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Self-injury
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation. 
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Down syndrome in adolescents
Teen years, no doubt, come with expected challenges. For teens with Down syndrome (DS), the challenges are exponentially greater. Although DS is associated with mental retardation, the vast majority of people with DS have only mild to moderate intellectual disability. Still, this can lead to a great deal of internal stress for the adolescent and anxiety and stress for the parents.
Many issues must be considered for the adolescent with DS. Annual surveillance changes as the child ages and the need for intervention do as well. For example, 50% of children with DS are born with congenital heart defect. During infancy, it is important to do echocardiograms to identify and follow specific lesions. Approximately 57% of adolescents with DS will develop mitral valve prolapse and 10% will develop aortic regurgitation.1 Therefore, close evaluation should be done, listening for new onset murmurs, clicks, and unexplained fatigue, and, if these are identified, an echocardiogram should be repeated.
Dysmorphic features such as midfacial hypoplasia, tonsillar hypertrophy, and narrow ear canals also lead to issues that develop in the adolescent years. Chronic otitis, conductive hearing loss because of chronic middle-ear effusion or impacted cerumen, and enlarged tonsils can result in obstructive sleep apnea. As individuals gain weight, these issues are further affected, and a sleep study may be required. Annual hearing screens are recommended.1
Musculoskeletal disorders such as ligamentous laxity and atlantoaxial instability can also present with complications in the adolescent years. Pes planus is a very common finding that can further lead to hip and knee pain. Obesity also further adds to its occurrence (14%-67%).3
Now, the most pressing and, likely, most overlooked issue is the issue of sexuality. We spend a great deal of time educating teens without DS about the risks of unprotected sex and exposures to STIs, but many assume that these issues do not affect teens with DS. Secondary sexual characteristics develop in the same manner and at the same age that they do in children without DS. Therefore, it is a safe assumption that sexual curiosity and arousal do as well. Given that there can be varying levels of mental impairment, the approach to sex education needs to be developmentally appropriate. Normalizing the feelings and having discussions on appropriate and inappropriate expression are important.
As with all teens, acceptance and inclusion are of utmost importance. Physical and learning disabilities set them apart despite shared sexual and emotional development. This can lead to anxiety, depression, and behavior issues. Understanding that these are real issues for the adolescent with DS is important when providing the appropriate resources and support.
Management of the menstrual cycle can add new challenges for both the adolescent and the parent and, thus, should be investigated during health maintenance visits. Amenorrhea can result from introduction of hormonal therapy and should be considered. Sexual abuse also is increased in this age group, so close supervision and awareness of this issue are important.
Assisting parents of children with DS through the teen years is imperative. Making them aware of local support groups and national organizations for children with disabilities will help them navigate these years. The American Academy of Pediatrics has guidelines for health maintenance for DS.2
Dr. Pearce is a pediatrician in Frankfort, Ill. She reported no relevant financial disclosures. Email her at [email protected]
References
1. J Pediatr Health Care. 2006 May-Jun;20(3):198-205.
2. Pediatrics. 2011. doi: 10.1542/peds.2011-1605.
3. Clin Obes. 2015;5(2):52-9.
Correction, 7/26/17: An earlier version of this article misstated a recommendation about radiologic evaluation of the cervical spine in asymptomatic children
Teen years, no doubt, come with expected challenges. For teens with Down syndrome (DS), the challenges are exponentially greater. Although DS is associated with mental retardation, the vast majority of people with DS have only mild to moderate intellectual disability. Still, this can lead to a great deal of internal stress for the adolescent and anxiety and stress for the parents.
Many issues must be considered for the adolescent with DS. Annual surveillance changes as the child ages and the need for intervention do as well. For example, 50% of children with DS are born with congenital heart defect. During infancy, it is important to do echocardiograms to identify and follow specific lesions. Approximately 57% of adolescents with DS will develop mitral valve prolapse and 10% will develop aortic regurgitation.1 Therefore, close evaluation should be done, listening for new onset murmurs, clicks, and unexplained fatigue, and, if these are identified, an echocardiogram should be repeated.
Dysmorphic features such as midfacial hypoplasia, tonsillar hypertrophy, and narrow ear canals also lead to issues that develop in the adolescent years. Chronic otitis, conductive hearing loss because of chronic middle-ear effusion or impacted cerumen, and enlarged tonsils can result in obstructive sleep apnea. As individuals gain weight, these issues are further affected, and a sleep study may be required. Annual hearing screens are recommended.1
Musculoskeletal disorders such as ligamentous laxity and atlantoaxial instability can also present with complications in the adolescent years. Pes planus is a very common finding that can further lead to hip and knee pain. Obesity also further adds to its occurrence (14%-67%).3
Now, the most pressing and, likely, most overlooked issue is the issue of sexuality. We spend a great deal of time educating teens without DS about the risks of unprotected sex and exposures to STIs, but many assume that these issues do not affect teens with DS. Secondary sexual characteristics develop in the same manner and at the same age that they do in children without DS. Therefore, it is a safe assumption that sexual curiosity and arousal do as well. Given that there can be varying levels of mental impairment, the approach to sex education needs to be developmentally appropriate. Normalizing the feelings and having discussions on appropriate and inappropriate expression are important.
As with all teens, acceptance and inclusion are of utmost importance. Physical and learning disabilities set them apart despite shared sexual and emotional development. This can lead to anxiety, depression, and behavior issues. Understanding that these are real issues for the adolescent with DS is important when providing the appropriate resources and support.
Management of the menstrual cycle can add new challenges for both the adolescent and the parent and, thus, should be investigated during health maintenance visits. Amenorrhea can result from introduction of hormonal therapy and should be considered. Sexual abuse also is increased in this age group, so close supervision and awareness of this issue are important.
Assisting parents of children with DS through the teen years is imperative. Making them aware of local support groups and national organizations for children with disabilities will help them navigate these years. The American Academy of Pediatrics has guidelines for health maintenance for DS.2
Dr. Pearce is a pediatrician in Frankfort, Ill. She reported no relevant financial disclosures. Email her at [email protected]
References
1. J Pediatr Health Care. 2006 May-Jun;20(3):198-205.
2. Pediatrics. 2011. doi: 10.1542/peds.2011-1605.
3. Clin Obes. 2015;5(2):52-9.
Correction, 7/26/17: An earlier version of this article misstated a recommendation about radiologic evaluation of the cervical spine in asymptomatic children
Teen years, no doubt, come with expected challenges. For teens with Down syndrome (DS), the challenges are exponentially greater. Although DS is associated with mental retardation, the vast majority of people with DS have only mild to moderate intellectual disability. Still, this can lead to a great deal of internal stress for the adolescent and anxiety and stress for the parents.
Many issues must be considered for the adolescent with DS. Annual surveillance changes as the child ages and the need for intervention do as well. For example, 50% of children with DS are born with congenital heart defect. During infancy, it is important to do echocardiograms to identify and follow specific lesions. Approximately 57% of adolescents with DS will develop mitral valve prolapse and 10% will develop aortic regurgitation.1 Therefore, close evaluation should be done, listening for new onset murmurs, clicks, and unexplained fatigue, and, if these are identified, an echocardiogram should be repeated.
Dysmorphic features such as midfacial hypoplasia, tonsillar hypertrophy, and narrow ear canals also lead to issues that develop in the adolescent years. Chronic otitis, conductive hearing loss because of chronic middle-ear effusion or impacted cerumen, and enlarged tonsils can result in obstructive sleep apnea. As individuals gain weight, these issues are further affected, and a sleep study may be required. Annual hearing screens are recommended.1
Musculoskeletal disorders such as ligamentous laxity and atlantoaxial instability can also present with complications in the adolescent years. Pes planus is a very common finding that can further lead to hip and knee pain. Obesity also further adds to its occurrence (14%-67%).3
Now, the most pressing and, likely, most overlooked issue is the issue of sexuality. We spend a great deal of time educating teens without DS about the risks of unprotected sex and exposures to STIs, but many assume that these issues do not affect teens with DS. Secondary sexual characteristics develop in the same manner and at the same age that they do in children without DS. Therefore, it is a safe assumption that sexual curiosity and arousal do as well. Given that there can be varying levels of mental impairment, the approach to sex education needs to be developmentally appropriate. Normalizing the feelings and having discussions on appropriate and inappropriate expression are important.
As with all teens, acceptance and inclusion are of utmost importance. Physical and learning disabilities set them apart despite shared sexual and emotional development. This can lead to anxiety, depression, and behavior issues. Understanding that these are real issues for the adolescent with DS is important when providing the appropriate resources and support.
Management of the menstrual cycle can add new challenges for both the adolescent and the parent and, thus, should be investigated during health maintenance visits. Amenorrhea can result from introduction of hormonal therapy and should be considered. Sexual abuse also is increased in this age group, so close supervision and awareness of this issue are important.
Assisting parents of children with DS through the teen years is imperative. Making them aware of local support groups and national organizations for children with disabilities will help them navigate these years. The American Academy of Pediatrics has guidelines for health maintenance for DS.2
Dr. Pearce is a pediatrician in Frankfort, Ill. She reported no relevant financial disclosures. Email her at [email protected]
References
1. J Pediatr Health Care. 2006 May-Jun;20(3):198-205.
2. Pediatrics. 2011. doi: 10.1542/peds.2011-1605.
3. Clin Obes. 2015;5(2):52-9.
Correction, 7/26/17: An earlier version of this article misstated a recommendation about radiologic evaluation of the cervical spine in asymptomatic children
Anxiety in children during a new administration; Why medical psychiatry is vital for my patients; And more
Anxiety in children during a new administration
Since the current administration took office, many children continue to grapple with the initial shock of the election results and the uncertainty of what the next 4 years will bring. In the days after the election, several patients sat in my office and spoke of intense feelings of sadness, anger, and worry. Their stress levels were elevated, and they searched desperately for refuge from the unknown. On the other side of the hospital, patients expressing suicidal ideation filed into the emergency room. A similar scene played out nationally when suicide prevention hotlines experienced a sharp increase in calls.
During this emotional time, it is critical to support our children. Some will be more affected than others. Children from immigrant backgrounds might be particularly fearful of what this means for them and their families. In the days after the election, a video surfaced from a middle school in Michigan featuring kids at lunch chanting, “Build the wall!”
Bullying also is a concern. Despite being a third-generation American, an 8-year-old boy woke up the day after the election confused and scared. One mother told me that a student confronted her 11-year-old son at school, yelling that the election outcome was a “good thing” and he should “go back to his country.” Like his mother, the 11-year-old was born in the United States.
Kids get their cues from the adults in their lives. Parents and teachers play an important role in modeling behavior and providing comfort. Adults need to support children and to do that properly they need make sure they have processed their own feelings. They do not need to be unrealistic or overly positive, but should offer hope and trust in our democratic system. With discussion, children should have ample opportunity to express how they feel. Psychiatrists can evaluate a child’s symptoms and presentation. Are current medications helping enough with the recent changes? Does a child need a medication adjustment or to be seen more often? Does he (she) need to be admitted to the hospital for evaluation of suicidal ideation? As a psychiatrist, do you need to revisit the list of resources in the community and give children a crisis hotline number? Also consider referring a child to a psychotherapist if needed. Some schools offered counseling after the election. It is worthwhile to contact school officials if a student is struggling or could benefit from additional support.
Although many unknowns remain, 1 thing is certain: children will have more questions and we must be ready to answer.
