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How will Donald Trump change health care?
Much speculation has already been written on what a Trump administration may look like, but comparatively little has been said about the potential impact of that administration on physicians, hospitals, and patients. While details will obviously not be available for some time, some early generalizations are possible, based on the position paper President-elect Donald Trump issued in March and the statements he has made since then.
One of Mr. Trump’s earliest and most repeated pledges was the one to repeal the Affordable Care Act and replace it with “something fantastic.” A repeal would be welcome news to many physicians, even without any idea of what its “fantastic” replacement might be; but Trump has hedged already. In mid-November, he told the Wall Street Journal that Obamacare would be “amended, or repealed and replaced,” which introduces considerable wiggle room.
In an interview with CNN, Mr. Trump indicated he would keep the individual mandate; but the next day, he tweeted – and then reiterated in his position paper – that he would remove the mandate and install a “backstop for preexisting conditions.” In the 1990s, when a few states tried to prohibit discrimination based on preexisting conditions without a corresponding mandate, premiums increased precipitously, driving away healthy customers, forcing insurers to stop selling policies in those states, and demonstrating that one cannot work without the other. Perhaps a more-informed Mr. Trump will come to see this.
Other proposals have been more enlightened. Mr. Trump has said that he favors portability of health insurance from state to state. In theory, this will introduce more competition into the system and drive premiums down. He has also proposed making health insurance premiums fully tax deductible for individuals, as they are now for businesses, further lowering premium costs.
He has proposed expanding the health savings account program, making contributions tax free, cumulative, and part of a patient’s estate. I have been a fan of HSAs since their inception because they eliminate the insurance “middleman,” which is good for physicians as well as for patients, who are more aware of what services they are receiving and what they are paying for them. Along the same lines, he has called for price transparency, so that patients can shop for the best prices for procedures and examinations, which now vary widely from one hospital or clinic to another.
Another good idea, in my opinion, is the removal of barriers to the sale of cheaper foreign-manufactured drugs in this country. Such barriers have kept drug prices higher here than anywhere else; consumers should be able to import their medications, from Canada, India, and elsewhere, as long as they are similarly safe and effective. Mr. Trump has also said that Medicare should be able to negotiate drug prices, which should have been true from the outset. The savings, particularly where biologics and other expensive new drugs are concerned, could be significant, since Medicare frequently sets the standard for prices in the industry. He also would raise the Medicare eligibility age, which I believe is a good idea as well.
Less inspired is his proposal to turn over administration of Medicaid to the states, supported by federal block grants. This plan does not take into account that Medicaid, an expensive and inefficient program with a narrow network of doctors, desperately needs an overhaul. Simply expanding it, and handing over full responsibility to the states, is not a viable solution, in my opinion.
Mr. Trump’s position paper also contains the dubious assumption that enforcing immigration laws will significantly decrease health care costs. Sealing the Southern border, he reasons, will help hospitals overburdened by the costs of services they provide to illegal immigrants who can’t pay for them and curtail the burgeoning heroin trade and its associated medical costs. There is little evidence to support either assumption – or even that the border can be effectively sealed in the first place.
So Mr. Trump has a health care plan, of sorts. How it will look by Inauguration Day, and what portion will be implemented, remains to be seen.
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].
Much speculation has already been written on what a Trump administration may look like, but comparatively little has been said about the potential impact of that administration on physicians, hospitals, and patients. While details will obviously not be available for some time, some early generalizations are possible, based on the position paper President-elect Donald Trump issued in March and the statements he has made since then.
One of Mr. Trump’s earliest and most repeated pledges was the one to repeal the Affordable Care Act and replace it with “something fantastic.” A repeal would be welcome news to many physicians, even without any idea of what its “fantastic” replacement might be; but Trump has hedged already. In mid-November, he told the Wall Street Journal that Obamacare would be “amended, or repealed and replaced,” which introduces considerable wiggle room.
In an interview with CNN, Mr. Trump indicated he would keep the individual mandate; but the next day, he tweeted – and then reiterated in his position paper – that he would remove the mandate and install a “backstop for preexisting conditions.” In the 1990s, when a few states tried to prohibit discrimination based on preexisting conditions without a corresponding mandate, premiums increased precipitously, driving away healthy customers, forcing insurers to stop selling policies in those states, and demonstrating that one cannot work without the other. Perhaps a more-informed Mr. Trump will come to see this.
Other proposals have been more enlightened. Mr. Trump has said that he favors portability of health insurance from state to state. In theory, this will introduce more competition into the system and drive premiums down. He has also proposed making health insurance premiums fully tax deductible for individuals, as they are now for businesses, further lowering premium costs.
He has proposed expanding the health savings account program, making contributions tax free, cumulative, and part of a patient’s estate. I have been a fan of HSAs since their inception because they eliminate the insurance “middleman,” which is good for physicians as well as for patients, who are more aware of what services they are receiving and what they are paying for them. Along the same lines, he has called for price transparency, so that patients can shop for the best prices for procedures and examinations, which now vary widely from one hospital or clinic to another.
Another good idea, in my opinion, is the removal of barriers to the sale of cheaper foreign-manufactured drugs in this country. Such barriers have kept drug prices higher here than anywhere else; consumers should be able to import their medications, from Canada, India, and elsewhere, as long as they are similarly safe and effective. Mr. Trump has also said that Medicare should be able to negotiate drug prices, which should have been true from the outset. The savings, particularly where biologics and other expensive new drugs are concerned, could be significant, since Medicare frequently sets the standard for prices in the industry. He also would raise the Medicare eligibility age, which I believe is a good idea as well.
Less inspired is his proposal to turn over administration of Medicaid to the states, supported by federal block grants. This plan does not take into account that Medicaid, an expensive and inefficient program with a narrow network of doctors, desperately needs an overhaul. Simply expanding it, and handing over full responsibility to the states, is not a viable solution, in my opinion.
Mr. Trump’s position paper also contains the dubious assumption that enforcing immigration laws will significantly decrease health care costs. Sealing the Southern border, he reasons, will help hospitals overburdened by the costs of services they provide to illegal immigrants who can’t pay for them and curtail the burgeoning heroin trade and its associated medical costs. There is little evidence to support either assumption – or even that the border can be effectively sealed in the first place.
So Mr. Trump has a health care plan, of sorts. How it will look by Inauguration Day, and what portion will be implemented, remains to be seen.
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].
Much speculation has already been written on what a Trump administration may look like, but comparatively little has been said about the potential impact of that administration on physicians, hospitals, and patients. While details will obviously not be available for some time, some early generalizations are possible, based on the position paper President-elect Donald Trump issued in March and the statements he has made since then.
One of Mr. Trump’s earliest and most repeated pledges was the one to repeal the Affordable Care Act and replace it with “something fantastic.” A repeal would be welcome news to many physicians, even without any idea of what its “fantastic” replacement might be; but Trump has hedged already. In mid-November, he told the Wall Street Journal that Obamacare would be “amended, or repealed and replaced,” which introduces considerable wiggle room.
In an interview with CNN, Mr. Trump indicated he would keep the individual mandate; but the next day, he tweeted – and then reiterated in his position paper – that he would remove the mandate and install a “backstop for preexisting conditions.” In the 1990s, when a few states tried to prohibit discrimination based on preexisting conditions without a corresponding mandate, premiums increased precipitously, driving away healthy customers, forcing insurers to stop selling policies in those states, and demonstrating that one cannot work without the other. Perhaps a more-informed Mr. Trump will come to see this.
Other proposals have been more enlightened. Mr. Trump has said that he favors portability of health insurance from state to state. In theory, this will introduce more competition into the system and drive premiums down. He has also proposed making health insurance premiums fully tax deductible for individuals, as they are now for businesses, further lowering premium costs.
He has proposed expanding the health savings account program, making contributions tax free, cumulative, and part of a patient’s estate. I have been a fan of HSAs since their inception because they eliminate the insurance “middleman,” which is good for physicians as well as for patients, who are more aware of what services they are receiving and what they are paying for them. Along the same lines, he has called for price transparency, so that patients can shop for the best prices for procedures and examinations, which now vary widely from one hospital or clinic to another.
Another good idea, in my opinion, is the removal of barriers to the sale of cheaper foreign-manufactured drugs in this country. Such barriers have kept drug prices higher here than anywhere else; consumers should be able to import their medications, from Canada, India, and elsewhere, as long as they are similarly safe and effective. Mr. Trump has also said that Medicare should be able to negotiate drug prices, which should have been true from the outset. The savings, particularly where biologics and other expensive new drugs are concerned, could be significant, since Medicare frequently sets the standard for prices in the industry. He also would raise the Medicare eligibility age, which I believe is a good idea as well.
Less inspired is his proposal to turn over administration of Medicaid to the states, supported by federal block grants. This plan does not take into account that Medicaid, an expensive and inefficient program with a narrow network of doctors, desperately needs an overhaul. Simply expanding it, and handing over full responsibility to the states, is not a viable solution, in my opinion.
Mr. Trump’s position paper also contains the dubious assumption that enforcing immigration laws will significantly decrease health care costs. Sealing the Southern border, he reasons, will help hospitals overburdened by the costs of services they provide to illegal immigrants who can’t pay for them and curtail the burgeoning heroin trade and its associated medical costs. There is little evidence to support either assumption – or even that the border can be effectively sealed in the first place.
So Mr. Trump has a health care plan, of sorts. How it will look by Inauguration Day, and what portion will be implemented, remains to be seen.
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 complex genetic landscape of AML
A unifying genetic basis has been sought to explain the complex and heterogeneous nature of myeloid neoplasms since before Janet Rowley’s quinacrine banding discovered the Philadelphia chromosome (Nature. 1973;243[5405]:290-3). In the decades following that discovery, groundbreaking work has uncovered new chromosomal abnormalities, new gene fusions, new recurrent mutations – often with prognostic implications, but rarely with therapeutic ones.
The recent work by Elli Papaemmanuil, PhD, of Memorial Sloan Kettering Cancer Center, New York, and her colleagues reaffirms the genetic heterogeneity of AML based on molecular profiling of patients from three large European trials. Yet the most insightful aspect of this reclassification is not just the detail of the genetic resolution but the realization that, even within a gene such as NRAS, the genetic background for acquisition of a codon 12/13 mutation is mutually exclusive with clones where NRAS codon 61 occurs.
When speaking with relapsed patients, I often say that, while we are very good at cutting down trees in AML, we still have not done very well with getting rid of the roots. Admittedly, this metaphor grossly oversimplifies cancer stem cell biology, but it gets at the real importance of the work by Dr. Papaemmanuil and her colleagues. The interactions of gene mutations such as NPM1 and DNMT3A are not uncommon and their co-mutation in isolation has an intermediate prognosis. The clonal acquisition of a codon 12/13 mutation in NRAS seems to result in a more favorable prognosis – lending to the likelihood that the tumor is simply more chemosensitive. In contrast, the acquisition of FLT3-ITD by the NPM1/DNMT3A co-mutant clone results in a very poor prognosis likely due to chemoresistance.
The real power of this study’s findings is the potential for building a toolbox of agents to push against the innate clonal selection and force the “tree” to grow in a direction that is detrimental to its survival. One could consider using FLT3 inhibitors in the wild-type setting of a genetic background primed towards FLT3-ITD evolution to prevent this resistant outgrowth. Of course, such an approach needs to be studied first in a laboratory setting, but similar therapeutic strategies have been applied to BRAF in melanoma. Peter Nowell urged “controlling the evolutionary process in tumors before it reaches the late stage,” and this new ordinal understanding of AML may help to do just that.
