughts and behavior with opioid use disorders, the frequency of overdoses, demographic factors, and recidivism with naloxone rescue, we should be very concerned that many overdoses are unrecognized suicide attempts. Many physicians can recount giving naloxone to a patient – reversing his or her overdose and simultaneously saving his or her life – only to be confronted with anger and combativeness on the part of the patient. When this response occurs, many physicians may attribute the behavioral dysregulation to the patient’s lack of experience with or tolerance to the drug (especially among naive users) or may disregard the emotional response altogether. The danger in physicians’ reacting like this to such behavior is that substantial ambiguity regarding the patient’s motives still remains: Did the patient intentionally use intravenously thinking he or she would die? Was the patient ambivalent about death? Did the patient wish he or she would die – or not wake up? Or was the patient just was playing a version of “Russian roulette” with needles and lethal quantities of opioids?
When considering logical next steps after naloxone reversal to ensure appropriate diagnosis of and treatment for the patient, a psychiatric consultation and thorough evaluation may be indispensable. This is particularly important given that those who attempt suicide or have active suicidal ideation often are evasive about their behavior and current state of mind.15 Thus, these individuals may be unwilling to disclose active suicidal ideation, intent, and/or plans when interviewed. A psychiatrist, however, has the skill set to evaluate risk and protective factors, assess for other psychiatric comorbidities carefully, and make recommendations for safe disposition and comprehensive treatment. Just as a comprehensive cardiovascular evaluation, formulation of a differential diagnosis, and treatment of chronic cardiovascular disease is the standard of care after a cardiac emergency intervention, we suggest quite similar practice standards for an opioid overdose intervention.
Dr. Srivastava is a fourth-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University. He also serves as chairman of the scientific advisory boards for RiverMend Health.
References
1. Med Care. 2016 Oct;54:901-6.
2. MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1445-52.
3. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82.
4. N Engl J Med. 2016 Dec 8;375(23):2213-15.
5. Drug Alcohol Depend. 2017 Sep 1;178:176-87.
6. BMJ. 2013 Jan 30;346:f174.
7. Nora’s Blog. 2017 Apr 20. https://www.drugabuse.gov/about-nida/noras-blog/2017/04/opioid-use-disorders-suicide-hidden-tragedy-guest-blog
8. NCHS Data Brief. 2016 Apr;(241):1-8.
9. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83.
10. Addict Behav. 2009 Jun-Jul;34(6-7):498-504.
11. J Affect Disord. 2013 May;147(1-3):17-28.
12. Drug Alcohol Depend. 2004 Dec 7;76 Suppl:S11-9.
13. Addiction. 2017 Jul;112(7):1193-1201.
14. NCHS Data Brief. 2017 Aug;282:1-7.
15. Am J Psychiatry. 2003 Nov;160(11 Suppl):1-60.
The current opioid epidemic in the United States has been universally recognized as one of the most important public health issues to date. This crisis has cost nearly $80 billion in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.1 Opioid overdoses have increased by 200% since 2000, with more than 33,000 individuals dying from opioid overdoses in 2015 alone.2,3
Currently, overdoses are considered accidental in origin until proved otherwise, and that assumption has become an acceptable hypothesis for the many parties involved: This hypothesis permits the patient to receive the much-needed overdose treatment, the physicians to discharge the patient from the emergency department after resuscitation and medical stabilization, the hospital to collect reimbursement, the pharmaceutical companies to continue to raise prices – and the health system to ignore recidivism and/or long-term outcomes.
However, while well accepted, the accidental overdose hypothesis might not tell the entire story. A recent, competing etiological hypothesis is that many opioid overdoses may, in fact, be misdiagnosed suicide attempts.7 National suicide prevalence has been increasing since 1999, and both all-cause mortality generally and suicides specifically have been increasing in white, male, and middle-aged patients, which encompass the same demographic groups affected by the opioid epidemic.8,9
Also, more than 50% of patients with opioid use disorder have histories of major depressive disorder,which, when untreated, may further drive suicidal thoughts and behavior.10,11Maria A. Oquendo, MD, PHD, immediate past president of the American Psychiatric Association, wrote in a guest post on the blog of Nora D. Volkow, MD, director of the National Institute on Drug Abuse, about the strong link between opioid use disorders and suicidal thoughts and behavior Furthermore, a 2004 literature review on substance use disorders and suicide found that individuals with opioid use disorders had a 13 times greater risk of completed suicide, compared with the general population.12
Additional associations
A recent study of nearly 5 million veterans enrolled in the Veterans Health Administration demonstrated that, even when adjusted for age and comorbid psychiatric diagnoses, opioid use disorder was associated with an increased risk for suicide; particularly striking was that this risk was doubled in women.13
A survey of 40,000 subjects from the 2014 National Survey on Drug Use and Health demonstrated that prescription opioid misuse was associated with an increased risk of suicidal ideation, and weekly misuse was associated with increased suicide planning and attempts.
The data regarding the prevalence of suicidal ideation in patients who have overdosed are limited, although recent evidence from the National Vital Statistics System on adolescent (aged 15-19 years) drug overdose is concerning, with 772 drug overdoses occurring in this age demographic in 2015 alone. Opioids were involved in the vast majority of fatal drug overdoses among this group, and the prevalence of death from opioid overdoses increased during 1999-2007 (0.8/100,000 to 2.7/100,000), stabilized during 2007-2011, declined during 2012-2014 (down to 2.0/100,000) then increased in 2015 (up to 2.4/100,000). While 80.4% of all drug overdoses in this group (including opioids) were considered unintentional, 13.5% were most likely completed suicides.14
These results suggest that, at the very least, some proportion of opioid overdoses are suicide attempts, and the actual prevalence may be much larger. All of this is difficult to discern as these data come from an epidemiological survey with data input as International Classification of Diseases, 10th revision, codes. Thus, the real-life and real-time quality of the psychiatric and postmortem evaluation that led to the determination of a suicide attempt is unknown. More explicitly, because a thorough evaluation and collateral history may have been lacking, this study may have underestimated the prevalence of overdoses that were actual suicide attempts.
Lessons for physicians
Given the epidemiological evidence linking suicidal thoughts and behavior with opioid use disorders, the frequency of overdoses, demographic factors, and recidivism with naloxone rescue, we should be very concerned that many overdoses are unrecognized suicide attempts. Many physicians can recount giving naloxone to a patient – reversing his or her overdose and simultaneously saving his or her life – only to be confronted with anger and combativeness on the part of the patient. When this response occurs, many physicians may attribute the behavioral dysregulation to the patient’s lack of experience with or tolerance to the drug (especially among naive users) or may disregard the emotional response altogether. The danger in physicians’ reacting like this to such behavior is that substantial ambiguity regarding the patient’s motives still remains: Did the patient intentionally use intravenously thinking he or she would die? Was the patient ambivalent about death? Did the patient wish he or she would die – or not wake up? Or was the patient just was playing a version of “Russian roulette” with needles and lethal quantities of opioids?
When considering logical next steps after naloxone reversal to ensure appropriate diagnosis of and treatment for the patient, a psychiatric consultation and thorough evaluation may be indispensable. This is particularly important given that those who attempt suicide or have active suicidal ideation often are evasive about their behavior and current state of mind.15 Thus, these individuals may be unwilling to disclose active suicidal ideation, intent, and/or plans when interviewed. A psychiatrist, however, has the skill set to evaluate risk and protective factors, assess for other psychiatric comorbidities carefully, and make recommendations for safe disposition and comprehensive treatment. Just as a comprehensive cardiovascular evaluation, formulation of a differential diagnosis, and treatment of chronic cardiovascular disease is the standard of care after a cardiac emergency intervention, we suggest quite similar practice standards for an opioid overdose intervention.
Dr. Srivastava is a fourth-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University. He also serves as chairman of the scientific advisory boards for RiverMend Health.
References
1. Med Care. 2016 Oct;54:901-6.
2. MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1445-52.
3. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82.