Balkozar S. Adam, MD
Associate Professor of Clinical Psychiatry Child and Adolescent Psychiatry
University of Missouri
Columbia, Missouri
Co-Editor
Missouri Psychiatry Newsletter
Jefferson City, Missouri
Two additional adjunctive therapies for mental health
I was excited to read Dr. Nasrallah’s editorial about adjunctive therapies for mental health disorders (Are you neuroprotecting your patients? 10 Adjunctive therapies to consider,
The article missed 2 important vitamins that play a crucial role in positive mental health treatment outcomes: folic acid and vitamin B12. In my practice, I have found up to 50% of my patients with depression have a vitamin B12 deficiency. After supplementation, these patients’ symptoms improve to the point that we often can reduce or eliminate medication. Folic acid deficiency has been found among individuals with depression and linked to poor response to treatment.1 Higher serum levels of homocysteine—a consequence of low folic acid levels—are linked to increased risk of developing depression later in life, as well as higher risk of cardiovascular disease.2,3 Folate also can be used for enhancing treatment response to antidepressants by increasing production of neurotransmitters.2
Another factor to consider is methylenetetrahydrofolate reductase (MTHFR) variants. Approximately 20% of the population cannot methylate B vitamins because of a variation on the MTHFR gene.4,5 These patients are at increased risk for depression because they are unable to use B vitamins, which are essential in the synthesis of serotonin and dopamine. These patients do not respond to B12 and folate supplements. For these individuals, I recommend methylated products, which can be purchased online.
I have found these practices, as well as many of those listed in the editorial, are effective in treating depression and anxiety.
Lara Kain, PA-C, MPAS
Psychiatric Physician Assistant
Tidewater Psychotherapy Services
Virginia Beach, Virginia
References
1. Kaner G, Soylu M, Yüksel N, et al. Evaluation of nutritional status of patients with depression. Biomed Res Int. 2015;2015:521481. doi: 10.1155/2015/521481.
2. Seppälä J, Koponen H, Kautiainen H, et al. Association between vitamin B12 and melancholic depressive symptoms: a Finnish population-based study. BMC Psychiatry. 2013;13:145. doi: 10.1186/1471-244X-13-145.
3. Petridou ET, Kousoulis AA, Michelakos T, et al. Folate and B12 serum levels in association with depression in the aged: a systemic review and meta-analysis. Aging Ment Health. 2016;20(9):965-973.
4. Lynch B. MTHFR mutations and the conditions they cause. MTHFR.Net. http://mthfr.net/mthfr-mutations-and-the-conditions-they-cause/2011/09/07. Accessed February 16, 2017.
5. Eszlari N, Kovacs D, Petschner P, et al. Distinct effects of folate pathway genes MTHFR and MTHFD1L on ruminative response style: a potential risk mechanism for depression. Transl Psychiatry. 2016;6(3):e745. doi: 10.1038/tp.2016.19.
An honest perspective on Cannabis in therapy
I enjoyed Dr. Nasrallah’s editorial “Maddening therapies: How hallucinogens morphed into novel treatments” (From the
As a psychiatrist specializing in bipolar and psychotic disorders—as well as the founder and Board President of Doctors for Cannabis Regulation—I appreciate his reservations about the potential of Cannabis to trigger psychosis in vulnerable individuals. My reading of the literature is there is good evidence for marijuana as a trigger—not as a cause—of the disease. However, what is the evidence for hallucinogens?
Cannabis can have adverse effects on brain development, but it is not clear whether those effects are worse than those caused by alcohol. In the absence of any head-to-head studies, how can we proceed?
David L. Nathan, MD, DFAPA
Clinical Associate Professor
Rutgers Robert Wood Johnson Medical School
Director of Continuing Medical Education
Princeton HealthCare System
Princeton, New Jersey
Dr. Nasrallah responds
LSD can cause psychosis, paranoid delusions, and altered thinking in addition to vivid visual hallucinations in some individuals but not all, because vulnerability occurs on a spectrum. I postulate that the recently discovered inverse agonist of the serotonin 5-HT2A receptor, pimavanserin (FDA-approved for visual hallucinations and delusions of Parkinson’s disease psychosis), might be effective for LSD psychosis because this hallucinogen has a strong binding affinity to the serotonin 5-HT2A receptors.
Studies show that marijuana can induce apoptosis, which would adversely affect brain development. Patients with schizophrenia who abuse marijuana have a lower gray matter volume than those who do not abuse the drug, and both groups have lower gray matter volume than matched healthy controls. I strongly advise a pregnant woman against smoking marijuana because it could impair the fetus’s brain development.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Self-administering LSD: Solution or abuse
Dr. Nasrallah’s editorial (From the Editor,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Nasrallah responds
I am not aware of any systematic data about self-prescribed use of microdoses of LSD to reduce anxiety and depression. Among persons with anxiety and depression who have not had access to psychiatric care, self-medicating with agents such as alcohol, stimulants, ketamine, or LSD is regarded as substance abuse. It also is questionable whether people can determine which microdose of LSD to use. Finally, most drugs of abuse are not “pure,” and many are laced with potentially harmful contaminants.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Why medical psychiatry is vital for my patients
Dr. Paul Summergrad’s guest editorial “Medical psychiatry: The skill of integrating medical and psychiatric care” (
For me, the most inspiring sentence in Dr. Summergrad’s editorial was, “It is incumbent on us to pursue the medical differential of patients when we think it is needed, even if other physicians disagree.” I believe that this describes our job as physicians who specialize in psychiatry. To have a clinician of Dr. Summergrad’s stature write this was inspiring because it goes to the core of what more of us should do.
Ruth Myers, MD
Psychiatrist
The Community Circle PLLC
Burnsville, Minnesota
Anxiety in children during a new administration
Since the current administration took office, many children continue to grapple with the initial shock of the election results and the uncertainty of what the next 4 years will bring. In the days after the election, several patients sat in my office and spoke of intense feelings of sadness, anger, and worry. Their stress levels were elevated, and they searched desperately for refuge from the unknown. On the other side of the hospital, patients expressing suicidal ideation filed into the emergency room. A similar scene played out nationally when suicide prevention hotlines experienced a sharp increase in calls.
During this emotional time, it is critical to support our children. Some will be more affected than others. Children from immigrant backgrounds might be particularly fearful of what this means for them and their families. In the days after the election, a video surfaced from a middle school in Michigan featuring kids at lunch chanting, “Build the wall!”
Bullying also is a concern. Despite being a third-generation American, an 8-year-old boy woke up the day after the election confused and scared. One mother told me that a student confronted her 11-year-old son at school, yelling that the election outcome was a “good thing” and he should “go back to his country.” Like his mother, the 11-year-old was born in the United States.
Kids get their cues from the adults in their lives. Parents and teachers play an important role in modeling behavior and providing comfort. Adults need to support children and to do that properly they need make sure they have processed their own feelings. They do not need to be unrealistic or overly positive, but should offer hope and trust in our democratic system. With discussion, children should have ample opportunity to express how they feel. Psychiatrists can evaluate a child’s symptoms and presentation. Are current medications helping enough with the recent changes? Does a child need a medication adjustment or to be seen more often? Does he (she) need to be admitted to the hospital for evaluation of suicidal ideation? As a psychiatrist, do you need to revisit the list of resources in the community and give children a crisis hotline number? Also consider referring a child to a psychotherapist if needed. Some schools offered counseling after the election. It is worthwhile to contact school officials if a student is struggling or could benefit from additional support.
Although many unknowns remain, 1 thing is certain: children will have more questions and we must be ready to answer.
Balkozar S. Adam, MD
Associate Professor of Clinical Psychiatry Child and Adolescent Psychiatry
University of Missouri
Columbia, Missouri
Co-Editor
Missouri Psychiatry Newsletter
Jefferson City, Missouri
Two additional adjunctive therapies for mental health
I was excited to read Dr. Nasrallah’s editorial about adjunctive therapies for mental health disorders (Are you neuroprotecting your patients? 10 Adjunctive therapies to consider,
The article missed 2 important vitamins that play a crucial role in positive mental health treatment outcomes: folic acid and vitamin B12. In my practice, I have found up to 50% of my patients with depression have a vitamin B12 deficiency. After supplementation, these patients’ symptoms improve to the point that we often can reduce or eliminate medication. Folic acid deficiency has been found among individuals with depression and linked to poor response to treatment.1 Higher serum levels of homocysteine—a consequence of low folic acid levels—are linked to increased risk of developing depression later in life, as well as higher risk of cardiovascular disease.2,3 Folate also can be used for enhancing treatment response to antidepressants by increasing production of neurotransmitters.2
Another factor to consider is methylenetetrahydrofolate reductase (MTHFR) variants. Approximately 20% of the population cannot methylate B vitamins because of a variation on the MTHFR gene.4,5 These patients are at increased risk for depression because they are unable to use B vitamins, which are essential in the synthesis of serotonin and dopamine. These patients do not respond to B12 and folate supplements. For these individuals, I recommend methylated products, which can be purchased online.
I have found these practices, as well as many of those listed in the editorial, are effective in treating depression and anxiety.
Lara Kain, PA-C, MPAS
Psychiatric Physician Assistant
Tidewater Psychotherapy Services
Virginia Beach, Virginia
References
1. Kaner G, Soylu M, Yüksel N, et al. Evaluation of nutritional status of patients with depression. Biomed Res Int. 2015;2015:521481. doi: 10.1155/2015/521481.
2. Seppälä J, Koponen H, Kautiainen H, et al. Association between vitamin B12 and melancholic depressive symptoms: a Finnish population-based study. BMC Psychiatry. 2013;13:145. doi: 10.1186/1471-244X-13-145.
3. Petridou ET, Kousoulis AA, Michelakos T, et al. Folate and B12 serum levels in association with depression in the aged: a systemic review and meta-analysis. Aging Ment Health. 2016;20(9):965-973.
4. Lynch B. MTHFR mutations and the conditions they cause. MTHFR.Net. http://mthfr.net/mthfr-mutations-and-the-conditions-they-cause/2011/09/07. Accessed February 16, 2017.
5. Eszlari N, Kovacs D, Petschner P, et al. Distinct effects of folate pathway genes MTHFR and MTHFD1L on ruminative response style: a potential risk mechanism for depression. Transl Psychiatry. 2016;6(3):e745. doi: 10.1038/tp.2016.19.
An honest perspective on Cannabis in therapy
I enjoyed Dr. Nasrallah’s editorial “Maddening therapies: How hallucinogens morphed into novel treatments” (From the
As a psychiatrist specializing in bipolar and psychotic disorders—as well as the founder and Board President of Doctors for Cannabis Regulation—I appreciate his reservations about the potential of Cannabis to trigger psychosis in vulnerable individuals. My reading of the literature is there is good evidence for marijuana as a trigger—not as a cause—of the disease. However, what is the evidence for hallucinogens?
Cannabis can have adverse effects on brain development, but it is not clear whether those effects are worse than those caused by alcohol. In the absence of any head-to-head studies, how can we proceed?
David L. Nathan, MD, DFAPA
Clinical Associate Professor
Rutgers Robert Wood Johnson Medical School
Director of Continuing Medical Education
Princeton HealthCare System
Princeton, New Jersey
Dr. Nasrallah responds
LSD can cause psychosis, paranoid delusions, and altered thinking in addition to vivid visual hallucinations in some individuals but not all, because vulnerability occurs on a spectrum. I postulate that the recently discovered inverse agonist of the serotonin 5-HT2A receptor, pimavanserin (FDA-approved for visual hallucinations and delusions of Parkinson’s disease psychosis), might be effective for LSD psychosis because this hallucinogen has a strong binding affinity to the serotonin 5-HT2A receptors.
