Commentary

 

Psychiatrists are trained to view involuntary treatment as an unpleasant means to a desirable end, a necessary evil. And we make the assumption that patients who are helped by the care they receive involuntarily will ultimately be grateful for that care.

Dinah Miller, MD, and Annette Hanson, MD, were inspired to write “Committed: The Battle Over Involuntary Psychiatric Care,” when they discovered that this assumption is false, that there are no clear data about the long-term effects of involuntary care, and that many patients whose mental illnesses improved as the result of involuntary care were terribly traumatized by their experiences of being forced into treatment. In writing “Committed,” Dr. Miller and Dr. Hanson set out to understand those experiences, and the contexts, both psychiatric and legal, in which they occurred.

“Committed” covers a broad range of topics related to involuntary care, including hospitalization, retention, medication, ECT, and outpatient commitment. It examines the differences in commitment laws between states. It describes groups with varying ideas about involuntary treatment. It looks at programs that create more humane ways to interact with psychiatric patients. It addresses the relationship between involuntary care and mass murders. And it does all this through the lens of individual cases.

There are two main cases that help tell the “Committed” “story,” Eleanor and Lily. Both were hospitalized involuntarily for psychotic episodes; both improved psychiatrically because of hospitalization; and both currently are functioning well. But years later, Eleanor is still resentful and traumatized, and Lily is grateful.

One of the many strengths of “Committed” is in the open-minded, nonpatronizing way it approaches differences in perspective. Numerous patients were interviewed for the book, and their complaints are taken seriously, not simply dismissed as manifestations of psychosis or “borderline traits.” At the same time, Dr. Miller and Dr. Hanson are well aware of distortions and errors in memory, as well as misperceptions about care, and they share their questioning of patients’ stories.

Another strength of “Committed” is that it does not shy away from controversy. It takes an honest look at the gamut of positions with regard to involuntary treatment, from Dr. E. Fuller Torrey’s Treatment Advocacy Center, which takes the view that it is a disservice not to force patients who are unaware that they are ill into treatment, to the Church of Scientology’s Citizens Commission on Human Rights, which doesn’t believe in the existence of mental illness, and therefore views involuntary treatment as unacceptable under any circumstance. The authors genuinely try to understand each group’s rationale, but they are also courageous enough to state their own position: that involuntary care should be avoided if at all possible but is sometimes necessary as a last resort. They also make the invaluable point that simply placing someone in a locked ward, or assigning him to involuntary outpatient care, will accomplish nothing if there are no adequate services to support his long-term care plan, and that those services require funding.

The book’s one drawback for me is the authors’ choice to break up Eleanor’s and Lily’s cases into segments. I found it a little difficult to pick up where the case had been left off several chapters earlier. But the reason for this choice is clearly that it allows the reader to consider an individual topic in the context of that topic’s application to the main cases.

“Committed” is easy to read and well-written, even waxing poetic at times. In describing Lily, Dr. Miller writes, “Her right cheek was punctuated by the best of dimples.” It is written in such a way that it is easily understandable by a lay person but still has a plethora of information that will be new and useful to mental health professionals. In fact, I am flabbergasted by the amount of research that went into writing it.

Committed bravely addresses the complex question of what it means to take away someone’s rights, not because she committed a crime, but because her mind is not working “normally.” It is an excellent book that should be required reading for anyone interested in the concept of autonomy, which is to say, everyone.

Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York City.

 

Psychiatrists are trained to view involuntary treatment as an unpleasant means to a desirable end, a necessary evil. And we make the assumption that patients who are helped by the care they receive involuntarily will ultimately be grateful for that care.

Dinah Miller, MD, and Annette Hanson, MD, were inspired to write “Committed: The Battle Over Involuntary Psychiatric Care,” when they discovered that this assumption is false, that there are no clear data about the long-term effects of involuntary care, and that many patients whose mental illnesses improved as the result of involuntary care were terribly traumatized by their experiences of being forced into treatment. In writing “Committed,” Dr. Miller and Dr. Hanson set out to understand those experiences, and the contexts, both psychiatric and legal, in which they occurred.

“Committed” covers a broad range of topics related to involuntary care, including hospitalization, retention, medication, ECT, and outpatient commitment. It examines the differences in commitment laws between states. It describes groups with varying ideas about involuntary treatment. It looks at programs that create more humane ways to interact with psychiatric patients. It addresses the relationship between involuntary care and mass murders. And it does all this through the lens of individual cases.

There are two main cases that help tell the “Committed” “story,” Eleanor and Lily. Both were hospitalized involuntarily for psychotic episodes; both improved psychiatrically because of hospitalization; and both currently are functioning well. But years later, Eleanor is still resentful and traumatized, and Lily is grateful.

One of the many strengths of “Committed” is in the open-minded, nonpatronizing way it approaches differences in perspective. Numerous patients were interviewed for the book, and their complaints are taken seriously, not simply dismissed as manifestations of psychosis or “borderline traits.” At the same time, Dr. Miller and Dr. Hanson are well aware of distortions and errors in memory, as well as misperceptions about care, and they share their questioning of patients’ stories.

Another strength of “Committed” is that it does not shy away from controversy. It takes an honest look at the gamut of positions with regard to involuntary treatment, from Dr. E. Fuller Torrey’s Treatment Advocacy Center, which takes the view that it is a disservice not to force patients who are unaware that they are ill into treatment, to the Church of Scientology’s Citizens Commission on Human Rights, which doesn’t believe in the existence of mental illness, and therefore views involuntary treatment as unacceptable under any circumstance. The authors genuinely try to understand each group’s rationale, but they are also courageous enough to state their own position: that involuntary care should be avoided if at all possible but is sometimes necessary as a last resort. They also make the invaluable point that simply placing someone in a locked ward, or assigning him to involuntary outpatient care, will accomplish nothing if there are no adequate services to support his long-term care plan, and that those services require funding.

The book’s one drawback for me is the authors’ choice to break up Eleanor’s and Lily’s cases into segments. I found it a little difficult to pick up where the case had been left off several chapters earlier. But the reason for this choice is clearly that it allows the reader to consider an individual topic in the context of that topic’s application to the main cases.

“Committed” is easy to read and well-written, even waxing poetic at times. In describing Lily, Dr. Miller writes, “Her right cheek was punctuated by the best of dimples.” It is written in such a way that it is easily understandable by a lay person but still has a plethora of information that will be new and useful to mental health professionals. In fact, I am flabbergasted by the amount of research that went into writing it.

Committed bravely addresses the complex question of what it means to take away someone’s rights, not because she committed a crime, but because her mind is not working “normally.” It is an excellent book that should be required reading for anyone interested in the concept of autonomy, which is to say, everyone.

Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York City.

 

Psychiatrists are trained to view involuntary treatment as an unpleasant means to a desirable end, a necessary evil. And we make the assumption that patients who are helped by the care they receive involuntarily will ultimately be grateful for that care.

Dinah Miller, MD, and Annette Hanson, MD, were inspired to write “Committed: The Battle Over Involuntary Psychiatric Care,” when they discovered that this assumption is false, that there are no clear data about the long-term effects of involuntary care, and that many patients whose mental illnesses improved as the result of involuntary care were terribly traumatized by their experiences of being forced into treatment. In writing “Committed,” Dr. Miller and Dr. Hanson set out to understand those experiences, and the contexts, both psychiatric and legal, in which they occurred.

“Committed” covers a broad range of topics related to involuntary care, including hospitalization, retention, medication, ECT, and outpatient commitment. It examines the differences in commitment laws between states. It describes groups with varying ideas about involuntary treatment. It looks at programs that create more humane ways to interact with psychiatric patients. It addresses the relationship between involuntary care and mass murders. And it does all this through the lens of individual cases.

There are two main cases that help tell the “Committed” “story,” Eleanor and Lily. Both were hospitalized involuntarily for psychotic episodes; both improved psychiatrically because of hospitalization; and both currently are functioning well. But years later, Eleanor is still resentful and traumatized, and Lily is grateful.

One of the many strengths of “Committed” is in the open-minded, nonpatronizing way it approaches differences in perspective. Numerous patients were interviewed for the book, and their complaints are taken seriously, not simply dismissed as manifestations of psychosis or “borderline traits.” At the same time, Dr. Miller and Dr. Hanson are well aware of distortions and errors in memory, as well as misperceptions about care, and they share their questioning of patients’ stories.