4. N Engl J Med. 2016 Dec 8;375(23):2213-15.
5. Drug Alcohol Depend. 2017 Sep 1;178:176-87.
6. BMJ. 2013 Jan 30;346:f174.
7. Nora’s Blog. 2017 Apr 20. https://www.drugabuse.gov/about-nida/noras-blog/2017/04/opioid-use-disorders-suicide-hidden-tragedy-guest-blog
8. NCHS Data Brief. 2016 Apr;(241):1-8.
9. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83.
10. Addict Behav. 2009 Jun-Jul;34(6-7):498-504.
11. J Affect Disord. 2013 May;147(1-3):17-28.
12. Drug Alcohol Depend. 2004 Dec 7;76 Suppl:S11-9.
13. Addiction. 2017 Jul;112(7):1193-1201.
14. NCHS Data Brief. 2017 Aug;282:1-7.
15. Am J Psychiatry. 2003 Nov;160(11 Suppl):1-60.
Test everyone with diagnosed HIV for drug resistance as they enter care
Antiretroviral therapy (ART) for HIV is critical for achieving viral suppression, which improves the health and longevity of people living with infection and dramatically reduces the risk of transmitting HIV to others. Despite these clear benefits, not everyone prescribed ART adheres to their medications, which can result in drug resistance – and transmission of drug-resistant HIV to others.
A Centers for Disease Control and Prevention analysis of eight U.S. cities found that more than 18 percent of 13,393 people with a recent HIV diagnosis had infections that were resistant to at least one form of treatment. Since 2007, the U.S. Department of Health & Human Services has recommended that everyone with diagnosed HIV infection be tested for drug resistance when HIV care begins; however, it’s not known how closely HIV care providers in the United States follow the guidelines.
To learn more, the CDC recently analyzed HIV surveillance data to examine testing patterns among people living with diagnosed HIV who had entered HIV medical care. The results of the study, published in AIDS Care (2017 May. doi: 10.1080/09540121.2017.1316356), indicated that, of the people with HIV diagnosed in 2013 who had entered medical care, only 66% had been tested for resistance. Of those tested, 68% received testing at the beginning of care.
The findings also show that resistance testing is performed less often among certain groups, including males who inject drugs. In recent reports, about a third of people who inject drugs in selected U.S. cities indicated they did not have health insurance, and nearly 80% lived at or below the federal poverty level. Lack of health care access and low socioeconomic status may be potential barriers to receiving medical care and laboratory testing. Additionally, this population might not be aware of available resources that support these services, including those provided through the Ryan White HIV/AIDS Program and federally qualified health centers.
Previous research has also shown that non-HIV specialists are less likely than HIV specialists to order resistance testing for their patients. With potentially more injection drug use and fewer specialist health care services available in less-populated communities, there is an urgent need both to improve HIV testing and increase resistance testing in rural communities. This is important given the growing potential for HIV outbreaks among people who inject drugs, as well as the substantial rise in the number of deaths attributed to opioid use in many communities throughout the nation.
The study findings also indicate that resistance testing is less common among people with higher CD4 counts in some states, including Michigan, New York, and Texas. CD4 cells are a type of white blood cell that helps in protecting the body from infections, but they are also targeted by HIV. CD4 cell counts can be used to determine the stage of HIV infection in a person. As HIV stays in the body longer, CD4 cells decrease. Even if treatment is delayed for a medical reason, such as coinfection with tuberculosis, resistance testing should still be conducted at a person’s entry to care to help ensure treatment success later.
These results have strong implications for clinical practice and management of people with newly diagnosed HIV. More research is needed to identify the factors influencing lacking or delayed resistance testing so that we can address differences in the development of resistance, as well as other clinical outcomes, over time.
Antiretroviral therapy (ART) for HIV is critical for achieving viral suppression, which improves the health and longevity of people living with infection and dramatically reduces the risk of transmitting HIV to others. Despite these clear benefits, not everyone prescribed ART adheres to their medications, which can result in drug resistance – and transmission of drug-resistant HIV to others.
A Centers for Disease Control and Prevention analysis of eight U.S. cities found that more than 18 percent of 13,393 people with a recent HIV diagnosis had infections that were resistant to at least one form of treatment. Since 2007, the U.S. Department of Health & Human Services has recommended that everyone with diagnosed HIV infection be tested for drug resistance when HIV care begins; however, it’s not known how closely HIV care providers in the United States follow the guidelines.
To learn more, the CDC recently analyzed HIV surveillance data to examine testing patterns among people living with diagnosed HIV who had entered HIV medical care. The results of the study, published in AIDS Care (2017 May. doi: 10.1080/09540121.2017.1316356), indicated that, of the people with HIV diagnosed in 2013 who had entered medical care, only 66% had been tested for resistance. Of those tested, 68% received testing at the beginning of care.
The findings also show that resistance testing is performed less often among certain groups, including males who inject drugs. In recent reports, about a third of people who inject drugs in selected U.S. cities indicated they did not have health insurance, and nearly 80% lived at or below the federal poverty level. Lack of health care access and low socioeconomic status may be potential barriers to receiving medical care and laboratory testing. Additionally, this population might not be aware of available resources that support these services, including those provided through the Ryan White HIV/AIDS Program and federally qualified health centers.
Previous research has also shown that non-HIV specialists are less likely than HIV specialists to order resistance testing for their patients. With potentially more injection drug use and fewer specialist health care services available in less-populated communities, there is an urgent need both to improve HIV testing and increase resistance testing in rural communities. This is important given the growing potential for HIV outbreaks among people who inject drugs, as well as the substantial rise in the number of deaths attributed to opioid use in many communities throughout the nation.
The study findings also indicate that resistance testing is less common among people with higher CD4 counts in some states, including Michigan, New York, and Texas. CD4 cells are a type of white blood cell that helps in protecting the body from infections, but they are also targeted by HIV. CD4 cell counts can be used to determine the stage of HIV infection in a person. As HIV stays in the body longer, CD4 cells decrease. Even if treatment is delayed for a medical reason, such as coinfection with tuberculosis, resistance testing should still be conducted at a person’s entry to care to help ensure treatment success later.
These results have strong implications for clinical practice and management of people with newly diagnosed HIV. More research is needed to identify the factors influencing lacking or delayed resistance testing so that we can address differences in the development of resistance, as well as other clinical outcomes, over time.
Antiretroviral therapy (ART) for HIV is critical for achieving viral suppression, which improves the health and longevity of people living with infection and dramatically reduces the risk of transmitting HIV to others. Despite these clear benefits, not everyone prescribed ART adheres to their medications, which can result in drug resistance – and transmission of drug-resistant HIV to others.
A Centers for Disease Control and Prevention analysis of eight U.S. cities found that more than 18 percent of 13,393 people with a recent HIV diagnosis had infections that were resistant to at least one form of treatment. Since 2007, the U.S. Department of Health & Human Services has recommended that everyone with diagnosed HIV infection be tested for drug resistance when HIV care begins; however, it’s not known how closely HIV care providers in the United States follow the guidelines.
To learn more, the CDC recently analyzed HIV surveillance data to examine testing patterns among people living with diagnosed HIV who had entered HIV medical care. The results of the study, published in AIDS Care (2017 May. doi: 10.1080/09540121.2017.1316356), indicated that, of the people with HIV diagnosed in 2013 who had entered medical care, only 66% had been tested for resistance. Of those tested, 68% received testing at the beginning of care.
The findings also show that resistance testing is performed less often among certain groups, including males who inject drugs. In recent reports, about a third of people who inject drugs in selected U.S. cities indicated they did not have health insurance, and nearly 80% lived at or below the federal poverty level. Lack of health care access and low socioeconomic status may be potential barriers to receiving medical care and laboratory testing. Additionally, this population might not be aware of available resources that support these services, including those provided through the Ryan White HIV/AIDS Program and federally qualified health centers.