[email protected]
On Twitter @thedoctorisvin
A unifying genetic basis has been sought to explain the complex and heterogeneous nature of myeloid neoplasms since before Janet Rowley’s quinacrine banding discovered the Philadelphia chromosome (Nature. 1973;243[5405]:290-3). In the decades following that discovery, groundbreaking work has uncovered new chromosomal abnormalities, new gene fusions, new recurrent mutations – often with prognostic implications, but rarely with therapeutic ones.
The recent work by Elli Papaemmanuil, PhD, of Memorial Sloan Kettering Cancer Center, New York, and her colleagues reaffirms the genetic heterogeneity of AML based on molecular profiling of patients from three large European trials. Yet the most insightful aspect of this reclassification is not just the detail of the genetic resolution but the realization that, even within a gene such as NRAS, the genetic background for acquisition of a codon 12/13 mutation is mutually exclusive with clones where NRAS codon 61 occurs.
When speaking with relapsed patients, I often say that, while we are very good at cutting down trees in AML, we still have not done very well with getting rid of the roots. Admittedly, this metaphor grossly oversimplifies cancer stem cell biology, but it gets at the real importance of the work by Dr. Papaemmanuil and her colleagues. The interactions of gene mutations such as NPM1 and DNMT3A are not uncommon and their co-mutation in isolation has an intermediate prognosis. The clonal acquisition of a codon 12/13 mutation in NRAS seems to result in a more favorable prognosis – lending to the likelihood that the tumor is simply more chemosensitive. In contrast, the acquisition of FLT3-ITD by the NPM1/DNMT3A co-mutant clone results in a very poor prognosis likely due to chemoresistance.
The real power of this study’s findings is the potential for building a toolbox of agents to push against the innate clonal selection and force the “tree” to grow in a direction that is detrimental to its survival. One could consider using FLT3 inhibitors in the wild-type setting of a genetic background primed towards FLT3-ITD evolution to prevent this resistant outgrowth. Of course, such an approach needs to be studied first in a laboratory setting, but similar therapeutic strategies have been applied to BRAF in melanoma. Peter Nowell urged “controlling the evolutionary process in tumors before it reaches the late stage,” and this new ordinal understanding of AML may help to do just that.
[email protected]
On Twitter @thedoctorisvin
A unifying genetic basis has been sought to explain the complex and heterogeneous nature of myeloid neoplasms since before Janet Rowley’s quinacrine banding discovered the Philadelphia chromosome (Nature. 1973;243[5405]:290-3). In the decades following that discovery, groundbreaking work has uncovered new chromosomal abnormalities, new gene fusions, new recurrent mutations – often with prognostic implications, but rarely with therapeutic ones.
The recent work by Elli Papaemmanuil, PhD, of Memorial Sloan Kettering Cancer Center, New York, and her colleagues reaffirms the genetic heterogeneity of AML based on molecular profiling of patients from three large European trials. Yet the most insightful aspect of this reclassification is not just the detail of the genetic resolution but the realization that, even within a gene such as NRAS, the genetic background for acquisition of a codon 12/13 mutation is mutually exclusive with clones where NRAS codon 61 occurs.
When speaking with relapsed patients, I often say that, while we are very good at cutting down trees in AML, we still have not done very well with getting rid of the roots. Admittedly, this metaphor grossly oversimplifies cancer stem cell biology, but it gets at the real importance of the work by Dr. Papaemmanuil and her colleagues. The interactions of gene mutations such as NPM1 and DNMT3A are not uncommon and their co-mutation in isolation has an intermediate prognosis. The clonal acquisition of a codon 12/13 mutation in NRAS seems to result in a more favorable prognosis – lending to the likelihood that the tumor is simply more chemosensitive. In contrast, the acquisition of FLT3-ITD by the NPM1/DNMT3A co-mutant clone results in a very poor prognosis likely due to chemoresistance.
The real power of this study’s findings is the potential for building a toolbox of agents to push against the innate clonal selection and force the “tree” to grow in a direction that is detrimental to its survival. One could consider using FLT3 inhibitors in the wild-type setting of a genetic background primed towards FLT3-ITD evolution to prevent this resistant outgrowth. Of course, such an approach needs to be studied first in a laboratory setting, but similar therapeutic strategies have been applied to BRAF in melanoma. Peter Nowell urged “controlling the evolutionary process in tumors before it reaches the late stage,” and this new ordinal understanding of AML may help to do just that.
[email protected]
On Twitter @thedoctorisvin
Two Truths About Substance Use and One Hope Unite Us
Given the recently concluded election season, it may seem that there are few things Americans have in common or can agree on. And although I did not conduct a poll or hold a debate, I suspect that a majority of those who work in the VA, DoD, or PHS would agree that one of the most serious and prevalent public health problems facing those in federal service and in the country at large is the epidemic of substance use disorders (SUDs).
In 2013 the National Institute on Drug Abuse reported that “members of the armed forces are not immune to the substance use problems that affect the rest of society.”1 Although active-duty service members use illicit drugs less frequently, as would be expected given the potential disciplinary consequences, the prevalence of problematic use of the legal ones—tobacco, alcohol, and particularly prescription medications—is greater among individuals in the military.
Substance use disorders affect every sector of federal health care practice from military pediatrics and VA pathology to PHS primary care. Reflecting this ubiquity, in this special substance use disorders issue of Federal Practitioner we focus on several distinctive and significant efforts of health care practitioners who care for patients with SUDs. All of medicine is becoming more interdisciplinary, multidisciplinary, and team-based, but perhaps no other area has as long a legacy or as intrinsic a need for team approaches to care than does the diagnosis and treatment of SUDs. We see this need reflected in this issue’s articles authored by clinical pharmacists, nurse practitioners, physicians, and physicians in training, among others.
Prescription opioids are the subject of 3 articles from VA practitioners: a look at primary, secondary, and tertiary forms of prevention of morbidity and mortality from substance use. Pharmacists at the Salt Lake City VAMC studied the epidemiology of veterans seen in emergency departments who were given naloxone for unintentional opioid overdoses. A second article reviews the distribution of naloxone at a VA facility, providing an example of a successful implementation of the VA Overdose Education and Naloxone Distribution network (OEND)—the only national naloxone program in any health care system.
Even farther upstream in the effort to reduce the large doses of opioids that are directly related to overdose deaths is an article on an outpatient opioid-monitoring clinic that uses evidence-based medicine to diagnose patients with opioid use disorder. Research in the VHA showed that in a 4-year period of study, “the risk of overdose deaths was directly related to the maximum prescribed daily dose of opioid medication.”2
Our colleagues in active duty underscore the challenge that new and emerging substances present not only to federal regulatory agencies like the Drug Enforcement Agency, but also to state and local law enforcement agencies. When spice (synthetic cannabinoids) and bath salts (synthetic cathinones) first appeared, no drug tests were available to detect them. Technically not illegal in the early phase of their use, they became the perfect and popular drugs of young service men and women.3
Tragically, history has shown 2 truths about humans and the use of psychoactive products. The first is that as soon as one product is outlawed, creative chemists invent another mind-altering product. Practical education regarding the latest of these underground drugs, kratom, which threatens our service members, is introduced in this issue.
The second truth is that nearly every drug that is originally prescribed for legitimate medical reasons is eventually misused for a nonmedical purpose and can lead to SUDs. By the time the medical community realizes the dark side of the medication, many individuals have already developed a disorder, and sadly some have died.
One of the oldest classes of drugs that brings both relief and torment to human culture—opioid medication—is now the scourge of postmodern society. Our well-intentioned efforts to succor real pain for patients using prescription opioids have paved a road to hellish suffering for others. A recent study examined whether a resurgence of heroin use among veterans—the likes of which has not been seen since the Vietnam era—was associated with the nonmedical use of yes, prescribed narcotics. The same study found that solely having chronic pain was not correlated with the use of heroin.4 This finding offers the hope that practitioners and patients together can learn to treat chronic pain with opioids in selected patients, which can be life-restoring in appropriate cases for limited duration, safely and responsibly while avoiding and minimizing the death dealing blow of opioid use disorders.
In this issue, we also feature a discussion with Karen Drexler, MD, the newly appointed Mental Health Program Director, Addictive Disorders. Dr. Drexler expertly discusses a wide array of SUD subjects relevant to Federal Practitioner readers, including the approach to patients using medical marijuana in the VA, the 2016 VA/DoD Clinical Practice Guidelines, and an inside view of the challenges and successes of VA SUD programs, from the vantage point of the new leader of these critical initiatives.
Finally, astute readers may notice the editorial attempts to avoid use of the value-laden terms addiction and substance abuse. Instead, the less stigmatizing terminology of DSM-5 is employed, which jettisons the problematic abuse and dependence distinction for the unitary domain of SUDs. This approach is not just a change in semantics but as thought leaders have shown, a real and meaningful comprehension of the role of words in shaping culture.5 The VA as a health care entity is moving to adopt better scientific framing of SUDs as a salient step toward a recovery-oriented program.
In the coming months, we intend to expand our coverage of this public health crisis, and we invite readers who care every day for patients wrestling with SUDs for control of their health and very lives, to educate, advocate for resources for active-duty service personnel and veterans, and share innovative efforts to turn the tide toward recovery.
1. National Institute on Drug Abuse. DrugFacts—substance abuse in the military. https://www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military. Revised March 2013. Accessed October 18, 2016.
2. Loeffler G, Hurst D, Penn A, Yung K. Spice, bath salts, and the U.S. military: the emergence of synthetic cannabinoid receptor agonists and cathinones in the U.S. Armed Forces. Mil Med. 2012;177(9):1041-1048.
3. Banerjee G, Edelman EJ, Barry DT, et al. Non-medical use of prescription opioids is associated with heroin initiation among U.S. veterans: a prospective cohort study. Addiction. 2016;111(11):2021-2031.
4. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid-related deaths. JAMA. 2011;305(13):1315-1321.
5. Botticelli MP, Koh HK. Changing the language of addiction. JAMA. 2016;316(13):1361-1362.
Given the recently concluded election season, it may seem that there are few things Americans have in common or can agree on. And although I did not conduct a poll or hold a debate, I suspect that a majority of those who work in the VA, DoD, or PHS would agree that one of the most serious and prevalent public health problems facing those in federal service and in the country at large is the epidemic of substance use disorders (SUDs).
In 2013 the National Institute on Drug Abuse reported that “members of the armed forces are not immune to the substance use problems that affect the rest of society.”1 Although active-duty service members use illicit drugs less frequently, as would be expected given the potential disciplinary consequences, the prevalence of problematic use of the legal ones—tobacco, alcohol, and particularly prescription medications—is greater among individuals in the military.
Substance use disorders affect every sector of federal health care practice from military pediatrics and VA pathology to PHS primary care. Reflecting this ubiquity, in this special substance use disorders issue of Federal Practitioner we focus on several distinctive and significant efforts of health care practitioners who care for patients with SUDs. All of medicine is becoming more interdisciplinary, multidisciplinary, and team-based, but perhaps no other area has as long a legacy or as intrinsic a need for team approaches to care than does the diagnosis and treatment of SUDs. We see this need reflected in this issue’s articles authored by clinical pharmacists, nurse practitioners, physicians, and physicians in training, among others.
Prescription opioids are the subject of 3 articles from VA practitioners: a look at primary, secondary, and tertiary forms of prevention of morbidity and mortality from substance use. Pharmacists at the Salt Lake City VAMC studied the epidemiology of veterans seen in emergency departments who were given naloxone for unintentional opioid overdoses. A second article reviews the distribution of naloxone at a VA facility, providing an example of a successful implementation of the VA Overdose Education and Naloxone Distribution network (OEND)—the only national naloxone program in any health care system.