Studies show that marijuana can induce apoptosis, which would adversely affect brain development. Patients with schizophrenia who abuse marijuana have a lower gray matter volume than those who do not abuse the drug, and both groups have lower gray matter volume than matched healthy controls. I strongly advise a pregnant woman against smoking marijuana because it could impair the fetus’s brain development.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Self-administering LSD: Solution or abuse
Dr. Nasrallah’s editorial (From the Editor,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Nasrallah responds
I am not aware of any systematic data about self-prescribed use of microdoses of LSD to reduce anxiety and depression. Among persons with anxiety and depression who have not had access to psychiatric care, self-medicating with agents such as alcohol, stimulants, ketamine, or LSD is regarded as substance abuse. It also is questionable whether people can determine which microdose of LSD to use. Finally, most drugs of abuse are not “pure,” and many are laced with potentially harmful contaminants.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Why medical psychiatry is vital for my patients
Dr. Paul Summergrad’s guest editorial “Medical psychiatry: The skill of integrating medical and psychiatric care” (
For me, the most inspiring sentence in Dr. Summergrad’s editorial was, “It is incumbent on us to pursue the medical differential of patients when we think it is needed, even if other physicians disagree.” I believe that this describes our job as physicians who specialize in psychiatry. To have a clinician of Dr. Summergrad’s stature write this was inspiring because it goes to the core of what more of us should do.
Ruth Myers, MD
Psychiatrist
The Community Circle PLLC
Burnsville, Minnesota
Anxiety in children during a new administration
Since the current administration took office, many children continue to grapple with the initial shock of the election results and the uncertainty of what the next 4 years will bring. In the days after the election, several patients sat in my office and spoke of intense feelings of sadness, anger, and worry. Their stress levels were elevated, and they searched desperately for refuge from the unknown. On the other side of the hospital, patients expressing suicidal ideation filed into the emergency room. A similar scene played out nationally when suicide prevention hotlines experienced a sharp increase in calls.
During this emotional time, it is critical to support our children. Some will be more affected than others. Children from immigrant backgrounds might be particularly fearful of what this means for them and their families. In the days after the election, a video surfaced from a middle school in Michigan featuring kids at lunch chanting, “Build the wall!”
Bullying also is a concern. Despite being a third-generation American, an 8-year-old boy woke up the day after the election confused and scared. One mother told me that a student confronted her 11-year-old son at school, yelling that the election outcome was a “good thing” and he should “go back to his country.” Like his mother, the 11-year-old was born in the United States.
Kids get their cues from the adults in their lives. Parents and teachers play an important role in modeling behavior and providing comfort. Adults need to support children and to do that properly they need make sure they have processed their own feelings. They do not need to be unrealistic or overly positive, but should offer hope and trust in our democratic system. With discussion, children should have ample opportunity to express how they feel. Psychiatrists can evaluate a child’s symptoms and presentation. Are current medications helping enough with the recent changes? Does a child need a medication adjustment or to be seen more often? Does he (she) need to be admitted to the hospital for evaluation of suicidal ideation? As a psychiatrist, do you need to revisit the list of resources in the community and give children a crisis hotline number? Also consider referring a child to a psychotherapist if needed. Some schools offered counseling after the election. It is worthwhile to contact school officials if a student is struggling or could benefit from additional support.
Although many unknowns remain, 1 thing is certain: children will have more questions and we must be ready to answer.
Balkozar S. Adam, MD
Associate Professor of Clinical Psychiatry Child and Adolescent Psychiatry
University of Missouri
Columbia, Missouri
Co-Editor
Missouri Psychiatry Newsletter
Jefferson City, Missouri
Two additional adjunctive therapies for mental health
I was excited to read Dr. Nasrallah’s editorial about adjunctive therapies for mental health disorders (Are you neuroprotecting your patients? 10 Adjunctive therapies to consider,
The article missed 2 important vitamins that play a crucial role in positive mental health treatment outcomes: folic acid and vitamin B12. In my practice, I have found up to 50% of my patients with depression have a vitamin B12 deficiency. After supplementation, these patients’ symptoms improve to the point that we often can reduce or eliminate medication. Folic acid deficiency has been found among individuals with depression and linked to poor response to treatment.1 Higher serum levels of homocysteine—a consequence of low folic acid levels—are linked to increased risk of developing depression later in life, as well as higher risk of cardiovascular disease.2,3 Folate also can be used for enhancing treatment response to antidepressants by increasing production of neurotransmitters.2
Another factor to consider is methylenetetrahydrofolate reductase (MTHFR) variants. Approximately 20% of the population cannot methylate B vitamins because of a variation on the MTHFR gene.4,5 These patients are at increased risk for depression because they are unable to use B vitamins, which are essential in the synthesis of serotonin and dopamine. These patients do not respond to B12 and folate supplements. For these individuals, I recommend methylated products, which can be purchased online.
I have found these practices, as well as many of those listed in the editorial, are effective in treating depression and anxiety.
Lara Kain, PA-C, MPAS
Psychiatric Physician Assistant
Tidewater Psychotherapy Services
Virginia Beach, Virginia
References
1. Kaner G, Soylu M, Yüksel N, et al. Evaluation of nutritional status of patients with depression. Biomed Res Int. 2015;2015:521481. doi: 10.1155/2015/521481.
2. Seppälä J, Koponen H, Kautiainen H, et al. Association between vitamin B12 and melancholic depressive symptoms: a Finnish population-based study. BMC Psychiatry. 2013;13:145. doi: 10.1186/1471-244X-13-145.
3. Petridou ET, Kousoulis AA, Michelakos T, et al. Folate and B12 serum levels in association with depression in the aged: a systemic review and meta-analysis. Aging Ment Health. 2016;20(9):965-973.
4. Lynch B. MTHFR mutations and the conditions they cause. MTHFR.Net. http://mthfr.net/mthfr-mutations-and-the-conditions-they-cause/2011/09/07. Accessed February 16, 2017.
5. Eszlari N, Kovacs D, Petschner P, et al. Distinct effects of folate pathway genes MTHFR and MTHFD1L on ruminative response style: a potential risk mechanism for depression. Transl Psychiatry. 2016;6(3):e745. doi: 10.1038/tp.2016.19.
An honest perspective on Cannabis in therapy
I enjoyed Dr. Nasrallah’s editorial “Maddening therapies: How hallucinogens morphed into novel treatments” (From the
As a psychiatrist specializing in bipolar and psychotic disorders—as well as the founder and Board President of Doctors for Cannabis Regulation—I appreciate his reservations about the potential of Cannabis to trigger psychosis in vulnerable individuals. My reading of the literature is there is good evidence for marijuana as a trigger—not as a cause—of the disease. However, what is the evidence for hallucinogens?
Cannabis can have adverse effects on brain development, but it is not clear whether those effects are worse than those caused by alcohol. In the absence of any head-to-head studies, how can we proceed?
David L. Nathan, MD, DFAPA
Clinical Associate Professor
Rutgers Robert Wood Johnson Medical School
Director of Continuing Medical Education
Princeton HealthCare System
Princeton, New Jersey
Dr. Nasrallah responds
LSD can cause psychosis, paranoid delusions, and altered thinking in addition to vivid visual hallucinations in some individuals but not all, because vulnerability occurs on a spectrum. I postulate that the recently discovered inverse agonist of the serotonin 5-HT2A receptor, pimavanserin (FDA-approved for visual hallucinations and delusions of Parkinson’s disease psychosis), might be effective for LSD psychosis because this hallucinogen has a strong binding affinity to the serotonin 5-HT2A receptors.
Studies show that marijuana can induce apoptosis, which would adversely affect brain development. Patients with schizophrenia who abuse marijuana have a lower gray matter volume than those who do not abuse the drug, and both groups have lower gray matter volume than matched healthy controls. I strongly advise a pregnant woman against smoking marijuana because it could impair the fetus’s brain development.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Self-administering LSD: Solution or abuse
Dr. Nasrallah’s editorial (From the Editor,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Nasrallah responds
I am not aware of any systematic data about self-prescribed use of microdoses of LSD to reduce anxiety and depression. Among persons with anxiety and depression who have not had access to psychiatric care, self-medicating with agents such as alcohol, stimulants, ketamine, or LSD is regarded as substance abuse. It also is questionable whether people can determine which microdose of LSD to use. Finally, most drugs of abuse are not “pure,” and many are laced with potentially harmful contaminants.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Why medical psychiatry is vital for my patients
Dr. Paul Summergrad’s guest editorial “Medical psychiatry: The skill of integrating medical and psychiatric care” (
For me, the most inspiring sentence in Dr. Summergrad’s editorial was, “It is incumbent on us to pursue the medical differential of patients when we think it is needed, even if other physicians disagree.” I believe that this describes our job as physicians who specialize in psychiatry. To have a clinician of Dr. Summergrad’s stature write this was inspiring because it goes to the core of what more of us should do.
Ruth Myers, MD
Psychiatrist
The Community Circle PLLC
Burnsville, Minnesota
Lonely in the middle
Those of us who consider ourselves centrists are feeling pretty lonely right now. It seems everyone else, or at least all of the folks in Washington, have fled to the extreme political poles and left us to search for a patch of middle ground to stand on. It appears that without courageous leadership the silent majority has splintered and gravitated to the tails of what was once a bell-shaped curve.
One issue that might attract support from both sides of the political spectrum emerged from the Nov. 18, 2016, report from the United States Department of Agriculture that listed sweetened drinks as the No. 1 purchase by households participating in SNAP (“Foods Typically Purchased by Supplemental Nutrition Assistance Program (SNAP) Households”). The data reveal that households in this $74 billion program are spending 5% of their food dollars on soft drinks and almost 10% on sweetened beverages – soft drinks, fruit juices, energy drinks, and sweetened teas.
Several states (including Maine), dozens of other municipalities (most notably New York City under Mayor Michael Bloomberg), and a variety of medical groups have asked the USDA to reconsider its guidelines. Arguing that selectively banning certain items would generate too much red tape and be unfair to food stamp recipients, the department has been resistant to change (“In the Shopping Cart of a Food Stamp Household: Lots of Soda,” by Anahad O’Connor, New York Times, Jan. 13, 2017). One has to wonder how much of the department’s hesitancy is a reflection of the millions of dollars the food and beverage industries have invested in lobbying against change.
There are some ultra liberals (or progressives if you prefer) who feel that no one should be deprived of the privilege of buying unhealthy food simply because he or she is poor. At the other end of the spectrum there are conservatives who would prefer to scrap the whole SNAP program because it is a wasteful frill of the welfare state. However, I have to believe that the vast majority of folks on both sides of the political divide believe that feeding the less fortunate is important, but that spending their tax money on junk food and soft drinks is a bad idea.
While we still are learning that the causes of our obesity epidemic are far more complex than we once imagined, I think most people believe that soft drinks and junk food are playing a significant role – even though these same folks may have found it difficult to change their own behavior. According to the New York Times article mentioned above, Kevin Concannon, the USDA undersecretary for food, nutrition, and consumer services, said that instead of restricting food, the USDA has prioritized incentive programs to encourage participants to purchase more nutritious foods. However, a 2014 study of more than 19,000 SNAP recipients by Stanford researchers determined that an incentive program would not affect obesity rates, while banning sugary drinks would “significantly reduce obesity prevalence and type 2 diabetes incidence” (Health Aff. Jun 2014;33[6]:1032-9).