Previous research has also shown that non-HIV specialists are less likely than HIV specialists to order resistance testing for their patients. With potentially more injection drug use and fewer specialist health care services available in less-populated communities, there is an urgent need both to improve HIV testing and increase resistance testing in rural communities. This is important given the growing potential for HIV outbreaks among people who inject drugs, as well as the substantial rise in the number of deaths attributed to opioid use in many communities throughout the nation.
The study findings also indicate that resistance testing is less common among people with higher CD4 counts in some states, including Michigan, New York, and Texas. CD4 cells are a type of white blood cell that helps in protecting the body from infections, but they are also targeted by HIV. CD4 cell counts can be used to determine the stage of HIV infection in a person. As HIV stays in the body longer, CD4 cells decrease. Even if treatment is delayed for a medical reason, such as coinfection with tuberculosis, resistance testing should still be conducted at a person’s entry to care to help ensure treatment success later.
These results have strong implications for clinical practice and management of people with newly diagnosed HIV. More research is needed to identify the factors influencing lacking or delayed resistance testing so that we can address differences in the development of resistance, as well as other clinical outcomes, over time.
More data show value of CBT for PTSD, anxiety, depression
So often in clinical practice, guidelines and directives about psychiatric treatments lag behind the results we see every day in our offices. Such is the case with cognitive-behavioral therapy.
Earlier this summer, the departments of Veterans Affairs and Defense deemed trauma-focused psychotherapies, such as CBT, as first-line treatments for posttraumatic stress disorder over medication management. Was I surprised by these findings? Absolutely not. Likewise, last year, the American College of Physicians released a guideline recommending CBT as first-line treatment for chronic insomnia disorder in adults. Surprising? Again, not in the least.
Pierre Janet, PhD, MD, the French psychiatrist, psychologist, and neurologist, more than a hundred years ago in his L’Automatisme Psychologique, advanced the idea that thoughts can be challenged and that perceptions leading to mental problems can be reversed. Dr. Janet completed his pioneering work, including an exploration of the power of hypnosis, even though the psychoanalytic movement was in full force and many parallel ideas about treating mental disorders were barely recognized.
By the middle of the 20th century, Albert Ellis, PhD, developed rational emotive behavior therapy, which focused on thoughtfully restructuring irrational beliefs into rational ones that led to improved skills and behaviors. A decade later, the great Aaron T. Beck, MD, developed a true form of CBT. Over the years, Dr. Beck went on to develop controlled clinical trials showing CBT to be more effective in treating a variety of psychiatric disorders, including depression, panic attacks, anxiety disorders, obsessive-compulsive disorders, various phobic disorders, and PTSD.
Yet, despite the effectiveness of CBT, too few young psychiatrists and mental health professionals learn how to use it, and fewer appear to practice it. Traditional psychiatric training, by and large, continues to rely on more psychodynamic approaches, which do have value but take longer to get results than does CBT.
Clearly, partnering with patients and helping them learn new constructs can lead to positive results. More and more research shows that CBT is efficacious for patients across many age and demographic groups.
In one randomized, controlled study of 96 Latino patients with depression, for example, researchers at the University of California, Berkeley, found that group CBT administered in a primary care setting led to a significant decrease in depressive symptoms as measured by the Spanish-language version of the Patient Health Questionnaire (PHQ-9) (Cog Behav Prac. 2017 Apr 17; doi: 10.1016/j.cbpra.2017.03.02). Of the 96 patients, 92 completed the PHQ-9 at least once, and 76 completed a baseline measure of the questionnaire on day 1 of group therapy, the researchers reported. At baseline, the average PHQ-9 score was 13.88, which points to the high end of moderate depression, moving toward moderately severe depression. For every week the patients were enrolled in the therapy, PHQ-9 scores fell by 0.15 points.
The spin on CBT that I created – which I call the learning, philosophizing, and action (LPA) technique – helps patients think through problematic issues and come away with new narratives. I developed and used the LPA technique as part of a smoking-cessation program I ran for many years at the New York University Langone Medical Center. In turn, that program developed into a short-term psychotherapy program with a focus on CBT and hypnosis/relaxation techniques.
We need better codification and organization on what kinds of therapies are and are not suited for specific diagnosable problems. It is hoped that a clearer understanding of genetics, laboratory testing, and imaging, as emphasized by the National Institute of Mental Health’s Research Domain Criteria, will better equip us to decide what works best. Again, for now, helping patients learn and relearn new ways of thinking and behaving, as developed through CBT, is among the best treatments available for many mental health problems.
Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2017. He has no disclosures.
So often in clinical practice, guidelines and directives about psychiatric treatments lag behind the results we see every day in our offices. Such is the case with cognitive-behavioral therapy.
Earlier this summer, the departments of Veterans Affairs and Defense deemed trauma-focused psychotherapies, such as CBT, as first-line treatments for posttraumatic stress disorder over medication management. Was I surprised by these findings? Absolutely not. Likewise, last year, the American College of Physicians released a guideline recommending CBT as first-line treatment for chronic insomnia disorder in adults. Surprising? Again, not in the least.
Pierre Janet, PhD, MD, the French psychiatrist, psychologist, and neurologist, more than a hundred years ago in his L’Automatisme Psychologique, advanced the idea that thoughts can be challenged and that perceptions leading to mental problems can be reversed. Dr. Janet completed his pioneering work, including an exploration of the power of hypnosis, even though the psychoanalytic movement was in full force and many parallel ideas about treating mental disorders were barely recognized.
By the middle of the 20th century, Albert Ellis, PhD, developed rational emotive behavior therapy, which focused on thoughtfully restructuring irrational beliefs into rational ones that led to improved skills and behaviors. A decade later, the great Aaron T. Beck, MD, developed a true form of CBT. Over the years, Dr. Beck went on to develop controlled clinical trials showing CBT to be more effective in treating a variety of psychiatric disorders, including depression, panic attacks, anxiety disorders, obsessive-compulsive disorders, various phobic disorders, and PTSD.
Yet, despite the effectiveness of CBT, too few young psychiatrists and mental health professionals learn how to use it, and fewer appear to practice it. Traditional psychiatric training, by and large, continues to rely on more psychodynamic approaches, which do have value but take longer to get results than does CBT.
Clearly, partnering with patients and helping them learn new constructs can lead to positive results. More and more research shows that CBT is efficacious for patients across many age and demographic groups.
In one randomized, controlled study of 96 Latino patients with depression, for example, researchers at the University of California, Berkeley, found that group CBT administered in a primary care setting led to a significant decrease in depressive symptoms as measured by the Spanish-language version of the Patient Health Questionnaire (PHQ-9) (Cog Behav Prac. 2017 Apr 17; doi: 10.1016/j.cbpra.2017.03.02). Of the 96 patients, 92 completed the PHQ-9 at least once, and 76 completed a baseline measure of the questionnaire on day 1 of group therapy, the researchers reported. At baseline, the average PHQ-9 score was 13.88, which points to the high end of moderate depression, moving toward moderately severe depression. For every week the patients were enrolled in the therapy, PHQ-9 scores fell by 0.15 points.
The spin on CBT that I created – which I call the learning, philosophizing, and action (LPA) technique – helps patients think through problematic issues and come away with new narratives. I developed and used the LPA technique as part of a smoking-cessation program I ran for many years at the New York University Langone Medical Center. In turn, that program developed into a short-term psychotherapy program with a focus on CBT and hypnosis/relaxation techniques.
We need better codification and organization on what kinds of therapies are and are not suited for specific diagnosable problems. It is hoped that a clearer understanding of genetics, laboratory testing, and imaging, as emphasized by the National Institute of Mental Health’s Research Domain Criteria, will better equip us to decide what works best. Again, for now, helping patients learn and relearn new ways of thinking and behaving, as developed through CBT, is among the best treatments available for many mental health problems.
Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2017. He has no disclosures.
So often in clinical practice, guidelines and directives about psychiatric treatments lag behind the results we see every day in our offices. Such is the case with cognitive-behavioral therapy.
Earlier this summer, the departments of Veterans Affairs and Defense deemed trauma-focused psychotherapies, such as CBT, as first-line treatments for posttraumatic stress disorder over medication management. Was I surprised by these findings? Absolutely not. Likewise, last year, the American College of Physicians released a guideline recommending CBT as first-line treatment for chronic insomnia disorder in adults. Surprising? Again, not in the least.
Pierre Janet, PhD, MD, the French psychiatrist, psychologist, and neurologist, more than a hundred years ago in his L’Automatisme Psychologique, advanced the idea that thoughts can be challenged and that perceptions leading to mental problems can be reversed. Dr. Janet completed his pioneering work, including an exploration of the power of hypnosis, even though the psychoanalytic movement was in full force and many parallel ideas about treating mental disorders were barely recognized.
By the middle of the 20th century, Albert Ellis, PhD, developed rational emotive behavior therapy, which focused on thoughtfully restructuring irrational beliefs into rational ones that led to improved skills and behaviors. A decade later, the great Aaron T. Beck, MD, developed a true form of CBT. Over the years, Dr. Beck went on to develop controlled clinical trials showing CBT to be more effective in treating a variety of psychiatric disorders, including depression, panic attacks, anxiety disorders, obsessive-compulsive disorders, various phobic disorders, and PTSD.
Yet, despite the effectiveness of CBT, too few young psychiatrists and mental health professionals learn how to use it, and fewer appear to practice it. Traditional psychiatric training, by and large, continues to rely on more psychodynamic approaches, which do have value but take longer to get results than does CBT.
Clearly, partnering with patients and helping them learn new constructs can lead to positive results. More and more research shows that CBT is efficacious for patients across many age and demographic groups.
In one randomized, controlled study of 96 Latino patients with depression, for example, researchers at the University of California, Berkeley, found that group CBT administered in a primary care setting led to a significant decrease in depressive symptoms as measured by the Spanish-language version of the Patient Health Questionnaire (PHQ-9) (Cog Behav Prac. 2017 Apr 17; doi: 10.1016/j.cbpra.2017.03.02). Of the 96 patients, 92 completed the PHQ-9 at least once, and 76 completed a baseline measure of the questionnaire on day 1 of group therapy, the researchers reported. At baseline, the average PHQ-9 score was 13.88, which points to the high end of moderate depression, moving toward moderately severe depression. For every week the patients were enrolled in the therapy, PHQ-9 scores fell by 0.15 points.
The spin on CBT that I created – which I call the learning, philosophizing, and action (LPA) technique – helps patients think through problematic issues and come away with new narratives. I developed and used the LPA technique as part of a smoking-cessation program I ran for many years at the New York University Langone Medical Center. In turn, that program developed into a short-term psychotherapy program with a focus on CBT and hypnosis/relaxation techniques.
We need better codification and organization on what kinds of therapies are and are not suited for specific diagnosable problems. It is hoped that a clearer understanding of genetics, laboratory testing, and imaging, as emphasized by the National Institute of Mental Health’s Research Domain Criteria, will better equip us to decide what works best. Again, for now, helping patients learn and relearn new ways of thinking and behaving, as developed through CBT, is among the best treatments available for many mental health problems.
Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2017. He has no disclosures.
Fixing the ACA: 11 practical solutions
The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.
Before that can happen, Democrats and Republicans need to make certain acknowledgments.
Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.
On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.
Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.
So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.
Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.
Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:
1. Incentivize or persuade more states to expand Medicaid.
2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.
3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.
4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.
5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.
6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.
7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.
8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.
9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.
10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.
11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.
The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.
Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.
The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.
Before that can happen, Democrats and Republicans need to make certain acknowledgments.
Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.
On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.
Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.
So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.
Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.
Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:
1. Incentivize or persuade more states to expand Medicaid.
2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.
3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.
4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.
5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.
6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.
7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.
8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.
9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.
10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.
11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.
The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.
Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.
The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.
Before that can happen, Democrats and Republicans need to make certain acknowledgments.
Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.
On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.
Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.
So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.
Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.
Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:
1. Incentivize or persuade more states to expand Medicaid.
2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.
3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.
4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.
5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.
6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.
7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.
8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.
9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.
10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.
11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.
The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.
Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.
Mental health courts: Is recidivism what counts?
In 2004, the federal government authorized $50 million for state initiatives to coordinate crime control efforts between the criminal justice and mental health systems. Some of that money was dedicated toward expansion of state mental health courts in an attempt to reduce the number of people with serious mental illness in jails and prisons.
Unlike traditional criminal courts, a mental health court is a nonadversarial problem-solving program that brings together all the stakeholders involved in a defendant’s criminal case and mental health care. A criminal defendant who agrees to participate in mental health court must participate in regular status hearings during which a judge reviews the defendant’s adherence to a court-imposed treatment plan and monitors his progress while on probation. The judge considers input from the prosecutor and the defense attorney, and also from the court’s social worker or case manager. A defendant who agrees to mental health court involvement is often placed on probation rather than sentenced to incarceration and is usually incarcerated for a shorter time pending trial.
Although mental health courts have been in existence for 20 years, data about program efficacy have been mixed. Outcome studies have been hampered by lack of truly blind subject assignment, inadequate controls, and selection bias because many mental health courts exclude defendants charged with serious violent crimes or sex offenses. Also, mental health courts are voluntary programs with significant dropout rates. Nevertheless, proponents of mental health courts believe that they prevent crime, reduce violent offending, and serve to stabilize people with serious mental illness in the community.
In a study published recently in Psychiatric Services (2017 Aug 15. doi: 10.1176/appi.ps.201700107), researchers from North Carolina University, Raleigh, addressed the effect of mental health court involvement on criminal recidivism. Lowder et al. looked at 17 outcome studies of mental health court participants published between 2004 and 2015. These studies included 16,129 participants followed for a minimum of 1 year.
Most of the included studies defined recidivism as a new arrest. For the purpose of the meta-analysis, researchers also included any incarceration, conviction, or new charge. Each study also included a comparison group of defendants processed through usual criminal procedures. Included studies generally looked at reoffending in the year after entry into the program or in the year following exit from the program.
The meta-analysis found a small but significant reduction in criminal recidivism, although the degree of this effect varied considerably between studies, and the effect disappeared completely when only moderate and high-quality studies were considered.
These results should not surprise anyone. Crime is a complex human behavior mediated by more than just psychiatric issues. Poverty, stressful life events, and substance abuse all play a role. And as an outcome variable, an arrest is not a sensitive measure because many crimes go unreported. Defendants with lower rates of reoffending may simply have more forgiving victims; for people with mental illness, that victim is often a family member.
Fortunately, crime prevention is not the sole justification for mental health programs. There are also the intangible social benefits that aren’t measured in these studies – benefits like improved quality of life, restored relationships, and the ability to participate more fully in all the joys that life has to offer. For people with serious mental illness who graduate from mental health court, that’s the outcome that counts.
Dr. Hanson is a forensic psychiatrist and coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene and the Maryland Division of Correction.
In 2004, the federal government authorized $50 million for state initiatives to coordinate crime control efforts between the criminal justice and mental health systems. Some of that money was dedicated toward expansion of state mental health courts in an attempt to reduce the number of people with serious mental illness in jails and prisons.
Unlike traditional criminal courts, a mental health court is a nonadversarial problem-solving program that brings together all the stakeholders involved in a defendant’s criminal case and mental health care. A criminal defendant who agrees to participate in mental health court must participate in regular status hearings during which a judge reviews the defendant’s adherence to a court-imposed treatment plan and monitors his progress while on probation. The judge considers input from the prosecutor and the defense attorney, and also from the court’s social worker or case manager. A defendant who agrees to mental health court involvement is often placed on probation rather than sentenced to incarceration and is usually incarcerated for a shorter time pending trial.
Although mental health courts have been in existence for 20 years, data about program efficacy have been mixed. Outcome studies have been hampered by lack of truly blind subject assignment, inadequate controls, and selection bias because many mental health courts exclude defendants charged with serious violent crimes or sex offenses. Also, mental health courts are voluntary programs with significant dropout rates. Nevertheless, proponents of mental health courts believe that they prevent crime, reduce violent offending, and serve to stabilize people with serious mental illness in the community.
In a study published recently in Psychiatric Services (2017 Aug 15. doi: 10.1176/appi.ps.201700107), researchers from North Carolina University, Raleigh, addressed the effect of mental health court involvement on criminal recidivism. Lowder et al. looked at 17 outcome studies of mental health court participants published between 2004 and 2015. These studies included 16,129 participants followed for a minimum of 1 year.
Most of the included studies defined recidivism as a new arrest. For the purpose of the meta-analysis, researchers also included any incarceration, conviction, or new charge. Each study also included a comparison group of defendants processed through usual criminal procedures. Included studies generally looked at reoffending in the year after entry into the program or in the year following exit from the program.
The meta-analysis found a small but significant reduction in criminal recidivism, although the degree of this effect varied considerably between studies, and the effect disappeared completely when only moderate and high-quality studies were considered.
These results should not surprise anyone. Crime is a complex human behavior mediated by more than just psychiatric issues. Poverty, stressful life events, and substance abuse all play a role. And as an outcome variable, an arrest is not a sensitive measure because many crimes go unreported. Defendants with lower rates of reoffending may simply have more forgiving victims; for people with mental illness, that victim is often a family member.
Fortunately, crime prevention is not the sole justification for mental health programs. There are also the intangible social benefits that aren’t measured in these studies – benefits like improved quality of life, restored relationships, and the ability to participate more fully in all the joys that life has to offer. For people with serious mental illness who graduate from mental health court, that’s the outcome that counts.
Dr. Hanson is a forensic psychiatrist and coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene and the Maryland Division of Correction.
In 2004, the federal government authorized $50 million for state initiatives to coordinate crime control efforts between the criminal justice and mental health systems. Some of that money was dedicated toward expansion of state mental health courts in an attempt to reduce the number of people with serious mental illness in jails and prisons.
Unlike traditional criminal courts, a mental health court is a nonadversarial problem-solving program that brings together all the stakeholders involved in a defendant’s criminal case and mental health care. A criminal defendant who agrees to participate in mental health court must participate in regular status hearings during which a judge reviews the defendant’s adherence to a court-imposed treatment plan and monitors his progress while on probation. The judge considers input from the prosecutor and the defense attorney, and also from the court’s social worker or case manager. A defendant who agrees to mental health court involvement is often placed on probation rather than sentenced to incarceration and is usually incarcerated for a shorter time pending trial.
Although mental health courts have been in existence for 20 years, data about program efficacy have been mixed. Outcome studies have been hampered by lack of truly blind subject assignment, inadequate controls, and selection bias because many mental health courts exclude defendants charged with serious violent crimes or sex offenses. Also, mental health courts are voluntary programs with significant dropout rates. Nevertheless, proponents of mental health courts believe that they prevent crime, reduce violent offending, and serve to stabilize people with serious mental illness in the community.
In a study published recently in Psychiatric Services (2017 Aug 15. doi: 10.1176/appi.ps.201700107), researchers from North Carolina University, Raleigh, addressed the effect of mental health court involvement on criminal recidivism. Lowder et al. looked at 17 outcome studies of mental health court participants published between 2004 and 2015. These studies included 16,129 participants followed for a minimum of 1 year.
Most of the included studies defined recidivism as a new arrest. For the purpose of the meta-analysis, researchers also included any incarceration, conviction, or new charge. Each study also included a comparison group of defendants processed through usual criminal procedures. Included studies generally looked at reoffending in the year after entry into the program or in the year following exit from the program.
The meta-analysis found a small but significant reduction in criminal recidivism, although the degree of this effect varied considerably between studies, and the effect disappeared completely when only moderate and high-quality studies were considered.
These results should not surprise anyone. Crime is a complex human behavior mediated by more than just psychiatric issues. Poverty, stressful life events, and substance abuse all play a role. And as an outcome variable, an arrest is not a sensitive measure because many crimes go unreported. Defendants with lower rates of reoffending may simply have more forgiving victims; for people with mental illness, that victim is often a family member.
Fortunately, crime prevention is not the sole justification for mental health programs. There are also the intangible social benefits that aren’t measured in these studies – benefits like improved quality of life, restored relationships, and the ability to participate more fully in all the joys that life has to offer. For people with serious mental illness who graduate from mental health court, that’s the outcome that counts.
Dr. Hanson is a forensic psychiatrist and coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene and the Maryland Division of Correction.
Consulting for the dead
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
The cost of experimental medicine
It has been a remarkable summer of milestones and crises for high-technology medicine.
An FDA panel has unanimously approved a gene therapy: The patient’s own immune cells are taken from his or her body, genetically modified, and reinfused to attack cancer. While the treatment has some dangers, it can be worth trying when conventional therapy has failed, and it appears to be curative when it works. Final FDA approval is expected in September.
While those breakthroughs were occurring, the parents of Charlie Gard, an infant in England with a very rare and devastating mitochondrial disease, were seeking experimental therapy for their child. The medical staff disagreed with the parents: They recommended that the best thing for Charlie would be to stop the ventilator and allow him to die, rather than let him to continue to suffer. Three British courts reviewed Charlie’s case and concurred with the medical staff; on appeal, the European Court of Human Rights also denied the parents’ wishes.
End of life cases similar to Charlie’s are not rare. In modern medicine, parents sometimes must make the heart-wrenching decision to stop aggressive therapies and accept that death is imminent and unavoidable. Many factors go into making that decision. Both the courts and medical staff presume that parents are the best decision makers. Generally, medical staff provide emotional and spiritual support to the parents, along with a tincture of time. In the vast majority of cases, parents and physicians come to agree on the course of care, but sometimes, there are irreconcilable disagreements.
It is rare for courts to overrule parents. The government typically intervenes only when the harm from a parent’s choice exceeds some threshold. For instance, it is not in a child’s best interest to be put in a car during a blizzard and driven to the store to get cigarettes. But neither is it wise to have an intrusive government reviewing every choice a parent makes. The potential harm must be large enough, likely enough, and imminent enough before most judges will intervene. The law will insist the child be in a car seat at least.
In Charlie’s case, the medical staff and the judges all explicitly said that the cost of therapy did not factor into their decision making; they looked solely at what was best for Charlie. The focus was on whether the unproven potential benefits of experimental therapy outweighed the risk of suffering caused by the therapy and continued intensive medical care.
Even when a bedside decision ignores the financial impact, money often structures which therapeutic choices are available. There are also issues of equitable access to be raised and weighed. Expenditures impact other social choices.
Money influenced the actions of Martin Shkreli, who is best known as the pharmacy company executive who markedly increased the price of a drug. Mr. Shkreli was recently convicted on three of eight charges for securities fraud, and sentencing is pending; the convictions were not related to the price increase.
The United States has created some amazing technologies to save individual, identifiable lives, but they come at a high price that often costs lives in ways more subtle than the incident in India. At some point, the government and the public are responsible for either financing or rationing care, but that doesn’t absolve the scientists completely. The Russell-Einstein (Pugwash) Manifesto established that scientists have a moral accountability for the negative consequences of creating new technology, and that includes the financial aspects.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]
It has been a remarkable summer of milestones and crises for high-technology medicine.
An FDA panel has unanimously approved a gene therapy: The patient’s own immune cells are taken from his or her body, genetically modified, and reinfused to attack cancer. While the treatment has some dangers, it can be worth trying when conventional therapy has failed, and it appears to be curative when it works. Final FDA approval is expected in September.
While those breakthroughs were occurring, the parents of Charlie Gard, an infant in England with a very rare and devastating mitochondrial disease, were seeking experimental therapy for their child. The medical staff disagreed with the parents: They recommended that the best thing for Charlie would be to stop the ventilator and allow him to die, rather than let him to continue to suffer. Three British courts reviewed Charlie’s case and concurred with the medical staff; on appeal, the European Court of Human Rights also denied the parents’ wishes.