Even farther upstream in the effort to reduce the large doses of opioids that are directly related to overdose deaths is an article on an outpatient opioid-monitoring clinic that uses evidence-based medicine to diagnose patients with opioid use disorder. Research in the VHA showed that in a 4-year period of study, “the risk of overdose deaths was directly related to the maximum prescribed daily dose of opioid medication.”2
Our colleagues in active duty underscore the challenge that new and emerging substances present not only to federal regulatory agencies like the Drug Enforcement Agency, but also to state and local law enforcement agencies. When spice (synthetic cannabinoids) and bath salts (synthetic cathinones) first appeared, no drug tests were available to detect them. Technically not illegal in the early phase of their use, they became the perfect and popular drugs of young service men and women.3
Tragically, history has shown 2 truths about humans and the use of psychoactive products. The first is that as soon as one product is outlawed, creative chemists invent another mind-altering product. Practical education regarding the latest of these underground drugs, kratom, which threatens our service members, is introduced in this issue.
The second truth is that nearly every drug that is originally prescribed for legitimate medical reasons is eventually misused for a nonmedical purpose and can lead to SUDs. By the time the medical community realizes the dark side of the medication, many individuals have already developed a disorder, and sadly some have died.
One of the oldest classes of drugs that brings both relief and torment to human culture—opioid medication—is now the scourge of postmodern society. Our well-intentioned efforts to succor real pain for patients using prescription opioids have paved a road to hellish suffering for others. A recent study examined whether a resurgence of heroin use among veterans—the likes of which has not been seen since the Vietnam era—was associated with the nonmedical use of yes, prescribed narcotics. The same study found that solely having chronic pain was not correlated with the use of heroin.4 This finding offers the hope that practitioners and patients together can learn to treat chronic pain with opioids in selected patients, which can be life-restoring in appropriate cases for limited duration, safely and responsibly while avoiding and minimizing the death dealing blow of opioid use disorders.
In this issue, we also feature a discussion with Karen Drexler, MD, the newly appointed Mental Health Program Director, Addictive Disorders. Dr. Drexler expertly discusses a wide array of SUD subjects relevant to Federal Practitioner readers, including the approach to patients using medical marijuana in the VA, the 2016 VA/DoD Clinical Practice Guidelines, and an inside view of the challenges and successes of VA SUD programs, from the vantage point of the new leader of these critical initiatives.
Finally, astute readers may notice the editorial attempts to avoid use of the value-laden terms addiction and substance abuse. Instead, the less stigmatizing terminology of DSM-5 is employed, which jettisons the problematic abuse and dependence distinction for the unitary domain of SUDs. This approach is not just a change in semantics but as thought leaders have shown, a real and meaningful comprehension of the role of words in shaping culture.5 The VA as a health care entity is moving to adopt better scientific framing of SUDs as a salient step toward a recovery-oriented program.
In the coming months, we intend to expand our coverage of this public health crisis, and we invite readers who care every day for patients wrestling with SUDs for control of their health and very lives, to educate, advocate for resources for active-duty service personnel and veterans, and share innovative efforts to turn the tide toward recovery.
Given the recently concluded election season, it may seem that there are few things Americans have in common or can agree on. And although I did not conduct a poll or hold a debate, I suspect that a majority of those who work in the VA, DoD, or PHS would agree that one of the most serious and prevalent public health problems facing those in federal service and in the country at large is the epidemic of substance use disorders (SUDs).
In 2013 the National Institute on Drug Abuse reported that “members of the armed forces are not immune to the substance use problems that affect the rest of society.”1 Although active-duty service members use illicit drugs less frequently, as would be expected given the potential disciplinary consequences, the prevalence of problematic use of the legal ones—tobacco, alcohol, and particularly prescription medications—is greater among individuals in the military.
Substance use disorders affect every sector of federal health care practice from military pediatrics and VA pathology to PHS primary care. Reflecting this ubiquity, in this special substance use disorders issue of Federal Practitioner we focus on several distinctive and significant efforts of health care practitioners who care for patients with SUDs. All of medicine is becoming more interdisciplinary, multidisciplinary, and team-based, but perhaps no other area has as long a legacy or as intrinsic a need for team approaches to care than does the diagnosis and treatment of SUDs. We see this need reflected in this issue’s articles authored by clinical pharmacists, nurse practitioners, physicians, and physicians in training, among others.
Prescription opioids are the subject of 3 articles from VA practitioners: a look at primary, secondary, and tertiary forms of prevention of morbidity and mortality from substance use. Pharmacists at the Salt Lake City VAMC studied the epidemiology of veterans seen in emergency departments who were given naloxone for unintentional opioid overdoses. A second article reviews the distribution of naloxone at a VA facility, providing an example of a successful implementation of the VA Overdose Education and Naloxone Distribution network (OEND)—the only national naloxone program in any health care system.
Even farther upstream in the effort to reduce the large doses of opioids that are directly related to overdose deaths is an article on an outpatient opioid-monitoring clinic that uses evidence-based medicine to diagnose patients with opioid use disorder. Research in the VHA showed that in a 4-year period of study, “the risk of overdose deaths was directly related to the maximum prescribed daily dose of opioid medication.”2
Our colleagues in active duty underscore the challenge that new and emerging substances present not only to federal regulatory agencies like the Drug Enforcement Agency, but also to state and local law enforcement agencies. When spice (synthetic cannabinoids) and bath salts (synthetic cathinones) first appeared, no drug tests were available to detect them. Technically not illegal in the early phase of their use, they became the perfect and popular drugs of young service men and women.3
Tragically, history has shown 2 truths about humans and the use of psychoactive products. The first is that as soon as one product is outlawed, creative chemists invent another mind-altering product. Practical education regarding the latest of these underground drugs, kratom, which threatens our service members, is introduced in this issue.
The second truth is that nearly every drug that is originally prescribed for legitimate medical reasons is eventually misused for a nonmedical purpose and can lead to SUDs. By the time the medical community realizes the dark side of the medication, many individuals have already developed a disorder, and sadly some have died.
One of the oldest classes of drugs that brings both relief and torment to human culture—opioid medication—is now the scourge of postmodern society. Our well-intentioned efforts to succor real pain for patients using prescription opioids have paved a road to hellish suffering for others. A recent study examined whether a resurgence of heroin use among veterans—the likes of which has not been seen since the Vietnam era—was associated with the nonmedical use of yes, prescribed narcotics. The same study found that solely having chronic pain was not correlated with the use of heroin.4 This finding offers the hope that practitioners and patients together can learn to treat chronic pain with opioids in selected patients, which can be life-restoring in appropriate cases for limited duration, safely and responsibly while avoiding and minimizing the death dealing blow of opioid use disorders.
In this issue, we also feature a discussion with Karen Drexler, MD, the newly appointed Mental Health Program Director, Addictive Disorders. Dr. Drexler expertly discusses a wide array of SUD subjects relevant to Federal Practitioner readers, including the approach to patients using medical marijuana in the VA, the 2016 VA/DoD Clinical Practice Guidelines, and an inside view of the challenges and successes of VA SUD programs, from the vantage point of the new leader of these critical initiatives.
Finally, astute readers may notice the editorial attempts to avoid use of the value-laden terms addiction and substance abuse. Instead, the less stigmatizing terminology of DSM-5 is employed, which jettisons the problematic abuse and dependence distinction for the unitary domain of SUDs. This approach is not just a change in semantics but as thought leaders have shown, a real and meaningful comprehension of the role of words in shaping culture.5 The VA as a health care entity is moving to adopt better scientific framing of SUDs as a salient step toward a recovery-oriented program.
In the coming months, we intend to expand our coverage of this public health crisis, and we invite readers who care every day for patients wrestling with SUDs for control of their health and very lives, to educate, advocate for resources for active-duty service personnel and veterans, and share innovative efforts to turn the tide toward recovery.
1. National Institute on Drug Abuse. DrugFacts—substance abuse in the military. https://www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military. Revised March 2013. Accessed October 18, 2016.
2. Loeffler G, Hurst D, Penn A, Yung K. Spice, bath salts, and the U.S. military: the emergence of synthetic cannabinoid receptor agonists and cathinones in the U.S. Armed Forces. Mil Med. 2012;177(9):1041-1048.
3. Banerjee G, Edelman EJ, Barry DT, et al. Non-medical use of prescription opioids is associated with heroin initiation among U.S. veterans: a prospective cohort study. Addiction. 2016;111(11):2021-2031.
4. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid-related deaths. JAMA. 2011;305(13):1315-1321.
5. Botticelli MP, Koh HK. Changing the language of addiction. JAMA. 2016;316(13):1361-1362.
1. National Institute on Drug Abuse. DrugFacts—substance abuse in the military. https://www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military. Revised March 2013. Accessed October 18, 2016.
2. Loeffler G, Hurst D, Penn A, Yung K. Spice, bath salts, and the U.S. military: the emergence of synthetic cannabinoid receptor agonists and cathinones in the U.S. Armed Forces. Mil Med. 2012;177(9):1041-1048.
3. Banerjee G, Edelman EJ, Barry DT, et al. Non-medical use of prescription opioids is associated with heroin initiation among U.S. veterans: a prospective cohort study. Addiction. 2016;111(11):2021-2031.
4. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid-related deaths. JAMA. 2011;305(13):1315-1321.
5. Botticelli MP, Koh HK. Changing the language of addiction. JAMA. 2016;316(13):1361-1362.
Mindfulness
How might mindfulness contribute to your mental collapse? Let’s say your work has become tedious. Tottering toward burnout, you decide to try mindfulness meditation to reverse your downward trend. However, you habitually fail to do your daily meditation. Now, “Meditate today” just piles on to your to-do list, a daily reminder of just how weak and disorganized you have become. Voila! Mindfulness is making you more crazy. There are things you can do to avoid this.
There are plenty of things to tip us doctors into burnout. We are not alone in the burnout epidemic, but we are overrepresented. More than 50% of physicians have burnout symptoms according to a recent Mayo Clinic study. Mindfulness training can help.
According to an interview with the program’s director, Douglas Zeidonis, MD, professor and chair of the department of psychiatry at the University of Massachusetts, most of the physicians reported that mindfulness training significantly benefited their work and personal lives. Mindfulness helped them feel more present and engaged with colleagues and patients and made them better clinicians – they reported showing more compassion toward patients.
Like any desirable habit, the key is to do it again and again and again. Here are a few recommendations to help you become more mindful during your workday.
1. Set random alarms (vibrate mode) on your smartphone to remind yourself to take a moment. When it goes off, do this: Breathe (4 seconds in, hold, then 8 seconds out) and be totally present for one minute.
2. Remove deliciously distracting apps from your phone’s home screen. Instead, tuck them away in a folder to reduce the likelihood you’ll click on them when you’re stressed.
3. Put meditation apps where you easily see them. You might try:
• The Mindfulness App: This app offers guided meditations in varying lengths from 3 to 30 minutes, so you can choose the one that’s right for you at any time of the day. Cool features include tracking your progress and setting reminders.
• Headspace: Headspace is known for helping people learn to meditate in just 10 easy minutes a day. Cool features include the ability to track your progress and to buddy up with a friend to help keep you motivated.
• Omvana: This app offers over 500 “transformative” audios to improve all areas of your life from work to personal relationships. Cool features include tracks to improve sleep, something more than a few of us might appreciate.
• Stop, Breathe, & Think: Quicker than Headspace, this app teaches you to meditate in 5 minutes a day and is easy to use at your workplace. Cool features include customizing meditations based upon your mood.
• Take a Break!: Ideal for the workplace, this app will help you carve out time each day to breathe, relax, and focus. Cool features include the ability to choose meditations with voice, music, or nature sounds.
4. Block a 10-minute mindfulness appointment on your schedule in the afternoon. Becoming more resilient will more than offset the short term lost revenue if you avoid retiring too soon due to burnout!
5. If you have an Apple watch, then try the new Breathe app. It reminds you to stop, breathe, and relax and even reports your heart rate afterward.
So unless you are expecting 2017 to be uneventful, I suggest you start building your mindfulness habit today.
Serenity now, serenity now.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
How might mindfulness contribute to your mental collapse? Let’s say your work has become tedious. Tottering toward burnout, you decide to try mindfulness meditation to reverse your downward trend. However, you habitually fail to do your daily meditation. Now, “Meditate today” just piles on to your to-do list, a daily reminder of just how weak and disorganized you have become. Voila! Mindfulness is making you more crazy. There are things you can do to avoid this.
There are plenty of things to tip us doctors into burnout. We are not alone in the burnout epidemic, but we are overrepresented. More than 50% of physicians have burnout symptoms according to a recent Mayo Clinic study. Mindfulness training can help.
According to an interview with the program’s director, Douglas Zeidonis, MD, professor and chair of the department of psychiatry at the University of Massachusetts, most of the physicians reported that mindfulness training significantly benefited their work and personal lives. Mindfulness helped them feel more present and engaged with colleagues and patients and made them better clinicians – they reported showing more compassion toward patients.
Like any desirable habit, the key is to do it again and again and again. Here are a few recommendations to help you become more mindful during your workday.
1. Set random alarms (vibrate mode) on your smartphone to remind yourself to take a moment. When it goes off, do this: Breathe (4 seconds in, hold, then 8 seconds out) and be totally present for one minute.
2. Remove deliciously distracting apps from your phone’s home screen. Instead, tuck them away in a folder to reduce the likelihood you’ll click on them when you’re stressed.
3. Put meditation apps where you easily see them. You might try:
• The Mindfulness App: This app offers guided meditations in varying lengths from 3 to 30 minutes, so you can choose the one that’s right for you at any time of the day. Cool features include tracking your progress and setting reminders.
• Headspace: Headspace is known for helping people learn to meditate in just 10 easy minutes a day. Cool features include the ability to track your progress and to buddy up with a friend to help keep you motivated.
• Omvana: This app offers over 500 “transformative” audios to improve all areas of your life from work to personal relationships. Cool features include tracks to improve sleep, something more than a few of us might appreciate.
• Stop, Breathe, & Think: Quicker than Headspace, this app teaches you to meditate in 5 minutes a day and is easy to use at your workplace. Cool features include customizing meditations based upon your mood.
• Take a Break!: Ideal for the workplace, this app will help you carve out time each day to breathe, relax, and focus. Cool features include the ability to choose meditations with voice, music, or nature sounds.
4. Block a 10-minute mindfulness appointment on your schedule in the afternoon. Becoming more resilient will more than offset the short term lost revenue if you avoid retiring too soon due to burnout!
5. If you have an Apple watch, then try the new Breathe app. It reminds you to stop, breathe, and relax and even reports your heart rate afterward.
So unless you are expecting 2017 to be uneventful, I suggest you start building your mindfulness habit today.
Serenity now, serenity now.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
How might mindfulness contribute to your mental collapse? Let’s say your work has become tedious. Tottering toward burnout, you decide to try mindfulness meditation to reverse your downward trend. However, you habitually fail to do your daily meditation. Now, “Meditate today” just piles on to your to-do list, a daily reminder of just how weak and disorganized you have become. Voila! Mindfulness is making you more crazy. There are things you can do to avoid this.
There are plenty of things to tip us doctors into burnout. We are not alone in the burnout epidemic, but we are overrepresented. More than 50% of physicians have burnout symptoms according to a recent Mayo Clinic study. Mindfulness training can help.
According to an interview with the program’s director, Douglas Zeidonis, MD, professor and chair of the department of psychiatry at the University of Massachusetts, most of the physicians reported that mindfulness training significantly benefited their work and personal lives. Mindfulness helped them feel more present and engaged with colleagues and patients and made them better clinicians – they reported showing more compassion toward patients.
Like any desirable habit, the key is to do it again and again and again. Here are a few recommendations to help you become more mindful during your workday.
1. Set random alarms (vibrate mode) on your smartphone to remind yourself to take a moment. When it goes off, do this: Breathe (4 seconds in, hold, then 8 seconds out) and be totally present for one minute.
2. Remove deliciously distracting apps from your phone’s home screen. Instead, tuck them away in a folder to reduce the likelihood you’ll click on them when you’re stressed.
3. Put meditation apps where you easily see them. You might try:
• The Mindfulness App: This app offers guided meditations in varying lengths from 3 to 30 minutes, so you can choose the one that’s right for you at any time of the day. Cool features include tracking your progress and setting reminders.
• Headspace: Headspace is known for helping people learn to meditate in just 10 easy minutes a day. Cool features include the ability to track your progress and to buddy up with a friend to help keep you motivated.
• Omvana: This app offers over 500 “transformative” audios to improve all areas of your life from work to personal relationships. Cool features include tracks to improve sleep, something more than a few of us might appreciate.
• Stop, Breathe, & Think: Quicker than Headspace, this app teaches you to meditate in 5 minutes a day and is easy to use at your workplace. Cool features include customizing meditations based upon your mood.
• Take a Break!: Ideal for the workplace, this app will help you carve out time each day to breathe, relax, and focus. Cool features include the ability to choose meditations with voice, music, or nature sounds.
4. Block a 10-minute mindfulness appointment on your schedule in the afternoon. Becoming more resilient will more than offset the short term lost revenue if you avoid retiring too soon due to burnout!
5. If you have an Apple watch, then try the new Breathe app. It reminds you to stop, breathe, and relax and even reports your heart rate afterward.
So unless you are expecting 2017 to be uneventful, I suggest you start building your mindfulness habit today.
Serenity now, serenity now.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected] . He has no disclosures related to this column.
From the Editors: Querencia
In the flood of emails, periodicals, Twitter, Facebook, Doximity, Medscape, and other information that washes over surgeons every day, why should they use their precious time to read ACS Surgery News? That question is foremost in the minds of the editors of this publication as we consider news stories and commentaries for inclusion. Is this an article our readers are going to find informative, pertinent, and stimulating? We want ACS Surgery News to be a querencia: a source of reliable, vetted information that gives surgeons a place of intellectual security along the information highway.
The editors of ACS Surgery News understand surgery from the scrub sink up. While our mission includes keeping our readers informed about these looming thunderstorms, we are also privileged to report progress and innovations that keep coming no matter how the forces of red tape and commerce play against our profession. Bringing news of both challenges and beacons of hope for our profession with commentary and perspective from our colleagues is our objective. For the editors, this is both a mission and a pleasure. Since most of the editors and our Editorial Advisory Board (EAB), like our readers, must focus primarily on our jobs as surgeons, teachers, and researchers, we cannot read every journal or attend every meeting. The role of ACS Surgery News is to find the relevant news of interest and importance to surgeons, wherever it may be found, and to report it succinctly and accurately in a readable form. Before an article appears in ACS Surgery News, it is reviewed by the author of the paper or presentation for accuracy and reviewed by the most appropriate member of the EAB as well as by both Co-Editors for importance and relevance to our surgeon readers. We do not want to shy away from controversial topics, but endeavor to present such topics with balance and sensitivity, just as the ACS itself always attempts to do: to shed light, rather than merely heat, on all subjects that we cover in our pages.
The editors of ACS Surgery News hope that in the months and years to come, this publication can be a querencia for the surgeon: a safe and secure place to engage all the forces that a surgeon must confront to be successful. In these pages we hope you will find knowledge, wisdom, camaraderie, and support for your practice, whatever that may be.
Surgery is a life of great joy and great sorrow, sometimes happening all within the same hour. We hope to be part of the joy and to soften the sorrow by being a publication you look forward to reading and wherein you find those things that contribute to your being a great surgeon and human being.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Co-Editor of ACS Surgery News.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
In the flood of emails, periodicals, Twitter, Facebook, Doximity, Medscape, and other information that washes over surgeons every day, why should they use their precious time to read ACS Surgery News? That question is foremost in the minds of the editors of this publication as we consider news stories and commentaries for inclusion. Is this an article our readers are going to find informative, pertinent, and stimulating? We want ACS Surgery News to be a querencia: a source of reliable, vetted information that gives surgeons a place of intellectual security along the information highway.
The editors of ACS Surgery News understand surgery from the scrub sink up. While our mission includes keeping our readers informed about these looming thunderstorms, we are also privileged to report progress and innovations that keep coming no matter how the forces of red tape and commerce play against our profession. Bringing news of both challenges and beacons of hope for our profession with commentary and perspective from our colleagues is our objective. For the editors, this is both a mission and a pleasure. Since most of the editors and our Editorial Advisory Board (EAB), like our readers, must focus primarily on our jobs as surgeons, teachers, and researchers, we cannot read every journal or attend every meeting. The role of ACS Surgery News is to find the relevant news of interest and importance to surgeons, wherever it may be found, and to report it succinctly and accurately in a readable form. Before an article appears in ACS Surgery News, it is reviewed by the author of the paper or presentation for accuracy and reviewed by the most appropriate member of the EAB as well as by both Co-Editors for importance and relevance to our surgeon readers. We do not want to shy away from controversial topics, but endeavor to present such topics with balance and sensitivity, just as the ACS itself always attempts to do: to shed light, rather than merely heat, on all subjects that we cover in our pages.
The editors of ACS Surgery News hope that in the months and years to come, this publication can be a querencia for the surgeon: a safe and secure place to engage all the forces that a surgeon must confront to be successful. In these pages we hope you will find knowledge, wisdom, camaraderie, and support for your practice, whatever that may be.
Surgery is a life of great joy and great sorrow, sometimes happening all within the same hour. We hope to be part of the joy and to soften the sorrow by being a publication you look forward to reading and wherein you find those things that contribute to your being a great surgeon and human being.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Co-Editor of ACS Surgery News.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
In the flood of emails, periodicals, Twitter, Facebook, Doximity, Medscape, and other information that washes over surgeons every day, why should they use their precious time to read ACS Surgery News? That question is foremost in the minds of the editors of this publication as we consider news stories and commentaries for inclusion. Is this an article our readers are going to find informative, pertinent, and stimulating? We want ACS Surgery News to be a querencia: a source of reliable, vetted information that gives surgeons a place of intellectual security along the information highway.
The editors of ACS Surgery News understand surgery from the scrub sink up. While our mission includes keeping our readers informed about these looming thunderstorms, we are also privileged to report progress and innovations that keep coming no matter how the forces of red tape and commerce play against our profession. Bringing news of both challenges and beacons of hope for our profession with commentary and perspective from our colleagues is our objective. For the editors, this is both a mission and a pleasure. Since most of the editors and our Editorial Advisory Board (EAB), like our readers, must focus primarily on our jobs as surgeons, teachers, and researchers, we cannot read every journal or attend every meeting. The role of ACS Surgery News is to find the relevant news of interest and importance to surgeons, wherever it may be found, and to report it succinctly and accurately in a readable form. Before an article appears in ACS Surgery News, it is reviewed by the author of the paper or presentation for accuracy and reviewed by the most appropriate member of the EAB as well as by both Co-Editors for importance and relevance to our surgeon readers. We do not want to shy away from controversial topics, but endeavor to present such topics with balance and sensitivity, just as the ACS itself always attempts to do: to shed light, rather than merely heat, on all subjects that we cover in our pages.
The editors of ACS Surgery News hope that in the months and years to come, this publication can be a querencia for the surgeon: a safe and secure place to engage all the forces that a surgeon must confront to be successful. In these pages we hope you will find knowledge, wisdom, camaraderie, and support for your practice, whatever that may be.
Surgery is a life of great joy and great sorrow, sometimes happening all within the same hour. We hope to be part of the joy and to soften the sorrow by being a publication you look forward to reading and wherein you find those things that contribute to your being a great surgeon and human being.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Co-Editor of ACS Surgery News.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
Pencils and paper ready!
No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.
It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.
It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.
Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.
At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.
I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.
If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected] .
No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.
It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.
It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.
Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.
At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.
I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.
If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected] .
No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.
It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.
It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.
Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.
At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.
I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.
If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected] .
Absorb’s problems will revise coronary scaffold standards
One-year outcome results of the first bioresorbable coronary scaffold on the U.S. and world markets, Absorb, failed to show longer-term problems with the device that only became apparent with 3-year follow-up.
The failure of Absorb to show benefits after 3 years in the ABSORB II trial will probably not dampen enthusiasm for the concept of a bioresorbable coronary scaffold (BRS). The idea of treating coronary stenoses with a stent that disappears after a few years once it has done its job is a powerfully attractive idea, and reports from several early-stage clinical tests of new BRSs during TCT 2016 showed that many next-generation versions of these devices are in very active development.
The surprising ABSORB II results showed more than just a failure of the Absorb BRS to produce 3 years after placement the improved coronary artery vasomotion and reduced late lumen loss that were the two primary efficacy endpoints of the trial.
The results also showed troubling signs of harm from the BRS, including significantly worse late lumen loss, compared with a contemporary drug-eluting metallic stent. In addition, there was a shocking 1%/year rate of late stent thrombosis during both the second and third years following Absorb placement in coronary arteries, the period when the Absorb BRS was in the process of disappearing, and which did not occur in the study’s control patients who received a conventional, metallic drug-eluting stent.
Patrick W. Serruys, MD, lead investigator of ABSORB II, attributed these adverse outcomes to the “highly thrombogenic” proteoglycan material that formed as the Absorb BRS resorbed, and a “structural discontinuity” of the BRS as it resorbed in some patients, resulting in parts of the scaffold remnant sticking out from the coronary artery wall toward the center of the vessel.
These late flaws in the bioresorption process will now need closer scrutiny during future studies of next-generation BRSs, and will surely mean longer follow-up of pivotal trials and a shift from the 1-year follow-up data used by the Food and Drug Administration when it approved the Absorb BRS last July.
“The challenge for the field [of BRS development] is the late results, as we saw in ABSORB II,” commented David J. Cohen, MD, an interventional cardiologist at Saint Luke’s Health System in Kansas City, Mo. The ABSORB II results “will lead to reexamination of the trial design and endpoints for the next generation of BRSs,” Dr. Cohen predicted at the meeting, sponsored by the Cardiovascular Research Foundation.
“It’s not clear that BRS reduces the duration for DAPT,” Dr. Cohen noted, at least for the Absorb device, which is not full resorbed until it’s been in patients for about 3 years.
A striking property of the next-generation BRSs reported at the meeting was their use of thinner struts and faster resorption times. “These iterations hold immense promise for improving late outcomes,” commented Dean J. Kereiakes, MD, an interventional cardiologist at the Christ Hospital in Cincinnati who helped lead the large U.S. clinical trial of the Absorb BRS, ABSORB III.
[email protected]
On Twitter @mitchelzoler
One-year outcome results of the first bioresorbable coronary scaffold on the U.S. and world markets, Absorb, failed to show longer-term problems with the device that only became apparent with 3-year follow-up.
The failure of Absorb to show benefits after 3 years in the ABSORB II trial will probably not dampen enthusiasm for the concept of a bioresorbable coronary scaffold (BRS). The idea of treating coronary stenoses with a stent that disappears after a few years once it has done its job is a powerfully attractive idea, and reports from several early-stage clinical tests of new BRSs during TCT 2016 showed that many next-generation versions of these devices are in very active development.
The surprising ABSORB II results showed more than just a failure of the Absorb BRS to produce 3 years after placement the improved coronary artery vasomotion and reduced late lumen loss that were the two primary efficacy endpoints of the trial.
The results also showed troubling signs of harm from the BRS, including significantly worse late lumen loss, compared with a contemporary drug-eluting metallic stent. In addition, there was a shocking 1%/year rate of late stent thrombosis during both the second and third years following Absorb placement in coronary arteries, the period when the Absorb BRS was in the process of disappearing, and which did not occur in the study’s control patients who received a conventional, metallic drug-eluting stent.
Patrick W. Serruys, MD, lead investigator of ABSORB II, attributed these adverse outcomes to the “highly thrombogenic” proteoglycan material that formed as the Absorb BRS resorbed, and a “structural discontinuity” of the BRS as it resorbed in some patients, resulting in parts of the scaffold remnant sticking out from the coronary artery wall toward the center of the vessel.
These late flaws in the bioresorption process will now need closer scrutiny during future studies of next-generation BRSs, and will surely mean longer follow-up of pivotal trials and a shift from the 1-year follow-up data used by the Food and Drug Administration when it approved the Absorb BRS last July.
“The challenge for the field [of BRS development] is the late results, as we saw in ABSORB II,” commented David J. Cohen, MD, an interventional cardiologist at Saint Luke’s Health System in Kansas City, Mo. The ABSORB II results “will lead to reexamination of the trial design and endpoints for the next generation of BRSs,” Dr. Cohen predicted at the meeting, sponsored by the Cardiovascular Research Foundation.
“It’s not clear that BRS reduces the duration for DAPT,” Dr. Cohen noted, at least for the Absorb device, which is not full resorbed until it’s been in patients for about 3 years.
A striking property of the next-generation BRSs reported at the meeting was their use of thinner struts and faster resorption times. “These iterations hold immense promise for improving late outcomes,” commented Dean J. Kereiakes, MD, an interventional cardiologist at the Christ Hospital in Cincinnati who helped lead the large U.S. clinical trial of the Absorb BRS, ABSORB III.
[email protected]
On Twitter @mitchelzoler
One-year outcome results of the first bioresorbable coronary scaffold on the U.S. and world markets, Absorb, failed to show longer-term problems with the device that only became apparent with 3-year follow-up.
The failure of Absorb to show benefits after 3 years in the ABSORB II trial will probably not dampen enthusiasm for the concept of a bioresorbable coronary scaffold (BRS). The idea of treating coronary stenoses with a stent that disappears after a few years once it has done its job is a powerfully attractive idea, and reports from several early-stage clinical tests of new BRSs during TCT 2016 showed that many next-generation versions of these devices are in very active development.
The surprising ABSORB II results showed more than just a failure of the Absorb BRS to produce 3 years after placement the improved coronary artery vasomotion and reduced late lumen loss that were the two primary efficacy endpoints of the trial.
The results also showed troubling signs of harm from the BRS, including significantly worse late lumen loss, compared with a contemporary drug-eluting metallic stent. In addition, there was a shocking 1%/year rate of late stent thrombosis during both the second and third years following Absorb placement in coronary arteries, the period when the Absorb BRS was in the process of disappearing, and which did not occur in the study’s control patients who received a conventional, metallic drug-eluting stent.
Patrick W. Serruys, MD, lead investigator of ABSORB II, attributed these adverse outcomes to the “highly thrombogenic” proteoglycan material that formed as the Absorb BRS resorbed, and a “structural discontinuity” of the BRS as it resorbed in some patients, resulting in parts of the scaffold remnant sticking out from the coronary artery wall toward the center of the vessel.
These late flaws in the bioresorption process will now need closer scrutiny during future studies of next-generation BRSs, and will surely mean longer follow-up of pivotal trials and a shift from the 1-year follow-up data used by the Food and Drug Administration when it approved the Absorb BRS last July.
“The challenge for the field [of BRS development] is the late results, as we saw in ABSORB II,” commented David J. Cohen, MD, an interventional cardiologist at Saint Luke’s Health System in Kansas City, Mo. The ABSORB II results “will lead to reexamination of the trial design and endpoints for the next generation of BRSs,” Dr. Cohen predicted at the meeting, sponsored by the Cardiovascular Research Foundation.
“It’s not clear that BRS reduces the duration for DAPT,” Dr. Cohen noted, at least for the Absorb device, which is not full resorbed until it’s been in patients for about 3 years.
A striking property of the next-generation BRSs reported at the meeting was their use of thinner struts and faster resorption times. “These iterations hold immense promise for improving late outcomes,” commented Dean J. Kereiakes, MD, an interventional cardiologist at the Christ Hospital in Cincinnati who helped lead the large U.S. clinical trial of the Absorb BRS, ABSORB III.
[email protected]
On Twitter @mitchelzoler
Why is the mental health burden in EDs rising?
The mounting impact of mental illness on patients and the American health care system has been of growing concern, especially in recent years. As such, now more than ever, it is important to understand the mental health burden and investigate the factors contributing to the elevated use of emergency departments to treat patients with psychiatric illness.
In recent years, the overall prevalence of mental illness has not changed drastically. According to the 2014 National Survey of Drug Use and Health, 18.1% of adults indicated having “any mental illness,” a prevalence that had not changed much since 2008.1 It is possible, however, that despite the relative stability in the prevalence of mental illness, the acuity of mental illness may be on the rise. For instance, 4.1% of adults indicated having a “serious mental illness” (SMI) in 2014, a prevalence that was 0.4% higher than that of 2008 and 2009.1 Also, of note, the prevalence of SMI among the 18-to-25-year-old population in 2014 had increased in previous years.1 Meanwhile, 6.6% of adults indicated having experienced a major depressive episode at least once in the preceding 12 months. That prevalence has held relatively steady over recent years.1
Despite the rising need for mental health services, the number of inpatient psychiatric beds has declined. During the 32 years between 1970 and 2002, the United States experienced a staggering nearly 60% decline in the number of inpatient psychiatric beds.4 Moreover, the number of psychiatric beds within the national public sector fell from 50,509 in 2005 to 43,318 in 2010, which is about a 14% decline.5 This decrease translated to a decrease from 17.1 beds/100,000 people in 2005 to 14.1 beds/100,000 in 2010 – both of which fall drastically below the “minimum number of public psychiatric beds deemed necessary for adequate psychiatric services (50/100,000).”5 Similarly, psychiatric practice has been unable to keep up with the increasing population size – the population-adjusted median number of psychiatrists declined 10.2% between 2003 and 2013.6
While inpatient psychiatric beds and psychiatrist availability have declined, the frequency of ED use for mental health reasons has increased. Mental health or substance abuse diagnoses directly accounted for 4.3% of ED visits in 2007 and were associated with 12.5% of ED visits.7 Specifically, there was a 19.3% increase in the rate of nonmaternal treat-and-release ED visits for mental health reasons between 2008-2012.8 Moreover, in a study assessing frequent treat-and-release ED visits among Medicaid patients, investigators found that while most ED visits were for non–mental health purposes, the odds of frequent ED use were higher among patients with either a psychiatric disorder or substance use problem across all levels of overall health complexity.9
What factors have been driving adults to increasingly rely on ED visits for their mental health care? Given the immense complexity of the U.S. mental health delivery system, it is evident that there is no clear-cut explanation. However, several specific factors may have contributed and must be investigated to better our understanding of this public health conundrum. The opioid epidemic, transition out of the correctional system, and coverage changes under the Affordable Care Act are hypotheses that will be examined further in the context of this pressing issue.
References
1. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.”
2. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief No. 241, April 2016.
3. Web-Based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention.
4. National Health Policy Forum Issue Brief (2007 Aug 1;[823]:1-21).
5. “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010,” Arlington, Va.: Treatment Advocacy Center, July 19, 2012.
6. “Population of U.S. Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access to Mental Health Care,” Health Aff (Millwood). 2016 Jul 1;35[7]:1271-7.
7. “Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007: Statistical Brief #92,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality, 2010).
8. “Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits, 2015: Statistical Brief #195,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality).
9. Nurs Res. 2015 Jan-Feb;64[1]3-12.
10. Ann Emerg Med. 2016 Apr;67[4]:525-30.
Ms. Kablanian is a 2nd-year medical student at the George Washington University, Washington, where she is enrolled in the Community and Urban Health Scholarly Concentration Program. Before attending medical school, she earned a master of public health degree in epidemiology from Columbia University, New York. She also holds a bachelor’s degree in biology and French from Scripps College, Claremont, Calif. Her interests include advocating for the urban underserved, contributing to medical curriculum development, and investigating population-level contributors to adverse health outcomes. Dr. Norris is assistant professor in the department of psychiatry & behavioral sciences, and assistant dean of student affairs at the George Washington University. He also is medical director of psychiatric & behavioral sciences at George Washington University Hospital. As part of his commitment to providing mental health care to patients with severe medical illness, Dr. Norris has been a leading voice within the psychiatric community on the value of palliative psychotherapy.
The mounting impact of mental illness on patients and the American health care system has been of growing concern, especially in recent years. As such, now more than ever, it is important to understand the mental health burden and investigate the factors contributing to the elevated use of emergency departments to treat patients with psychiatric illness.
In recent years, the overall prevalence of mental illness has not changed drastically. According to the 2014 National Survey of Drug Use and Health, 18.1% of adults indicated having “any mental illness,” a prevalence that had not changed much since 2008.1 It is possible, however, that despite the relative stability in the prevalence of mental illness, the acuity of mental illness may be on the rise. For instance, 4.1% of adults indicated having a “serious mental illness” (SMI) in 2014, a prevalence that was 0.4% higher than that of 2008 and 2009.1 Also, of note, the prevalence of SMI among the 18-to-25-year-old population in 2014 had increased in previous years.1 Meanwhile, 6.6% of adults indicated having experienced a major depressive episode at least once in the preceding 12 months. That prevalence has held relatively steady over recent years.1
Despite the rising need for mental health services, the number of inpatient psychiatric beds has declined. During the 32 years between 1970 and 2002, the United States experienced a staggering nearly 60% decline in the number of inpatient psychiatric beds.4 Moreover, the number of psychiatric beds within the national public sector fell from 50,509 in 2005 to 43,318 in 2010, which is about a 14% decline.5 This decrease translated to a decrease from 17.1 beds/100,000 people in 2005 to 14.1 beds/100,000 in 2010 – both of which fall drastically below the “minimum number of public psychiatric beds deemed necessary for adequate psychiatric services (50/100,000).”5 Similarly, psychiatric practice has been unable to keep up with the increasing population size – the population-adjusted median number of psychiatrists declined 10.2% between 2003 and 2013.6
While inpatient psychiatric beds and psychiatrist availability have declined, the frequency of ED use for mental health reasons has increased. Mental health or substance abuse diagnoses directly accounted for 4.3% of ED visits in 2007 and were associated with 12.5% of ED visits.7 Specifically, there was a 19.3% increase in the rate of nonmaternal treat-and-release ED visits for mental health reasons between 2008-2012.8 Moreover, in a study assessing frequent treat-and-release ED visits among Medicaid patients, investigators found that while most ED visits were for non–mental health purposes, the odds of frequent ED use were higher among patients with either a psychiatric disorder or substance use problem across all levels of overall health complexity.9
What factors have been driving adults to increasingly rely on ED visits for their mental health care? Given the immense complexity of the U.S. mental health delivery system, it is evident that there is no clear-cut explanation. However, several specific factors may have contributed and must be investigated to better our understanding of this public health conundrum. The opioid epidemic, transition out of the correctional system, and coverage changes under the Affordable Care Act are hypotheses that will be examined further in the context of this pressing issue.
References
1. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.”
2. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief No. 241, April 2016.
3. Web-Based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention.
4. National Health Policy Forum Issue Brief (2007 Aug 1;[823]:1-21).
5. “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010,” Arlington, Va.: Treatment Advocacy Center, July 19, 2012.
6. “Population of U.S. Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access to Mental Health Care,” Health Aff (Millwood). 2016 Jul 1;35[7]:1271-7.
7. “Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007: Statistical Brief #92,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality, 2010).
8. “Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits, 2015: Statistical Brief #195,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality).
9. Nurs Res. 2015 Jan-Feb;64[1]3-12.
10. Ann Emerg Med. 2016 Apr;67[4]:525-30.
Ms. Kablanian is a 2nd-year medical student at the George Washington University, Washington, where she is enrolled in the Community and Urban Health Scholarly Concentration Program. Before attending medical school, she earned a master of public health degree in epidemiology from Columbia University, New York. She also holds a bachelor’s degree in biology and French from Scripps College, Claremont, Calif. Her interests include advocating for the urban underserved, contributing to medical curriculum development, and investigating population-level contributors to adverse health outcomes. Dr. Norris is assistant professor in the department of psychiatry & behavioral sciences, and assistant dean of student affairs at the George Washington University. He also is medical director of psychiatric & behavioral sciences at George Washington University Hospital. As part of his commitment to providing mental health care to patients with severe medical illness, Dr. Norris has been a leading voice within the psychiatric community on the value of palliative psychotherapy.
The mounting impact of mental illness on patients and the American health care system has been of growing concern, especially in recent years. As such, now more than ever, it is important to understand the mental health burden and investigate the factors contributing to the elevated use of emergency departments to treat patients with psychiatric illness.
In recent years, the overall prevalence of mental illness has not changed drastically. According to the 2014 National Survey of Drug Use and Health, 18.1% of adults indicated having “any mental illness,” a prevalence that had not changed much since 2008.1 It is possible, however, that despite the relative stability in the prevalence of mental illness, the acuity of mental illness may be on the rise. For instance, 4.1% of adults indicated having a “serious mental illness” (SMI) in 2014, a prevalence that was 0.4% higher than that of 2008 and 2009.1 Also, of note, the prevalence of SMI among the 18-to-25-year-old population in 2014 had increased in previous years.1 Meanwhile, 6.6% of adults indicated having experienced a major depressive episode at least once in the preceding 12 months. That prevalence has held relatively steady over recent years.1
Despite the rising need for mental health services, the number of inpatient psychiatric beds has declined. During the 32 years between 1970 and 2002, the United States experienced a staggering nearly 60% decline in the number of inpatient psychiatric beds.4 Moreover, the number of psychiatric beds within the national public sector fell from 50,509 in 2005 to 43,318 in 2010, which is about a 14% decline.5 This decrease translated to a decrease from 17.1 beds/100,000 people in 2005 to 14.1 beds/100,000 in 2010 – both of which fall drastically below the “minimum number of public psychiatric beds deemed necessary for adequate psychiatric services (50/100,000).”5 Similarly, psychiatric practice has been unable to keep up with the increasing population size – the population-adjusted median number of psychiatrists declined 10.2% between 2003 and 2013.6
While inpatient psychiatric beds and psychiatrist availability have declined, the frequency of ED use for mental health reasons has increased. Mental health or substance abuse diagnoses directly accounted for 4.3% of ED visits in 2007 and were associated with 12.5% of ED visits.7 Specifically, there was a 19.3% increase in the rate of nonmaternal treat-and-release ED visits for mental health reasons between 2008-2012.8 Moreover, in a study assessing frequent treat-and-release ED visits among Medicaid patients, investigators found that while most ED visits were for non–mental health purposes, the odds of frequent ED use were higher among patients with either a psychiatric disorder or substance use problem across all levels of overall health complexity.9
What factors have been driving adults to increasingly rely on ED visits for their mental health care? Given the immense complexity of the U.S. mental health delivery system, it is evident that there is no clear-cut explanation. However, several specific factors may have contributed and must be investigated to better our understanding of this public health conundrum. The opioid epidemic, transition out of the correctional system, and coverage changes under the Affordable Care Act are hypotheses that will be examined further in the context of this pressing issue.
References
1. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health.”
2. “Increase in Suicide in the United States, 1999-2014.” NCHS Data Brief No. 241, April 2016.
3. Web-Based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention.
4. National Health Policy Forum Issue Brief (2007 Aug 1;[823]:1-21).
5. “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010,” Arlington, Va.: Treatment Advocacy Center, July 19, 2012.
6. “Population of U.S. Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access to Mental Health Care,” Health Aff (Millwood). 2016 Jul 1;35[7]:1271-7.
7. “Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007: Statistical Brief #92,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality, 2010).
8. “Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits, 2015: Statistical Brief #195,” in Healthcare Cost and Utilization Project Statistical Briefs, (Rockville, Md.: Agency for Healthcare Research and Quality).
9. Nurs Res. 2015 Jan-Feb;64[1]3-12.
10. Ann Emerg Med. 2016 Apr;67[4]:525-30.
Ms. Kablanian is a 2nd-year medical student at the George Washington University, Washington, where she is enrolled in the Community and Urban Health Scholarly Concentration Program. Before attending medical school, she earned a master of public health degree in epidemiology from Columbia University, New York. She also holds a bachelor’s degree in biology and French from Scripps College, Claremont, Calif. Her interests include advocating for the urban underserved, contributing to medical curriculum development, and investigating population-level contributors to adverse health outcomes. Dr. Norris is assistant professor in the department of psychiatry & behavioral sciences, and assistant dean of student affairs at the George Washington University. He also is medical director of psychiatric & behavioral sciences at George Washington University Hospital. As part of his commitment to providing mental health care to patients with severe medical illness, Dr. Norris has been a leading voice within the psychiatric community on the value of palliative psychotherapy.
The voice of the patient in a doctor-centric world
The American health care system has been plagued by poor medical outcomes and an inefficient cost structure for many years.1,2 The primary loser in this game is the patient, the player who bears the brunt of health care expenses, either directly or through taxes, and whose voice has been largely ignored until recently. As with many other service industries, health care delivery represents a highly complex process that is difficult to define or measure. Innovative procedures and state-of-the-art medical therapies have provided effective options that extend or improve life, but at increasing cost.
Further complicating the existing cost-vs.-benefit debate is a relatively new polemic regarding the degree to which patient satisfaction should be a measure of health care quality. How satisfied will a patient be with his or her health care experience? This depends, in large part, on the medical outcome.3
Many public and private organizations use patient satisfaction surveys to measure the performance of health care delivery systems. In many cases, patient satisfaction data are being used to determine insurance payouts, physician compensation, and institutional rankings.5 It may seem logical to adopt pay-for-performance strategies based on patient satisfaction surveys, but there is a fundamental flaw: Survey data are not always accurate.
It is not entirely clear what constitutes a positive or negative health care experience. Much of this depends on the expectations of the consumer.6 Those with low expectations may be delighted with mediocre performance. Those with inflated expectations may be disappointed even when provided excellent customer service.
Surveys are not durable. That is, when performed under distinct environmental conditions or at different times, surveys may not produce the same results when repeated by the same respondent.7 Surveys are easily manipulated by simple changes in wording or punctuation. Some specific encounters may be rated as “unsatisfactory” because of external factors, circumstances beyond the control of the health care provider.
Many health care providers feel that surveys are poor indicators of individual performance. Some critics highlight a paucity of data. A limited number of returned surveys, relative to the total number of encounters, may yield results that are not statistically significant. Increasing the amount of data decreases the risk that a sample set taken from the studied population is the result of sampling error alone. Nonetheless, sampling error is never completely eliminated, and it is not entirely clear to what degree statistical significance should be used to substantiate satisfaction, a subjective measure.
Surveys often provide data in a very small range, making ranking of facilities or providers difficult. For example, national polling services utilize surveys with thousands of respondents and the margin of error often exceeds plus or minus 3%. Data sets with a smaller number of responses have margins of error that are even greater. Even plus or minus 3% is a sizable deviation when considering that health care survey results often are compared and ranked based on a distribution of scores in a narrow response range. In the author’s experience, a 6% difference in survey scores can represent the difference between a ranking of “excellent” and “poor.”
Many patients are disenfranchised by survey methodology. In the most extreme example, deceased or severely disabled patients are unable to provide feedback. Patients transferred to other facilities and those who are lost to follow-up will be missed also. Many patient surveys may not be successfully retrieved from the homeless, the illiterate, minors, or those without phone or e-mail access. Because surveys are voluntarily submitted, the results may skew opinion toward a select group of outspoken customers who may not be representative of the general population.
The use of patient satisfaction surveys, especially when they are linked to employee compensation, may create a system of survey-based value. This is similar to the problem of defensive medicine, where providers perform medicine in a way that reduces legal risk. Aware that patients will be asked to fill out satisfaction surveys, associates may perform in a way that increases patient satisfaction scores at the expense of patient outcomes or the bottom line. Some institutions may inappropriately “cherry-pick” the easy-to-treat patient and transfer medically complex cases elsewhere.
It is not clear how to best measure the quality of a health care experience. With the broad range of patient encounter types and the inherent complexity of collaboration among providers, it is difficult to determine to what degree satisfaction can be attributed to individual providers or specific environmental factors. Patients do not typically interact with a specific provider, but are treated by a service delivery system, which often encompasses multiple players and multiple physical locations. Moreover, it is not always clear when the patient encounter begins and ends.
Despite the criticism of patient satisfaction survey methodology, the patient must ultimately define the value of the health care service offering. This “voice of the customer” approach is a diversion from the antiquated practitioner-centric model. Traditionally, patient appointment times and locations are decided by the availability and convenience of the provider. Many consumers have compensated for this inefficiency by accessing local emergency departments for nonurgent ambulatory care. Nonetheless,EDs often suffer from long waits and higher costs. Facilities designed for urgent, but nonemergent, care have attempted to address convenience issues but these facilities sacrifice continuity and specialization of care. In a truly patient-centric health care model, patients would be provided the care that they need, when and where they need it.
The patient satisfaction survey remains a primary tool for linking patient-centered value to health care reform. Ranking the results among market competitors can provide an incentive for improvement. Health care professionals are competitive by nature and the extrinsic motivation of quality rankings can be beneficial if well controlled. Employers should use caution when using survey data for performance measurement because survey data are subject to a variety of sources of bias or error. Patient survey data should be used to drive improvement, not to punish. Further research on patient survey methodology is needed to elucidate improved methods of bringing the voice of the patient to the forefront of health care reform.
References
1. N Engl J Med. 2003 Aug 21;349(8):768-75.
2. Centers for Medicare & Medicaid Services. Medicare hospital quality chartbook: Performance report on outcome measures. September 2014.
3. N Engl J Med. 2008 Oct 30;359(18):1921-31.
4. “Better Customer Insight – in Real Time,” by Emma K. Macdonald, Hugh N. Wilson, and Umut Konuş (Harvard Business Review, September 2012).
5. “The Dangers of Linking Pay to Customer Feedback,” by Rob Markey, (Harvard Business Review, Sept. 8, 2011).
6. “Health Care’s Service Fanatics,” by James I. Merlino and Ananth Raman, (Harvard Business Review, May 2013).
7. Trochim, WMK. Research Methods Knowledge Base.
Dr. Davis is a pediatric gastroenterologists at University of Florida Health, Gainesville. He has no financial relationships relevant to this article to disclose.
The American health care system has been plagued by poor medical outcomes and an inefficient cost structure for many years.1,2 The primary loser in this game is the patient, the player who bears the brunt of health care expenses, either directly or through taxes, and whose voice has been largely ignored until recently. As with many other service industries, health care delivery represents a highly complex process that is difficult to define or measure. Innovative procedures and state-of-the-art medical therapies have provided effective options that extend or improve life, but at increasing cost.
Further complicating the existing cost-vs.-benefit debate is a relatively new polemic regarding the degree to which patient satisfaction should be a measure of health care quality. How satisfied will a patient be with his or her health care experience? This depends, in large part, on the medical outcome.3
Many public and private organizations use patient satisfaction surveys to measure the performance of health care delivery systems. In many cases, patient satisfaction data are being used to determine insurance payouts, physician compensation, and institutional rankings.5 It may seem logical to adopt pay-for-performance strategies based on patient satisfaction surveys, but there is a fundamental flaw: Survey data are not always accurate.
It is not entirely clear what constitutes a positive or negative health care experience. Much of this depends on the expectations of the consumer.6 Those with low expectations may be delighted with mediocre performance. Those with inflated expectations may be disappointed even when provided excellent customer service.
Surveys are not durable. That is, when performed under distinct environmental conditions or at different times, surveys may not produce the same results when repeated by the same respondent.7 Surveys are easily manipulated by simple changes in wording or punctuation. Some specific encounters may be rated as “unsatisfactory” because of external factors, circumstances beyond the control of the health care provider.
Many health care providers feel that surveys are poor indicators of individual performance. Some critics highlight a paucity of data. A limited number of returned surveys, relative to the total number of encounters, may yield results that are not statistically significant. Increasing the amount of data decreases the risk that a sample set taken from the studied population is the result of sampling error alone. Nonetheless, sampling error is never completely eliminated, and it is not entirely clear to what degree statistical significance should be used to substantiate satisfaction, a subjective measure.
Surveys often provide data in a very small range, making ranking of facilities or providers difficult. For example, national polling services utilize surveys with thousands of respondents and the margin of error often exceeds plus or minus 3%. Data sets with a smaller number of responses have margins of error that are even greater. Even plus or minus 3% is a sizable deviation when considering that health care survey results often are compared and ranked based on a distribution of scores in a narrow response range. In the author’s experience, a 6% difference in survey scores can represent the difference between a ranking of “excellent” and “poor.”
Many patients are disenfranchised by survey methodology. In the most extreme example, deceased or severely disabled patients are unable to provide feedback. Patients transferred to other facilities and those who are lost to follow-up will be missed also. Many patient surveys may not be successfully retrieved from the homeless, the illiterate, minors, or those without phone or e-mail access. Because surveys are voluntarily submitted, the results may skew opinion toward a select group of outspoken customers who may not be representative of the general population.
The use of patient satisfaction surveys, especially when they are linked to employee compensation, may create a system of survey-based value. This is similar to the problem of defensive medicine, where providers perform medicine in a way that reduces legal risk. Aware that patients will be asked to fill out satisfaction surveys, associates may perform in a way that increases patient satisfaction scores at the expense of patient outcomes or the bottom line. Some institutions may inappropriately “cherry-pick” the easy-to-treat patient and transfer medically complex cases elsewhere.
It is not clear how to best measure the quality of a health care experience. With the broad range of patient encounter types and the inherent complexity of collaboration among providers, it is difficult to determine to what degree satisfaction can be attributed to individual providers or specific environmental factors. Patients do not typically interact with a specific provider, but are treated by a service delivery system, which often encompasses multiple players and multiple physical locations. Moreover, it is not always clear when the patient encounter begins and ends.
Despite the criticism of patient satisfaction survey methodology, the patient must ultimately define the value of the health care service offering. This “voice of the customer” approach is a diversion from the antiquated practitioner-centric model. Traditionally, patient appointment times and locations are decided by the availability and convenience of the provider. Many consumers have compensated for this inefficiency by accessing local emergency departments for nonurgent ambulatory care. Nonetheless,EDs often suffer from long waits and higher costs. Facilities designed for urgent, but nonemergent, care have attempted to address convenience issues but these facilities sacrifice continuity and specialization of care. In a truly patient-centric health care model, patients would be provided the care that they need, when and where they need it.
The patient satisfaction survey remains a primary tool for linking patient-centered value to health care reform. Ranking the results among market competitors can provide an incentive for improvement. Health care professionals are competitive by nature and the extrinsic motivation of quality rankings can be beneficial if well controlled. Employers should use caution when using survey data for performance measurement because survey data are subject to a variety of sources of bias or error. Patient survey data should be used to drive improvement, not to punish. Further research on patient survey methodology is needed to elucidate improved methods of bringing the voice of the patient to the forefront of health care reform.
References
1. N Engl J Med. 2003 Aug 21;349(8):768-75.
2. Centers for Medicare & Medicaid Services. Medicare hospital quality chartbook: Performance report on outcome measures. September 2014.
3. N Engl J Med. 2008 Oct 30;359(18):1921-31.
4. “Better Customer Insight – in Real Time,” by Emma K. Macdonald, Hugh N. Wilson, and Umut Konuş (Harvard Business Review, September 2012).
5. “The Dangers of Linking Pay to Customer Feedback,” by Rob Markey, (Harvard Business Review, Sept. 8, 2011).
6. “Health Care’s Service Fanatics,” by James I. Merlino and Ananth Raman, (Harvard Business Review, May 2013).
7. Trochim, WMK. Research Methods Knowledge Base.
Dr. Davis is a pediatric gastroenterologists at University of Florida Health, Gainesville. He has no financial relationships relevant to this article to disclose.
The American health care system has been plagued by poor medical outcomes and an inefficient cost structure for many years.1,2 The primary loser in this game is the patient, the player who bears the brunt of health care expenses, either directly or through taxes, and whose voice has been largely ignored until recently. As with many other service industries, health care delivery represents a highly complex process that is difficult to define or measure. Innovative procedures and state-of-the-art medical therapies have provided effective options that extend or improve life, but at increasing cost.
Further complicating the existing cost-vs.-benefit debate is a relatively new polemic regarding the degree to which patient satisfaction should be a measure of health care quality. How satisfied will a patient be with his or her health care experience? This depends, in large part, on the medical outcome.3
Many public and private organizations use patient satisfaction surveys to measure the performance of health care delivery systems. In many cases, patient satisfaction data are being used to determine insurance payouts, physician compensation, and institutional rankings.5 It may seem logical to adopt pay-for-performance strategies based on patient satisfaction surveys, but there is a fundamental flaw: Survey data are not always accurate.
It is not entirely clear what constitutes a positive or negative health care experience. Much of this depends on the expectations of the consumer.6 Those with low expectations may be delighted with mediocre performance. Those with inflated expectations may be disappointed even when provided excellent customer service.
Surveys are not durable. That is, when performed under distinct environmental conditions or at different times, surveys may not produce the same results when repeated by the same respondent.7 Surveys are easily manipulated by simple changes in wording or punctuation. Some specific encounters may be rated as “unsatisfactory” because of external factors, circumstances beyond the control of the health care provider.
Many health care providers feel that surveys are poor indicators of individual performance. Some critics highlight a paucity of data. A limited number of returned surveys, relative to the total number of encounters, may yield results that are not statistically significant. Increasing the amount of data decreases the risk that a sample set taken from the studied population is the result of sampling error alone. Nonetheless, sampling error is never completely eliminated, and it is not entirely clear to what degree statistical significance should be used to substantiate satisfaction, a subjective measure.
Surveys often provide data in a very small range, making ranking of facilities or providers difficult. For example, national polling services utilize surveys with thousands of respondents and the margin of error often exceeds plus or minus 3%. Data sets with a smaller number of responses have margins of error that are even greater. Even plus or minus 3% is a sizable deviation when considering that health care survey results often are compared and ranked based on a distribution of scores in a narrow response range. In the author’s experience, a 6% difference in survey scores can represent the difference between a ranking of “excellent” and “poor.”
Many patients are disenfranchised by survey methodology. In the most extreme example, deceased or severely disabled patients are unable to provide feedback. Patients transferred to other facilities and those who are lost to follow-up will be missed also. Many patient surveys may not be successfully retrieved from the homeless, the illiterate, minors, or those without phone or e-mail access. Because surveys are voluntarily submitted, the results may skew opinion toward a select group of outspoken customers who may not be representative of the general population.
The use of patient satisfaction surveys, especially when they are linked to employee compensation, may create a system of survey-based value. This is similar to the problem of defensive medicine, where providers perform medicine in a way that reduces legal risk. Aware that patients will be asked to fill out satisfaction surveys, associates may perform in a way that increases patient satisfaction scores at the expense of patient outcomes or the bottom line. Some institutions may inappropriately “cherry-pick” the easy-to-treat patient and transfer medically complex cases elsewhere.
It is not clear how to best measure the quality of a health care experience. With the broad range of patient encounter types and the inherent complexity of collaboration among providers, it is difficult to determine to what degree satisfaction can be attributed to individual providers or specific environmental factors. Patients do not typically interact with a specific provider, but are treated by a service delivery system, which often encompasses multiple players and multiple physical locations. Moreover, it is not always clear when the patient encounter begins and ends.
Despite the criticism of patient satisfaction survey methodology, the patient must ultimately define the value of the health care service offering. This “voice of the customer” approach is a diversion from the antiquated practitioner-centric model. Traditionally, patient appointment times and locations are decided by the availability and convenience of the provider. Many consumers have compensated for this inefficiency by accessing local emergency departments for nonurgent ambulatory care. Nonetheless,EDs often suffer from long waits and higher costs. Facilities designed for urgent, but nonemergent, care have attempted to address convenience issues but these facilities sacrifice continuity and specialization of care. In a truly patient-centric health care model, patients would be provided the care that they need, when and where they need it.
The patient satisfaction survey remains a primary tool for linking patient-centered value to health care reform. Ranking the results among market competitors can provide an incentive for improvement. Health care professionals are competitive by nature and the extrinsic motivation of quality rankings can be beneficial if well controlled. Employers should use caution when using survey data for performance measurement because survey data are subject to a variety of sources of bias or error. Patient survey data should be used to drive improvement, not to punish. Further research on patient survey methodology is needed to elucidate improved methods of bringing the voice of the patient to the forefront of health care reform.
References
1. N Engl J Med. 2003 Aug 21;349(8):768-75.
2. Centers for Medicare & Medicaid Services. Medicare hospital quality chartbook: Performance report on outcome measures. September 2014.
3. N Engl J Med. 2008 Oct 30;359(18):1921-31.
4. “Better Customer Insight – in Real Time,” by Emma K. Macdonald, Hugh N. Wilson, and Umut Konuş (Harvard Business Review, September 2012).
5. “The Dangers of Linking Pay to Customer Feedback,” by Rob Markey, (Harvard Business Review, Sept. 8, 2011).
6. “Health Care’s Service Fanatics,” by James I. Merlino and Ananth Raman, (Harvard Business Review, May 2013).
7. Trochim, WMK. Research Methods Knowledge Base.
Dr. Davis is a pediatric gastroenterologists at University of Florida Health, Gainesville. He has no financial relationships relevant to this article to disclose.
Back to the Future
Those who cannot remember the past are condemned to repeat it.
—George Santayana (Life of Reason, 1905)
Zero. That’s the number I put on the screen when I start the lecture I give to residents about the future of orthopedics. It represents the number of cases I still do exactly the same way now as I did when I graduated from my residency program. It represents the commitment to lifelong learning that we’ve made as orthopedists. Surgical techniques innovate so rapidly that they often outpace our research, leaving us performing new techniques based solely on industry and key opinion leader recommendation, and not on randomized controlled studies. Sometimes we’re led down the wrong path (remember when the meniscus was thought to be vestigial?) and other times new techniques lead to disappoint
So it seems “everything old is new again.” That’s why this issue of AJO is called The Throwback Issue. In this issue, we revisit ideas whose time has come and gone and now come again.
Our lead article this month focuses on ACL repair. Once abandoned after a landmark paper by Feagin and Curl1 showed poor mid-term results, new and innovative techniques and instrumentation for knee surgery have made this possible. Investigators such as Murray2 and DiFelice3 have done outstanding work showing the feasibility of ACL repair. In this issue we offer a comprehensive review and surgical technique for adding ACL repair to your portfolio of surgical offerings (see pages 408 and 454). Expanded versions of both of these articles are available at amjorthopedics.com.
Our second feature article discusses the reemergence of the ALL, an idea so hot in the public domain that it has been featured as a Jeopardy question. Described originally by Müller4 as the missing link in persistent rotational instability, the ALL might offer the key to improved long-term outcomes for patients undergoing ACL surgery. Read the article on page 418 and learn how to identify which patients are candidates for ALL reconstruction, and a simple surgical technique you can apply to your practice. Scan the provided QR code to watch the accompanying surgical technique video.
The Throwback Issue marks the fifth edition of the “new AJO.” It’s time to let us know how we are doing. Please email us at [email protected] to suggest future themes, articles you’d like to read, or suggestions for improvement.
Recently, based on the work of the authors mentioned above, I’ve begun offering ACL repair to select patients in my practice. I wouldn’t be able to do this if we as orthopedists weren’t constantly looking to improve, and weren’t willing to revisit old ideas to do it. Our goal at AJO is to present something in every article that can be immediately applied to your practice. Take a look at the articles presented this month, as we go “Back to the Future” to see what discarded ideas from our recent past can be applied to improve outcomes for your patients in the future.
1. Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med. 1976;4(3):95-100.
2. Murray MM, Fleming BC. Use of a bioactive scaffold to stimulate anterior cruciate ligament healing also minimizes posttraumatic osteoarthritis after surgery. Am J Sports Med. 2013;41(8):1762-1770.
3. DiFelice GS, Villegas C, Taylor SA. Anterior cruciate ligament preservation: early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair. Arthroscopy. 2015;31(11):2162-2171.
4. Müller W. The Knee: Form, Function, and Ligament Reconstruction. Berlin: Springer-Verlag, 1983.
Those who cannot remember the past are condemned to repeat it.
—George Santayana (Life of Reason, 1905)
Zero. That’s the number I put on the screen when I start the lecture I give to residents about the future of orthopedics. It represents the number of cases I still do exactly the same way now as I did when I graduated from my residency program. It represents the commitment to lifelong learning that we’ve made as orthopedists. Surgical techniques innovate so rapidly that they often outpace our research, leaving us performing new techniques based solely on industry and key opinion leader recommendation, and not on randomized controlled studies. Sometimes we’re led down the wrong path (remember when the meniscus was thought to be vestigial?) and other times new techniques lead to disappoint
So it seems “everything old is new again.” That’s why this issue of AJO is called The Throwback Issue. In this issue, we revisit ideas whose time has come and gone and now come again.
Our lead article this month focuses on ACL repair. Once abandoned after a landmark paper by Feagin and Curl1 showed poor mid-term results, new and innovative techniques and instrumentation for knee surgery have made this possible. Investigators such as Murray2 and DiFelice3 have done outstanding work showing the feasibility of ACL repair. In this issue we offer a comprehensive review and surgical technique for adding ACL repair to your portfolio of surgical offerings (see pages 408 and 454). Expanded versions of both of these articles are available at amjorthopedics.com.
Our second feature article discusses the reemergence of the ALL, an idea so hot in the public domain that it has been featured as a Jeopardy question. Described originally by Müller4 as the missing link in persistent rotational instability, the ALL might offer the key to improved long-term outcomes for patients undergoing ACL surgery. Read the article on page 418 and learn how to identify which patients are candidates for ALL reconstruction, and a simple surgical technique you can apply to your practice. Scan the provided QR code to watch the accompanying surgical technique video.
The Throwback Issue marks the fifth edition of the “new AJO.” It’s time to let us know how we are doing. Please email us at [email protected] to suggest future themes, articles you’d like to read, or suggestions for improvement.
Recently, based on the work of the authors mentioned above, I’ve begun offering ACL repair to select patients in my practice. I wouldn’t be able to do this if we as orthopedists weren’t constantly looking to improve, and weren’t willing to revisit old ideas to do it. Our goal at AJO is to present something in every article that can be immediately applied to your practice. Take a look at the articles presented this month, as we go “Back to the Future” to see what discarded ideas from our recent past can be applied to improve outcomes for your patients in the future.
Those who cannot remember the past are condemned to repeat it.
—George Santayana (Life of Reason, 1905)
Zero. That’s the number I put on the screen when I start the lecture I give to residents about the future of orthopedics. It represents the number of cases I still do exactly the same way now as I did when I graduated from my residency program. It represents the commitment to lifelong learning that we’ve made as orthopedists. Surgical techniques innovate so rapidly that they often outpace our research, leaving us performing new techniques based solely on industry and key opinion leader recommendation, and not on randomized controlled studies. Sometimes we’re led down the wrong path (remember when the meniscus was thought to be vestigial?) and other times new techniques lead to disappoint
So it seems “everything old is new again.” That’s why this issue of AJO is called The Throwback Issue. In this issue, we revisit ideas whose time has come and gone and now come again.
Our lead article this month focuses on ACL repair. Once abandoned after a landmark paper by Feagin and Curl1 showed poor mid-term results, new and innovative techniques and instrumentation for knee surgery have made this possible. Investigators such as Murray2 and DiFelice3 have done outstanding work showing the feasibility of ACL repair. In this issue we offer a comprehensive review and surgical technique for adding ACL repair to your portfolio of surgical offerings (see pages 408 and 454). Expanded versions of both of these articles are available at amjorthopedics.com.
Our second feature article discusses the reemergence of the ALL, an idea so hot in the public domain that it has been featured as a Jeopardy question. Described originally by Müller4 as the missing link in persistent rotational instability, the ALL might offer the key to improved long-term outcomes for patients undergoing ACL surgery. Read the article on page 418 and learn how to identify which patients are candidates for ALL reconstruction, and a simple surgical technique you can apply to your practice. Scan the provided QR code to watch the accompanying surgical technique video.
The Throwback Issue marks the fifth edition of the “new AJO.” It’s time to let us know how we are doing. Please email us at [email protected] to suggest future themes, articles you’d like to read, or suggestions for improvement.
Recently, based on the work of the authors mentioned above, I’ve begun offering ACL repair to select patients in my practice. I wouldn’t be able to do this if we as orthopedists weren’t constantly looking to improve, and weren’t willing to revisit old ideas to do it. Our goal at AJO is to present something in every article that can be immediately applied to your practice. Take a look at the articles presented this month, as we go “Back to the Future” to see what discarded ideas from our recent past can be applied to improve outcomes for your patients in the future.
1. Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med. 1976;4(3):95-100.
2. Murray MM, Fleming BC. Use of a bioactive scaffold to stimulate anterior cruciate ligament healing also minimizes posttraumatic osteoarthritis after surgery. Am J Sports Med. 2013;41(8):1762-1770.
3. DiFelice GS, Villegas C, Taylor SA. Anterior cruciate ligament preservation: early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair. Arthroscopy. 2015;31(11):2162-2171.
4. Müller W. The Knee: Form, Function, and Ligament Reconstruction. Berlin: Springer-Verlag, 1983.
1. Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med. 1976;4(3):95-100.
2. Murray MM, Fleming BC. Use of a bioactive scaffold to stimulate anterior cruciate ligament healing also minimizes posttraumatic osteoarthritis after surgery. Am J Sports Med. 2013;41(8):1762-1770.
3. DiFelice GS, Villegas C, Taylor SA. Anterior cruciate ligament preservation: early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair. Arthroscopy. 2015;31(11):2162-2171.
4. Müller W. The Knee: Form, Function, and Ligament Reconstruction. Berlin: Springer-Verlag, 1983.