Another strength of “Committed” is that it does not shy away from controversy. It takes an honest look at the gamut of positions with regard to involuntary treatment, from Dr. E. Fuller Torrey’s Treatment Advocacy Center, which takes the view that it is a disservice not to force patients who are unaware that they are ill into treatment, to the Church of Scientology’s Citizens Commission on Human Rights, which doesn’t believe in the existence of mental illness, and therefore views involuntary treatment as unacceptable under any circumstance. The authors genuinely try to understand each group’s rationale, but they are also courageous enough to state their own position: that involuntary care should be avoided if at all possible but is sometimes necessary as a last resort. They also make the invaluable point that simply placing someone in a locked ward, or assigning him to involuntary outpatient care, will accomplish nothing if there are no adequate services to support his long-term care plan, and that those services require funding.

The book’s one drawback for me is the authors’ choice to break up Eleanor’s and Lily’s cases into segments. I found it a little difficult to pick up where the case had been left off several chapters earlier. But the reason for this choice is clearly that it allows the reader to consider an individual topic in the context of that topic’s application to the main cases.

“Committed” is easy to read and well-written, even waxing poetic at times. In describing Lily, Dr. Miller writes, “Her right cheek was punctuated by the best of dimples.” It is written in such a way that it is easily understandable by a lay person but still has a plethora of information that will be new and useful to mental health professionals. In fact, I am flabbergasted by the amount of research that went into writing it.

Committed bravely addresses the complex question of what it means to take away someone’s rights, not because she committed a crime, but because her mind is not working “normally.” It is an excellent book that should be required reading for anyone interested in the concept of autonomy, which is to say, everyone.

Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York City.

 

In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.

The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.

The Zika virus was a very popular topic. The states with reported cases discussed their efforts to inform patients about the virus and contain its spread. Funding and legislation in support of these efforts was discussed. A relatively new legislative action is exempting feminine hygiene products from state tax, the so-called tampon tax. This tax exemption was recently endorsed by the ACOG Committee on Government Affairs.

Another topic discussed was the push to create a Maternal Mortality Committee in each state. Some states have had this committee for many years and shared pearls for how to get the legislation passed. Collaboration with advocates in the medical community and with the state departments of health was considered to be critical in the passage of legislation to support the creation of these committees.

There was prolonged discussion in the general session, as well as in breakout sessions, about the different types of midwives and the goal to establish a collaborative working relationship with them. Questions discussed included the educational goals for each group, as well as their level of responsibility. The licensing of midwives varies between states, ranging from the State Board of Midwifery to the State Board of Nursing to the State Board of Medicine. Maine was recognized as a state that has successfully created a collaborative relationship with the midwives who practice there. ACOG continues to work with the American College of Nurse-Midwives to create collaborative practice relationships.

Another breakout session focused on reproductive health. This group discussed legislation that interferes with the patient-physician relationship, including mandating an outdated protocol for administering medication abortion and even threatening physicians who provide abortion services with jail time. State legislation to allow pharmacists to prescribe hormonal contraception was also reviewed.

There was consensus among the meeting participants that communication with legislators about evidence-based medicine and sound science, along with ob.gyns.’ advocacy in state legislatures, is critical to counterbalancing inappropriate political interference in the patient-physician relationship. The discussion also touched on the importance of continued collaboration with partners across the medical community, since attempts to legislate the practice of medicine can negatively impact a wide range of clinical practices.

Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

 

In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.

The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.

The Zika virus was a very popular topic. The states with reported cases discussed their efforts to inform patients about the virus and contain its spread. Funding and legislation in support of these efforts was discussed. A relatively new legislative action is exempting feminine hygiene products from state tax, the so-called tampon tax. This tax exemption was recently endorsed by the ACOG Committee on Government Affairs.

Another topic discussed was the push to create a Maternal Mortality Committee in each state. Some states have had this committee for many years and shared pearls for how to get the legislation passed. Collaboration with advocates in the medical community and with the state departments of health was considered to be critical in the passage of legislation to support the creation of these committees.

There was prolonged discussion in the general session, as well as in breakout sessions, about the different types of midwives and the goal to establish a collaborative working relationship with them. Questions discussed included the educational goals for each group, as well as their level of responsibility. The licensing of midwives varies between states, ranging from the State Board of Midwifery to the State Board of Nursing to the State Board of Medicine. Maine was recognized as a state that has successfully created a collaborative relationship with the midwives who practice there. ACOG continues to work with the American College of Nurse-Midwives to create collaborative practice relationships.

Another breakout session focused on reproductive health. This group discussed legislation that interferes with the patient-physician relationship, including mandating an outdated protocol for administering medication abortion and even threatening physicians who provide abortion services with jail time. State legislation to allow pharmacists to prescribe hormonal contraception was also reviewed.

There was consensus among the meeting participants that communication with legislators about evidence-based medicine and sound science, along with ob.gyns.’ advocacy in state legislatures, is critical to counterbalancing inappropriate political interference in the patient-physician relationship. The discussion also touched on the importance of continued collaboration with partners across the medical community, since attempts to legislate the practice of medicine can negatively impact a wide range of clinical practices.

Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

 

In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.

The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.

The Zika virus was a very popular topic. The states with reported cases discussed their efforts to inform patients about the virus and contain its spread. Funding and legislation in support of these efforts was discussed. A relatively new legislative action is exempting feminine hygiene products from state tax, the so-called tampon tax. This tax exemption was recently endorsed by the ACOG Committee on Government Affairs.

Another topic discussed was the push to create a Maternal Mortality Committee in each state. Some states have had this committee for many years and shared pearls for how to get the legislation passed. Collaboration with advocates in the medical community and with the state departments of health was considered to be critical in the passage of legislation to support the creation of these committees.

There was prolonged discussion in the general session, as well as in breakout sessions, about the different types of midwives and the goal to establish a collaborative working relationship with them. Questions discussed included the educational goals for each group, as well as their level of responsibility. The licensing of midwives varies between states, ranging from the State Board of Midwifery to the State Board of Nursing to the State Board of Medicine. Maine was recognized as a state that has successfully created a collaborative relationship with the midwives who practice there. ACOG continues to work with the American College of Nurse-Midwives to create collaborative practice relationships.

Another breakout session focused on reproductive health. This group discussed legislation that interferes with the patient-physician relationship, including mandating an outdated protocol for administering medication abortion and even threatening physicians who provide abortion services with jail time. State legislation to allow pharmacists to prescribe hormonal contraception was also reviewed.

There was consensus among the meeting participants that communication with legislators about evidence-based medicine and sound science, along with ob.gyns.’ advocacy in state legislatures, is critical to counterbalancing inappropriate political interference in the patient-physician relationship. The discussion also touched on the importance of continued collaboration with partners across the medical community, since attempts to legislate the practice of medicine can negatively impact a wide range of clinical practices.

Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

 

The following opinions are my own and not those of the Veterans Health Administration.

A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”

There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.

Know that most service members (active duty Army, Navy, Air Force, and Marines) and recent veterans (for example, those recently discharged from the military and no longer on active duty) do not want to be talking to you, “the shrink”). They may have had bad experiences with either military behavioral health care or the Department of Veterans Affairs.

Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”

So start with neutral subjects and their strengths.

I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).

Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.

The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.

What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.

This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.

Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.

Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”

Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.

So again, focus on strengths. “What did you do in the military that you are most proud of?”

A very practical approach about other issues, such as housing and employment, will go a long way.

Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)

I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.

Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.

So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
 

Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)

 

The following opinions are my own and not those of the Veterans Health Administration.

A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”

There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.

Know that most service members (active duty Army, Navy, Air Force, and Marines) and recent veterans (for example, those recently discharged from the military and no longer on active duty) do not want to be talking to you, “the shrink”). They may have had bad experiences with either military behavioral health care or the Department of Veterans Affairs.

Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”

So start with neutral subjects and their strengths.

I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).

Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.

The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.

What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.

This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.

Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.

Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”

Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.

So again, focus on strengths. “What did you do in the military that you are most proud of?”

A very practical approach about other issues, such as housing and employment, will go a long way.

Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)

I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.

Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.

So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
 

Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)

 

The following opinions are my own and not those of the Veterans Health Administration.

A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”

There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.

Know that most service members (active duty Army, Navy, Air Force, and Marines) and recent veterans (for example, those recently discharged from the military and no longer on active duty) do not want to be talking to you, “the shrink”). They may have had bad experiences with either military behavioral health care or the Department of Veterans Affairs.

Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”

So start with neutral subjects and their strengths.

I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).

Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.

The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.

What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.

This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.

Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.

Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”

Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.

So again, focus on strengths. “What did you do in the military that you are most proud of?”

A very practical approach about other issues, such as housing and employment, will go a long way.

Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)

I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.

Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.

So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
 

Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)

Writing should be fun! While some may view writing as painful (i.e., something you rather put off until all your household work, taxes, and even changing the litter boxes are done), writing can and will become more enjoyable the more you do it. Over the years that I have been writing with students, residents, and faculty, I have found that writing the discussion section of a manuscript remains the most daunting aspect of writing a paper and the No. 1 reason people put off writing. Thus, I have developed a strategy that distills this process into a very simple task. When followed, manuscript writing won’t seem so intimidating.