End of life cases similar to Charlie’s are not rare. In modern medicine, parents sometimes must make the heart-wrenching decision to stop aggressive therapies and accept that death is imminent and unavoidable. Many factors go into making that decision. Both the courts and medical staff presume that parents are the best decision makers. Generally, medical staff provide emotional and spiritual support to the parents, along with a tincture of time. In the vast majority of cases, parents and physicians come to agree on the course of care, but sometimes, there are irreconcilable disagreements.
It is rare for courts to overrule parents. The government typically intervenes only when the harm from a parent’s choice exceeds some threshold. For instance, it is not in a child’s best interest to be put in a car during a blizzard and driven to the store to get cigarettes. But neither is it wise to have an intrusive government reviewing every choice a parent makes. The potential harm must be large enough, likely enough, and imminent enough before most judges will intervene. The law will insist the child be in a car seat at least.
In Charlie’s case, the medical staff and the judges all explicitly said that the cost of therapy did not factor into their decision making; they looked solely at what was best for Charlie. The focus was on whether the unproven potential benefits of experimental therapy outweighed the risk of suffering caused by the therapy and continued intensive medical care.
Even when a bedside decision ignores the financial impact, money often structures which therapeutic choices are available. There are also issues of equitable access to be raised and weighed. Expenditures impact other social choices.
Money influenced the actions of Martin Shkreli, who is best known as the pharmacy company executive who markedly increased the price of a drug. Mr. Shkreli was recently convicted on three of eight charges for securities fraud, and sentencing is pending; the convictions were not related to the price increase.
The United States has created some amazing technologies to save individual, identifiable lives, but they come at a high price that often costs lives in ways more subtle than the incident in India. At some point, the government and the public are responsible for either financing or rationing care, but that doesn’t absolve the scientists completely. The Russell-Einstein (Pugwash) Manifesto established that scientists have a moral accountability for the negative consequences of creating new technology, and that includes the financial aspects.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]
It has been a remarkable summer of milestones and crises for high-technology medicine.
An FDA panel has unanimously approved a gene therapy: The patient’s own immune cells are taken from his or her body, genetically modified, and reinfused to attack cancer. While the treatment has some dangers, it can be worth trying when conventional therapy has failed, and it appears to be curative when it works. Final FDA approval is expected in September.
While those breakthroughs were occurring, the parents of Charlie Gard, an infant in England with a very rare and devastating mitochondrial disease, were seeking experimental therapy for their child. The medical staff disagreed with the parents: They recommended that the best thing for Charlie would be to stop the ventilator and allow him to die, rather than let him to continue to suffer. Three British courts reviewed Charlie’s case and concurred with the medical staff; on appeal, the European Court of Human Rights also denied the parents’ wishes.
End of life cases similar to Charlie’s are not rare. In modern medicine, parents sometimes must make the heart-wrenching decision to stop aggressive therapies and accept that death is imminent and unavoidable. Many factors go into making that decision. Both the courts and medical staff presume that parents are the best decision makers. Generally, medical staff provide emotional and spiritual support to the parents, along with a tincture of time. In the vast majority of cases, parents and physicians come to agree on the course of care, but sometimes, there are irreconcilable disagreements.
It is rare for courts to overrule parents. The government typically intervenes only when the harm from a parent’s choice exceeds some threshold. For instance, it is not in a child’s best interest to be put in a car during a blizzard and driven to the store to get cigarettes. But neither is it wise to have an intrusive government reviewing every choice a parent makes. The potential harm must be large enough, likely enough, and imminent enough before most judges will intervene. The law will insist the child be in a car seat at least.
In Charlie’s case, the medical staff and the judges all explicitly said that the cost of therapy did not factor into their decision making; they looked solely at what was best for Charlie. The focus was on whether the unproven potential benefits of experimental therapy outweighed the risk of suffering caused by the therapy and continued intensive medical care.
Even when a bedside decision ignores the financial impact, money often structures which therapeutic choices are available. There are also issues of equitable access to be raised and weighed. Expenditures impact other social choices.
Money influenced the actions of Martin Shkreli, who is best known as the pharmacy company executive who markedly increased the price of a drug. Mr. Shkreli was recently convicted on three of eight charges for securities fraud, and sentencing is pending; the convictions were not related to the price increase.
The United States has created some amazing technologies to save individual, identifiable lives, but they come at a high price that often costs lives in ways more subtle than the incident in India. At some point, the government and the public are responsible for either financing or rationing care, but that doesn’t absolve the scientists completely. The Russell-Einstein (Pugwash) Manifesto established that scientists have a moral accountability for the negative consequences of creating new technology, and that includes the financial aspects.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]
Confronting hate and violence against the LGBT community
It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.
It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.1 In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.2 Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.3 There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,4 and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.5 The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.6 Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.7
What can we do to stand up to the hate and violence against marginalized groups, such as the LGBT community? First, make your office a safe space. With the recent brazen display of hate and violence going around, members the LGBT community are desperate to feel protected. A good place to start is a guide by Advocates for Youth. Second, educate yourself and others. The title physician means “teacher,” and I feel it is your responsibility to teach your peers, colleagues, and the public about how anti-LGBT violence affects the health of LGBT individuals. To be an effective teacher, you need to be up to date on the research on how hatred and intolerance affects the health of the LGBT community. A good place to start is the Human Rights Campaign, which has accurate statistics on anti-LGBT violence and resources to address this problem. Finally, be an advocate. You don’t need to be in the streets with picket signs, nor do you necessarily need to lead the charge against anti-LGBT hate and violence – others will be at the front lines. What you can do is to call for your local, state, and federal government to institute policies that address anti-LGBT violence. Many medical organizations have resources that help health care providers engage with policy makers (check out the American Academy of Pediatrics advocacy page for these resources). Many of our elected officials take our professional opinions seriously.
Anti-gay and anti-trans violence is all too common in the LGBT community, especially violence against LGBT people of color, and this violence can adversely affect their health. Health care providers have a responsibility and the influence to confront these nexuses of hate and intolerance. You don’t need to do something heroic to accomplish this. You are members of a privileged and respected group of professionals, so small actions can coalesce into something that has a large impact on the health and well-being of the communities you serve.
Resources
• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit
• Human Rights Campaign. www.hrc.org/resources/
• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/
References
1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.
2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.
3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.
4. J Sch Health. 2011 May;81(5):223-30.
5. Prev Sci. 2015 Jul;16(5):734-43.
6. Dev Psychol. 2010 Nov;46(6):1580-9.
7. Psychol Bull. 2003 Sep;129(5):674-97.
8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.
9. The Hippocratic Oath Today. 2001 or Do. No. Harm.
It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.
It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.1 In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.2 Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.3 There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,4 and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.5 The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.6 Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.7
What can we do to stand up to the hate and violence against marginalized groups, such as the LGBT community? First, make your office a safe space. With the recent brazen display of hate and violence going around, members the LGBT community are desperate to feel protected. A good place to start is a guide by Advocates for Youth. Second, educate yourself and others. The title physician means “teacher,” and I feel it is your responsibility to teach your peers, colleagues, and the public about how anti-LGBT violence affects the health of LGBT individuals. To be an effective teacher, you need to be up to date on the research on how hatred and intolerance affects the health of the LGBT community. A good place to start is the Human Rights Campaign, which has accurate statistics on anti-LGBT violence and resources to address this problem. Finally, be an advocate. You don’t need to be in the streets with picket signs, nor do you necessarily need to lead the charge against anti-LGBT hate and violence – others will be at the front lines. What you can do is to call for your local, state, and federal government to institute policies that address anti-LGBT violence. Many medical organizations have resources that help health care providers engage with policy makers (check out the American Academy of Pediatrics advocacy page for these resources). Many of our elected officials take our professional opinions seriously.
Anti-gay and anti-trans violence is all too common in the LGBT community, especially violence against LGBT people of color, and this violence can adversely affect their health. Health care providers have a responsibility and the influence to confront these nexuses of hate and intolerance. You don’t need to do something heroic to accomplish this. You are members of a privileged and respected group of professionals, so small actions can coalesce into something that has a large impact on the health and well-being of the communities you serve.
Resources
• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit
• Human Rights Campaign. www.hrc.org/resources/
• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/
References
1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.
2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.
3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.
4. J Sch Health. 2011 May;81(5):223-30.
5. Prev Sci. 2015 Jul;16(5):734-43.
6. Dev Psychol. 2010 Nov;46(6):1580-9.
7. Psychol Bull. 2003 Sep;129(5):674-97.
8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.
9. The Hippocratic Oath Today. 2001 or Do. No. Harm.
It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.
It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.1 In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.2 Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.3 There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,4 and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.5 The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.6 Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.7
What can we do to stand up to the hate and violence against marginalized groups, such as the LGBT community? First, make your office a safe space. With the recent brazen display of hate and violence going around, members the LGBT community are desperate to feel protected. A good place to start is a guide by Advocates for Youth. Second, educate yourself and others. The title physician means “teacher,” and I feel it is your responsibility to teach your peers, colleagues, and the public about how anti-LGBT violence affects the health of LGBT individuals. To be an effective teacher, you need to be up to date on the research on how hatred and intolerance affects the health of the LGBT community. A good place to start is the Human Rights Campaign, which has accurate statistics on anti-LGBT violence and resources to address this problem. Finally, be an advocate. You don’t need to be in the streets with picket signs, nor do you necessarily need to lead the charge against anti-LGBT hate and violence – others will be at the front lines. What you can do is to call for your local, state, and federal government to institute policies that address anti-LGBT violence. Many medical organizations have resources that help health care providers engage with policy makers (check out the American Academy of Pediatrics advocacy page for these resources). Many of our elected officials take our professional opinions seriously.
Anti-gay and anti-trans violence is all too common in the LGBT community, especially violence against LGBT people of color, and this violence can adversely affect their health. Health care providers have a responsibility and the influence to confront these nexuses of hate and intolerance. You don’t need to do something heroic to accomplish this. You are members of a privileged and respected group of professionals, so small actions can coalesce into something that has a large impact on the health and well-being of the communities you serve.
Resources
• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit
• Human Rights Campaign. www.hrc.org/resources/
• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/
References
1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.
2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.
3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.
4. J Sch Health. 2011 May;81(5):223-30.
5. Prev Sci. 2015 Jul;16(5):734-43.
6. Dev Psychol. 2010 Nov;46(6):1580-9.
7. Psychol Bull. 2003 Sep;129(5):674-97.
8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.
9. The Hippocratic Oath Today. 2001 or Do. No. Harm.
Key steps to preventing patient injury
Physicians often encounter a “black box” in terms of where to focus their patient safety efforts. Obstetricians care for two patients – mothers and babies – simultaneously, which presents significant challenges. Safe obstetric care requires a multidisciplinary team with good communication skills. At the same time, gynecologic procedures are becoming more complex, and caring for a patient with complications can be quite challenging.
Breakdowns in communication often lead to adverse outcomes. Using closed obstetric malpractice claims allows practicing clinicians to understand where to focus their improvement efforts. The Doctors Company recently performed an analysis of 944 closed obstetric-gynecologic claims using a lexicon that is common to many other insurers. The study found that across patient claims, communication-related issues were common to nearly all allegations of ob.gyn.-related patient injury. The claims data revealed that key communication failures were in two major areas: communications with our patients and communication among team members, including the physician. 
Physician-patient communication
Consider this example: Dr. S. is caring for a patient at term. At delivery, the infant has no heart rate and no respiratory effort and undergoes a full code and has APGAR scores of 0,0, and 3. While the indication for cesarean delivery was a nonreassuring fetal status, this was a surprising outcome. The team sent the placenta to the pathologist and there was an unusual finding of an amniotic web and the umbilical cord showed venous necrosis. A family meeting was held with the pathologist to explain the findings and the relationship to the baby’s need for support. While the presentation of the information did not change the outcome for the infant, it helped the patients and family to understand how the neonatal outcome occurred and that it was remote from delivery.
Common factors contributing to communication issues between physicians and patients/families include inadequate consent for treatment options; poor patient rapport, including unsympathetic responses to the patient; and language barriers, according to The Doctors Company’s clinical guide to improving patient safety and managing risks.
A fundamental step to address these factors is early education for patients and families about the risks and benefits of treatment, which is essential to reinforce understanding of potential interventions. Informed consent is a critical element of early education, but is often done in a rush, in a busy office setting – making it a critical risk factor. Having the informed consent conversation when the decision is made to go to surgery is important, but encouraging patients to bring forward questions and allowing their loved ones to have a clear understanding of their recovery process is also very helpful. When an unexpected complication occurs, having had a complete discussion about risks can help to mitigate an otherwise difficult situation.
We are often busy and stressed when complications arise, and the reflex is to withdraw from the patient who has suffered the complication. Demonstrating genuine empathy toward these patients allows the human side of physician-patient interaction to become apparent, which not only can reduce the patient’s and the family’s anger and frustration at a complicated situation but also can reduce the legal risk for the physician.
Provider communication
Consider another example: Ms. G is a 36-year old G1P0 who presented to the labor and delivery unit with severe preeclampsia. Failure to communicate a clear plan of action for management of her severe hypertension to all team members led to undertreated hypertension, a major stroke, and maternal death.
Both obstetrics and gynecology are specialties that require multidisciplinary teams, including nursing, anesthesia colleagues, consultants, and if at a teaching hospital, residents and medical and nursing students. Teamwork training initiatives can encourage providers to move out of their individual silos, practice more collaboratively, and share information across disciplines in a succinct and timely fashion. Understanding patients’ plans of care and competing resource demands allows a team to manage risk together.
Having a shared mental model and situation awareness across the team also creates a safety net for patients. This type of shared information is something highly reliable teams train on and communicate across disciplines, as this is not often taught in medical or nursing schools. Having clear roles and responsibilities allows professionals to create and understand expectations, especially around sharing safety concerns.
In situ simulations of high-risk situations both in labor and delivery and in the operating rooms are wonderful and instructive ways to practice teamwork behaviors. This type of exercise allows staff to practice skills together while discovering system failures in a nonthreatening environment. Later debriefing these activities allows staff to reflect on their own behavior and learn from one another, as well as to identify systems that need additional work.
Addressing patient safety risks effectively means focusing our energy and efforts toward underlying vulnerabilities that place patients at risk and increase liability for doctors. Sharing the results of lessons learned, through the evaluation of malpractice claims, helps to identify areas of vulnerabilities. Working to improve our communication with patients, families, and other providers, we can systematically lower risk to the patient and lower the risk of litigation to physicians.
Dr. Mann, an ob.gyn., is an assistant professor, part-time, at Harvard Medical School in Boston, and is a national consultant in patient safety and quality improvement in the field of obstetrics. She is a member of the Obstetrics Advisory Board of The Doctors Company. She is also a consultant at Harvard’s Risk Management Foundation, Dana-Farber Cancer Institute, and many institutions across the United States.
Physicians often encounter a “black box” in terms of where to focus their patient safety efforts. Obstetricians care for two patients – mothers and babies – simultaneously, which presents significant challenges. Safe obstetric care requires a multidisciplinary team with good communication skills. At the same time, gynecologic procedures are becoming more complex, and caring for a patient with complications can be quite challenging.
Breakdowns in communication often lead to adverse outcomes. Using closed obstetric malpractice claims allows practicing clinicians to understand where to focus their improvement efforts. The Doctors Company recently performed an analysis of 944 closed obstetric-gynecologic claims using a lexicon that is common to many other insurers. The study found that across patient claims, communication-related issues were common to nearly all allegations of ob.gyn.-related patient injury. The claims data revealed that key communication failures were in two major areas: communications with our patients and communication among team members, including the physician.