All we need now are a few courageous senators and congressmen to buck the soft drink lobby and bring this issue to the front burner. I have to believe that there are more than enough people, both liberals and conservatives, who would venture together on the middle ground and support removing sweetened drinks from the SNAP program. If I’m correct, it would be a refreshing example of some much needed legislative cooperation. Or, am I just a lonely dreamer longing for some company here in the center?
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Those of us who consider ourselves centrists are feeling pretty lonely right now. It seems everyone else, or at least all of the folks in Washington, have fled to the extreme political poles and left us to search for a patch of middle ground to stand on. It appears that without courageous leadership the silent majority has splintered and gravitated to the tails of what was once a bell-shaped curve.
One issue that might attract support from both sides of the political spectrum emerged from the Nov. 18, 2016, report from the United States Department of Agriculture that listed sweetened drinks as the No. 1 purchase by households participating in SNAP (“Foods Typically Purchased by Supplemental Nutrition Assistance Program (SNAP) Households”). The data reveal that households in this $74 billion program are spending 5% of their food dollars on soft drinks and almost 10% on sweetened beverages – soft drinks, fruit juices, energy drinks, and sweetened teas.
Several states (including Maine), dozens of other municipalities (most notably New York City under Mayor Michael Bloomberg), and a variety of medical groups have asked the USDA to reconsider its guidelines. Arguing that selectively banning certain items would generate too much red tape and be unfair to food stamp recipients, the department has been resistant to change (“In the Shopping Cart of a Food Stamp Household: Lots of Soda,” by Anahad O’Connor, New York Times, Jan. 13, 2017). One has to wonder how much of the department’s hesitancy is a reflection of the millions of dollars the food and beverage industries have invested in lobbying against change.
There are some ultra liberals (or progressives if you prefer) who feel that no one should be deprived of the privilege of buying unhealthy food simply because he or she is poor. At the other end of the spectrum there are conservatives who would prefer to scrap the whole SNAP program because it is a wasteful frill of the welfare state. However, I have to believe that the vast majority of folks on both sides of the political divide believe that feeding the less fortunate is important, but that spending their tax money on junk food and soft drinks is a bad idea.
While we still are learning that the causes of our obesity epidemic are far more complex than we once imagined, I think most people believe that soft drinks and junk food are playing a significant role – even though these same folks may have found it difficult to change their own behavior. According to the New York Times article mentioned above, Kevin Concannon, the USDA undersecretary for food, nutrition, and consumer services, said that instead of restricting food, the USDA has prioritized incentive programs to encourage participants to purchase more nutritious foods. However, a 2014 study of more than 19,000 SNAP recipients by Stanford researchers determined that an incentive program would not affect obesity rates, while banning sugary drinks would “significantly reduce obesity prevalence and type 2 diabetes incidence” (Health Aff. Jun 2014;33[6]:1032-9).
All we need now are a few courageous senators and congressmen to buck the soft drink lobby and bring this issue to the front burner. I have to believe that there are more than enough people, both liberals and conservatives, who would venture together on the middle ground and support removing sweetened drinks from the SNAP program. If I’m correct, it would be a refreshing example of some much needed legislative cooperation. Or, am I just a lonely dreamer longing for some company here in the center?
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Those of us who consider ourselves centrists are feeling pretty lonely right now. It seems everyone else, or at least all of the folks in Washington, have fled to the extreme political poles and left us to search for a patch of middle ground to stand on. It appears that without courageous leadership the silent majority has splintered and gravitated to the tails of what was once a bell-shaped curve.
One issue that might attract support from both sides of the political spectrum emerged from the Nov. 18, 2016, report from the United States Department of Agriculture that listed sweetened drinks as the No. 1 purchase by households participating in SNAP (“Foods Typically Purchased by Supplemental Nutrition Assistance Program (SNAP) Households”). The data reveal that households in this $74 billion program are spending 5% of their food dollars on soft drinks and almost 10% on sweetened beverages – soft drinks, fruit juices, energy drinks, and sweetened teas.
Several states (including Maine), dozens of other municipalities (most notably New York City under Mayor Michael Bloomberg), and a variety of medical groups have asked the USDA to reconsider its guidelines. Arguing that selectively banning certain items would generate too much red tape and be unfair to food stamp recipients, the department has been resistant to change (“In the Shopping Cart of a Food Stamp Household: Lots of Soda,” by Anahad O’Connor, New York Times, Jan. 13, 2017). One has to wonder how much of the department’s hesitancy is a reflection of the millions of dollars the food and beverage industries have invested in lobbying against change.
There are some ultra liberals (or progressives if you prefer) who feel that no one should be deprived of the privilege of buying unhealthy food simply because he or she is poor. At the other end of the spectrum there are conservatives who would prefer to scrap the whole SNAP program because it is a wasteful frill of the welfare state. However, I have to believe that the vast majority of folks on both sides of the political divide believe that feeding the less fortunate is important, but that spending their tax money on junk food and soft drinks is a bad idea.
While we still are learning that the causes of our obesity epidemic are far more complex than we once imagined, I think most people believe that soft drinks and junk food are playing a significant role – even though these same folks may have found it difficult to change their own behavior. According to the New York Times article mentioned above, Kevin Concannon, the USDA undersecretary for food, nutrition, and consumer services, said that instead of restricting food, the USDA has prioritized incentive programs to encourage participants to purchase more nutritious foods. However, a 2014 study of more than 19,000 SNAP recipients by Stanford researchers determined that an incentive program would not affect obesity rates, while banning sugary drinks would “significantly reduce obesity prevalence and type 2 diabetes incidence” (Health Aff. Jun 2014;33[6]:1032-9).
All we need now are a few courageous senators and congressmen to buck the soft drink lobby and bring this issue to the front burner. I have to believe that there are more than enough people, both liberals and conservatives, who would venture together on the middle ground and support removing sweetened drinks from the SNAP program. If I’m correct, it would be a refreshing example of some much needed legislative cooperation. Or, am I just a lonely dreamer longing for some company here in the center?
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The power of interaction – Supporting language and play development
Engaging caregivers in the management and treatment of early childhood developmental challenges is a critical component of effective intervention.1 Family-centered care helps to promote positive outcomes with early intervention (across developmental domains), and there’s increasing evidence that parent-training programs can be effective in promoting skill generalization and targeting core impairments in toddlers with autism.2
Furthermore, a 2014 randomized controlled trial revealed that individual Early Social Interaction (ESI) with home coaching using the SCERTS (Social Communication, Emotional Regulation, and Transactional Support) curriculum was associated with improvement of a range of child outcomes, compared with group ESI. The authors commented on the importance of individualized parent coaching in natural environments as a way to improve social components of communication and receptive language for toddlers with autism.3
For many parents and at-home caregivers, however, engaging in home-based and parent-delivered interventions can be overwhelming and anxiety-provoking, as well as complicated by other barriers (competing responsibilities, cultural beliefs, and so on). Additionally, these interventions can themselves be a source of stress for some families.
Case
Jake is a 3-year-old boy with a history of global developmental delays, who presents with particular struggles: relating his expressive communication, ability to engage peers in an age-appropriate manner, and capacity to self-regulate when frustrated. He and his family participated in an comprehensive autism diagnostic assessment. In reviewing the history and presentation, considerable challenges in the two core symptom domains that characterize an autism spectrum disorder were noted. A diagnosis of autism was provided, and treatment recommendations were discussed. “What can I do at home to help Jake learn?” his mother asked, noting that, with one-on-one attention, he does seem to demonstrate increased responsiveness, less use of echolalic language, and improved eye contact.
Discussion
To complement the autism services that Jake would likely qualify for through an Early Education program, in-home interaction and play to ensure skill development was discussed at length with his mother, who readily acknowledged her own care-giving struggles that, in part, are informed by her own mental health troubles.
We openly explored Jake’s mother’s perceived challenges in engaging with her son at home and developed initial recommendations for interaction that didn’t risk overwhelming her. We impressed upon Jake’s mother that, regardless of a child’s developmental profile, toddlers use play to learn and she can be Jake’s “favorite toy.” After all, “play is really the work of childhood,” as Fred Rogers said.
With all children, back-and-forth interactions serve as the foundation for future development. Using scaffolding techniques, parent support is a primary driver of “how children develop cognitive, language, social-emotional, and higher-level thinking skills.”4 In particular, the quality of parental interaction can influence language development, and, when considering children with autism, there are several recommendations for what parents can do to help build social, play, and communication skills.5 The Hanen Program is a great resource for providers and parents to learn more about parent engagement in early learning, the power of building communication through everyday experiences and attention to responsiveness, and the use of a child’s strengths to help make family interactions more meaningful and enjoyable. Additionally, the 2012 book “An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn” by Sally Rogers, PhD, et al. is an easy-to-read text for parents and caregivers for learning effective and practical strategies for engaging their child with autism.
With Jake and his mother, our team offered the following in-home recommendations:
- Try to keep interaction fun. Be enthusiastic when encouraging Jake’s attempts to communicate.
- Teach Jake song-gesture games. Encourage him to produce routine, predictable gestures to keep the song going (in imitation of mom). Using songs with vowel emphasis is encouraged (for example: Farmer in the Dell with “E I E I OOOOO”).
- Encourage Jake to produce responsive gestures in play and daily routines not involving songs, such as open arms to receive a ball, reaching to mom when about to be tickled, or having his arms up to have his shirt taken off.
- Capitalize on Jake’s natural desires and personal preferences. Activate a wind-up toy, let it deactivate, and then hand it to Jake.
- Initiate a familiar social game with Jake until he expresses pleasure. Then stop the game and wait for him to initiate continuance.
- Adapt the environment so that Jake will need to frequently request objects of assistance to make choices (place favorite toys in clear containers which may be difficult to open so that he must request help).
Clinical pearl
The United States Department of Education recognizes the importance of family engagement in a child’s early years. Their 2015 policy statement notes that “families are their children’s first and most important teachers, advocates, and nurturers. As such, strong family engagement is central – not supplemental – to the success of early childhood systems and programs that promote children’s healthy development, learning, and wellness.”
By recognizing this principle, primary care providers are in a position to talk with parents about how much youth learn through play and regular interaction. This especially holds true for children with autism. Developing in-home strategies to facilitate active engagement, even strategies that may not be a formal component of a home-based intervention program, are instrumental in fostering positive family- and child-based outcomes and wellness.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].
References
1. Annu Rev Clin Psychol. 2010;6:447-68.
2. J Autism Dev Disord. 2010 Sep;40(9):1045-56.
3. Pediatrics. 2014 Dec;134(6):1084-93.
4. JAMA Pediatr. 2016 Feb;170(2):112-3.
5. Child Dev. 2012 Sep-Oct;83(5):1762-74.
Engaging caregivers in the management and treatment of early childhood developmental challenges is a critical component of effective intervention.1 Family-centered care helps to promote positive outcomes with early intervention (across developmental domains), and there’s increasing evidence that parent-training programs can be effective in promoting skill generalization and targeting core impairments in toddlers with autism.2
Furthermore, a 2014 randomized controlled trial revealed that individual Early Social Interaction (ESI) with home coaching using the SCERTS (Social Communication, Emotional Regulation, and Transactional Support) curriculum was associated with improvement of a range of child outcomes, compared with group ESI. The authors commented on the importance of individualized parent coaching in natural environments as a way to improve social components of communication and receptive language for toddlers with autism.3
For many parents and at-home caregivers, however, engaging in home-based and parent-delivered interventions can be overwhelming and anxiety-provoking, as well as complicated by other barriers (competing responsibilities, cultural beliefs, and so on). Additionally, these interventions can themselves be a source of stress for some families.
Case
Jake is a 3-year-old boy with a history of global developmental delays, who presents with particular struggles: relating his expressive communication, ability to engage peers in an age-appropriate manner, and capacity to self-regulate when frustrated. He and his family participated in an comprehensive autism diagnostic assessment. In reviewing the history and presentation, considerable challenges in the two core symptom domains that characterize an autism spectrum disorder were noted. A diagnosis of autism was provided, and treatment recommendations were discussed. “What can I do at home to help Jake learn?” his mother asked, noting that, with one-on-one attention, he does seem to demonstrate increased responsiveness, less use of echolalic language, and improved eye contact.
Discussion
To complement the autism services that Jake would likely qualify for through an Early Education program, in-home interaction and play to ensure skill development was discussed at length with his mother, who readily acknowledged her own care-giving struggles that, in part, are informed by her own mental health troubles.
We openly explored Jake’s mother’s perceived challenges in engaging with her son at home and developed initial recommendations for interaction that didn’t risk overwhelming her. We impressed upon Jake’s mother that, regardless of a child’s developmental profile, toddlers use play to learn and she can be Jake’s “favorite toy.” After all, “play is really the work of childhood,” as Fred Rogers said.
With all children, back-and-forth interactions serve as the foundation for future development. Using scaffolding techniques, parent support is a primary driver of “how children develop cognitive, language, social-emotional, and higher-level thinking skills.”4 In particular, the quality of parental interaction can influence language development, and, when considering children with autism, there are several recommendations for what parents can do to help build social, play, and communication skills.5 The Hanen Program is a great resource for providers and parents to learn more about parent engagement in early learning, the power of building communication through everyday experiences and attention to responsiveness, and the use of a child’s strengths to help make family interactions more meaningful and enjoyable. Additionally, the 2012 book “An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn” by Sally Rogers, PhD, et al. is an easy-to-read text for parents and caregivers for learning effective and practical strategies for engaging their child with autism.
With Jake and his mother, our team offered the following in-home recommendations:
- Try to keep interaction fun. Be enthusiastic when encouraging Jake’s attempts to communicate.
- Teach Jake song-gesture games. Encourage him to produce routine, predictable gestures to keep the song going (in imitation of mom). Using songs with vowel emphasis is encouraged (for example: Farmer in the Dell with “E I E I OOOOO”).
- Encourage Jake to produce responsive gestures in play and daily routines not involving songs, such as open arms to receive a ball, reaching to mom when about to be tickled, or having his arms up to have his shirt taken off.
- Capitalize on Jake’s natural desires and personal preferences. Activate a wind-up toy, let it deactivate, and then hand it to Jake.
- Initiate a familiar social game with Jake until he expresses pleasure. Then stop the game and wait for him to initiate continuance.
- Adapt the environment so that Jake will need to frequently request objects of assistance to make choices (place favorite toys in clear containers which may be difficult to open so that he must request help).
Clinical pearl
The United States Department of Education recognizes the importance of family engagement in a child’s early years. Their 2015 policy statement notes that “families are their children’s first and most important teachers, advocates, and nurturers. As such, strong family engagement is central – not supplemental – to the success of early childhood systems and programs that promote children’s healthy development, learning, and wellness.”
By recognizing this principle, primary care providers are in a position to talk with parents about how much youth learn through play and regular interaction. This especially holds true for children with autism. Developing in-home strategies to facilitate active engagement, even strategies that may not be a formal component of a home-based intervention program, are instrumental in fostering positive family- and child-based outcomes and wellness.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].
References
1. Annu Rev Clin Psychol. 2010;6:447-68.
2. J Autism Dev Disord. 2010 Sep;40(9):1045-56.
3. Pediatrics. 2014 Dec;134(6):1084-93.
4. JAMA Pediatr. 2016 Feb;170(2):112-3.
5. Child Dev. 2012 Sep-Oct;83(5):1762-74.
Engaging caregivers in the management and treatment of early childhood developmental challenges is a critical component of effective intervention.1 Family-centered care helps to promote positive outcomes with early intervention (across developmental domains), and there’s increasing evidence that parent-training programs can be effective in promoting skill generalization and targeting core impairments in toddlers with autism.2
Furthermore, a 2014 randomized controlled trial revealed that individual Early Social Interaction (ESI) with home coaching using the SCERTS (Social Communication, Emotional Regulation, and Transactional Support) curriculum was associated with improvement of a range of child outcomes, compared with group ESI. The authors commented on the importance of individualized parent coaching in natural environments as a way to improve social components of communication and receptive language for toddlers with autism.3
For many parents and at-home caregivers, however, engaging in home-based and parent-delivered interventions can be overwhelming and anxiety-provoking, as well as complicated by other barriers (competing responsibilities, cultural beliefs, and so on). Additionally, these interventions can themselves be a source of stress for some families.
Case
Jake is a 3-year-old boy with a history of global developmental delays, who presents with particular struggles: relating his expressive communication, ability to engage peers in an age-appropriate manner, and capacity to self-regulate when frustrated. He and his family participated in an comprehensive autism diagnostic assessment. In reviewing the history and presentation, considerable challenges in the two core symptom domains that characterize an autism spectrum disorder were noted. A diagnosis of autism was provided, and treatment recommendations were discussed. “What can I do at home to help Jake learn?” his mother asked, noting that, with one-on-one attention, he does seem to demonstrate increased responsiveness, less use of echolalic language, and improved eye contact.
Discussion
To complement the autism services that Jake would likely qualify for through an Early Education program, in-home interaction and play to ensure skill development was discussed at length with his mother, who readily acknowledged her own care-giving struggles that, in part, are informed by her own mental health troubles.
We openly explored Jake’s mother’s perceived challenges in engaging with her son at home and developed initial recommendations for interaction that didn’t risk overwhelming her. We impressed upon Jake’s mother that, regardless of a child’s developmental profile, toddlers use play to learn and she can be Jake’s “favorite toy.” After all, “play is really the work of childhood,” as Fred Rogers said.
With all children, back-and-forth interactions serve as the foundation for future development. Using scaffolding techniques, parent support is a primary driver of “how children develop cognitive, language, social-emotional, and higher-level thinking skills.”4 In particular, the quality of parental interaction can influence language development, and, when considering children with autism, there are several recommendations for what parents can do to help build social, play, and communication skills.5 The Hanen Program is a great resource for providers and parents to learn more about parent engagement in early learning, the power of building communication through everyday experiences and attention to responsiveness, and the use of a child’s strengths to help make family interactions more meaningful and enjoyable. Additionally, the 2012 book “An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn” by Sally Rogers, PhD, et al. is an easy-to-read text for parents and caregivers for learning effective and practical strategies for engaging their child with autism.
With Jake and his mother, our team offered the following in-home recommendations:
- Try to keep interaction fun. Be enthusiastic when encouraging Jake’s attempts to communicate.
- Teach Jake song-gesture games. Encourage him to produce routine, predictable gestures to keep the song going (in imitation of mom). Using songs with vowel emphasis is encouraged (for example: Farmer in the Dell with “E I E I OOOOO”).
- Encourage Jake to produce responsive gestures in play and daily routines not involving songs, such as open arms to receive a ball, reaching to mom when about to be tickled, or having his arms up to have his shirt taken off.
- Capitalize on Jake’s natural desires and personal preferences. Activate a wind-up toy, let it deactivate, and then hand it to Jake.
- Initiate a familiar social game with Jake until he expresses pleasure. Then stop the game and wait for him to initiate continuance.
- Adapt the environment so that Jake will need to frequently request objects of assistance to make choices (place favorite toys in clear containers which may be difficult to open so that he must request help).
Clinical pearl
The United States Department of Education recognizes the importance of family engagement in a child’s early years. Their 2015 policy statement notes that “families are their children’s first and most important teachers, advocates, and nurturers. As such, strong family engagement is central – not supplemental – to the success of early childhood systems and programs that promote children’s healthy development, learning, and wellness.”
By recognizing this principle, primary care providers are in a position to talk with parents about how much youth learn through play and regular interaction. This especially holds true for children with autism. Developing in-home strategies to facilitate active engagement, even strategies that may not be a formal component of a home-based intervention program, are instrumental in fostering positive family- and child-based outcomes and wellness.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].
References
1. Annu Rev Clin Psychol. 2010;6:447-68.
2. J Autism Dev Disord. 2010 Sep;40(9):1045-56.
3. Pediatrics. 2014 Dec;134(6):1084-93.
4. JAMA Pediatr. 2016 Feb;170(2):112-3.
5. Child Dev. 2012 Sep-Oct;83(5):1762-74.
Update on malpractice trends
Question: Recent developments in malpractice include the following:
A. Severity and frequency rates continue to rise.
B. Apology laws appear to be very effective in reducing claims.
C. Litigation surrounds whether an assistant may obtain a patient’s informed consent on behalf of the doctor.
D. A and B.
E. A, B, and C.
Answer: C. Over the past decade, malpractice claims have in fact diminished, accompanied by a leveling or reduction in premiums.1 Rates have plummeted to roughly half of previous levels, averaging six claims per 100 doctors in 2016.
According to The Doctors Company, internists paid an average premium of $15,853, compared with an average of $19,900 in 2006, general surgeons $52,905 instead of $68,186, and obstetricians $72,999, a drop from $93,230. Even claims-plagued Florida’s Dade County has seen a dramatic drop in internist premiums by some $27,000, down to $47,707.2
The latest attack on MICRA, in 2015, concerned a wrongful death suit brought by a woman whose mother died from hemorrhagic complications related to Coumadin use following heart surgery.4 Her constitutional challenges included violation of equal protection, due process, and the right to a jury trial. But these were essentially all grounded on an entitlement to recover additional noneconomic damages sufficient to cover attorney fees. The trial court had reduced her $1 million noneconomic damages to $250,000 as required by MICRA. A California appeals court rejected her claim as being “contrary to many well-established legal principles.”
Disclosure of medical errors is a relative newcomer as an ethical and effective way of thwarting potential malpractice claims. Many states have enacted so-called “apology laws,” an outgrowth of the communication and resolution programs popularized by the Lexington (Ky.) VA Medical Center, University of Michigan Health System, Harvard’s affiliated institutions, and Colorado’s COPIC Insurance.
Apology laws disallow statements of sympathy from being admitted into evidence. In some cases, these laws may assist the physician. For example, the Ohio Supreme Court has ruled that a surgeon’s comments and alleged admission of guilt (“I take full responsibility for this” regarding accidentally sectioning the common bile duct) were properly shielded from discovery by the state’s apology statute, even though the incident took place before the law went into effect.5
However, apology laws do vary from state to state, and some do not shield admissions regarding causation of error or fault.
A recent study suggests that apology laws don’t work. A Vanderbilt University study published online used a unique dataset covering all malpractice claims for 90% of physicians practicing in a single specialty across the country.6 The findings revealed that, for physicians who do not regularly perform surgery, apology laws actually increased the probability of facing a lawsuit. For surgeons, apology laws do not have a substantial effect on the probability of facing a claim or the average payment made to resolve a claim.
The study’s authors concluded that “apology laws are not substitutes for specific physician disclosure programs, and that the experiences of these types of programs are not generalizable to the physician population at large. In other words, simply being allowed to apologize is not enough to reduce malpractice risk.”
In the informed consent arena, the latest development in the law revolves around whether a physician assistant, in lieu of the surgeon himself, can obtain informed consent from a patient.
In Shinal v. Toms,7 Megan Shinal underwent surgery to remove a craniopharyngioma, but it regrew and required re-exploration by Dr. Steven Toms. Dr. Toms testified that Ms. Shinal had agreed that he would determine during the surgery whether he should remove the entire tumor or perform a partial resection. The operation was complicated by a carotid artery perforation, which left the patient with impaired vision and ambulation.
The complaint asserted that Dr. Toms’s physician assistant, not Dr. Toms himself, had provided the actual discussion during the informed consent process, and thus the patient’s consent was invalid.
The jury was allowed to consider the information provided by the doctor’s support staff, and the Superior Court of Pennsylvania affirmed the validity of the patient’s consent, holding that consent is based on the scope of information relayed rather than the identity of the individual communicating the information. This carefully watched case is now on final appeal before the Supreme Court of Pennsylvania.
At a personal level, physicians dread the stress surrounding medical malpractice litigation. The process frontally attacks their competence and consumes much time and energy, notwithstanding there being little or no exposure of personal assets because of insurance protection. Virtually all doctors practice defensive medicine, which has been defined as “deviation from sound medical practice that is induced primarily by a threat of liability.”
At a societal level, defensive medicine is reported to add substantially to the nation’s medical bill. The figure tossed around is $12 billion to $50 billion a year, based mostly on estimates by the American Medical Association and an older study extrapolating potential Medicare savings from litigation over heart disease.8
A more recent report continues to emphasize the high cost of defensive medicine.9 Jackson Healthcare invited 138,686 physicians to participate in a confidential online survey to quantify the costs and impact of defensive medicine. More than 3,000 physicians spanning all states and medical specialties completed the survey; however, this represented only a 2.21% response rate.
The authors concluded that defensive medicine is a significant force driving the high cost of health care in the United States, and that physicians estimate the cost of defensive medicine to be in the $650 billion to $850 billion range, or between 26% and 34% of annual health care costs.
Skeptics question the way the profession defines defensive medicine, pointing out that malpractice concerns may not be the primary reason, as most interventions add some marginal value to patient care. There may also be conflicting motivations of physicians, such as financial or other personal rewards.
Above all, there is no acceptable method for measuring the extent and use of defensive medicine, and survey reports are apt to be misleading because of bias and the lack of controls and baseline data.
Looking ahead, what can we expect for malpractice law under the Trump administration? Tom Price, MD, a former Republican congressman from Georgia, is an orthopedic surgeon and the new secretary of the Department of Health & Human Services. He has previously spoken passionately about tort reforms such as defensive medicine, damage caps, health tribunals, and practice guidelines. Many states have already incorporated some of these measures into their own tort reforms – with salutary results. It remains to be seen whether HHS will deem any omnibus federal legislation necessary at this point.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials have been taken from my earlier columns in Internal Medicine News. For additional information, readers may contact the author at [email protected].
References
1. JAMA. 2014 Nov 26;312(20):2146-55.
2. “Malpractice 2017: Do We Need Reform?” Internal Medicine News, March 1, 2017, page 1.
3. Fein v. Permanente, 38 Cal.3d 137 (1985).
4. Chan v. Curran, 237 CA 4th 601 (2015).
5. Estate of Johnson v. Randall Smith, Inc., 135 Ohio St.3d 440 (2013).
6. Available at https://papers.ssrn.com/sol3/papers2.cfm?abstract_id=2883693.
7. Shinal v. Toms, 122 A. 3d 1066 (Pa. Super. Ct. 2015).
8. Q J Econ. (1996) 111 (2): 353-390.
9. Available at www.jacksonhealthcare.com/media/8968/defensivemedicine_ebook_final.pdf.
Question: Recent developments in malpractice include the following:
A. Severity and frequency rates continue to rise.
B. Apology laws appear to be very effective in reducing claims.
C. Litigation surrounds whether an assistant may obtain a patient’s informed consent on behalf of the doctor.
D. A and B.
E. A, B, and C.
Answer: C. Over the past decade, malpractice claims have in fact diminished, accompanied by a leveling or reduction in premiums.1 Rates have plummeted to roughly half of previous levels, averaging six claims per 100 doctors in 2016.
According to The Doctors Company, internists paid an average premium of $15,853, compared with an average of $19,900 in 2006, general surgeons $52,905 instead of $68,186, and obstetricians $72,999, a drop from $93,230. Even claims-plagued Florida’s Dade County has seen a dramatic drop in internist premiums by some $27,000, down to $47,707.2
The latest attack on MICRA, in 2015, concerned a wrongful death suit brought by a woman whose mother died from hemorrhagic complications related to Coumadin use following heart surgery.4 Her constitutional challenges included violation of equal protection, due process, and the right to a jury trial. But these were essentially all grounded on an entitlement to recover additional noneconomic damages sufficient to cover attorney fees. The trial court had reduced her $1 million noneconomic damages to $250,000 as required by MICRA. A California appeals court rejected her claim as being “contrary to many well-established legal principles.”
Disclosure of medical errors is a relative newcomer as an ethical and effective way of thwarting potential malpractice claims. Many states have enacted so-called “apology laws,” an outgrowth of the communication and resolution programs popularized by the Lexington (Ky.) VA Medical Center, University of Michigan Health System, Harvard’s affiliated institutions, and Colorado’s COPIC Insurance.
Apology laws disallow statements of sympathy from being admitted into evidence. In some cases, these laws may assist the physician. For example, the Ohio Supreme Court has ruled that a surgeon’s comments and alleged admission of guilt (“I take full responsibility for this” regarding accidentally sectioning the common bile duct) were properly shielded from discovery by the state’s apology statute, even though the incident took place before the law went into effect.5
However, apology laws do vary from state to state, and some do not shield admissions regarding causation of error or fault.
A recent study suggests that apology laws don’t work. A Vanderbilt University study published online used a unique dataset covering all malpractice claims for 90% of physicians practicing in a single specialty across the country.6 The findings revealed that, for physicians who do not regularly perform surgery, apology laws actually increased the probability of facing a lawsuit. For surgeons, apology laws do not have a substantial effect on the probability of facing a claim or the average payment made to resolve a claim.
The study’s authors concluded that “apology laws are not substitutes for specific physician disclosure programs, and that the experiences of these types of programs are not generalizable to the physician population at large. In other words, simply being allowed to apologize is not enough to reduce malpractice risk.”
In the informed consent arena, the latest development in the law revolves around whether a physician assistant, in lieu of the surgeon himself, can obtain informed consent from a patient.
In Shinal v. Toms,7 Megan Shinal underwent surgery to remove a craniopharyngioma, but it regrew and required re-exploration by Dr. Steven Toms. Dr. Toms testified that Ms. Shinal had agreed that he would determine during the surgery whether he should remove the entire tumor or perform a partial resection. The operation was complicated by a carotid artery perforation, which left the patient with impaired vision and ambulation.
The complaint asserted that Dr. Toms’s physician assistant, not Dr. Toms himself, had provided the actual discussion during the informed consent process, and thus the patient’s consent was invalid.
The jury was allowed to consider the information provided by the doctor’s support staff, and the Superior Court of Pennsylvania affirmed the validity of the patient’s consent, holding that consent is based on the scope of information relayed rather than the identity of the individual communicating the information. This carefully watched case is now on final appeal before the Supreme Court of Pennsylvania.
At a personal level, physicians dread the stress surrounding medical malpractice litigation. The process frontally attacks their competence and consumes much time and energy, notwithstanding there being little or no exposure of personal assets because of insurance protection. Virtually all doctors practice defensive medicine, which has been defined as “deviation from sound medical practice that is induced primarily by a threat of liability.”
At a societal level, defensive medicine is reported to add substantially to the nation’s medical bill. The figure tossed around is $12 billion to $50 billion a year, based mostly on estimates by the American Medical Association and an older study extrapolating potential Medicare savings from litigation over heart disease.8
A more recent report continues to emphasize the high cost of defensive medicine.9 Jackson Healthcare invited 138,686 physicians to participate in a confidential online survey to quantify the costs and impact of defensive medicine. More than 3,000 physicians spanning all states and medical specialties completed the survey; however, this represented only a 2.21% response rate.
The authors concluded that defensive medicine is a significant force driving the high cost of health care in the United States, and that physicians estimate the cost of defensive medicine to be in the $650 billion to $850 billion range, or between 26% and 34% of annual health care costs.
Skeptics question the way the profession defines defensive medicine, pointing out that malpractice concerns may not be the primary reason, as most interventions add some marginal value to patient care. There may also be conflicting motivations of physicians, such as financial or other personal rewards.
Above all, there is no acceptable method for measuring the extent and use of defensive medicine, and survey reports are apt to be misleading because of bias and the lack of controls and baseline data.
Looking ahead, what can we expect for malpractice law under the Trump administration? Tom Price, MD, a former Republican congressman from Georgia, is an orthopedic surgeon and the new secretary of the Department of Health & Human Services. He has previously spoken passionately about tort reforms such as defensive medicine, damage caps, health tribunals, and practice guidelines. Many states have already incorporated some of these measures into their own tort reforms – with salutary results. It remains to be seen whether HHS will deem any omnibus federal legislation necessary at this point.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials have been taken from my earlier columns in Internal Medicine News. For additional information, readers may contact the author at [email protected].
References
1. JAMA. 2014 Nov 26;312(20):2146-55.
2. “Malpractice 2017: Do We Need Reform?” Internal Medicine News, March 1, 2017, page 1.
3. Fein v. Permanente, 38 Cal.3d 137 (1985).
4. Chan v. Curran, 237 CA 4th 601 (2015).
5. Estate of Johnson v. Randall Smith, Inc., 135 Ohio St.3d 440 (2013).
6. Available at https://papers.ssrn.com/sol3/papers2.cfm?abstract_id=2883693.
7. Shinal v. Toms, 122 A. 3d 1066 (Pa. Super. Ct. 2015).
8. Q J Econ. (1996) 111 (2): 353-390.
9. Available at www.jacksonhealthcare.com/media/8968/defensivemedicine_ebook_final.pdf.
Question: Recent developments in malpractice include the following:
A. Severity and frequency rates continue to rise.
B. Apology laws appear to be very effective in reducing claims.
C. Litigation surrounds whether an assistant may obtain a patient’s informed consent on behalf of the doctor.
D. A and B.
E. A, B, and C.
Answer: C. Over the past decade, malpractice claims have in fact diminished, accompanied by a leveling or reduction in premiums.1 Rates have plummeted to roughly half of previous levels, averaging six claims per 100 doctors in 2016.
According to The Doctors Company, internists paid an average premium of $15,853, compared with an average of $19,900 in 2006, general surgeons $52,905 instead of $68,186, and obstetricians $72,999, a drop from $93,230. Even claims-plagued Florida’s Dade County has seen a dramatic drop in internist premiums by some $27,000, down to $47,707.2
The latest attack on MICRA, in 2015, concerned a wrongful death suit brought by a woman whose mother died from hemorrhagic complications related to Coumadin use following heart surgery.4 Her constitutional challenges included violation of equal protection, due process, and the right to a jury trial. But these were essentially all grounded on an entitlement to recover additional noneconomic damages sufficient to cover attorney fees. The trial court had reduced her $1 million noneconomic damages to $250,000 as required by MICRA. A California appeals court rejected her claim as being “contrary to many well-established legal principles.”
Disclosure of medical errors is a relative newcomer as an ethical and effective way of thwarting potential malpractice claims. Many states have enacted so-called “apology laws,” an outgrowth of the communication and resolution programs popularized by the Lexington (Ky.) VA Medical Center, University of Michigan Health System, Harvard’s affiliated institutions, and Colorado’s COPIC Insurance.
Apology laws disallow statements of sympathy from being admitted into evidence. In some cases, these laws may assist the physician. For example, the Ohio Supreme Court has ruled that a surgeon’s comments and alleged admission of guilt (“I take full responsibility for this” regarding accidentally sectioning the common bile duct) were properly shielded from discovery by the state’s apology statute, even though the incident took place before the law went into effect.5
However, apology laws do vary from state to state, and some do not shield admissions regarding causation of error or fault.
A recent study suggests that apology laws don’t work. A Vanderbilt University study published online used a unique dataset covering all malpractice claims for 90% of physicians practicing in a single specialty across the country.6 The findings revealed that, for physicians who do not regularly perform surgery, apology laws actually increased the probability of facing a lawsuit. For surgeons, apology laws do not have a substantial effect on the probability of facing a claim or the average payment made to resolve a claim.
The study’s authors concluded that “apology laws are not substitutes for specific physician disclosure programs, and that the experiences of these types of programs are not generalizable to the physician population at large. In other words, simply being allowed to apologize is not enough to reduce malpractice risk.”
In the informed consent arena, the latest development in the law revolves around whether a physician assistant, in lieu of the surgeon himself, can obtain informed consent from a patient.
In Shinal v. Toms,7 Megan Shinal underwent surgery to remove a craniopharyngioma, but it regrew and required re-exploration by Dr. Steven Toms. Dr. Toms testified that Ms. Shinal had agreed that he would determine during the surgery whether he should remove the entire tumor or perform a partial resection. The operation was complicated by a carotid artery perforation, which left the patient with impaired vision and ambulation.
The complaint asserted that Dr. Toms’s physician assistant, not Dr. Toms himself, had provided the actual discussion during the informed consent process, and thus the patient’s consent was invalid.
The jury was allowed to consider the information provided by the doctor’s support staff, and the Superior Court of Pennsylvania affirmed the validity of the patient’s consent, holding that consent is based on the scope of information relayed rather than the identity of the individual communicating the information. This carefully watched case is now on final appeal before the Supreme Court of Pennsylvania.
At a personal level, physicians dread the stress surrounding medical malpractice litigation. The process frontally attacks their competence and consumes much time and energy, notwithstanding there being little or no exposure of personal assets because of insurance protection. Virtually all doctors practice defensive medicine, which has been defined as “deviation from sound medical practice that is induced primarily by a threat of liability.”
At a societal level, defensive medicine is reported to add substantially to the nation’s medical bill. The figure tossed around is $12 billion to $50 billion a year, based mostly on estimates by the American Medical Association and an older study extrapolating potential Medicare savings from litigation over heart disease.8
A more recent report continues to emphasize the high cost of defensive medicine.9 Jackson Healthcare invited 138,686 physicians to participate in a confidential online survey to quantify the costs and impact of defensive medicine. More than 3,000 physicians spanning all states and medical specialties completed the survey; however, this represented only a 2.21% response rate.
The authors concluded that defensive medicine is a significant force driving the high cost of health care in the United States, and that physicians estimate the cost of defensive medicine to be in the $650 billion to $850 billion range, or between 26% and 34% of annual health care costs.
Skeptics question the way the profession defines defensive medicine, pointing out that malpractice concerns may not be the primary reason, as most interventions add some marginal value to patient care. There may also be conflicting motivations of physicians, such as financial or other personal rewards.
Above all, there is no acceptable method for measuring the extent and use of defensive medicine, and survey reports are apt to be misleading because of bias and the lack of controls and baseline data.
Looking ahead, what can we expect for malpractice law under the Trump administration? Tom Price, MD, a former Republican congressman from Georgia, is an orthopedic surgeon and the new secretary of the Department of Health & Human Services. He has previously spoken passionately about tort reforms such as defensive medicine, damage caps, health tribunals, and practice guidelines. Many states have already incorporated some of these measures into their own tort reforms – with salutary results. It remains to be seen whether HHS will deem any omnibus federal legislation necessary at this point.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the materials have been taken from my earlier columns in Internal Medicine News. For additional information, readers may contact the author at [email protected].
References
1. JAMA. 2014 Nov 26;312(20):2146-55.
2. “Malpractice 2017: Do We Need Reform?” Internal Medicine News, March 1, 2017, page 1.
3. Fein v. Permanente, 38 Cal.3d 137 (1985).
4. Chan v. Curran, 237 CA 4th 601 (2015).
5. Estate of Johnson v. Randall Smith, Inc., 135 Ohio St.3d 440 (2013).
6. Available at https://papers.ssrn.com/sol3/papers2.cfm?abstract_id=2883693.
7. Shinal v. Toms, 122 A. 3d 1066 (Pa. Super. Ct. 2015).
8. Q J Econ. (1996) 111 (2): 353-390.
9. Available at www.jacksonhealthcare.com/media/8968/defensivemedicine_ebook_final.pdf.
Hold your breath
“Exercising my ‘reasoned judgment,’ I have no doubt that the right to a climate system capable of sustaining human life is fundamental to a free and ordered society.”
– U.S. District Judge Ann Aiken in Kelsey Cascadia Rose Juliana vs. United States of America, et al.
In many areas of the world, the simple act of breathing has become hazardous to people’s health.
According to the World Health Organization, more people die every day from air pollution than from HIV/AIDS, tuberculosis, and road injuries combined. In China, more than 1 million deaths annually are linked to polluted air (76/100,000); in India the number of deaths is more than 600,000 annually (49/100,000); and in the United States, that figure comes to more than 38,000 (12/100,000).
And yet, nonpolluting, alternative options – such as sun and wind power – are readily available.
Dirty air is visible on a hot summer day – when, mixed with other substances, it forms smog. Higher temperatures can then speed up the chemical reactions that form smog. We breathe in that polluted air, especially on days when the air is stagnant or there is temperature inversion.
The health effects of climate change
Black carbon found in air pollution leads to drug-resistant bacteria and alters antibiotic tolerance.1 The pollution also is associated with multiple cancers: lung, liver, ovarian, and, possibly, breast.2,3,4,5 It causes inflammation linked to the development of coronary artery disease (seen even in children!) and plaque formation leading to heart attacks and cardiac arrhythmias – including atrial fibrillation. Air pollution causes, triggers, or worsens respiratory illnesses – chronic obstructive pulmonary disease, emphysema, asthma, infections – and is responsible for lifelong diminished lung volume in children (a reason families are leaving Beijing.) Exponentially increased rates of autism are linked to bad air quality, as are autoimmune diseases, which also are on the rise.6,7 Polluted air causes brain inflammation – living near sources of air pollution increases the risk of dementia – and other neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s, and amyotrophic lateral sclerosis.8 The blood brain barrier protects the brain from most foreign matter, but particulate matter, especially ultrafine particulate matter of less than 1 mcm such as magnetite, can cross directly into the brain via the olfactory nerve. (Magnetite has been identified in the brain tissue of residents living in areas where the substance is produced as a result of industrial waste.) While particulate matter of 2.5 mcmis measured in the United States, ultrafine particulate matter is not.
Psychiatric symptoms and chronic psychiatric disorders also are associated with polluted air: On days with poor air quality, a statistically significant increase is seen in suicide threats and visits to emergency departments for panic attacks.9,10
A rise in aggression occurs when there are abnormally high temperatures and significant changes in rainfall. More assaults, murders, suicides, domestic violence, and child abuse can be expected, and a rise in unrest around the world should come as no surprise.
As a consequence of increased CO2 in the atmosphere, temperatures have already risen by 2° F: Sixteen of the hottest years on record have occurred in the last 17 years, with 2016 as the hottest year ever recorded. In Iraq and Kuwait, the temperature last summer reached 129.2° F.
We are experiencing more frequent and extreme weather events, chronic climate conditions, and the cascading disruption of ecosystems. Drought and sea level rise are leading to physical and psychological impacts – both direct and indirect. Some regions of the world have become destabilized, triggering migrations and the refugee crisis.
Along with these psychological impacts, CO2 affects cognition: A recent study by the Harvard School of Public Health, Boston, shows that the indoor levels of CO2 to which American workers typically are exposed impair cognitive functioning, particularly in the areas of strategic thinking, information processing, and crisis management.11
What do we do about it?
As mental health professionals, we know that aggression can be overt or passive (from inaction). Overwhelming evidence shows harm to public health from burning fossil fuels, and yet, though we are making progress, resistance still exists in the transition to clean, renewable energy critical for the health of our families and communities. When political will is what stands between us and getting back on a path to breathing clean air, how can inaction be understood as anything but an act of aggression?
This issue has reached U.S. courts: In a landmark case, 21 youths aged 9-20 years represented by “Our Children’s Trust” are suing the U.S. government in the Oregon U.S. District Court for failure to act on climate. The case, heard by Judge Ann Aiken, is now headed to trial.
All of us have a duty to collectively, repeatedly, and forcefully call on policy makers to take action.
That leads me to what we can do as doctors. In this effort to quickly transition to safe, clean renewable energy, we all have a role to play. The notion that we can’t do anything as individuals is no more credible than saying “my vote doesn’t matter.” Just as our actions as voters in a democracy demonstrate the collective civic responsibility we owe one another, so too do our actions on climate. As global citizens, all actions that we take to help us live within the planet’s means are opportunities to restore balance.
What we do collectively drives markets and determines the social norms that powerfully influence the decisions of others – sometimes even unconsciously.
As doctors, we have a unique role to play in the places we work – urging hospitals, clinics, academic centers, and other organizations and facilities to lead by example, become role models for energy efficiency, and choose clean renewable energy sources over the ones harming our health. We can start by choosing wind and solar to power our homes and influencing others to do the same.
We are the voices because this is a health message.
Dr. Van Susteren is a practicing general and forensic psychiatrist in Washington. She serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. Dr. Van Susteren is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. She also founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.
References
1. Environ Microbiol. 2017 Feb 14. doi: 10.1111/1462-2920.13686.
2. Environ Health Perspect. 2017 Mar;125[3]:378-84.
3. J Hepatol. 2015;63[6]:1397-1404.
4. J Toxicol Environ Health A. 2012;75[3]:174-82.
5. Environ Health Perspect. 2012 Nov; 118[11]:1578-83.
6. J Child Psychol Psychiatry. 2016; 57[3]:271-92.
7. Curr Opin Pediatr. 2010;22[2]219-25.
8. Inhal Toxicol. 2008;20[5]:499-506.
9. J Psychiatr Res. 2015 Mar;62:130-5.
10. Schizophr Res. 2016 Oct 5. doi: 10.1016/j.schres.2016.10.003.
11. Environ Health Perspect. 2016 Jun;124[6]:805-12.
“Exercising my ‘reasoned judgment,’ I have no doubt that the right to a climate system capable of sustaining human life is fundamental to a free and ordered society.”
– U.S. District Judge Ann Aiken in Kelsey Cascadia Rose Juliana vs. United States of America, et al.
In many areas of the world, the simple act of breathing has become hazardous to people’s health.
According to the World Health Organization, more people die every day from air pollution than from HIV/AIDS, tuberculosis, and road injuries combined. In China, more than 1 million deaths annually are linked to polluted air (76/100,000); in India the number of deaths is more than 600,000 annually (49/100,000); and in the United States, that figure comes to more than 38,000 (12/100,000).
And yet, nonpolluting, alternative options – such as sun and wind power – are readily available.
Dirty air is visible on a hot summer day – when, mixed with other substances, it forms smog. Higher temperatures can then speed up the chemical reactions that form smog. We breathe in that polluted air, especially on days when the air is stagnant or there is temperature inversion.
The health effects of climate change
Black carbon found in air pollution leads to drug-resistant bacteria and alters antibiotic tolerance.1 The pollution also is associated with multiple cancers: lung, liver, ovarian, and, possibly, breast.2,3,4,5 It causes inflammation linked to the development of coronary artery disease (seen even in children!) and plaque formation leading to heart attacks and cardiac arrhythmias – including atrial fibrillation. Air pollution causes, triggers, or worsens respiratory illnesses – chronic obstructive pulmonary disease, emphysema, asthma, infections – and is responsible for lifelong diminished lung volume in children (a reason families are leaving Beijing.) Exponentially increased rates of autism are linked to bad air quality, as are autoimmune diseases, which also are on the rise.6,7 Polluted air causes brain inflammation – living near sources of air pollution increases the risk of dementia – and other neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s, and amyotrophic lateral sclerosis.8 The blood brain barrier protects the brain from most foreign matter, but particulate matter, especially ultrafine particulate matter of less than 1 mcm such as magnetite, can cross directly into the brain via the olfactory nerve. (Magnetite has been identified in the brain tissue of residents living in areas where the substance is produced as a result of industrial waste.) While particulate matter of 2.5 mcmis measured in the United States, ultrafine particulate matter is not.
Psychiatric symptoms and chronic psychiatric disorders also are associated with polluted air: On days with poor air quality, a statistically significant increase is seen in suicide threats and visits to emergency departments for panic attacks.9,10
A rise in aggression occurs when there are abnormally high temperatures and significant changes in rainfall. More assaults, murders, suicides, domestic violence, and child abuse can be expected, and a rise in unrest around the world should come as no surprise.
As a consequence of increased CO2 in the atmosphere, temperatures have already risen by 2° F: Sixteen of the hottest years on record have occurred in the last 17 years, with 2016 as the hottest year ever recorded. In Iraq and Kuwait, the temperature last summer reached 129.2° F.
We are experiencing more frequent and extreme weather events, chronic climate conditions, and the cascading disruption of ecosystems. Drought and sea level rise are leading to physical and psychological impacts – both direct and indirect. Some regions of the world have become destabilized, triggering migrations and the refugee crisis.
Along with these psychological impacts, CO2 affects cognition: A recent study by the Harvard School of Public Health, Boston, shows that the indoor levels of CO2 to which American workers typically are exposed impair cognitive functioning, particularly in the areas of strategic thinking, information processing, and crisis management.11
What do we do about it?
As mental health professionals, we know that aggression can be overt or passive (from inaction). Overwhelming evidence shows harm to public health from burning fossil fuels, and yet, though we are making progress, resistance still exists in the transition to clean, renewable energy critical for the health of our families and communities. When political will is what stands between us and getting back on a path to breathing clean air, how can inaction be understood as anything but an act of aggression?
This issue has reached U.S. courts: In a landmark case, 21 youths aged 9-20 years represented by “Our Children’s Trust” are suing the U.S. government in the Oregon U.S. District Court for failure to act on climate. The case, heard by Judge Ann Aiken, is now headed to trial.
All of us have a duty to collectively, repeatedly, and forcefully call on policy makers to take action.
That leads me to what we can do as doctors. In this effort to quickly transition to safe, clean renewable energy, we all have a role to play. The notion that we can’t do anything as individuals is no more credible than saying “my vote doesn’t matter.” Just as our actions as voters in a democracy demonstrate the collective civic responsibility we owe one another, so too do our actions on climate. As global citizens, all actions that we take to help us live within the planet’s means are opportunities to restore balance.
What we do collectively drives markets and determines the social norms that powerfully influence the decisions of others – sometimes even unconsciously.
As doctors, we have a unique role to play in the places we work – urging hospitals, clinics, academic centers, and other organizations and facilities to lead by example, become role models for energy efficiency, and choose clean renewable energy sources over the ones harming our health. We can start by choosing wind and solar to power our homes and influencing others to do the same.
We are the voices because this is a health message.
Dr. Van Susteren is a practicing general and forensic psychiatrist in Washington. She serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. Dr. Van Susteren is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. She also founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.
References
1. Environ Microbiol. 2017 Feb 14. doi: 10.1111/1462-2920.13686.
2. Environ Health Perspect. 2017 Mar;125[3]:378-84.
3. J Hepatol. 2015;63[6]:1397-1404.
4. J Toxicol Environ Health A. 2012;75[3]:174-82.
5. Environ Health Perspect. 2012 Nov; 118[11]:1578-83.
6. J Child Psychol Psychiatry. 2016; 57[3]:271-92.
7. Curr Opin Pediatr. 2010;22[2]219-25.
8. Inhal Toxicol. 2008;20[5]:499-506.
9. J Psychiatr Res. 2015 Mar;62:130-5.
10. Schizophr Res. 2016 Oct 5. doi: 10.1016/j.schres.2016.10.003.
11. Environ Health Perspect. 2016 Jun;124[6]:805-12.
“Exercising my ‘reasoned judgment,’ I have no doubt that the right to a climate system capable of sustaining human life is fundamental to a free and ordered society.”
– U.S. District Judge Ann Aiken in Kelsey Cascadia Rose Juliana vs. United States of America, et al.
In many areas of the world, the simple act of breathing has become hazardous to people’s health.
According to the World Health Organization, more people die every day from air pollution than from HIV/AIDS, tuberculosis, and road injuries combined. In China, more than 1 million deaths annually are linked to polluted air (76/100,000); in India the number of deaths is more than 600,000 annually (49/100,000); and in the United States, that figure comes to more than 38,000 (12/100,000).
And yet, nonpolluting, alternative options – such as sun and wind power – are readily available.
Dirty air is visible on a hot summer day – when, mixed with other substances, it forms smog. Higher temperatures can then speed up the chemical reactions that form smog. We breathe in that polluted air, especially on days when the air is stagnant or there is temperature inversion.
The health effects of climate change
Black carbon found in air pollution leads to drug-resistant bacteria and alters antibiotic tolerance.1 The pollution also is associated with multiple cancers: lung, liver, ovarian, and, possibly, breast.2,3,4,5 It causes inflammation linked to the development of coronary artery disease (seen even in children!) and plaque formation leading to heart attacks and cardiac arrhythmias – including atrial fibrillation. Air pollution causes, triggers, or worsens respiratory illnesses – chronic obstructive pulmonary disease, emphysema, asthma, infections – and is responsible for lifelong diminished lung volume in children (a reason families are leaving Beijing.) Exponentially increased rates of autism are linked to bad air quality, as are autoimmune diseases, which also are on the rise.6,7 Polluted air causes brain inflammation – living near sources of air pollution increases the risk of dementia – and other neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s, and amyotrophic lateral sclerosis.8 The blood brain barrier protects the brain from most foreign matter, but particulate matter, especially ultrafine particulate matter of less than 1 mcm such as magnetite, can cross directly into the brain via the olfactory nerve. (Magnetite has been identified in the brain tissue of residents living in areas where the substance is produced as a result of industrial waste.) While particulate matter of 2.5 mcmis measured in the United States, ultrafine particulate matter is not.
Psychiatric symptoms and chronic psychiatric disorders also are associated with polluted air: On days with poor air quality, a statistically significant increase is seen in suicide threats and visits to emergency departments for panic attacks.9,10
A rise in aggression occurs when there are abnormally high temperatures and significant changes in rainfall. More assaults, murders, suicides, domestic violence, and child abuse can be expected, and a rise in unrest around the world should come as no surprise.
As a consequence of increased CO2 in the atmosphere, temperatures have already risen by 2° F: Sixteen of the hottest years on record have occurred in the last 17 years, with 2016 as the hottest year ever recorded. In Iraq and Kuwait, the temperature last summer reached 129.2° F.
We are experiencing more frequent and extreme weather events, chronic climate conditions, and the cascading disruption of ecosystems. Drought and sea level rise are leading to physical and psychological impacts – both direct and indirect. Some regions of the world have become destabilized, triggering migrations and the refugee crisis.
Along with these psychological impacts, CO2 affects cognition: A recent study by the Harvard School of Public Health, Boston, shows that the indoor levels of CO2 to which American workers typically are exposed impair cognitive functioning, particularly in the areas of strategic thinking, information processing, and crisis management.11
What do we do about it?
As mental health professionals, we know that aggression can be overt or passive (from inaction). Overwhelming evidence shows harm to public health from burning fossil fuels, and yet, though we are making progress, resistance still exists in the transition to clean, renewable energy critical for the health of our families and communities. When political will is what stands between us and getting back on a path to breathing clean air, how can inaction be understood as anything but an act of aggression?
This issue has reached U.S. courts: In a landmark case, 21 youths aged 9-20 years represented by “Our Children’s Trust” are suing the U.S. government in the Oregon U.S. District Court for failure to act on climate. The case, heard by Judge Ann Aiken, is now headed to trial.
All of us have a duty to collectively, repeatedly, and forcefully call on policy makers to take action.
That leads me to what we can do as doctors. In this effort to quickly transition to safe, clean renewable energy, we all have a role to play. The notion that we can’t do anything as individuals is no more credible than saying “my vote doesn’t matter.” Just as our actions as voters in a democracy demonstrate the collective civic responsibility we owe one another, so too do our actions on climate. As global citizens, all actions that we take to help us live within the planet’s means are opportunities to restore balance.
What we do collectively drives markets and determines the social norms that powerfully influence the decisions of others – sometimes even unconsciously.
As doctors, we have a unique role to play in the places we work – urging hospitals, clinics, academic centers, and other organizations and facilities to lead by example, become role models for energy efficiency, and choose clean renewable energy sources over the ones harming our health. We can start by choosing wind and solar to power our homes and influencing others to do the same.
We are the voices because this is a health message.
Dr. Van Susteren is a practicing general and forensic psychiatrist in Washington. She serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. Dr. Van Susteren is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. She also founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.
References
1. Environ Microbiol. 2017 Feb 14. doi: 10.1111/1462-2920.13686.
2. Environ Health Perspect. 2017 Mar;125[3]:378-84.
3. J Hepatol. 2015;63[6]:1397-1404.
4. J Toxicol Environ Health A. 2012;75[3]:174-82.
5. Environ Health Perspect. 2012 Nov; 118[11]:1578-83.
6. J Child Psychol Psychiatry. 2016; 57[3]:271-92.
7. Curr Opin Pediatr. 2010;22[2]219-25.
8. Inhal Toxicol. 2008;20[5]:499-506.
9. J Psychiatr Res. 2015 Mar;62:130-5.
10. Schizophr Res. 2016 Oct 5. doi: 10.1016/j.schres.2016.10.003.
11. Environ Health Perspect. 2016 Jun;124[6]:805-12.
MACRA: Not going away any time soon
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.