I like to consider the writing process in three phases: preparing to write, writing, and then revising. Let’s address each one of these.

 

Preparing to write

In preparing to write, it is important to know what audience you want to reach when selecting a journal. I recommend that you peruse the table of contents of the journals you have in mind to determine if that journal is publishing papers similar to yours. You also may want to consider the impact factor of the journal, as the journals you publish in can have an effect on your promotion and tenure process. Once you have decided upon a journal, retrieve the Instructions for Authors (IFA). This section will contain very important information about how the journal would like for you to format the manuscript. Follow these instructions!

If you do not follow these instructions, the journal may reject your manuscript without ever sending it out for review (that is, the managing editor will reject it). Think of it this way, if an editor takes the time to develop the IFA, you’d better believe that the requirements are important to that editor.

Once you have decided upon the journal and read the IFA, it is time to make an OUTLINE. Yes – I said it – an outline. So often we skip this simple task that we were taught in grade school. For a manuscript, the outline I start with includes the figures and/or tables. Your figures and/or tables should tell the story. If they don’t tell a cohesive story, something is wrong. I like to draw out story board on 8.5” x 11” plain paper. Each sheet of paper represents one figure (or table), and I literally draw out each panel. Then I spread the pieces of paper out on a desk to see if they tell the story I want. Once the story is determined, the writing begins.
 

Writing

The main structure of a manuscript is simple: introduction, methods, results, and discussion. The introduction section should tell the reader why you did the study. The methods section should tell the reader how you did the study. The results section should tell the reader what you found when you did the study. The discussion section should tell the reader what it all means. The introduction should spark the readers interest and provide them with enough information to understand why you conducted the study. It should consist of two to three paragraphs. The first paragraph should state the problem. The second paragraph should state what is known and unknown about the problem. The third paragraph should logically follow with your aim and hypothesis. All manuscripts can and should have a hypothesis.

The methods section should be presented in a straightforward and logical manner and include enough information for others to reproduce the experiments. The information should be presented with subheadings for each different section. For example, a clinical manuscript may have the follow subheadings: study design, study population, primary outcome, secondary outcomes, and statistical analysis.

The results section should also be presented in a logical manner, with subheadings that make sense. Be sure to refer to the IFA on the type of subheadings to use (descriptive versus simple, etc.) and remember to tell a story. The story can be told with data of most to least important, in chronological order, in vitro to in vivo, etc. The main point is to tell a good story that the reader will want to read! Be sure to cite your figures and table, but don’t duplicate the information in the figures and tables.

A nice trick is to present the data in each paragraph, and end with a sentence summarizing the results. Remember, data are the facts obtained from the experiments while results are statements that interpret the data.

The discussion section should be seen as a straightforward section to write instead of an intimidating discourse. The discussion section is where you tell the reader what the data might mean, how else the data could be interpreted, if other studies had similar or dissimilar results, the limitations of the study, and what should be done next. I propose that all discussion sections can be written in five paragraphs.

Paragraph 1 should summarize the findings with respect to the hypothesis. Paragraphs 2 and 3 should compare and contrast your data with published literature. Paragraph 4 should address limitations of the study. Paragraph 5 should conclude what it all means and what should happen next. If you start by outlining these five paragraphs, the discussion section becomes simple to write.
 

Revising

The most important aspect of writing a manuscript is revising. The importance of this is often overlooked. We all make mistakes in writing. The more you reread and revise your own work, the better it gets. Aim for writing simple sentences that are easy for your reader to read. Choose words carefully and precisely. Write well-designed sentences and structured paragraphs. The Internet has many short online tutorials to remind one how to do this. Use abbreviations sparingly and avoid wordiness. Avoid writing flaws, especially with the subject and verb. For example, “Controls were performed” should read “Control experiments were performed.”

In summary, writing should be an enjoyable process in which one can communicate exciting ideas to others. In this short article, I have presented a few tips and tricks on how to write and revise a manuscript. For a more in-depth resource, I refer the reader to “How to write a paper,” published in 2013 (ANZ J Surg. Jan;83[1-2]:90-2).

Dr. Kibbe is the Zack D. Owens Professor and Chair, department of surgery, the University of North Carolina at Chapel Hill.
 

Writing should be fun! While some may view writing as painful (i.e., something you rather put off until all your household work, taxes, and even changing the litter boxes are done), writing can and will become more enjoyable the more you do it. Over the years that I have been writing with students, residents, and faculty, I have found that writing the discussion section of a manuscript remains the most daunting aspect of writing a paper and the No. 1 reason people put off writing. Thus, I have developed a strategy that distills this process into a very simple task. When followed, manuscript writing won’t seem so intimidating.

I like to consider the writing process in three phases: preparing to write, writing, and then revising. Let’s address each one of these.

 

Preparing to write

In preparing to write, it is important to know what audience you want to reach when selecting a journal. I recommend that you peruse the table of contents of the journals you have in mind to determine if that journal is publishing papers similar to yours. You also may want to consider the impact factor of the journal, as the journals you publish in can have an effect on your promotion and tenure process. Once you have decided upon a journal, retrieve the Instructions for Authors (IFA). This section will contain very important information about how the journal would like for you to format the manuscript. Follow these instructions!

If you do not follow these instructions, the journal may reject your manuscript without ever sending it out for review (that is, the managing editor will reject it). Think of it this way, if an editor takes the time to develop the IFA, you’d better believe that the requirements are important to that editor.

Once you have decided upon the journal and read the IFA, it is time to make an OUTLINE. Yes – I said it – an outline. So often we skip this simple task that we were taught in grade school. For a manuscript, the outline I start with includes the figures and/or tables. Your figures and/or tables should tell the story. If they don’t tell a cohesive story, something is wrong. I like to draw out story board on 8.5” x 11” plain paper. Each sheet of paper represents one figure (or table), and I literally draw out each panel. Then I spread the pieces of paper out on a desk to see if they tell the story I want. Once the story is determined, the writing begins.
 

Writing

The main structure of a manuscript is simple: introduction, methods, results, and discussion. The introduction section should tell the reader why you did the study. The methods section should tell the reader how you did the study. The results section should tell the reader what you found when you did the study. The discussion section should tell the reader what it all means. The introduction should spark the readers interest and provide them with enough information to understand why you conducted the study. It should consist of two to three paragraphs. The first paragraph should state the problem. The second paragraph should state what is known and unknown about the problem. The third paragraph should logically follow with your aim and hypothesis. All manuscripts can and should have a hypothesis.

The methods section should be presented in a straightforward and logical manner and include enough information for others to reproduce the experiments. The information should be presented with subheadings for each different section. For example, a clinical manuscript may have the follow subheadings: study design, study population, primary outcome, secondary outcomes, and statistical analysis.

The results section should also be presented in a logical manner, with subheadings that make sense. Be sure to refer to the IFA on the type of subheadings to use (descriptive versus simple, etc.) and remember to tell a story. The story can be told with data of most to least important, in chronological order, in vitro to in vivo, etc. The main point is to tell a good story that the reader will want to read! Be sure to cite your figures and table, but don’t duplicate the information in the figures and tables.

A nice trick is to present the data in each paragraph, and end with a sentence summarizing the results. Remember, data are the facts obtained from the experiments while results are statements that interpret the data.

The discussion section should be seen as a straightforward section to write instead of an intimidating discourse. The discussion section is where you tell the reader what the data might mean, how else the data could be interpreted, if other studies had similar or dissimilar results, the limitations of the study, and what should be done next. I propose that all discussion sections can be written in five paragraphs.

Paragraph 1 should summarize the findings with respect to the hypothesis. Paragraphs 2 and 3 should compare and contrast your data with published literature. Paragraph 4 should address limitations of the study. Paragraph 5 should conclude what it all means and what should happen next. If you start by outlining these five paragraphs, the discussion section becomes simple to write.
 

Revising

The most important aspect of writing a manuscript is revising. The importance of this is often overlooked. We all make mistakes in writing. The more you reread and revise your own work, the better it gets. Aim for writing simple sentences that are easy for your reader to read. Choose words carefully and precisely. Write well-designed sentences and structured paragraphs. The Internet has many short online tutorials to remind one how to do this. Use abbreviations sparingly and avoid wordiness. Avoid writing flaws, especially with the subject and verb. For example, “Controls were performed” should read “Control experiments were performed.”

In summary, writing should be an enjoyable process in which one can communicate exciting ideas to others. In this short article, I have presented a few tips and tricks on how to write and revise a manuscript. For a more in-depth resource, I refer the reader to “How to write a paper,” published in 2013 (ANZ J Surg. Jan;83[1-2]:90-2).