Physician-patient communication
Consider this example: Dr. S. is caring for a patient at term. At delivery, the infant has no heart rate and no respiratory effort and undergoes a full code and has APGAR scores of 0,0, and 3. While the indication for cesarean delivery was a nonreassuring fetal status, this was a surprising outcome. The team sent the placenta to the pathologist and there was an unusual finding of an amniotic web and the umbilical cord showed venous necrosis. A family meeting was held with the pathologist to explain the findings and the relationship to the baby’s need for support. While the presentation of the information did not change the outcome for the infant, it helped the patients and family to understand how the neonatal outcome occurred and that it was remote from delivery.
Common factors contributing to communication issues between physicians and patients/families include inadequate consent for treatment options; poor patient rapport, including unsympathetic responses to the patient; and language barriers, according to The Doctors Company’s clinical guide to improving patient safety and managing risks.
A fundamental step to address these factors is early education for patients and families about the risks and benefits of treatment, which is essential to reinforce understanding of potential interventions. Informed consent is a critical element of early education, but is often done in a rush, in a busy office setting – making it a critical risk factor. Having the informed consent conversation when the decision is made to go to surgery is important, but encouraging patients to bring forward questions and allowing their loved ones to have a clear understanding of their recovery process is also very helpful. When an unexpected complication occurs, having had a complete discussion about risks can help to mitigate an otherwise difficult situation.
We are often busy and stressed when complications arise, and the reflex is to withdraw from the patient who has suffered the complication. Demonstrating genuine empathy toward these patients allows the human side of physician-patient interaction to become apparent, which not only can reduce the patient’s and the family’s anger and frustration at a complicated situation but also can reduce the legal risk for the physician.
Provider communication
Consider another example: Ms. G is a 36-year old G1P0 who presented to the labor and delivery unit with severe preeclampsia. Failure to communicate a clear plan of action for management of her severe hypertension to all team members led to undertreated hypertension, a major stroke, and maternal death.
Both obstetrics and gynecology are specialties that require multidisciplinary teams, including nursing, anesthesia colleagues, consultants, and if at a teaching hospital, residents and medical and nursing students. Teamwork training initiatives can encourage providers to move out of their individual silos, practice more collaboratively, and share information across disciplines in a succinct and timely fashion. Understanding patients’ plans of care and competing resource demands allows a team to manage risk together.
Having a shared mental model and situation awareness across the team also creates a safety net for patients. This type of shared information is something highly reliable teams train on and communicate across disciplines, as this is not often taught in medical or nursing schools. Having clear roles and responsibilities allows professionals to create and understand expectations, especially around sharing safety concerns.
In situ simulations of high-risk situations both in labor and delivery and in the operating rooms are wonderful and instructive ways to practice teamwork behaviors. This type of exercise allows staff to practice skills together while discovering system failures in a nonthreatening environment. Later debriefing these activities allows staff to reflect on their own behavior and learn from one another, as well as to identify systems that need additional work.
Addressing patient safety risks effectively means focusing our energy and efforts toward underlying vulnerabilities that place patients at risk and increase liability for doctors. Sharing the results of lessons learned, through the evaluation of malpractice claims, helps to identify areas of vulnerabilities. Working to improve our communication with patients, families, and other providers, we can systematically lower risk to the patient and lower the risk of litigation to physicians.
Dr. Mann, an ob.gyn., is an assistant professor, part-time, at Harvard Medical School in Boston, and is a national consultant in patient safety and quality improvement in the field of obstetrics. She is a member of the Obstetrics Advisory Board of The Doctors Company. She is also a consultant at Harvard’s Risk Management Foundation, Dana-Farber Cancer Institute, and many institutions across the United States.
Physicians often encounter a “black box” in terms of where to focus their patient safety efforts. Obstetricians care for two patients – mothers and babies – simultaneously, which presents significant challenges. Safe obstetric care requires a multidisciplinary team with good communication skills. At the same time, gynecologic procedures are becoming more complex, and caring for a patient with complications can be quite challenging.
Breakdowns in communication often lead to adverse outcomes. Using closed obstetric malpractice claims allows practicing clinicians to understand where to focus their improvement efforts. The Doctors Company recently performed an analysis of 944 closed obstetric-gynecologic claims using a lexicon that is common to many other insurers. The study found that across patient claims, communication-related issues were common to nearly all allegations of ob.gyn.-related patient injury. The claims data revealed that key communication failures were in two major areas: communications with our patients and communication among team members, including the physician.
Physician-patient communication
Consider this example: Dr. S. is caring for a patient at term. At delivery, the infant has no heart rate and no respiratory effort and undergoes a full code and has APGAR scores of 0,0, and 3. While the indication for cesarean delivery was a nonreassuring fetal status, this was a surprising outcome. The team sent the placenta to the pathologist and there was an unusual finding of an amniotic web and the umbilical cord showed venous necrosis. A family meeting was held with the pathologist to explain the findings and the relationship to the baby’s need for support. While the presentation of the information did not change the outcome for the infant, it helped the patients and family to understand how the neonatal outcome occurred and that it was remote from delivery.
Common factors contributing to communication issues between physicians and patients/families include inadequate consent for treatment options; poor patient rapport, including unsympathetic responses to the patient; and language barriers, according to The Doctors Company’s clinical guide to improving patient safety and managing risks.
A fundamental step to address these factors is early education for patients and families about the risks and benefits of treatment, which is essential to reinforce understanding of potential interventions. Informed consent is a critical element of early education, but is often done in a rush, in a busy office setting – making it a critical risk factor. Having the informed consent conversation when the decision is made to go to surgery is important, but encouraging patients to bring forward questions and allowing their loved ones to have a clear understanding of their recovery process is also very helpful. When an unexpected complication occurs, having had a complete discussion about risks can help to mitigate an otherwise difficult situation.
We are often busy and stressed when complications arise, and the reflex is to withdraw from the patient who has suffered the complication. Demonstrating genuine empathy toward these patients allows the human side of physician-patient interaction to become apparent, which not only can reduce the patient’s and the family’s anger and frustration at a complicated situation but also can reduce the legal risk for the physician.
Provider communication
Consider another example: Ms. G is a 36-year old G1P0 who presented to the labor and delivery unit with severe preeclampsia. Failure to communicate a clear plan of action for management of her severe hypertension to all team members led to undertreated hypertension, a major stroke, and maternal death.
Both obstetrics and gynecology are specialties that require multidisciplinary teams, including nursing, anesthesia colleagues, consultants, and if at a teaching hospital, residents and medical and nursing students. Teamwork training initiatives can encourage providers to move out of their individual silos, practice more collaboratively, and share information across disciplines in a succinct and timely fashion. Understanding patients’ plans of care and competing resource demands allows a team to manage risk together.
Having a shared mental model and situation awareness across the team also creates a safety net for patients. This type of shared information is something highly reliable teams train on and communicate across disciplines, as this is not often taught in medical or nursing schools. Having clear roles and responsibilities allows professionals to create and understand expectations, especially around sharing safety concerns.
In situ simulations of high-risk situations both in labor and delivery and in the operating rooms are wonderful and instructive ways to practice teamwork behaviors. This type of exercise allows staff to practice skills together while discovering system failures in a nonthreatening environment. Later debriefing these activities allows staff to reflect on their own behavior and learn from one another, as well as to identify systems that need additional work.
Addressing patient safety risks effectively means focusing our energy and efforts toward underlying vulnerabilities that place patients at risk and increase liability for doctors. Sharing the results of lessons learned, through the evaluation of malpractice claims, helps to identify areas of vulnerabilities. Working to improve our communication with patients, families, and other providers, we can systematically lower risk to the patient and lower the risk of litigation to physicians.
Dr. Mann, an ob.gyn., is an assistant professor, part-time, at Harvard Medical School in Boston, and is a national consultant in patient safety and quality improvement in the field of obstetrics. She is a member of the Obstetrics Advisory Board of The Doctors Company. She is also a consultant at Harvard’s Risk Management Foundation, Dana-Farber Cancer Institute, and many institutions across the United States.