Commentary

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.”¹ Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.² In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.^3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.⁵ Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.⁶

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.⁷ Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”⁸ Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.⁹ But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.¹⁰ Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.¹¹

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.¹² This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.¹³

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.¹⁴ And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.¹⁵ This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.¹⁶

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­[email protected].

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.”¹ Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.² In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.^3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.⁵ Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.⁶

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.⁷ Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”⁸ Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.⁹ But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.¹⁰ Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.¹¹

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.¹² This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.¹³

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.¹⁴ And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.¹⁵ This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.¹⁶

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­[email protected].

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.”¹ Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.² In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.^3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.⁵ Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.⁶

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.⁷ Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”⁸ Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.⁹ But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.¹⁰ Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.¹¹

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.¹² This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.¹³

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.¹⁴ And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.¹⁵ This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.¹⁶

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­[email protected].

In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.

According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.

By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period. 

In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.

EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction. 

In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.

According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.

By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period. 

In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.

EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction. 

In this issue of EM, EP-toxicologists Rama Rao, MD, and Lewis Nelson, MD, review the salient features of the current opioid epidemic in the United States. The authors differentiate this epidemic from prior patterns of heroin and opioid abuse partly by the clinical features that now make timely diagnosis and treatment in the ED more difficult.

According to the CDC, between 2000 and 2015, the number of opioid overdose deaths in this country quadrupled to half a million, or 91 deaths a day (http://bit.ly/2jEOHfs). We know now that prescription opioids have been driving this 15-year increase. Since 1999, both the amount of opioids prescribed and the number of opioid deaths in the US have quadrupled. Ironically, during that same period, the amount of pain reported has not changed overall (http://bit.ly/2jEOHfs). In 2015 alone, opioids were involved with 33,091 deaths, of which more than 15,000 were due to prescription opioid overdoses—most commonly methadone, oxycodone, and hydrocodone (http://bit.ly/2jZ1TfO and http://bit.ly/2iwagAI). Adding to the misery has been a sharp increase in deaths due to heroin since 2010, and a similar increase in deaths due to fentanyl, tramadol, and other synthetics since 2013. Currently, more than 1,000 people are treated in EDs each day for misusing prescription opioids (http://bit.ly/2iwagAI).

The road to the current epidemic began to be paved with good intentions in the late 1990s when, soon after the FDA approved the controlled-release form of oxycodone (Oxycontin), the American Pain Society introduced the phrase “pain as the fifth vital sign.” In 1999, the Department of Veterans Affairs embraced the statement, as did other organizations. The Joint Commission standards for pain management in 2001 stated “pain is assessed in all patients” (all was dropped in 2009) and contained a passing reference to pain as the fifth vital sign. In 2012, CMS added to its ED performance core measures timely pain treatment for long bone fractures, emphasizing parenteral medications.

By 2010, the problems created by emphasizing effective pain management had become evident, and measures began to be introduced to restrict the prescribing and availability of pharmaceutical opioids. The restrictions sent many patients to EDs seeking pain meds. Others sought substitutes on the street and ultimately ended up in EDs as overdoses from very potent synthetics. Many EPs began to limit opioid prescriptions to 3 days for acute painful conditions, though not all patients were able to obtain follow-up appointments with PCPs within that time period. 

In April 2016, the Joint Commission issued a statement claiming it was not responsible for “pain as the fifth vital sign” or for suggesting that pain be treated with opioids. In June 2016, the AMA urged dropping “pain-as-the-fifth-vital-sign” policies, and in 2014, CMS modified its core measure emphasis on parenteral medication in the timely treatment of long bone fractures. But the damage has been done, leaving many people requiring help managing their pain and others suffering the consequences of opioid dependence.

EPs must continue to deal with victims of overdoses without denying pain treatment to those with acute, acute-on-chronic, and recurrent pain. Increased use of effective non-opioid pain meds such as NSAIDs may help, although not everyone can tolerate them and there are long-term risks. For large, overcrowded, urban EDs where treatment of pain is not always timely or consistent, 24/7 ED pain management teams working with EPs could be a tremendous asset, just as 24/7 ED pharmacists have proven to be. Until both effective pain treatment and the resultant opioid dependence and overdoses can be successfully addressed, regulatory agencies should deemphasize, without completely eliminating, pain treatment questions in scoring patient satisfaction. 

The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.

Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.

Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.

Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.

Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.

Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.

Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.

Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.

“The Pill” – as it is often referred to – was introduced in May of 1950.¹ At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.¹ Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.

Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.

Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.

©areeya_ann/Thinkstock.com

References

1. Can Fam Physician. 2012 Dec;58(12):e757–60.

2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.

3. Obstet Gynecol. 2009;114:1428-31.

4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.

5. Pediatr Rev. 2008;29(11);386-97.

6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.

7. Obstet Gynecol. 2005 Sep;106(3):492-501.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.

“The Pill” – as it is often referred to – was introduced in May of 1950.¹ At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.¹ Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.

Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.

Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.

©areeya_ann/Thinkstock.com

References

1. Can Fam Physician. 2012 Dec;58(12):e757–60.

2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.

3. Obstet Gynecol. 2009;114:1428-31.

4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.

5. Pediatr Rev. 2008;29(11);386-97.

6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.

7. Obstet Gynecol. 2005 Sep;106(3):492-501.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.

“The Pill” – as it is often referred to – was introduced in May of 1950.¹ At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.¹ Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.

Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.

Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.

©areeya_ann/Thinkstock.com

References

1. Can Fam Physician. 2012 Dec;58(12):e757–60.

2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.

3. Obstet Gynecol. 2009;114:1428-31.

4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.

5. Pediatr Rev. 2008;29(11);386-97.

6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.