Dr. Kibbe is the Zack D. Owens Professor and Chair, department of surgery, the University of North Carolina at Chapel Hill.
 

Writing should be fun! While some may view writing as painful (i.e., something you rather put off until all your household work, taxes, and even changing the litter boxes are done), writing can and will become more enjoyable the more you do it. Over the years that I have been writing with students, residents, and faculty, I have found that writing the discussion section of a manuscript remains the most daunting aspect of writing a paper and the No. 1 reason people put off writing. Thus, I have developed a strategy that distills this process into a very simple task. When followed, manuscript writing won’t seem so intimidating.

I like to consider the writing process in three phases: preparing to write, writing, and then revising. Let’s address each one of these.

 

Preparing to write

In preparing to write, it is important to know what audience you want to reach when selecting a journal. I recommend that you peruse the table of contents of the journals you have in mind to determine if that journal is publishing papers similar to yours. You also may want to consider the impact factor of the journal, as the journals you publish in can have an effect on your promotion and tenure process. Once you have decided upon a journal, retrieve the Instructions for Authors (IFA). This section will contain very important information about how the journal would like for you to format the manuscript. Follow these instructions!

If you do not follow these instructions, the journal may reject your manuscript without ever sending it out for review (that is, the managing editor will reject it). Think of it this way, if an editor takes the time to develop the IFA, you’d better believe that the requirements are important to that editor.

Once you have decided upon the journal and read the IFA, it is time to make an OUTLINE. Yes – I said it – an outline. So often we skip this simple task that we were taught in grade school. For a manuscript, the outline I start with includes the figures and/or tables. Your figures and/or tables should tell the story. If they don’t tell a cohesive story, something is wrong. I like to draw out story board on 8.5” x 11” plain paper. Each sheet of paper represents one figure (or table), and I literally draw out each panel. Then I spread the pieces of paper out on a desk to see if they tell the story I want. Once the story is determined, the writing begins.
 

Writing

The main structure of a manuscript is simple: introduction, methods, results, and discussion. The introduction section should tell the reader why you did the study. The methods section should tell the reader how you did the study. The results section should tell the reader what you found when you did the study. The discussion section should tell the reader what it all means. The introduction should spark the readers interest and provide them with enough information to understand why you conducted the study. It should consist of two to three paragraphs. The first paragraph should state the problem. The second paragraph should state what is known and unknown about the problem. The third paragraph should logically follow with your aim and hypothesis. All manuscripts can and should have a hypothesis.

The methods section should be presented in a straightforward and logical manner and include enough information for others to reproduce the experiments. The information should be presented with subheadings for each different section. For example, a clinical manuscript may have the follow subheadings: study design, study population, primary outcome, secondary outcomes, and statistical analysis.

The results section should also be presented in a logical manner, with subheadings that make sense. Be sure to refer to the IFA on the type of subheadings to use (descriptive versus simple, etc.) and remember to tell a story. The story can be told with data of most to least important, in chronological order, in vitro to in vivo, etc. The main point is to tell a good story that the reader will want to read! Be sure to cite your figures and table, but don’t duplicate the information in the figures and tables.

A nice trick is to present the data in each paragraph, and end with a sentence summarizing the results. Remember, data are the facts obtained from the experiments while results are statements that interpret the data.

The discussion section should be seen as a straightforward section to write instead of an intimidating discourse. The discussion section is where you tell the reader what the data might mean, how else the data could be interpreted, if other studies had similar or dissimilar results, the limitations of the study, and what should be done next. I propose that all discussion sections can be written in five paragraphs.

Paragraph 1 should summarize the findings with respect to the hypothesis. Paragraphs 2 and 3 should compare and contrast your data with published literature. Paragraph 4 should address limitations of the study. Paragraph 5 should conclude what it all means and what should happen next. If you start by outlining these five paragraphs, the discussion section becomes simple to write.
 

Revising

The most important aspect of writing a manuscript is revising. The importance of this is often overlooked. We all make mistakes in writing. The more you reread and revise your own work, the better it gets. Aim for writing simple sentences that are easy for your reader to read. Choose words carefully and precisely. Write well-designed sentences and structured paragraphs. The Internet has many short online tutorials to remind one how to do this. Use abbreviations sparingly and avoid wordiness. Avoid writing flaws, especially with the subject and verb. For example, “Controls were performed” should read “Control experiments were performed.”

In summary, writing should be an enjoyable process in which one can communicate exciting ideas to others. In this short article, I have presented a few tips and tricks on how to write and revise a manuscript. For a more in-depth resource, I refer the reader to “How to write a paper,” published in 2013 (ANZ J Surg. Jan;83[1-2]:90-2).

Dr. Kibbe is the Zack D. Owens Professor and Chair, department of surgery, the University of North Carolina at Chapel Hill.
 

 

How much is 15%?

Not that much, on paper. With any drug, at least 15% of people will get some kind of side effect. Usually they all list dizziness and headaches at the top.

But what if a commonly used drug that we all viewed as fairly benign (acetaminophen 650 mg, for example) had a 15% risk of causing death or some other serious side effect? Would you still prescribe it? Or use it yourself? Probably not. There’s a big difference between saving 15% on Amazon and a 15% morbidity and mortality rate.

Could the same be true of a seemingly harmless technology?

Voice recognition software has become pretty commonplace in modern medicine but is far from perfect. I try to be pretty careful about proofreading my dictations, but many docs, especially those in emergency room, don’t have the time to. So VR errors slip by, persisting in 71% of notes.

Most of these errors are just silly and obvious for what they are. But a recent study at a level I ER found that 15% of dictations contained one or more errors deemed as “critical,” with the potential to adversely affect patient care (Int J Med Inform. 2016 Sep;93:70-3).

Communication among doctors, nurses, and all the other key players in the hospital environment is one of the most critical areas in modern medicine. So many people often rely on the initial dictation for an idea of what’s going on that a critical error can affect the way they think about the case from the get-go.

Another issue, sadly, in today’s hospital is that no one takes (or has) the time to get a patient’s past medical history. It’s commonplace to pull the history out of previous admission notes. (Admittedly, sometimes in a demented or unconscious patient you don’t have a choice.) As a result, errors of this sort tend to propagate down the line, from an admission, to the consults, to the discharge summary, and into the next admission.

So let’s get back to that 15%.

I have to assume that 15% of people being admitted aren’t having catastrophic events from medical errors, hopefully because the doctors and nurses handling patient care are thinking for themselves, recognizing dictation errors, and addressing them appropriately.

But even if we dial it down to a tenth of that, say 1.5%, it’s still a serious concern. Bad outcomes in medicine are never entirely avoidable. That’s the nature of the job.

But bad outcomes caused by too much trust in a still-faulty technology are avoidable.

If 15% of people had a serious outcome from a medication, you’d be very cautious about using it. We need to treat these technological gadgets with the same concerns we extend to drugs and procedures. Avoidable bad outcomes, regardless of cause, are never good.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

How much is 15%?

Not that much, on paper. With any drug, at least 15% of people will get some kind of side effect. Usually they all list dizziness and headaches at the top.

But what if a commonly used drug that we all viewed as fairly benign (acetaminophen 650 mg, for example) had a 15% risk of causing death or some other serious side effect? Would you still prescribe it? Or use it yourself? Probably not. There’s a big difference between saving 15% on Amazon and a 15% morbidity and mortality rate.

Could the same be true of a seemingly harmless technology?

Voice recognition software has become pretty commonplace in modern medicine but is far from perfect. I try to be pretty careful about proofreading my dictations, but many docs, especially those in emergency room, don’t have the time to. So VR errors slip by, persisting in 71% of notes.

Most of these errors are just silly and obvious for what they are. But a recent study at a level I ER found that 15% of dictations contained one or more errors deemed as “critical,” with the potential to adversely affect patient care (Int J Med Inform. 2016 Sep;93:70-3).

Communication among doctors, nurses, and all the other key players in the hospital environment is one of the most critical areas in modern medicine. So many people often rely on the initial dictation for an idea of what’s going on that a critical error can affect the way they think about the case from the get-go.

Another issue, sadly, in today’s hospital is that no one takes (or has) the time to get a patient’s past medical history. It’s commonplace to pull the history out of previous admission notes. (Admittedly, sometimes in a demented or unconscious patient you don’t have a choice.) As a result, errors of this sort tend to propagate down the line, from an admission, to the consults, to the discharge summary, and into the next admission.

So let’s get back to that 15%.

I have to assume that 15% of people being admitted aren’t having catastrophic events from medical errors, hopefully because the doctors and nurses handling patient care are thinking for themselves, recognizing dictation errors, and addressing them appropriately.

But even if we dial it down to a tenth of that, say 1.5%, it’s still a serious concern. Bad outcomes in medicine are never entirely avoidable. That’s the nature of the job.

But bad outcomes caused by too much trust in a still-faulty technology are avoidable.

If 15% of people had a serious outcome from a medication, you’d be very cautious about using it. We need to treat these technological gadgets with the same concerns we extend to drugs and procedures. Avoidable bad outcomes, regardless of cause, are never good.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

How much is 15%?

Not that much, on paper. With any drug, at least 15% of people will get some kind of side effect. Usually they all list dizziness and headaches at the top.

But what if a commonly used drug that we all viewed as fairly benign (acetaminophen 650 mg, for example) had a 15% risk of causing death or some other serious side effect? Would you still prescribe it? Or use it yourself? Probably not. There’s a big difference between saving 15% on Amazon and a 15% morbidity and mortality rate.

Could the same be true of a seemingly harmless technology?

Voice recognition software has become pretty commonplace in modern medicine but is far from perfect. I try to be pretty careful about proofreading my dictations, but many docs, especially those in emergency room, don’t have the time to. So VR errors slip by, persisting in 71% of notes.

Most of these errors are just silly and obvious for what they are. But a recent study at a level I ER found that 15% of dictations contained one or more errors deemed as “critical,” with the potential to adversely affect patient care (Int J Med Inform. 2016 Sep;93:70-3).

Communication among doctors, nurses, and all the other key players in the hospital environment is one of the most critical areas in modern medicine. So many people often rely on the initial dictation for an idea of what’s going on that a critical error can affect the way they think about the case from the get-go.

Another issue, sadly, in today’s hospital is that no one takes (or has) the time to get a patient’s past medical history. It’s commonplace to pull the history out of previous admission notes. (Admittedly, sometimes in a demented or unconscious patient you don’t have a choice.) As a result, errors of this sort tend to propagate down the line, from an admission, to the consults, to the discharge summary, and into the next admission.

So let’s get back to that 15%.

I have to assume that 15% of people being admitted aren’t having catastrophic events from medical errors, hopefully because the doctors and nurses handling patient care are thinking for themselves, recognizing dictation errors, and addressing them appropriately.

But even if we dial it down to a tenth of that, say 1.5%, it’s still a serious concern. Bad outcomes in medicine are never entirely avoidable. That’s the nature of the job.

But bad outcomes caused by too much trust in a still-faulty technology are avoidable.

If 15% of people had a serious outcome from a medication, you’d be very cautious about using it. We need to treat these technological gadgets with the same concerns we extend to drugs and procedures. Avoidable bad outcomes, regardless of cause, are never good.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.

Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)¹ and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),² do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.

Our team developed the hospital medicine comportment and communication observation tool (HMCCOT) as a way to assess a hospitalist’s performance at the bedside while they saw patients.³ The tool was iteratively revised and validated using multiple methods. An observer watches a hospitalist care for a patient and notes whether or not desirable behaviors are executed. A score is calculated using the HMCCOT variables, and places where the provider does not score highly can be used as a coaching tool to give immediate feedback related to comportment and communication with patients.

In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.

Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.⁴ Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.⁵ Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.

Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”⁶ A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.

Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.

Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.
 

1. Press Ganey. Accessed Dec. 15, 2015.

2. HCAHPS. Accessed Feb. 2, 2016.

3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647.

4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7.

5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.

6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.

Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.

 

With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.

Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)¹ and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),² do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.

Our team developed the hospital medicine comportment and communication observation tool (HMCCOT) as a way to assess a hospitalist’s performance at the bedside while they saw patients.³ The tool was iteratively revised and validated using multiple methods. An observer watches a hospitalist care for a patient and notes whether or not desirable behaviors are executed. A score is calculated using the HMCCOT variables, and places where the provider does not score highly can be used as a coaching tool to give immediate feedback related to comportment and communication with patients.

In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.

Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.⁴ Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.⁵ Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.

Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”⁶ A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.

Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.

Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.
 

1. Press Ganey. Accessed Dec. 15, 2015.

2. HCAHPS. Accessed Feb. 2, 2016.

3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647.

4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7.

5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.

6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.

Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.

 

With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.

Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)¹ and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),² do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.

Our team developed the hospital medicine comportment and communication observation tool (HMCCOT) as a way to assess a hospitalist’s performance at the bedside while they saw patients.³ The tool was iteratively revised and validated using multiple methods. An observer watches a hospitalist care for a patient and notes whether or not desirable behaviors are executed. A score is calculated using the HMCCOT variables, and places where the provider does not score highly can be used as a coaching tool to give immediate feedback related to comportment and communication with patients.

In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.

Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.⁴ Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.⁵ Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.

Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”⁶ A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.

Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.

Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.
 

1. Press Ganey. Accessed Dec. 15, 2015.

2. HCAHPS. Accessed Feb. 2, 2016.

3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647.

4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7.

5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.

6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.

Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.

 

Enhanced recovery surgical principles were first described in the 1990s.¹ These principles postulate that the body’s stress response to surgical injury and deviation from normal physiology is the source of postoperative morbidity. Thus, enhanced recovery programs are designed around perioperative interventions that mitigate and help the body cope with the surgical stress response.

Many of these interventions run counter to traditional perioperative care paradigms. Enhanced recovery protocols are diverse but have common themes of avoiding preoperative fasting and bowel preparation, early oral intake, limiting use of drains and catheters, multimodal analgesia, early ambulation, and prioritizing euvolemia and normothermia. Individual interventions in these areas are combined to create a master protocol, which is implemented as a bundle to improve surgical outcomes.

Current components

Minimizing preoperative fasting, early postoperative refeeding, and preoperative carbohydrate-loading drinks are all key aspects of enhanced recovery protocols. “NPO after midnight” has been a longstanding rule due to the risk of aspiration with intubation. However, a Cochrane review found no evidence that a shortened period of fasting was associated with an increased risk of aspiration or related morbidity. Currently, the American Society of Anesthesiologists recommends only a 6-hour fast for solid foods and 2 hours for clear liquids.^2,3

Preoperative fasting causes depletion of glycogen stores leading to insulin resistance and hyperglycemia, which are both associated with postoperative complications and morbidity.⁴ Preoperative carbohydrate-loading drinks can reverse some of the effects of limited preoperative fasting including preventing insulin resistance and hyperglycemia.⁵

Postoperative fasting should also be avoided. Early enteral intake is very important to decrease time spent in a catabolic state and decrease insulin resistance. In gynecology patients, early refeeding is associated with a faster return of bowel function and a decreased length of stay without an increase in postoperative complications.⁶ Notably, patients undergoing early feeding consistently experience more nausea and vomiting, but this is not associated with complications.⁷

The fluid management goal in enhanced recovery is to maintain perioperative euvolemia, as both hypovolemia and hypervolemia have negative physiologic consequences. When studied, fluid protocols designed to minimize the use of postoperative fluids have resulted in decreased cardiopulmonary complications, decreased postoperative morbidity, faster return of bowel function, and shorter hospital stays.⁸ Given the morbidity associated with fluid overload, enhanced recovery protocols recommend that minimal fluids be given in the operating room and intravenous fluids be removed as quickly as possible, often with first oral intake or postoperative day 1 at the latest.

High-quality postoperative pain control is critical to achieve the goals of early mobilization and early feeding. Pain management strategies focus on decreasing the total amount of intravenous opioids by combining regional anesthetics techniques with multimodal pharmacologic pain management. Minimizing the surgical insult and other deviations from normal physiology are important as well. This includes avoiding peritoneal drains, no routine use of nasogastric tubes, quick removal of urinary catheters, and use of minimally invasive surgery and the smallest laparotomy incision if possible.

Engagement of the patient in their perioperative recovery with patient education materials and expectations for postoperative tasks, such as early refeeding, spirometry, and ambulation are all important components of enhanced recovery. Patients become partners in achieving postoperative milestones, and this results in improved outcomes such as decreased pain scores and shorter recoveries.

Evidence in gynecology

Enhanced recovery has been studied in many surgical disciplines including urology, colorectal surgery, hepatobiliary surgery, and gynecology. High-quality studies of abdominal and vaginal hysterectomy patients have consistently found a decrease in length of stay with no difference in readmission or postoperative complication rates.⁹ An interesting study also found that an enhanced recovery program was associated with decreased nursing time required for patient care.¹⁰

For ovarian cancer patients, enhanced recovery is associated with decreased length of stay, decreased time to return of bowel function, and improved quality of life. Enhanced recovery is also cost saving, saving $257-$697 per vaginal hysterectomy patient and $5,410-$7,600 per ovarian cancer patient.¹¹

Enhanced recovery protocols are safe, evidenced based, cost saving, and are increasingly being adopted as clinicians and health systems become aware of their benefits.

References

1. Br J Anaesth. 1997 May;78(5):606-17.

2. Cochrane Database Syst Rev. 2003 Oct 20;(4):CD004423.

3. Anesthesiology. 1999 Mar;90(3):896-905.

4. J Am Coll Surg. 2012 Jan;214(1):68-80.

5. Clin Nutr. 1998 Apr;17(2):65-71.

6. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508.

7. Obstet Gynecol. 1998 Jul;92(1):94-7.

8. Br J Surg. 2009 Apr;96(4):331-41.

9. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.

10. Qual Saf Health Care. 2009 Jun;18(3):236-40.

11. Gynecol Oncol. 2008 Feb;108(2):282-6.
 

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Barber is a third-year fellow in gynecologic oncology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].

 

Enhanced recovery surgical principles were first described in the 1990s.¹ These principles postulate that the body’s stress response to surgical injury and deviation from normal physiology is the source of postoperative morbidity. Thus, enhanced recovery programs are designed around perioperative interventions that mitigate and help the body cope with the surgical stress response.

Many of these interventions run counter to traditional perioperative care paradigms. Enhanced recovery protocols are diverse but have common themes of avoiding preoperative fasting and bowel preparation, early oral intake, limiting use of drains and catheters, multimodal analgesia, early ambulation, and prioritizing euvolemia and normothermia. Individual interventions in these areas are combined to create a master protocol, which is implemented as a bundle to improve surgical outcomes.

Current components

Minimizing preoperative fasting, early postoperative refeeding, and preoperative carbohydrate-loading drinks are all key aspects of enhanced recovery protocols. “NPO after midnight” has been a longstanding rule due to the risk of aspiration with intubation. However, a Cochrane review found no evidence that a shortened period of fasting was associated with an increased risk of aspiration or related morbidity. Currently, the American Society of Anesthesiologists recommends only a 6-hour fast for solid foods and 2 hours for clear liquids.^2,3

Preoperative fasting causes depletion of glycogen stores leading to insulin resistance and hyperglycemia, which are both associated with postoperative complications and morbidity.⁴ Preoperative carbohydrate-loading drinks can reverse some of the effects of limited preoperative fasting including preventing insulin resistance and hyperglycemia.⁵

Postoperative fasting should also be avoided. Early enteral intake is very important to decrease time spent in a catabolic state and decrease insulin resistance. In gynecology patients, early refeeding is associated with a faster return of bowel function and a decreased length of stay without an increase in postoperative complications.⁶ Notably, patients undergoing early feeding consistently experience more nausea and vomiting, but this is not associated with complications.⁷

The fluid management goal in enhanced recovery is to maintain perioperative euvolemia, as both hypovolemia and hypervolemia have negative physiologic consequences. When studied, fluid protocols designed to minimize the use of postoperative fluids have resulted in decreased cardiopulmonary complications, decreased postoperative morbidity, faster return of bowel function, and shorter hospital stays.⁸ Given the morbidity associated with fluid overload, enhanced recovery protocols recommend that minimal fluids be given in the operating room and intravenous fluids be removed as quickly as possible, often with first oral intake or postoperative day 1 at the latest.

High-quality postoperative pain control is critical to achieve the goals of early mobilization and early feeding. Pain management strategies focus on decreasing the total amount of intravenous opioids by combining regional anesthetics techniques with multimodal pharmacologic pain management. Minimizing the surgical insult and other deviations from normal physiology are important as well. This includes avoiding peritoneal drains, no routine use of nasogastric tubes, quick removal of urinary catheters, and use of minimally invasive surgery and the smallest laparotomy incision if possible.

Engagement of the patient in their perioperative recovery with patient education materials and expectations for postoperative tasks, such as early refeeding, spirometry, and ambulation are all important components of enhanced recovery. Patients become partners in achieving postoperative milestones, and this results in improved outcomes such as decreased pain scores and shorter recoveries.

Evidence in gynecology

Enhanced recovery has been studied in many surgical disciplines including urology, colorectal surgery, hepatobiliary surgery, and gynecology. High-quality studies of abdominal and vaginal hysterectomy patients have consistently found a decrease in length of stay with no difference in readmission or postoperative complication rates.⁹ An interesting study also found that an enhanced recovery program was associated with decreased nursing time required for patient care.¹⁰

For ovarian cancer patients, enhanced recovery is associated with decreased length of stay, decreased time to return of bowel function, and improved quality of life. Enhanced recovery is also cost saving, saving $257-$697 per vaginal hysterectomy patient and $5,410-$7,600 per ovarian cancer patient.¹¹

Enhanced recovery protocols are safe, evidenced based, cost saving, and are increasingly being adopted as clinicians and health systems become aware of their benefits.

References

1. Br J Anaesth. 1997 May;78(5):606-17.

2. Cochrane Database Syst Rev. 2003 Oct 20;(4):CD004423.

3. Anesthesiology. 1999 Mar;90(3):896-905.

4. J Am Coll Surg. 2012 Jan;214(1):68-80.

5. Clin Nutr. 1998 Apr;17(2):65-71.

6. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508.

7. Obstet Gynecol. 1998 Jul;92(1):94-7.

8. Br J Surg. 2009 Apr;96(4):331-41.

9. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.

10. Qual Saf Health Care. 2009 Jun;18(3):236-40.

11. Gynecol Oncol. 2008 Feb;108(2):282-6.
 

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Barber is a third-year fellow in gynecologic oncology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].

 

Enhanced recovery surgical principles were first described in the 1990s.¹ These principles postulate that the body’s stress response to surgical injury and deviation from normal physiology is the source of postoperative morbidity. Thus, enhanced recovery programs are designed around perioperative interventions that mitigate and help the body cope with the surgical stress response.

Many of these interventions run counter to traditional perioperative care paradigms. Enhanced recovery protocols are diverse but have common themes of avoiding preoperative fasting and bowel preparation, early oral intake, limiting use of drains and catheters, multimodal analgesia, early ambulation, and prioritizing euvolemia and normothermia. Individual interventions in these areas are combined to create a master protocol, which is implemented as a bundle to improve surgical outcomes.

Current components

Minimizing preoperative fasting, early postoperative refeeding, and preoperative carbohydrate-loading drinks are all key aspects of enhanced recovery protocols. “NPO after midnight” has been a longstanding rule due to the risk of aspiration with intubation. However, a Cochrane review found no evidence that a shortened period of fasting was associated with an increased risk of aspiration or related morbidity. Currently, the American Society of Anesthesiologists recommends only a 6-hour fast for solid foods and 2 hours for clear liquids.^2,3

Preoperative fasting causes depletion of glycogen stores leading to insulin resistance and hyperglycemia, which are both associated with postoperative complications and morbidity.⁴ Preoperative carbohydrate-loading drinks can reverse some of the effects of limited preoperative fasting including preventing insulin resistance and hyperglycemia.⁵

Postoperative fasting should also be avoided. Early enteral intake is very important to decrease time spent in a catabolic state and decrease insulin resistance. In gynecology patients, early refeeding is associated with a faster return of bowel function and a decreased length of stay without an increase in postoperative complications.⁶ Notably, patients undergoing early feeding consistently experience more nausea and vomiting, but this is not associated with complications.⁷

The fluid management goal in enhanced recovery is to maintain perioperative euvolemia, as both hypovolemia and hypervolemia have negative physiologic consequences. When studied, fluid protocols designed to minimize the use of postoperative fluids have resulted in decreased cardiopulmonary complications, decreased postoperative morbidity, faster return of bowel function, and shorter hospital stays.⁸ Given the morbidity associated with fluid overload, enhanced recovery protocols recommend that minimal fluids be given in the operating room and intravenous fluids be removed as quickly as possible, often with first oral intake or postoperative day 1 at the latest.

High-quality postoperative pain control is critical to achieve the goals of early mobilization and early feeding. Pain management strategies focus on decreasing the total amount of intravenous opioids by combining regional anesthetics techniques with multimodal pharmacologic pain management. Minimizing the surgical insult and other deviations from normal physiology are important as well. This includes avoiding peritoneal drains, no routine use of nasogastric tubes, quick removal of urinary catheters, and use of minimally invasive surgery and the smallest laparotomy incision if possible.

Engagement of the patient in their perioperative recovery with patient education materials and expectations for postoperative tasks, such as early refeeding, spirometry, and ambulation are all important components of enhanced recovery. Patients become partners in achieving postoperative milestones, and this results in improved outcomes such as decreased pain scores and shorter recoveries.

Evidence in gynecology

Enhanced recovery has been studied in many surgical disciplines including urology, colorectal surgery, hepatobiliary surgery, and gynecology. High-quality studies of abdominal and vaginal hysterectomy patients have consistently found a decrease in length of stay with no difference in readmission or postoperative complication rates.⁹ An interesting study also found that an enhanced recovery program was associated with decreased nursing time required for patient care.¹⁰

For ovarian cancer patients, enhanced recovery is associated with decreased length of stay, decreased time to return of bowel function, and improved quality of life. Enhanced recovery is also cost saving, saving $257-$697 per vaginal hysterectomy patient and $5,410-$7,600 per ovarian cancer patient.¹¹

Enhanced recovery protocols are safe, evidenced based, cost saving, and are increasingly being adopted as clinicians and health systems become aware of their benefits.

References

1. Br J Anaesth. 1997 May;78(5):606-17.

2. Cochrane Database Syst Rev. 2003 Oct 20;(4):CD004423.

3. Anesthesiology. 1999 Mar;90(3):896-905.

4. J Am Coll Surg. 2012 Jan;214(1):68-80.

5. Clin Nutr. 1998 Apr;17(2):65-71.

6. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508.

7. Obstet Gynecol. 1998 Jul;92(1):94-7.

8. Br J Surg. 2009 Apr;96(4):331-41.

9. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.

10. Qual Saf Health Care. 2009 Jun;18(3):236-40.

11. Gynecol Oncol. 2008 Feb;108(2):282-6.
 

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Barber is a third-year fellow in gynecologic oncology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].

 

In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.¹ The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.² Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.³ Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.⁴ Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

On any given night, our urban, downtown emergency department is chaotic, whether from the trauma case arriving minutes earlier or perhaps the patient high on PCP shouting from the “quiet room.” In the ED, psychiatric patients are placed on elopement precautions and assigned to recliners or beds near the center of the ED so they can be watched by sitters. These patients, who come to the ED with a chief complaint of emotional suffering, are exposed to the epicenter of the controlled chaos.

If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.

When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.⁵ I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.

The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.

However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
 

 

References

1. BMC Health Serv Res. 2006;6:150.

2. Health Policy. 2000 Oct;53(3):157-84.

3. Adm Policy Ment Health. 2012 May;39(3):200-9.

4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.

5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

 

In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.¹ The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.² Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.³ Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.⁴ Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

On any given night, our urban, downtown emergency department is chaotic, whether from the trauma case arriving minutes earlier or perhaps the patient high on PCP shouting from the “quiet room.” In the ED, psychiatric patients are placed on elopement precautions and assigned to recliners or beds near the center of the ED so they can be watched by sitters. These patients, who come to the ED with a chief complaint of emotional suffering, are exposed to the epicenter of the controlled chaos.

If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.

When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.⁵ I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.

The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.

However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
 

 

References

1. BMC Health Serv Res. 2006;6:150.

2. Health Policy. 2000 Oct;53(3):157-84.

3. Adm Policy Ment Health. 2012 May;39(3):200-9.

4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.

5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

 

In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.¹ The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.² Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.³ Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.⁴ Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

On any given night, our urban, downtown emergency department is chaotic, whether from the trauma case arriving minutes earlier or perhaps the patient high on PCP shouting from the “quiet room.” In the ED, psychiatric patients are placed on elopement precautions and assigned to recliners or beds near the center of the ED so they can be watched by sitters. These patients, who come to the ED with a chief complaint of emotional suffering, are exposed to the epicenter of the controlled chaos.

If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.

When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.⁵ I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.

The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.

However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
 

 

References

1. BMC Health Serv Res. 2006;6:150.

2. Health Policy. 2000 Oct;53(3):157-84.

3. Adm Policy Ment Health. 2012 May;39(3):200-9.

4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.

5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

 

Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.

Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU) regulations, and adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC).

When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).

The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov.) And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
 

 

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] .

 

Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.

Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU) regulations, and adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC).

When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).

The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov.) And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
 

 

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] .

 

Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.

Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU) regulations, and adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC).

When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).

The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov.) And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
 

 

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] .

 

A 55-year-old man presents to the emergency department with substernal chest pain. The pain has occurred off and on over the past 2 hours. He has no family history of coronary artery disease. He has no history of diabetes, hypertension, or cigarette smoking. His most recent total cholesterol was 220 mg/dL (HDL, 40; LDL, 155). Blood pressure is 130/70. An ECG obtained on arrival is unremarkable. When he reached the ED, he received a nitroglycerin tablet with resolution of his pain within 4 minutes.

What is the most accurate statement?

A. The chance of CAD in this man over the next 10 years was 8% before his symptoms and is now greater than 20%.

B. The chance of CAD in this man over the next 10 years was 8% and is still 8%.

C. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 100%.

D. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 50%.

For years, giving nitroglycerin to patients who present with chest pain has been considered a good therapy, and the response to the medication has been considered a sign that the pain was likely due to cardiac ischemia. Is there evidence that this is true?

Eric A. Shry, MD, and his colleagues looked at the usefulness of nitroglycerin response in the treatment of chest pain as a predictor of ischemic chest pain in an emergency department setting.¹

The study was a retrospective review of 223 patients who presented to the ED over a 5-month period with ongoing chest pain. They looked at patients who had ongoing chest pain in the ED, received nitroglycerin, and did not receive any therapy other than aspirin within 10 minutes of receiving nitroglycerin. Nitroglycerin response was compared with the final diagnosis of cardiac versus noncardiac chest pain.

Of the patients with a final determination of cardiac chest pain, 88% had a nitroglycerin response, whereas 92% of the patients with noncardiac chest pain had a nitroglycerin response (P = .50).

Deborah B. Diercks, MD, and her colleagues looked at improvement in chest pain scores in the ED in patients treated with nitroglycerin and whether it correlated with a cardiac etiology of chest pain.² The study was a prospective, observational study of 664 patients in an urban tertiary care ED over a 16-month period. An 11-point numeric chest pain scale was assessed and recorded by research assistants before and 5 minutes after receiving nitroglycerin. The scale ranged from 0 (no pain) to 10 (worst pain imaginable).

A final diagnosis of a cardiac etiology for chest pain was found in 18% of the patients in the study. Of the patients who had cardiac-related chest pain, 20% had no reduction in pain with nitroglycerin, compared with 19% of the patients without cardiac-related chest pain. Complete or significant reduction in chest pain occurred with nitroglycerin in 31% of patients with cardiac chest pain and 27% of the patients without cardiac chest pain (P = .76).

Two other studies with similar designs showed similar results. Robert Steele, MD, and his colleagues studied 270 patients in a prospective observational cohort study of patients with chest pain presenting to an urban ED.³ Patients presenting to the ED with active chest pain who received nitroglycerin were enrolled.

The sensitivity in this study for nitroglycerin relief determining cardiac chest pain was 72%, and the specificity was 37%, with a positive likelihood ratio for coronary artery disease if nitroglycerin response of 1.1 (0.96-1.34).

In another prospective, observational cohort study, 459 patients who presented to an ED with chest pain were evaluated for response to nitroglycerin as a marker for ischemic cardiac disease.⁴ In this study, presence of ischemic cardiac disease was defined as diagnosis in the ED or during a 4-month follow-up period. Nitroglycerin relieved chest pain in 35% of patients who had coronary disease, whereas 41% of patients without coronary disease had a nitroglycerin response. This study had a much lower overall nitroglycerin response rate than any of the other studies.

Katherine Grailey, MD, and Paul Glasziou, MD, PhD, published a meta-analysis of nitroglycerin use for the diagnosis of chest pain, using the above referenced studies. They concluded that in the acute setting, nitroglycerin is not a reliable test of treatment for use in diagnosis of coronary artery disease.⁵

High response rate for nitroglycerin in the noncoronary artery groups in the studies may be due to a strong placebo effect and/or that nitroglycerin may help with pain caused by esophageal spasm. The lack of specificity in the pain relief response for nitroglycerin makes it not a helpful test. Note that all the studies have been in the acute, ED setting for chest pain. In the case presented at the beginning of the article, the response the patient had to nitroglycerin would not change the probability that he has coronary artery disease.
 

 

References

1. Am J Cardiol. 2002 Dec 1;90(11):1264-6.

2. Ann Emerg Med. 2005 Jun;45(6):581-5.

3. CJEM. 2006 May;8(3):164-9.

4. Ann Intern Med. 2003 Dec 16;139(12):979-86.

5. Emerg Med J. 2012 Mar;29(3):173-6.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected] .

 

A 55-year-old man presents to the emergency department with substernal chest pain. The pain has occurred off and on over the past 2 hours. He has no family history of coronary artery disease. He has no history of diabetes, hypertension, or cigarette smoking. His most recent total cholesterol was 220 mg/dL (HDL, 40; LDL, 155). Blood pressure is 130/70. An ECG obtained on arrival is unremarkable. When he reached the ED, he received a nitroglycerin tablet with resolution of his pain within 4 minutes.

What is the most accurate statement?

A. The chance of CAD in this man over the next 10 years was 8% before his symptoms and is now greater than 20%.

B. The chance of CAD in this man over the next 10 years was 8% and is still 8%.

C. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 100%.

D. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 50%.

For years, giving nitroglycerin to patients who present with chest pain has been considered a good therapy, and the response to the medication has been considered a sign that the pain was likely due to cardiac ischemia. Is there evidence that this is true?

Eric A. Shry, MD, and his colleagues looked at the usefulness of nitroglycerin response in the treatment of chest pain as a predictor of ischemic chest pain in an emergency department setting.¹

The study was a retrospective review of 223 patients who presented to the ED over a 5-month period with ongoing chest pain. They looked at patients who had ongoing chest pain in the ED, received nitroglycerin, and did not receive any therapy other than aspirin within 10 minutes of receiving nitroglycerin. Nitroglycerin response was compared with the final diagnosis of cardiac versus noncardiac chest pain.

Of the patients with a final determination of cardiac chest pain, 88% had a nitroglycerin response, whereas 92% of the patients with noncardiac chest pain had a nitroglycerin response (P = .50).

Deborah B. Diercks, MD, and her colleagues looked at improvement in chest pain scores in the ED in patients treated with nitroglycerin and whether it correlated with a cardiac etiology of chest pain.² The study was a prospective, observational study of 664 patients in an urban tertiary care ED over a 16-month period. An 11-point numeric chest pain scale was assessed and recorded by research assistants before and 5 minutes after receiving nitroglycerin. The scale ranged from 0 (no pain) to 10 (worst pain imaginable).

A final diagnosis of a cardiac etiology for chest pain was found in 18% of the patients in the study. Of the patients who had cardiac-related chest pain, 20% had no reduction in pain with nitroglycerin, compared with 19% of the patients without cardiac-related chest pain. Complete or significant reduction in chest pain occurred with nitroglycerin in 31% of patients with cardiac chest pain and 27% of the patients without cardiac chest pain (P = .76).

Two other studies with similar designs showed similar results. Robert Steele, MD, and his colleagues studied 270 patients in a prospective observational cohort study of patients with chest pain presenting to an urban ED.³ Patients presenting to the ED with active chest pain who received nitroglycerin were enrolled.

The sensitivity in this study for nitroglycerin relief determining cardiac chest pain was 72%, and the specificity was 37%, with a positive likelihood ratio for coronary artery disease if nitroglycerin response of 1.1 (0.96-1.34).

In another prospective, observational cohort study, 459 patients who presented to an ED with chest pain were evaluated for response to nitroglycerin as a marker for ischemic cardiac disease.⁴ In this study, presence of ischemic cardiac disease was defined as diagnosis in the ED or during a 4-month follow-up period. Nitroglycerin relieved chest pain in 35% of patients who had coronary disease, whereas 41% of patients without coronary disease had a nitroglycerin response. This study had a much lower overall nitroglycerin response rate than any of the other studies.

Katherine Grailey, MD, and Paul Glasziou, MD, PhD, published a meta-analysis of nitroglycerin use for the diagnosis of chest pain, using the above referenced studies. They concluded that in the acute setting, nitroglycerin is not a reliable test of treatment for use in diagnosis of coronary artery disease.⁵

High response rate for nitroglycerin in the noncoronary artery groups in the studies may be due to a strong placebo effect and/or that nitroglycerin may help with pain caused by esophageal spasm. The lack of specificity in the pain relief response for nitroglycerin makes it not a helpful test. Note that all the studies have been in the acute, ED setting for chest pain. In the case presented at the beginning of the article, the response the patient had to nitroglycerin would not change the probability that he has coronary artery disease.
 

 

References

1. Am J Cardiol. 2002 Dec 1;90(11):1264-6.

2. Ann Emerg Med. 2005 Jun;45(6):581-5.

3. CJEM. 2006 May;8(3):164-9.

4. Ann Intern Med. 2003 Dec 16;139(12):979-86.

5. Emerg Med J. 2012 Mar;29(3):173-6.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected] .

 

A 55-year-old man presents to the emergency department with substernal chest pain. The pain has occurred off and on over the past 2 hours. He has no family history of coronary artery disease. He has no history of diabetes, hypertension, or cigarette smoking. His most recent total cholesterol was 220 mg/dL (HDL, 40; LDL, 155). Blood pressure is 130/70. An ECG obtained on arrival is unremarkable. When he reached the ED, he received a nitroglycerin tablet with resolution of his pain within 4 minutes.

What is the most accurate statement?

A. The chance of CAD in this man over the next 10 years was 8% before his symptoms and is now greater than 20%.

B. The chance of CAD in this man over the next 10 years was 8% and is still 8%.

C. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 100%.

D. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 50%.

For years, giving nitroglycerin to patients who present with chest pain has been considered a good therapy, and the response to the medication has been considered a sign that the pain was likely due to cardiac ischemia. Is there evidence that this is true?

Eric A. Shry, MD, and his colleagues looked at the usefulness of nitroglycerin response in the treatment of chest pain as a predictor of ischemic chest pain in an emergency department setting.¹

The study was a retrospective review of 223 patients who presented to the ED over a 5-month period with ongoing chest pain. They looked at patients who had ongoing chest pain in the ED, received nitroglycerin, and did not receive any therapy other than aspirin within 10 minutes of receiving nitroglycerin. Nitroglycerin response was compared with the final diagnosis of cardiac versus noncardiac chest pain.

Of the patients with a final determination of cardiac chest pain, 88% had a nitroglycerin response, whereas 92% of the patients with noncardiac chest pain had a nitroglycerin response (P = .50).

Deborah B. Diercks, MD, and her colleagues looked at improvement in chest pain scores in the ED in patients treated with nitroglycerin and whether it correlated with a cardiac etiology of chest pain.² The study was a prospective, observational study of 664 patients in an urban tertiary care ED over a 16-month period. An 11-point numeric chest pain scale was assessed and recorded by research assistants before and 5 minutes after receiving nitroglycerin. The scale ranged from 0 (no pain) to 10 (worst pain imaginable).

A final diagnosis of a cardiac etiology for chest pain was found in 18% of the patients in the study. Of the patients who had cardiac-related chest pain, 20% had no reduction in pain with nitroglycerin, compared with 19% of the patients without cardiac-related chest pain. Complete or significant reduction in chest pain occurred with nitroglycerin in 31% of patients with cardiac chest pain and 27% of the patients without cardiac chest pain (P = .76).

Two other studies with similar designs showed similar results. Robert Steele, MD, and his colleagues studied 270 patients in a prospective observational cohort study of patients with chest pain presenting to an urban ED.³ Patients presenting to the ED with active chest pain who received nitroglycerin were enrolled.

The sensitivity in this study for nitroglycerin relief determining cardiac chest pain was 72%, and the specificity was 37%, with a positive likelihood ratio for coronary artery disease if nitroglycerin response of 1.1 (0.96-1.34).

In another prospective, observational cohort study, 459 patients who presented to an ED with chest pain were evaluated for response to nitroglycerin as a marker for ischemic cardiac disease.⁴ In this study, presence of ischemic cardiac disease was defined as diagnosis in the ED or during a 4-month follow-up period. Nitroglycerin relieved chest pain in 35% of patients who had coronary disease, whereas 41% of patients without coronary disease had a nitroglycerin response. This study had a much lower overall nitroglycerin response rate than any of the other studies.

Katherine Grailey, MD, and Paul Glasziou, MD, PhD, published a meta-analysis of nitroglycerin use for the diagnosis of chest pain, using the above referenced studies. They concluded that in the acute setting, nitroglycerin is not a reliable test of treatment for use in diagnosis of coronary artery disease.⁵

High response rate for nitroglycerin in the noncoronary artery groups in the studies may be due to a strong placebo effect and/or that nitroglycerin may help with pain caused by esophageal spasm. The lack of specificity in the pain relief response for nitroglycerin makes it not a helpful test. Note that all the studies have been in the acute, ED setting for chest pain. In the case presented at the beginning of the article, the response the patient had to nitroglycerin would not change the probability that he has coronary artery disease.
 

 

References

1. Am J Cardiol. 2002 Dec 1;90(11):1264-6.

2. Ann Emerg Med. 2005 Jun;45(6):581-5.

3. CJEM. 2006 May;8(3):164-9.

4. Ann Intern Med. 2003 Dec 16;139(12):979-86.

5. Emerg Med J. 2012 Mar;29(3):173-6.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected] .