7. Obstet Gynecol. 2005 Sep;106(3):492-501.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.

The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”

Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:

• 1: a unified body of individuals: as
  a: state, commonwealth
  b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
  c: an interacting population of various kinds of individuals (as species) in a common location
  d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
  e: a group linked by a common policy
  f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
  g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community)
• 2: society at large
• 3a: joint ownership or participation (community of goods)
  b: common character: likeness (community of interests)
  c: social activity: fellowship d: a social state or condition
  d: a social state or condition

There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.

What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.

Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.

Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.

A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.

Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.

At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.

There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.

Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.

One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.

The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”

Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:

• 1: a unified body of individuals: as
  a: state, commonwealth
  b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
  c: an interacting population of various kinds of individuals (as species) in a common location
  d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
  e: a group linked by a common policy
  f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
  g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community)
• 2: society at large
• 3a: joint ownership or participation (community of goods)
  b: common character: likeness (community of interests)
  c: social activity: fellowship d: a social state or condition
  d: a social state or condition

There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.

What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.

Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.

Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.

A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.

Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.

At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.

There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.

Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.

One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.

The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”

Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:

• 1: a unified body of individuals: as
  a: state, commonwealth
  b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
  c: an interacting population of various kinds of individuals (as species) in a common location
  d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
  e: a group linked by a common policy
  f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
  g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community)
• 2: society at large
• 3a: joint ownership or participation (community of goods)
  b: common character: likeness (community of interests)
  c: social activity: fellowship d: a social state or condition
  d: a social state or condition

There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.

What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.

Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.

Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.

A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.

Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.

At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.

There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.

Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.

One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.

Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.

However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.

My years training in internal medicine were full of patients with neuro­psychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.

The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.¹ At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.

What is medical psychiatry, and why is it relevant now?

There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.

Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.

Whether due to infectious, auto­immune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.

An illustrative case

I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.²

Medicine is our calling

Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-d-aspartate receptor antibodies as well as other causes. Pursuing this understanding is important from another perspective. As we consider other potential mechanisms for onset of psychiatric illness (eg, inflammation), our understanding of the mechanisms associated with general medical conditions may provide unexpected insight into the etiology of psychiatric illnesses where no general medical cause has been found. No other physician specialists are as attuned to the nuances of psychiatric illnesses, their typical and atypical presentations as psychiatrists. It is incumbent on us to pursue the medical differential of patients when we think it is needed, even if other physicians disagree.

Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.

At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 1977¹—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”

Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.

However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.

My years training in internal medicine were full of patients with neuro­psychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.

The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.¹ At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.

What is medical psychiatry, and why is it relevant now?

There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.

Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.

Whether due to infectious, auto­immune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.

An illustrative case

I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.²

Medicine is our calling

Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-d-aspartate receptor antibodies as well as other causes. Pursuing this understanding is important from another perspective. As we consider other potential mechanisms for onset of psychiatric illness (eg, inflammation), our understanding of the mechanisms associated with general medical conditions may provide unexpected insight into the etiology of psychiatric illnesses where no general medical cause has been found. No other physician specialists are as attuned to the nuances of psychiatric illnesses, their typical and atypical presentations as psychiatrists. It is incumbent on us to pursue the medical differential of patients when we think it is needed, even if other physicians disagree.

Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.

At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 1977¹—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”

Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.

However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.

My years training in internal medicine were full of patients with neuro­psychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.

The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.¹ At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.

What is medical psychiatry, and why is it relevant now?

There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.

Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.

Whether due to infectious, auto­immune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.

An illustrative case

I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.²

Medicine is our calling

Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-d-aspartate receptor antibodies as well as other causes. Pursuing this understanding is important from another perspective. As we consider other potential mechanisms for onset of psychiatric illness (eg, inflammation), our understanding of the mechanisms associated with general medical conditions may provide unexpected insight into the etiology of psychiatric illnesses where no general medical cause has been found. No other physician specialists are as attuned to the nuances of psychiatric illnesses, their typical and atypical presentations as psychiatrists. It is incumbent on us to pursue the medical differential of patients when we think it is needed, even if other physicians disagree.

Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.

At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 1977¹—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”

Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews, Current Psychiatry, December 2016, p. 18-21,24-28,32). I believe the application of the innovative and scholarly message of self-compassion will not only be a boon to patients and the public but also to psychiatrists and mental health clinicians. Why? We, psychiatrists, seem to be experiencing a rising and epidemic rate of burnout, and self-compassion can help us to stop blaming ourselves for being unable to do our best when the system inhibits us. In turn, if we help our own well-being, we will be better able to help our patients.

H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin

Dr. Warren responds

We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.¹

The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,² discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,³ stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”

Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan

Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews, Current Psychiatry, December 2016, p. 18-21,24-28,32). I believe the application of the innovative and scholarly message of self-compassion will not only be a boon to patients and the public but also to psychiatrists and mental health clinicians. Why? We, psychiatrists, seem to be experiencing a rising and epidemic rate of burnout, and self-compassion can help us to stop blaming ourselves for being unable to do our best when the system inhibits us. In turn, if we help our own well-being, we will be better able to help our patients.

H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin

Dr. Warren responds

We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.¹

The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,² discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,³ stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”

Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan

Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews, Current Psychiatry, December 2016, p. 18-21,24-28,32). I believe the application of the innovative and scholarly message of self-compassion will not only be a boon to patients and the public but also to psychiatrists and mental health clinicians. Why? We, psychiatrists, seem to be experiencing a rising and epidemic rate of burnout, and self-compassion can help us to stop blaming ourselves for being unable to do our best when the system inhibits us. In turn, if we help our own well-being, we will be better able to help our patients.

H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin

Dr. Warren responds

We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.¹

The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,² discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,³ stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”

Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan