Commentary

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

Treatment of patients admitted to the hospital with an upper respiratory infection is often complicated by the lack of diagnostics. Even in cases where a patient has a confirmed case of influenza, there is still the possibility that they may have, or become infected by, a secondary bacterial infection. This leads clinicians to treat patients empirically with antibiotics, which can result in unnecessary antibiotic use among patients without a bacterial infection.

Though antibiotics can be a lifesaving drug, their use is not without risks. Estimates suggest that 20% of patients taking common antibiotics experience some side effect. While most side effects are not life-threatening gastrointestinal effects, other nonnegligible side effects include anaphylactic shock, drug‐induced liver injury, increases in the risk of retinal detachment, serious arrhythmias, and superinfection with resistant bacteria. Antibiotics can also lead to secondary infections, such as Clostridium difficile.

Yet, despite these risks, there has been limited research on the percentage of patients with influenza who actually have a bacterial coinfection. A recent systematic review and meta-analysis conducted by my colleagues at Johns Hopkins University and the Center for Disease Dynamics, Economics & Policy examined the frequency of bacterial coinfection among hospitalized patients with influenza and identified the most common infecting bacterial species.

The findings, published in the journal Influenza and Other Respiratory Viruses, found that in the majority of studies, between 11% and 35% of patients with confirmed influenza had a bacterial coinfection. The most common coinfecting bacteria were found to be Streptococcus pneumoniae and Staphylococcus aureus. Combined, S. pneumoniae and S. aureus accounted for more than 60% of the identified coinfecting bacteria; however, many other bacterial species were found to cause infections as well.

The results suggest that while bacterial infection is common in influenza patients, only about a quarter of patients are likely to be infected. However, the studies were widely heterogeneous, both in patient makeup and results. Analyses of age, setting, enrollment year, study type, study size, and bacterial collection methods did not reveal a source for the heterogeneity in results. Thus, additional factors, such as patient comorbidities or prior antibiotic use, which could not be systematically assessed, may affect the likelihood of coinfection.

Given that the symptoms of influenza and bacterial infection often overlap, correctly diagnosing bacterial coinfection without a laboratory culture can present a challenge. This diagnostic uncertainty leads to significant overuse of antibiotics in patients with influenza alone. Most influenza cases will never result in serious bacterial infections (particularly in nonhospitalized patients), and thus a lot of antibiotic use is unnecessary. As mentioned earlier, unnecessary antibiotic use poses a nonnegligible risk to patients, but it also contributes significantly to rising rates of antibiotic resistance, a major public health issue.

The results from this study highlight that the majority of patients hospitalized with influenza are unlikely to be coinfected with a bacterial pathogen. Thus, it is important for clinicians to appropriately treat patients with antiviral drugs, and ensure that bacterial testing is done when presumptively starting patients on antibiotics. Based on the microbiology results, antibiotics can be stopped if no pathogen is identified or altered to be more appropriate depending on the pathogen found.

Although the findings of this study suggest we need a more thorough analysis of the issue, the results should still aid clinicians by improving their understanding of the likelihood of bacterial coinfection in hospitalized patients with influenza, and thus help them balance the need to minimize patient risks as well as the individual and societal risks of nonessential antibiotic use.

Eili Klein, PhD, is assistant professor in the department of emergency medicine at Johns Hopkins Medicine, Baltimore.

Treatment of patients admitted to the hospital with an upper respiratory infection is often complicated by the lack of diagnostics. Even in cases where a patient has a confirmed case of influenza, there is still the possibility that they may have, or become infected by, a secondary bacterial infection. This leads clinicians to treat patients empirically with antibiotics, which can result in unnecessary antibiotic use among patients without a bacterial infection.

Though antibiotics can be a lifesaving drug, their use is not without risks. Estimates suggest that 20% of patients taking common antibiotics experience some side effect. While most side effects are not life-threatening gastrointestinal effects, other nonnegligible side effects include anaphylactic shock, drug‐induced liver injury, increases in the risk of retinal detachment, serious arrhythmias, and superinfection with resistant bacteria. Antibiotics can also lead to secondary infections, such as Clostridium difficile.

Yet, despite these risks, there has been limited research on the percentage of patients with influenza who actually have a bacterial coinfection. A recent systematic review and meta-analysis conducted by my colleagues at Johns Hopkins University and the Center for Disease Dynamics, Economics & Policy examined the frequency of bacterial coinfection among hospitalized patients with influenza and identified the most common infecting bacterial species.

The findings, published in the journal Influenza and Other Respiratory Viruses, found that in the majority of studies, between 11% and 35% of patients with confirmed influenza had a bacterial coinfection. The most common coinfecting bacteria were found to be Streptococcus pneumoniae and Staphylococcus aureus. Combined, S. pneumoniae and S. aureus accounted for more than 60% of the identified coinfecting bacteria; however, many other bacterial species were found to cause infections as well.

The results suggest that while bacterial infection is common in influenza patients, only about a quarter of patients are likely to be infected. However, the studies were widely heterogeneous, both in patient makeup and results. Analyses of age, setting, enrollment year, study type, study size, and bacterial collection methods did not reveal a source for the heterogeneity in results. Thus, additional factors, such as patient comorbidities or prior antibiotic use, which could not be systematically assessed, may affect the likelihood of coinfection.

Given that the symptoms of influenza and bacterial infection often overlap, correctly diagnosing bacterial coinfection without a laboratory culture can present a challenge. This diagnostic uncertainty leads to significant overuse of antibiotics in patients with influenza alone. Most influenza cases will never result in serious bacterial infections (particularly in nonhospitalized patients), and thus a lot of antibiotic use is unnecessary. As mentioned earlier, unnecessary antibiotic use poses a nonnegligible risk to patients, but it also contributes significantly to rising rates of antibiotic resistance, a major public health issue.

The results from this study highlight that the majority of patients hospitalized with influenza are unlikely to be coinfected with a bacterial pathogen. Thus, it is important for clinicians to appropriately treat patients with antiviral drugs, and ensure that bacterial testing is done when presumptively starting patients on antibiotics. Based on the microbiology results, antibiotics can be stopped if no pathogen is identified or altered to be more appropriate depending on the pathogen found.

Although the findings of this study suggest we need a more thorough analysis of the issue, the results should still aid clinicians by improving their understanding of the likelihood of bacterial coinfection in hospitalized patients with influenza, and thus help them balance the need to minimize patient risks as well as the individual and societal risks of nonessential antibiotic use.

Eili Klein, PhD, is assistant professor in the department of emergency medicine at Johns Hopkins Medicine, Baltimore.

Treatment of patients admitted to the hospital with an upper respiratory infection is often complicated by the lack of diagnostics. Even in cases where a patient has a confirmed case of influenza, there is still the possibility that they may have, or become infected by, a secondary bacterial infection. This leads clinicians to treat patients empirically with antibiotics, which can result in unnecessary antibiotic use among patients without a bacterial infection.

Though antibiotics can be a lifesaving drug, their use is not without risks. Estimates suggest that 20% of patients taking common antibiotics experience some side effect. While most side effects are not life-threatening gastrointestinal effects, other nonnegligible side effects include anaphylactic shock, drug‐induced liver injury, increases in the risk of retinal detachment, serious arrhythmias, and superinfection with resistant bacteria. Antibiotics can also lead to secondary infections, such as Clostridium difficile.

Yet, despite these risks, there has been limited research on the percentage of patients with influenza who actually have a bacterial coinfection. A recent systematic review and meta-analysis conducted by my colleagues at Johns Hopkins University and the Center for Disease Dynamics, Economics & Policy examined the frequency of bacterial coinfection among hospitalized patients with influenza and identified the most common infecting bacterial species.

The findings, published in the journal Influenza and Other Respiratory Viruses, found that in the majority of studies, between 11% and 35% of patients with confirmed influenza had a bacterial coinfection. The most common coinfecting bacteria were found to be Streptococcus pneumoniae and Staphylococcus aureus. Combined, S. pneumoniae and S. aureus accounted for more than 60% of the identified coinfecting bacteria; however, many other bacterial species were found to cause infections as well.

The results suggest that while bacterial infection is common in influenza patients, only about a quarter of patients are likely to be infected. However, the studies were widely heterogeneous, both in patient makeup and results. Analyses of age, setting, enrollment year, study type, study size, and bacterial collection methods did not reveal a source for the heterogeneity in results. Thus, additional factors, such as patient comorbidities or prior antibiotic use, which could not be systematically assessed, may affect the likelihood of coinfection.

Given that the symptoms of influenza and bacterial infection often overlap, correctly diagnosing bacterial coinfection without a laboratory culture can present a challenge. This diagnostic uncertainty leads to significant overuse of antibiotics in patients with influenza alone. Most influenza cases will never result in serious bacterial infections (particularly in nonhospitalized patients), and thus a lot of antibiotic use is unnecessary. As mentioned earlier, unnecessary antibiotic use poses a nonnegligible risk to patients, but it also contributes significantly to rising rates of antibiotic resistance, a major public health issue.

The results from this study highlight that the majority of patients hospitalized with influenza are unlikely to be coinfected with a bacterial pathogen. Thus, it is important for clinicians to appropriately treat patients with antiviral drugs, and ensure that bacterial testing is done when presumptively starting patients on antibiotics. Based on the microbiology results, antibiotics can be stopped if no pathogen is identified or altered to be more appropriate depending on the pathogen found.

Although the findings of this study suggest we need a more thorough analysis of the issue, the results should still aid clinicians by improving their understanding of the likelihood of bacterial coinfection in hospitalized patients with influenza, and thus help them balance the need to minimize patient risks as well as the individual and societal risks of nonessential antibiotic use.

Eili Klein, PhD, is assistant professor in the department of emergency medicine at Johns Hopkins Medicine, Baltimore.

Many patients we see need blood work as part of their evaluation. Although labs are cheap compared with other tests we order, they can still be frustrating to get.

It’s not hard to order them. Ordering any test is pretty easy.

But I hate duplicating tests. Patients often say they just had labs done, which “were all fine,” but that tells me nothing. For all I know, it was a lipid panel and PSA, entirely unrelated to what I’m seeing them for.

Occasionally, they bring labs in with them, or I’ve gotten them in advance, but usually I’m working blind.

Back when I was new to practice, I just ordered everything I wanted. I figured it was easier than trying to get the previous ones. I think we all do that sometimes. And there’s kind of an ivory-tower mentality we all have early in our careers that “I’m the doctor, and I’ll do what I want.”

I quickly learned that often backfires. If the same labs were done recently, many insurance companies won’t pay for them ... and the patients get a bill. Then they call my office and complain. It didn’t take me long to realize this approach was a waste of their time, money, and blood.

So now I always ask if they’ve had labs done since the symptoms started. If the answer is yes, I’ll call or fax the other doctor to get them. This can take (depending on the other office) a few hours to days. But the majority of outpatient neurology is nonurgent, and a extra few days usually doesn’t matter in the things I treat.

When I get the labs, it’s easy to make some quick notes on what was done and what still needs to be checked. I scribble out a lab order, mail or fax it, and have my staff notify the patient the ball is rolling. It’s not hard.

Patients appreciate it. I’m saving them time, blood, money, and maybe even a venipuncture. I get the tests I want, still in a timely fashion. It also keeps insurance costs down for all of us.

Obviously, there are some cases where urgency has to take priority. But for the majority of them, duplicating tests needlessly is a bad idea for all involved.

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

Many patients we see need blood work as part of their evaluation. Although labs are cheap compared with other tests we order, they can still be frustrating to get.

It’s not hard to order them. Ordering any test is pretty easy.

But I hate duplicating tests. Patients often say they just had labs done, which “were all fine,” but that tells me nothing. For all I know, it was a lipid panel and PSA, entirely unrelated to what I’m seeing them for.

Occasionally, they bring labs in with them, or I’ve gotten them in advance, but usually I’m working blind.

Back when I was new to practice, I just ordered everything I wanted. I figured it was easier than trying to get the previous ones. I think we all do that sometimes. And there’s kind of an ivory-tower mentality we all have early in our careers that “I’m the doctor, and I’ll do what I want.”

I quickly learned that often backfires. If the same labs were done recently, many insurance companies won’t pay for them ... and the patients get a bill. Then they call my office and complain. It didn’t take me long to realize this approach was a waste of their time, money, and blood.

So now I always ask if they’ve had labs done since the symptoms started. If the answer is yes, I’ll call or fax the other doctor to get them. This can take (depending on the other office) a few hours to days. But the majority of outpatient neurology is nonurgent, and a extra few days usually doesn’t matter in the things I treat.

When I get the labs, it’s easy to make some quick notes on what was done and what still needs to be checked. I scribble out a lab order, mail or fax it, and have my staff notify the patient the ball is rolling. It’s not hard.

Patients appreciate it. I’m saving them time, blood, money, and maybe even a venipuncture. I get the tests I want, still in a timely fashion. It also keeps insurance costs down for all of us.

Obviously, there are some cases where urgency has to take priority. But for the majority of them, duplicating tests needlessly is a bad idea for all involved.

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

Many patients we see need blood work as part of their evaluation. Although labs are cheap compared with other tests we order, they can still be frustrating to get.

It’s not hard to order them. Ordering any test is pretty easy.

But I hate duplicating tests. Patients often say they just had labs done, which “were all fine,” but that tells me nothing. For all I know, it was a lipid panel and PSA, entirely unrelated to what I’m seeing them for.

Occasionally, they bring labs in with them, or I’ve gotten them in advance, but usually I’m working blind.

Back when I was new to practice, I just ordered everything I wanted. I figured it was easier than trying to get the previous ones. I think we all do that sometimes. And there’s kind of an ivory-tower mentality we all have early in our careers that “I’m the doctor, and I’ll do what I want.”

I quickly learned that often backfires. If the same labs were done recently, many insurance companies won’t pay for them ... and the patients get a bill. Then they call my office and complain. It didn’t take me long to realize this approach was a waste of their time, money, and blood.

So now I always ask if they’ve had labs done since the symptoms started. If the answer is yes, I’ll call or fax the other doctor to get them. This can take (depending on the other office) a few hours to days. But the majority of outpatient neurology is nonurgent, and a extra few days usually doesn’t matter in the things I treat.

When I get the labs, it’s easy to make some quick notes on what was done and what still needs to be checked. I scribble out a lab order, mail or fax it, and have my staff notify the patient the ball is rolling. It’s not hard.

Patients appreciate it. I’m saving them time, blood, money, and maybe even a venipuncture. I get the tests I want, still in a timely fashion. It also keeps insurance costs down for all of us.

Obviously, there are some cases where urgency has to take priority. But for the majority of them, duplicating tests needlessly is a bad idea for all involved.

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

The continued use of perioperative clopidogrel is appropriate

Surgeons have always worried about bleeding risks for procedures we do. Complex vascular procedures are further complicated by the myriad of available antiplatelet agents designed to reduce ischemic events from cardiovascular disease burden at the expense of potential bleeding complications if antiplatelet medications are continued. Rather than relying on anecdotal reports by historical vignettes, let’s look at the evidence.

There probably is no other drug available in our vascular toolbox which has been studied more in the last 20 years than clopidogrel. Multiple randomized and double blinded studies such as CASPAR¹ and CHARISMA² have amplified what was known since the early CAPRIE trial in the 1990’s and that is that clopidogrel is safe when used as a single medication or as a dual agent with aspirin (duel antiplatelet therapy [DAPT]).

But not all our patients need DAPT. There is no level 1 evidence demonstrating the need for any antiplatelet therapy in the primary prevention of cardiovascular events for patients deemed at low or moderate risk of cardiovascular disease from a large meta-analysis review of six primary prevention trials encompassing over 95,000 patients.³

If our patients do present with vascular disease, current ACCP guidelines recommend single-agent antiplatelet medication (either ASA or clopidogrel) for symptomatic peripheral arterial disease (PAD) whether planning LE revascularization with bypass or via endovascular means with grade 1A evidence.⁴ This works fine for single-focus vascular disease and each antiplatelet agent have proponents but either works well.

That’s great, but what about all those sick cardiac patients we see the most of? First, CHARISMA subgroup analysis of patients with preexisting coronary and/or cerebrovascular disease demonstrate a 7.1% risk reduction in MI, cerebrovascular events, and cardiac ischemic deaths when continuing DAPT over aspirin alone, and similar risk reduction is found in PAD patients for endpoints of MI and ischemic cardiovascular events. Second, there was no significant difference in severe, fatal, or moderate bleeding in those receiving DAPT vs. aspirin alone with only minor bleeding increased using DAPT. Third, real-life practice echoes multiple trial experiences such as the Vascular Study Group of New England study group confirmed in reviewing 16 centers and 66 surgeons with more than 10,000 patients. Approximately 39% underwent major aortic or lower extremity bypass operations.

No statistical difference could be found for reoperation (P = .74), transfusion (P = .1) or operative type between DAPT or aspirin use alone.⁵ This is rediscovered once again by Saadeh and Sfeir in their prospective study of 647 major arterial procedures over 7 years finding no significant difference in reoperation for bleeding or bleeding mortality between DAPT vs. aspirin alone.⁶

So can we stop bashing clopidogrel as an evil agent of bleeding as Dr. Dalsing wishes to do? After all, he has been on record as stating, “I don’t know if our bleeding risk is worse or better … something we have to do to keep our grafts going.” Evidence tells us the benefits for continuing DAPT as seen in risk reduction in primary cardiovascular outcomes far outweigh the risk of minor bleeding associated with continued use.

Let the science dictate practice. Patients with low or moderate risk for cardiovascular disease need no antiplatelet medication unless undergoing PAD treatment where a single agent, either aspirin or clopidogrel alone, is sufficient. In those patients having a large cardiovascular burden of disease, combination of aspirin and clopidogrel improves survival benefit and reduces ischemic events without a significant risk of reoperation, transfusion, or bleeding-related mortality. As many of our patients require DAPT for drug eluting coronary stents, withholding clopidogrel preoperatively increases overall risk beyond acceptable limits. Improving surgical skills and paying attention to hemostasis during the operation will allow naysayers to achieve improved patient survival without fear of bleeding when continuing best medical therapy such as DAPT.

Gary Lemmon, MD, is professor of vascular surgery at Indiana University, Indianapolis, and chief, vascular surgery, Indianapolis VA Medical Center. He reported no relevant conflicts.

References

1. J Vasc Surg. 2010;52:825-33

2. Eur Heart J. 2009;30:192-201

3. Lancet. 2009;373:1849-604. Chest. 2012;141:e669s-90s

5. J Vasc Surg. 2011;54: 779-84

6. J Vasc Surg. 2013;58: 1586-92

The continued use of perioperative clopidogrel is debatable!

There are cases in which clopidogrel should not be discontinued for a needed vascular intervention. Delaying operation or maintaining clopidogrel during operation if your patient required a recent coronary stent is warranted unless you are willing to accept an acute coronary thrombosis.

However, in other cases, for example infrainguinal grafts, the risk of potential increased bleeding when adding clopidogrel to aspirin may outweigh potential improvements in graft patency. This is especially true of below-knee vein bypass grafts where data do not support improved patency. However, in the CASPAR trial, prosthetic graft patency did appear to be beneficial, but only in subgroup analysis.¹

It is true that severe bleeding was not increased (intracranial hemorrhage, or hemodynamic compromise: 1 vs 2.7%, P = NS) but moderate bleeding (transfusion required: 0.7 vs 3.7%, P = .012) and mild bleeding (5.4 vs 12.1%, P = .004) was increased when this agent was used especially in vein graft surgery. This risk of bleeding was present even when clopidogrel was begun 2 or more days after surgery.¹

To complicate this decision, a Cochrane review did not consider subgroup analysis as statistically valid and so the authors considered infrainguinal graft patency as not improved with clopidogrel but bleeding risk was increased. One might even question the use of acetylsalicylic acid (ASA) for vein graft bypasses based on the results of this metanalysis.2 Carotid endarterectomy is a common vascular surgery procedure in which antiplatelet use has been evaluated in the real-world situation and with large cohorts. As is always the case when dealing with patient issues, the addition of one agent does not tell the entire story and patient demographics can have a significant influence on the outcome. A report from the Vascular Quality Initiative (VQI) database controlled for patient differences by propensity matching with more than 4,500 patients in each of the two groups; ASA vs. ASA + clopidogrel; demonstrated that major bleeding, defined as return to the OR for bleeding, was statistically more common with dual therapy (1.3% vs. 0.7%, P = .004).³

The addition of clopidogrel did statistically decrease the risk of ipsilateral TIA or stroke (0.8% vs. 1.2%, P = .02) but not the risk of death (0.2% vs. 0.3%, P = .3) or postoperative MI (1% vs. 0.8%, P = .4). Reoperation for bleeding is not inconsequential since in patients requiring this intervention, there is a significantly worse outcome in regard to stroke (3.7% vs. 0.8%, P = .001), MI (6.2% vs. 0.8%, P = .001), and death (2.5% vs. 0.2%,P = .001). Further drill down involving propensity score–matched analysis stratified by symptom status (asymptomatic vs. symptomatic) was quite interesting in that in only asymptomatic patients did the addition of clopidogrel actually demonstrate a statistically significant reduction in TIA or stroke, any stroke, or composite stroke/death. Symptomatic patients taking dual therapy demonstrated a slight reduction in TIA or stroke (1.4% vs. 1.7%, P = .6), any stroke (1.1% vs. 1.2%, P = .9) and composite stroke/death (1.2% vs. 1.5%, P = .5) but in no instance was statistical significance reached. The use of protamine did help to decrease the risk of bleeding.

Regarding the use of dual therapy during open aortic operations, an earlier report of the VQI database demonstrated no significant difference in bleeding risk statistically, but if one delves deeper the data indicate something different. In the majority of cases, vascular surgeons do not feel comfortable preforming this extensive dissection on dual therapy. Of the cases reported, 1,074 were preformed either free of either drug or only on ASA while 42 were on dual therapy and only 12 on clopidogrel only. In fact, in the conclusions, the authors note that they do not believe that conclusions regarding clopidogrel use in patient undergoing open abdominal aortic aneurysm repair can be drawn based on their results since the potential for a type II error was too great.⁴

It may be that our current level of sophistication is not sufficiently mature to determine the actual effect that clopidogrel is having on our patients. Clopidogrel, a thienopyridine, inhibits platelet activation by blocking the ADP-binding site for the P2Y12 receptor. Over 85% of ingested drug is metabolized into inactive metabolites while 15% is metabolized by the liver via a two-step oxidative process into the active thiol metabolite. Inter-individual variability in the antiplatelet response to thienopyridines is noted and partially caused by genetic mutations in the CP isoenzymes. Platelet reactivity testing is possible but most of the work has been conducted for those patients requiring coronary artery revascularization. Results of tailoring intervention to maximize therapeutic benefit and decrease the risk of bleeding have been inconsistent but, in some studies, appear to be promising.⁵ This approach may ultimately be found superior to determining how effective clopidogrel actually is in a particular case with some insight into the bleeding risk as well. With this determination, whether or not to hold clopidogrel perioperatively can be made with some science behind the decision.

Clearly, a blanket statement that the risk of bleeding should be accepted or ignored because of the demonstrated benefits of clopidogrel in patients requiring vascular surgery is not accurate. In some cases, there is no clear benefit, so eliminating the bleeding risk may well be the appropriate decision. The astute vascular surgeon understands the details of the written word in order to make an educated decision and understands that new information such as determining platelet reactivity may provide more clarity to such decisions in the future.

Michael C. Dalsing, MD, is chief of vascular surgery at Indiana University, Indianapolis. He reported no relevant conflicts.

References

1. J Vasc Surg. 2010;52:825-33

2. Cochrane Database Syst Rev. 2015, Issue 2. Art. No.: CD000535

3. J Vasc Surg. 2016;63:1262-70

4.J Vasc Surg. 2011;54:779-84

5. Vascul Pharmacol. 2016;77:19-27

The continued use of perioperative clopidogrel is appropriate

Surgeons have always worried about bleeding risks for procedures we do. Complex vascular procedures are further complicated by the myriad of available antiplatelet agents designed to reduce ischemic events from cardiovascular disease burden at the expense of potential bleeding complications if antiplatelet medications are continued. Rather than relying on anecdotal reports by historical vignettes, let’s look at the evidence.

There probably is no other drug available in our vascular toolbox which has been studied more in the last 20 years than clopidogrel. Multiple randomized and double blinded studies such as CASPAR¹ and CHARISMA² have amplified what was known since the early CAPRIE trial in the 1990’s and that is that clopidogrel is safe when used as a single medication or as a dual agent with aspirin (duel antiplatelet therapy [DAPT]).

But not all our patients need DAPT. There is no level 1 evidence demonstrating the need for any antiplatelet therapy in the primary prevention of cardiovascular events for patients deemed at low or moderate risk of cardiovascular disease from a large meta-analysis review of six primary prevention trials encompassing over 95,000 patients.³

If our patients do present with vascular disease, current ACCP guidelines recommend single-agent antiplatelet medication (either ASA or clopidogrel) for symptomatic peripheral arterial disease (PAD) whether planning LE revascularization with bypass or via endovascular means with grade 1A evidence.⁴ This works fine for single-focus vascular disease and each antiplatelet agent have proponents but either works well.

That’s great, but what about all those sick cardiac patients we see the most of? First, CHARISMA subgroup analysis of patients with preexisting coronary and/or cerebrovascular disease demonstrate a 7.1% risk reduction in MI, cerebrovascular events, and cardiac ischemic deaths when continuing DAPT over aspirin alone, and similar risk reduction is found in PAD patients for endpoints of MI and ischemic cardiovascular events. Second, there was no significant difference in severe, fatal, or moderate bleeding in those receiving DAPT vs. aspirin alone with only minor bleeding increased using DAPT. Third, real-life practice echoes multiple trial experiences such as the Vascular Study Group of New England study group confirmed in reviewing 16 centers and 66 surgeons with more than 10,000 patients. Approximately 39% underwent major aortic or lower extremity bypass operations.

No statistical difference could be found for reoperation (P = .74), transfusion (P = .1) or operative type between DAPT or aspirin use alone.⁵ This is rediscovered once again by Saadeh and Sfeir in their prospective study of 647 major arterial procedures over 7 years finding no significant difference in reoperation for bleeding or bleeding mortality between DAPT vs. aspirin alone.⁶

So can we stop bashing clopidogrel as an evil agent of bleeding as Dr. Dalsing wishes to do? After all, he has been on record as stating, “I don’t know if our bleeding risk is worse or better … something we have to do to keep our grafts going.” Evidence tells us the benefits for continuing DAPT as seen in risk reduction in primary cardiovascular outcomes far outweigh the risk of minor bleeding associated with continued use.

Let the science dictate practice. Patients with low or moderate risk for cardiovascular disease need no antiplatelet medication unless undergoing PAD treatment where a single agent, either aspirin or clopidogrel alone, is sufficient. In those patients having a large cardiovascular burden of disease, combination of aspirin and clopidogrel improves survival benefit and reduces ischemic events without a significant risk of reoperation, transfusion, or bleeding-related mortality. As many of our patients require DAPT for drug eluting coronary stents, withholding clopidogrel preoperatively increases overall risk beyond acceptable limits. Improving surgical skills and paying attention to hemostasis during the operation will allow naysayers to achieve improved patient survival without fear of bleeding when continuing best medical therapy such as DAPT.

Gary Lemmon, MD, is professor of vascular surgery at Indiana University, Indianapolis, and chief, vascular surgery, Indianapolis VA Medical Center. He reported no relevant conflicts.

References

1. J Vasc Surg. 2010;52:825-33

2. Eur Heart J. 2009;30:192-201

3. Lancet. 2009;373:1849-604. Chest. 2012;141:e669s-90s

5. J Vasc Surg. 2011;54: 779-84

6. J Vasc Surg. 2013;58: 1586-92

The continued use of perioperative clopidogrel is debatable!

There are cases in which clopidogrel should not be discontinued for a needed vascular intervention. Delaying operation or maintaining clopidogrel during operation if your patient required a recent coronary stent is warranted unless you are willing to accept an acute coronary thrombosis.

However, in other cases, for example infrainguinal grafts, the risk of potential increased bleeding when adding clopidogrel to aspirin may outweigh potential improvements in graft patency. This is especially true of below-knee vein bypass grafts where data do not support improved patency. However, in the CASPAR trial, prosthetic graft patency did appear to be beneficial, but only in subgroup analysis.¹

It is true that severe bleeding was not increased (intracranial hemorrhage, or hemodynamic compromise: 1 vs 2.7%, P = NS) but moderate bleeding (transfusion required: 0.7 vs 3.7%, P = .012) and mild bleeding (5.4 vs 12.1%, P = .004) was increased when this agent was used especially in vein graft surgery. This risk of bleeding was present even when clopidogrel was begun 2 or more days after surgery.¹

To complicate this decision, a Cochrane review did not consider subgroup analysis as statistically valid and so the authors considered infrainguinal graft patency as not improved with clopidogrel but bleeding risk was increased. One might even question the use of acetylsalicylic acid (ASA) for vein graft bypasses based on the results of this metanalysis.2 Carotid endarterectomy is a common vascular surgery procedure in which antiplatelet use has been evaluated in the real-world situation and with large cohorts. As is always the case when dealing with patient issues, the addition of one agent does not tell the entire story and patient demographics can have a significant influence on the outcome. A report from the Vascular Quality Initiative (VQI) database controlled for patient differences by propensity matching with more than 4,500 patients in each of the two groups; ASA vs. ASA + clopidogrel; demonstrated that major bleeding, defined as return to the OR for bleeding, was statistically more common with dual therapy (1.3% vs. 0.7%, P = .004).³

The addition of clopidogrel did statistically decrease the risk of ipsilateral TIA or stroke (0.8% vs. 1.2%, P = .02) but not the risk of death (0.2% vs. 0.3%, P = .3) or postoperative MI (1% vs. 0.8%, P = .4). Reoperation for bleeding is not inconsequential since in patients requiring this intervention, there is a significantly worse outcome in regard to stroke (3.7% vs. 0.8%, P = .001), MI (6.2% vs. 0.8%, P = .001), and death (2.5% vs. 0.2%,P = .001). Further drill down involving propensity score–matched analysis stratified by symptom status (asymptomatic vs. symptomatic) was quite interesting in that in only asymptomatic patients did the addition of clopidogrel actually demonstrate a statistically significant reduction in TIA or stroke, any stroke, or composite stroke/death. Symptomatic patients taking dual therapy demonstrated a slight reduction in TIA or stroke (1.4% vs. 1.7%, P = .6), any stroke (1.1% vs. 1.2%, P = .9) and composite stroke/death (1.2% vs. 1.5%, P = .5) but in no instance was statistical significance reached. The use of protamine did help to decrease the risk of bleeding.

Regarding the use of dual therapy during open aortic operations, an earlier report of the VQI database demonstrated no significant difference in bleeding risk statistically, but if one delves deeper the data indicate something different. In the majority of cases, vascular surgeons do not feel comfortable preforming this extensive dissection on dual therapy. Of the cases reported, 1,074 were preformed either free of either drug or only on ASA while 42 were on dual therapy and only 12 on clopidogrel only. In fact, in the conclusions, the authors note that they do not believe that conclusions regarding clopidogrel use in patient undergoing open abdominal aortic aneurysm repair can be drawn based on their results since the potential for a type II error was too great.⁴

It may be that our current level of sophistication is not sufficiently mature to determine the actual effect that clopidogrel is having on our patients. Clopidogrel, a thienopyridine, inhibits platelet activation by blocking the ADP-binding site for the P2Y12 receptor. Over 85% of ingested drug is metabolized into inactive metabolites while 15% is metabolized by the liver via a two-step oxidative process into the active thiol metabolite. Inter-individual variability in the antiplatelet response to thienopyridines is noted and partially caused by genetic mutations in the CP isoenzymes. Platelet reactivity testing is possible but most of the work has been conducted for those patients requiring coronary artery revascularization. Results of tailoring intervention to maximize therapeutic benefit and decrease the risk of bleeding have been inconsistent but, in some studies, appear to be promising.⁵ This approach may ultimately be found superior to determining how effective clopidogrel actually is in a particular case with some insight into the bleeding risk as well. With this determination, whether or not to hold clopidogrel perioperatively can be made with some science behind the decision.

Clearly, a blanket statement that the risk of bleeding should be accepted or ignored because of the demonstrated benefits of clopidogrel in patients requiring vascular surgery is not accurate. In some cases, there is no clear benefit, so eliminating the bleeding risk may well be the appropriate decision. The astute vascular surgeon understands the details of the written word in order to make an educated decision and understands that new information such as determining platelet reactivity may provide more clarity to such decisions in the future.

Michael C. Dalsing, MD, is chief of vascular surgery at Indiana University, Indianapolis. He reported no relevant conflicts.

References

1. J Vasc Surg. 2010;52:825-33

2. Cochrane Database Syst Rev. 2015, Issue 2. Art. No.: CD000535

3. J Vasc Surg. 2016;63:1262-70

4.J Vasc Surg. 2011;54:779-84

5. Vascul Pharmacol. 2016;77:19-27

The continued use of perioperative clopidogrel is appropriate

Surgeons have always worried about bleeding risks for procedures we do. Complex vascular procedures are further complicated by the myriad of available antiplatelet agents designed to reduce ischemic events from cardiovascular disease burden at the expense of potential bleeding complications if antiplatelet medications are continued. Rather than relying on anecdotal reports by historical vignettes, let’s look at the evidence.

There probably is no other drug available in our vascular toolbox which has been studied more in the last 20 years than clopidogrel. Multiple randomized and double blinded studies such as CASPAR¹ and CHARISMA² have amplified what was known since the early CAPRIE trial in the 1990’s and that is that clopidogrel is safe when used as a single medication or as a dual agent with aspirin (duel antiplatelet therapy [DAPT]).

But not all our patients need DAPT. There is no level 1 evidence demonstrating the need for any antiplatelet therapy in the primary prevention of cardiovascular events for patients deemed at low or moderate risk of cardiovascular disease from a large meta-analysis review of six primary prevention trials encompassing over 95,000 patients.³

If our patients do present with vascular disease, current ACCP guidelines recommend single-agent antiplatelet medication (either ASA or clopidogrel) for symptomatic peripheral arterial disease (PAD) whether planning LE revascularization with bypass or via endovascular means with grade 1A evidence.⁴ This works fine for single-focus vascular disease and each antiplatelet agent have proponents but either works well.

That’s great, but what about all those sick cardiac patients we see the most of? First, CHARISMA subgroup analysis of patients with preexisting coronary and/or cerebrovascular disease demonstrate a 7.1% risk reduction in MI, cerebrovascular events, and cardiac ischemic deaths when continuing DAPT over aspirin alone, and similar risk reduction is found in PAD patients for endpoints of MI and ischemic cardiovascular events. Second, there was no significant difference in severe, fatal, or moderate bleeding in those receiving DAPT vs. aspirin alone with only minor bleeding increased using DAPT. Third, real-life practice echoes multiple trial experiences such as the Vascular Study Group of New England study group confirmed in reviewing 16 centers and 66 surgeons with more than 10,000 patients. Approximately 39% underwent major aortic or lower extremity bypass operations.

No statistical difference could be found for reoperation (P = .74), transfusion (P = .1) or operative type between DAPT or aspirin use alone.⁵ This is rediscovered once again by Saadeh and Sfeir in their prospective study of 647 major arterial procedures over 7 years finding no significant difference in reoperation for bleeding or bleeding mortality between DAPT vs. aspirin alone.⁶

So can we stop bashing clopidogrel as an evil agent of bleeding as Dr. Dalsing wishes to do? After all, he has been on record as stating, “I don’t know if our bleeding risk is worse or better … something we have to do to keep our grafts going.” Evidence tells us the benefits for continuing DAPT as seen in risk reduction in primary cardiovascular outcomes far outweigh the risk of minor bleeding associated with continued use.

Let the science dictate practice. Patients with low or moderate risk for cardiovascular disease need no antiplatelet medication unless undergoing PAD treatment where a single agent, either aspirin or clopidogrel alone, is sufficient. In those patients having a large cardiovascular burden of disease, combination of aspirin and clopidogrel improves survival benefit and reduces ischemic events without a significant risk of reoperation, transfusion, or bleeding-related mortality. As many of our patients require DAPT for drug eluting coronary stents, withholding clopidogrel preoperatively increases overall risk beyond acceptable limits. Improving surgical skills and paying attention to hemostasis during the operation will allow naysayers to achieve improved patient survival without fear of bleeding when continuing best medical therapy such as DAPT.

Gary Lemmon, MD, is professor of vascular surgery at Indiana University, Indianapolis, and chief, vascular surgery, Indianapolis VA Medical Center. He reported no relevant conflicts.

References

1. J Vasc Surg. 2010;52:825-33

2. Eur Heart J. 2009;30:192-201

3. Lancet. 2009;373:1849-604. Chest. 2012;141:e669s-90s

5. J Vasc Surg. 2011;54: 779-84

6. J Vasc Surg. 2013;58: 1586-92

The continued use of perioperative clopidogrel is debatable!

There are cases in which clopidogrel should not be discontinued for a needed vascular intervention. Delaying operation or maintaining clopidogrel during operation if your patient required a recent coronary stent is warranted unless you are willing to accept an acute coronary thrombosis.

However, in other cases, for example infrainguinal grafts, the risk of potential increased bleeding when adding clopidogrel to aspirin may outweigh potential improvements in graft patency. This is especially true of below-knee vein bypass grafts where data do not support improved patency. However, in the CASPAR trial, prosthetic graft patency did appear to be beneficial, but only in subgroup analysis.¹

It is true that severe bleeding was not increased (intracranial hemorrhage, or hemodynamic compromise: 1 vs 2.7%, P = NS) but moderate bleeding (transfusion required: 0.7 vs 3.7%, P = .012) and mild bleeding (5.4 vs 12.1%, P = .004) was increased when this agent was used especially in vein graft surgery. This risk of bleeding was present even when clopidogrel was begun 2 or more days after surgery.¹

To complicate this decision, a Cochrane review did not consider subgroup analysis as statistically valid and so the authors considered infrainguinal graft patency as not improved with clopidogrel but bleeding risk was increased. One might even question the use of acetylsalicylic acid (ASA) for vein graft bypasses based on the results of this metanalysis.2 Carotid endarterectomy is a common vascular surgery procedure in which antiplatelet use has been evaluated in the real-world situation and with large cohorts. As is always the case when dealing with patient issues, the addition of one agent does not tell the entire story and patient demographics can have a significant influence on the outcome. A report from the Vascular Quality Initiative (VQI) database controlled for patient differences by propensity matching with more than 4,500 patients in each of the two groups; ASA vs. ASA + clopidogrel; demonstrated that major bleeding, defined as return to the OR for bleeding, was statistically more common with dual therapy (1.3% vs. 0.7%, P = .004).³

The addition of clopidogrel did statistically decrease the risk of ipsilateral TIA or stroke (0.8% vs. 1.2%, P = .02) but not the risk of death (0.2% vs. 0.3%, P = .3) or postoperative MI (1% vs. 0.8%, P = .4). Reoperation for bleeding is not inconsequential since in patients requiring this intervention, there is a significantly worse outcome in regard to stroke (3.7% vs. 0.8%, P = .001), MI (6.2% vs. 0.8%, P = .001), and death (2.5% vs. 0.2%,P = .001). Further drill down involving propensity score–matched analysis stratified by symptom status (asymptomatic vs. symptomatic) was quite interesting in that in only asymptomatic patients did the addition of clopidogrel actually demonstrate a statistically significant reduction in TIA or stroke, any stroke, or composite stroke/death. Symptomatic patients taking dual therapy demonstrated a slight reduction in TIA or stroke (1.4% vs. 1.7%, P = .6), any stroke (1.1% vs. 1.2%, P = .9) and composite stroke/death (1.2% vs. 1.5%, P = .5) but in no instance was statistical significance reached. The use of protamine did help to decrease the risk of bleeding.

Regarding the use of dual therapy during open aortic operations, an earlier report of the VQI database demonstrated no significant difference in bleeding risk statistically, but if one delves deeper the data indicate something different. In the majority of cases, vascular surgeons do not feel comfortable preforming this extensive dissection on dual therapy. Of the cases reported, 1,074 were preformed either free of either drug or only on ASA while 42 were on dual therapy and only 12 on clopidogrel only. In fact, in the conclusions, the authors note that they do not believe that conclusions regarding clopidogrel use in patient undergoing open abdominal aortic aneurysm repair can be drawn based on their results since the potential for a type II error was too great.⁴

It may be that our current level of sophistication is not sufficiently mature to determine the actual effect that clopidogrel is having on our patients. Clopidogrel, a thienopyridine, inhibits platelet activation by blocking the ADP-binding site for the P2Y12 receptor. Over 85% of ingested drug is metabolized into inactive metabolites while 15% is metabolized by the liver via a two-step oxidative process into the active thiol metabolite. Inter-individual variability in the antiplatelet response to thienopyridines is noted and partially caused by genetic mutations in the CP isoenzymes. Platelet reactivity testing is possible but most of the work has been conducted for those patients requiring coronary artery revascularization. Results of tailoring intervention to maximize therapeutic benefit and decrease the risk of bleeding have been inconsistent but, in some studies, appear to be promising.⁵ This approach may ultimately be found superior to determining how effective clopidogrel actually is in a particular case with some insight into the bleeding risk as well. With this determination, whether or not to hold clopidogrel perioperatively can be made with some science behind the decision.

Clearly, a blanket statement that the risk of bleeding should be accepted or ignored because of the demonstrated benefits of clopidogrel in patients requiring vascular surgery is not accurate. In some cases, there is no clear benefit, so eliminating the bleeding risk may well be the appropriate decision. The astute vascular surgeon understands the details of the written word in order to make an educated decision and understands that new information such as determining platelet reactivity may provide more clarity to such decisions in the future.

Michael C. Dalsing, MD, is chief of vascular surgery at Indiana University, Indianapolis. He reported no relevant conflicts.

References

1. J Vasc Surg. 2010;52:825-33

2. Cochrane Database Syst Rev. 2015, Issue 2. Art. No.: CD000535

3. J Vasc Surg. 2016;63:1262-70

4.J Vasc Surg. 2011;54:779-84

5. Vascul Pharmacol. 2016;77:19-27

Conventional wisdom holds that for randomized, controlled trials, it’s all about the primary endpoint. If it’s negative or neutral, then none of the other results means much beyond “hypothesis generating.”

This strict-constructionist thinking has now been called into question. A recent article in the New England Journal of Medicine declared “an unreasonable yet widespread practice is the labeling of all randomized trials as either positive or negative on the basis of whether the P value for the primary outcome is less than .05. This view is overly simplistic.” (2016 Sept 1;375[9]:861-70).

Mitchel L. Zoler/Frontline Medical News

The article, by the highly experienced and respected trialists Stuart J. Pocock, PhD, and Gregg W. Stone, MD, adds this: “If the primary outcome is negative, positive findings for secondary outcomes are usually considered to be hypothesis generating. Certainly, regulatory approval of a new drug is unlikely to follow. However, in some instances, secondary findings are compelling enough to affect guidelines and practice.”

This unconventional take from a pair of high-level trialists was especially timely given the buzz around the results from two studies reported at the European Society of Cardiology annual congress in late August, DANISH and NORSTENT.

The DANISH trial compared the impact of implantable cardioverter-defibrillators (ICDs) plus optimal care against optimal care without ICDs in 1,116 patients with nonischemic systolic heart failure. The primary outcome, all-cause death during more than 5 years of follow-up, was a relative 13% less with ICD use, a difference that was not statistically significant, and one secondary outcome, cardiovascular death, was cut by a relative 25% with ICD use, also not statistically significant.

Mitchel L. Zoler/Frontline Medical News

But for the study’s second prespecified secondary endpoint of sudden cardiac death, treatment with ICDs cut the rate in half, compared with nonischemic heart failure patients who did not receive an ICD, a 4-percentage-point difference that was statistically significant.

And in a prespecified secondary analysis of the primary endpoint that broke down the study group by age, the two-thirds of patients younger than 68 years had a significant reduction in all-cause mortality with ICD use, a benefit not seen in patients aged 68 or older.

Discussion of the results at the meeting mainly focused on what meaning, if any, could be drawn from these strongly positive secondary outcomes in a trial neutral for its primary outcome.

“The ICDs did what they were supposed to, prevent sudden cardiac death,” said the lead investigator of the study, Lars Køber, MD. “As a principle I say don’t believe in a subgroup, but guidelines are often based on subgroup analyses.”

“The primary outcome was neutral, but the reduction in sudden cardiac death, the primary objective of an ICD, was significant, so an ICD should be taken into consideration,” commented Michel Komajda, MD, a discussant for the report.

Frontline Medical News

After I wrote a news article about the DANISH report at ESC, I received an email from a reader who objected to spinning the results this way and insisted that no valid lessons can be drawn from the DANISH results because the study’s primary endpoint failed to show a statistical significance. This purist view misses the important, relevant lessons from the DANISH results. The DANISH trial was not designed to provide pivotal data for regulatory approval of ICDs in these patients. Rather, Dr. Køber and his associates designed DANISH to see whether ICD use in these patients could cut all-cause death over a fairly long follow-up. It was a very high bar and ICDs failed, but the deck was stacked against an ICD win. Enrolled patients averaged 64 years old at entry into the study, and they all had New York Heart Association class II or III heart failure. “The overall survival curves start to diverge, but then converge after 5 years because of the comorbidities and patients dying for other reasons,” Dr. Køber noted.

“The message is, in younger patients with less morbidity and more life expectancy, sudden cardiac death is a bigger problem, and they had a substantial drop in mortality” with ICD use, commented heart failure specialist Javed Butler, MD. “It’s very consistent with the way we think about providing ICD treatment to patients.”

Mitchel L. Zoler/Frontline Medical News

In other words, the DANISH results showed that all patients with nonischemic systolic heart failure can’t expect to live substantially longer during extended follow-up if they get an ICD, because the cut in sudden cardiac death the devices provide eventually gets washed out by the many other risks for death these patients face. But younger, relatively healthier patients might very well see their reduced rate of sudden cardiac death translate into an overall mortality benefit even when they are followed for at least 5 years. That’s important information to help an individual patient decide whether to have an ICD placed, and an important message from the DANISH trial despite the neutral primary endpoint.

NORSTENT involved a similar scenario in a trial that addressed a totally different issue: Should patients with either stable or unstable coronary artery disease who are undergoing coronary stenting receive a drug-eluting stent (DES) or a bare metal stent (BMS)? The trial randomized 9,013 patients to receive either of the two stent types plus optimal medical therapy. The primary endpoint was the rate of all-cause death or nonfatal MI during 5 years of follow-up, and the results showed no statistically significant difference between the patients who received a DES and those who got a BMS (N Engl J Med. 2016 Aug 30. doi: 10.1056/NEJMoa1607991).

But for the secondary endpoint of repeat revascularizations performed during follow-up, the use of a DES cut the procedure rate by 3.3 percentage points, a 17% relative risk reduction that was statistically significant. The use of a DES also cut the stent thrombosis rate by 0.4 percentage points, a one-third relative drop in these events that was also statistically significant.

Mitchel L. Zoler/Frontline Medical News

In short, despite the neutral primary endpoint for the trial, the results showed that drug-eluting stents did what they were designed to do relative to bare metal stents: cut the rate of target lesion restenosis and the need for repeat revascularization. Several interventional cardiologists who heard the results at the meeting said that the findings would not change their practice and that they would continue to use the DES as their default device for percutaneous coronary interventions. Although “the long-term benefit of contemporary DES over BMS was less than expected,” said Kaare H. Bønaa, MD, lead investigator for the NORSTENT trial, the secondary benefit of significantly reduced repeat revascularization and the very modest price difference that now exists between drug-eluting stents and bare metal stents means that many interventionalists will continue to use a DES for most patients.

The message from Dr. Pocock and Dr. Stone, underscored by the DANISH and NORSTENT results, is that large and well-run randomized trials can yield important evidence to inform practice that transcends a simple black or white statistical assessment of the primary endpoint.

[email protected]

On Twitter @mitchelzoler

Conventional wisdom holds that for randomized, controlled trials, it’s all about the primary endpoint. If it’s negative or neutral, then none of the other results means much beyond “hypothesis generating.”

This strict-constructionist thinking has now been called into question. A recent article in the New England Journal of Medicine declared “an unreasonable yet widespread practice is the labeling of all randomized trials as either positive or negative on the basis of whether the P value for the primary outcome is less than .05. This view is overly simplistic.” (2016 Sept 1;375[9]:861-70).

Mitchel L. Zoler/Frontline Medical News

The article, by the highly experienced and respected trialists Stuart J. Pocock, PhD, and Gregg W. Stone, MD, adds this: “If the primary outcome is negative, positive findings for secondary outcomes are usually considered to be hypothesis generating. Certainly, regulatory approval of a new drug is unlikely to follow. However, in some instances, secondary findings are compelling enough to affect guidelines and practice.”

This unconventional take from a pair of high-level trialists was especially timely given the buzz around the results from two studies reported at the European Society of Cardiology annual congress in late August, DANISH and NORSTENT.

The DANISH trial compared the impact of implantable cardioverter-defibrillators (ICDs) plus optimal care against optimal care without ICDs in 1,116 patients with nonischemic systolic heart failure. The primary outcome, all-cause death during more than 5 years of follow-up, was a relative 13% less with ICD use, a difference that was not statistically significant, and one secondary outcome, cardiovascular death, was cut by a relative 25% with ICD use, also not statistically significant.

Mitchel L. Zoler/Frontline Medical News

But for the study’s second prespecified secondary endpoint of sudden cardiac death, treatment with ICDs cut the rate in half, compared with nonischemic heart failure patients who did not receive an ICD, a 4-percentage-point difference that was statistically significant.

And in a prespecified secondary analysis of the primary endpoint that broke down the study group by age, the two-thirds of patients younger than 68 years had a significant reduction in all-cause mortality with ICD use, a benefit not seen in patients aged 68 or older.

Discussion of the results at the meeting mainly focused on what meaning, if any, could be drawn from these strongly positive secondary outcomes in a trial neutral for its primary outcome.

“The ICDs did what they were supposed to, prevent sudden cardiac death,” said the lead investigator of the study, Lars Køber, MD. “As a principle I say don’t believe in a subgroup, but guidelines are often based on subgroup analyses.”

“The primary outcome was neutral, but the reduction in sudden cardiac death, the primary objective of an ICD, was significant, so an ICD should be taken into consideration,” commented Michel Komajda, MD, a discussant for the report.

Frontline Medical News

After I wrote a news article about the DANISH report at ESC, I received an email from a reader who objected to spinning the results this way and insisted that no valid lessons can be drawn from the DANISH results because the study’s primary endpoint failed to show a statistical significance. This purist view misses the important, relevant lessons from the DANISH results. The DANISH trial was not designed to provide pivotal data for regulatory approval of ICDs in these patients. Rather, Dr. Køber and his associates designed DANISH to see whether ICD use in these patients could cut all-cause death over a fairly long follow-up. It was a very high bar and ICDs failed, but the deck was stacked against an ICD win. Enrolled patients averaged 64 years old at entry into the study, and they all had New York Heart Association class II or III heart failure. “The overall survival curves start to diverge, but then converge after 5 years because of the comorbidities and patients dying for other reasons,” Dr. Køber noted.

“The message is, in younger patients with less morbidity and more life expectancy, sudden cardiac death is a bigger problem, and they had a substantial drop in mortality” with ICD use, commented heart failure specialist Javed Butler, MD. “It’s very consistent with the way we think about providing ICD treatment to patients.”

Mitchel L. Zoler/Frontline Medical News

In other words, the DANISH results showed that all patients with nonischemic systolic heart failure can’t expect to live substantially longer during extended follow-up if they get an ICD, because the cut in sudden cardiac death the devices provide eventually gets washed out by the many other risks for death these patients face. But younger, relatively healthier patients might very well see their reduced rate of sudden cardiac death translate into an overall mortality benefit even when they are followed for at least 5 years. That’s important information to help an individual patient decide whether to have an ICD placed, and an important message from the DANISH trial despite the neutral primary endpoint.

NORSTENT involved a similar scenario in a trial that addressed a totally different issue: Should patients with either stable or unstable coronary artery disease who are undergoing coronary stenting receive a drug-eluting stent (DES) or a bare metal stent (BMS)? The trial randomized 9,013 patients to receive either of the two stent types plus optimal medical therapy. The primary endpoint was the rate of all-cause death or nonfatal MI during 5 years of follow-up, and the results showed no statistically significant difference between the patients who received a DES and those who got a BMS (N Engl J Med. 2016 Aug 30. doi: 10.1056/NEJMoa1607991).

But for the secondary endpoint of repeat revascularizations performed during follow-up, the use of a DES cut the procedure rate by 3.3 percentage points, a 17% relative risk reduction that was statistically significant. The use of a DES also cut the stent thrombosis rate by 0.4 percentage points, a one-third relative drop in these events that was also statistically significant.

Mitchel L. Zoler/Frontline Medical News

In short, despite the neutral primary endpoint for the trial, the results showed that drug-eluting stents did what they were designed to do relative to bare metal stents: cut the rate of target lesion restenosis and the need for repeat revascularization. Several interventional cardiologists who heard the results at the meeting said that the findings would not change their practice and that they would continue to use the DES as their default device for percutaneous coronary interventions. Although “the long-term benefit of contemporary DES over BMS was less than expected,” said Kaare H. Bønaa, MD, lead investigator for the NORSTENT trial, the secondary benefit of significantly reduced repeat revascularization and the very modest price difference that now exists between drug-eluting stents and bare metal stents means that many interventionalists will continue to use a DES for most patients.

The message from Dr. Pocock and Dr. Stone, underscored by the DANISH and NORSTENT results, is that large and well-run randomized trials can yield important evidence to inform practice that transcends a simple black or white statistical assessment of the primary endpoint.

[email protected]

On Twitter @mitchelzoler

Conventional wisdom holds that for randomized, controlled trials, it’s all about the primary endpoint. If it’s negative or neutral, then none of the other results means much beyond “hypothesis generating.”

This strict-constructionist thinking has now been called into question. A recent article in the New England Journal of Medicine declared “an unreasonable yet widespread practice is the labeling of all randomized trials as either positive or negative on the basis of whether the P value for the primary outcome is less than .05. This view is overly simplistic.” (2016 Sept 1;375[9]:861-70).

Mitchel L. Zoler/Frontline Medical News

The article, by the highly experienced and respected trialists Stuart J. Pocock, PhD, and Gregg W. Stone, MD, adds this: “If the primary outcome is negative, positive findings for secondary outcomes are usually considered to be hypothesis generating. Certainly, regulatory approval of a new drug is unlikely to follow. However, in some instances, secondary findings are compelling enough to affect guidelines and practice.”

This unconventional take from a pair of high-level trialists was especially timely given the buzz around the results from two studies reported at the European Society of Cardiology annual congress in late August, DANISH and NORSTENT.

The DANISH trial compared the impact of implantable cardioverter-defibrillators (ICDs) plus optimal care against optimal care without ICDs in 1,116 patients with nonischemic systolic heart failure. The primary outcome, all-cause death during more than 5 years of follow-up, was a relative 13% less with ICD use, a difference that was not statistically significant, and one secondary outcome, cardiovascular death, was cut by a relative 25% with ICD use, also not statistically significant.

Mitchel L. Zoler/Frontline Medical News

But for the study’s second prespecified secondary endpoint of sudden cardiac death, treatment with ICDs cut the rate in half, compared with nonischemic heart failure patients who did not receive an ICD, a 4-percentage-point difference that was statistically significant.

And in a prespecified secondary analysis of the primary endpoint that broke down the study group by age, the two-thirds of patients younger than 68 years had a significant reduction in all-cause mortality with ICD use, a benefit not seen in patients aged 68 or older.

Discussion of the results at the meeting mainly focused on what meaning, if any, could be drawn from these strongly positive secondary outcomes in a trial neutral for its primary outcome.

“The ICDs did what they were supposed to, prevent sudden cardiac death,” said the lead investigator of the study, Lars Køber, MD. “As a principle I say don’t believe in a subgroup, but guidelines are often based on subgroup analyses.”

“The primary outcome was neutral, but the reduction in sudden cardiac death, the primary objective of an ICD, was significant, so an ICD should be taken into consideration,” commented Michel Komajda, MD, a discussant for the report.

Frontline Medical News

After I wrote a news article about the DANISH report at ESC, I received an email from a reader who objected to spinning the results this way and insisted that no valid lessons can be drawn from the DANISH results because the study’s primary endpoint failed to show a statistical significance. This purist view misses the important, relevant lessons from the DANISH results. The DANISH trial was not designed to provide pivotal data for regulatory approval of ICDs in these patients. Rather, Dr. Køber and his associates designed DANISH to see whether ICD use in these patients could cut all-cause death over a fairly long follow-up. It was a very high bar and ICDs failed, but the deck was stacked against an ICD win. Enrolled patients averaged 64 years old at entry into the study, and they all had New York Heart Association class II or III heart failure. “The overall survival curves start to diverge, but then converge after 5 years because of the comorbidities and patients dying for other reasons,” Dr. Køber noted.

“The message is, in younger patients with less morbidity and more life expectancy, sudden cardiac death is a bigger problem, and they had a substantial drop in mortality” with ICD use, commented heart failure specialist Javed Butler, MD. “It’s very consistent with the way we think about providing ICD treatment to patients.”

Mitchel L. Zoler/Frontline Medical News

In other words, the DANISH results showed that all patients with nonischemic systolic heart failure can’t expect to live substantially longer during extended follow-up if they get an ICD, because the cut in sudden cardiac death the devices provide eventually gets washed out by the many other risks for death these patients face. But younger, relatively healthier patients might very well see their reduced rate of sudden cardiac death translate into an overall mortality benefit even when they are followed for at least 5 years. That’s important information to help an individual patient decide whether to have an ICD placed, and an important message from the DANISH trial despite the neutral primary endpoint.

NORSTENT involved a similar scenario in a trial that addressed a totally different issue: Should patients with either stable or unstable coronary artery disease who are undergoing coronary stenting receive a drug-eluting stent (DES) or a bare metal stent (BMS)? The trial randomized 9,013 patients to receive either of the two stent types plus optimal medical therapy. The primary endpoint was the rate of all-cause death or nonfatal MI during 5 years of follow-up, and the results showed no statistically significant difference between the patients who received a DES and those who got a BMS (N Engl J Med. 2016 Aug 30. doi: 10.1056/NEJMoa1607991).

But for the secondary endpoint of repeat revascularizations performed during follow-up, the use of a DES cut the procedure rate by 3.3 percentage points, a 17% relative risk reduction that was statistically significant. The use of a DES also cut the stent thrombosis rate by 0.4 percentage points, a one-third relative drop in these events that was also statistically significant.

Mitchel L. Zoler/Frontline Medical News

In short, despite the neutral primary endpoint for the trial, the results showed that drug-eluting stents did what they were designed to do relative to bare metal stents: cut the rate of target lesion restenosis and the need for repeat revascularization. Several interventional cardiologists who heard the results at the meeting said that the findings would not change their practice and that they would continue to use the DES as their default device for percutaneous coronary interventions. Although “the long-term benefit of contemporary DES over BMS was less than expected,” said Kaare H. Bønaa, MD, lead investigator for the NORSTENT trial, the secondary benefit of significantly reduced repeat revascularization and the very modest price difference that now exists between drug-eluting stents and bare metal stents means that many interventionalists will continue to use a DES for most patients.

The message from Dr. Pocock and Dr. Stone, underscored by the DANISH and NORSTENT results, is that large and well-run randomized trials can yield important evidence to inform practice that transcends a simple black or white statistical assessment of the primary endpoint.

[email protected]

On Twitter @mitchelzoler

Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.

Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.

This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.

We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:

“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”

Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.

Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.

Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.

Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.

This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.

We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:

“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”

Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.

Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.

Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.

Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.

This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.

We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:

“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”

Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.

Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.

Just over 2 years ago, I finished a psychiatry residency at the Mayo Clinic, turned down an offer to stay on staff, and topped it off by taking a position at the VA. Not one of my brighter moments—or so one of my friends thought. “Are you off your rocker? Don’t you know that the VA is terrible? Why would you go work there?” he jabbed incredulously. I cringed, knowing that I had passed up an opportunity to stay in arguably the best hospital system in the nation, possibly the world, to work at what some (maybe even a lot) view as a corpulent and recalcitrant bastion of ineptitude bound by the dictates of a fickle Congress.

In the wake of the Phoenix wait-time scandal (and no, it’s not like Disneyland), the suicide by self-immolation of Charles Richard Ingram III outside a VA facility in New Jersey, the new data on veteran suicide showing progress but continued significant concern, and the ongoing VA privatization discussion, the prevailing discourse about the VA is largely negative.^1,2 And in a high-voltage election cycle where public outrage can serve as an efficient tool to garner support, the VA risks getting pummeled.

Add to this the shocking research that shows nearly half of VA psychiatrists are considering leaving the VA within the next 2 years, and it’s clear that dissatisfaction within and outside the VA is high.³ This does not bode well for veterans at a time when suicide and mental health care needs are so critically important. But while the bureaucracy of the VA is often the focus of negative press, it also filters down and unfortunately has the potential to directly affect VA practitioners and veterans. When we lose sight of what the VA does well, we risk being caught up in a vortex of negativity and a profound sense of inadequacy and helplessness. More attention to what is already being done well can help us as a nation more realistically chart a path forward rather than being fueled by negative rhetoric and rage.

Despite the challenges, the VA is currently succeeding in a number of areas that deserve recognition:

Medical school and resident education and collaboration with VA. In 2014, > 41,000 medical residents and nearly 23,000 medical students had some or all of their training in a VA setting. More than 95% of allopathic medical schools and nearly 90% of osteopathic medical schools had affiliation agreements with the VA in 2014.⁴ Suffice it to say, if the educational endeavors of the VA were curtailed, there would be an unholy scramble to provide well-trained physicians for our nation. (This does not include the dentists, psychologists, pharmacists, social workers, nurses, and other health care professionals whose training involves the VA in some capacity.) In addition, the VA often provides loan repayment assistance, which is very important given that many young professionals carry substantial school debt after completing training.

Mental health and primary care integration. Medical care overall is changing, and there is an increasing shift away from volume-based, fee-for-service care to integrated, team-based models. The VA is one of several successful leaders at a time when most U.S. health care providers are being scrutinized for their use of health care dollars and overall national health outcomes.⁵ In addition to primary care integration, the VA uses home-based primary care and mental health intensive case management teams for vulnerable veterans, adding flexibility, continuity, and access for many.

Overall excellent mental health care. A recent study by Watkins and colleagues found that when comparing quality measures for medication evaluation and management for schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, and substance use disorders, “In every case, VA performance was superior to that of the private sector by more than 30%.”⁶ This is not an aberration and not limited to mental health care. It is a consistent finding about which books have been written.⁷ However, the availability of evidence-based care may not be consistent across all VA facilities nationally, depending on demand and staffing.

Despite the rumors, VA has high customer satisfaction. According to the American Customer Satisfaction Index, the VA has consistently performed well in measures of customer satisfaction compared with those of the private sector health care providers.⁸ Let’s not ignore what veterans have actually said and continue to say about their care.

Once in, you’re in! I recently missed an initial appointment with a private sector pediatrician for one of my sons. I was tersely invited to find another doctor. This seemed scandalous since I have become accustomed in my role as a VA physician to reaching out, sometimes incessantly, to patients who do not come in for either a new or follow-up appointment. Yes, I call my patients; personally, directly, and often. In many clinics, patients receive reminder letters about upcoming appointments and then phone calls and sometimes letters when appointments are missed. My colleagues and I have jokingly referred to this practice as “benign stalking.”

Further, if a veteran is dissatisfied with care, there is a process to review and make adjustments if necessary, including transfer to a different doctor. Additionally, and sometimes alarmingly, veterans are not “fired” (and actually can’t be) for bad behavior (including direct threats to VA staff). Time, place, and manner of care can be tailored based on assessed risk, and VA police may be involved, but veterans continue to get care. I can assure you that if I made a threat to one of my doctors in private practice, I would very quickly be searching for a new doctor and answering some tough questions from law enforcement. Unlike many patients in private care, veterans have consistent access via phone (though admittedly not always user-friendly), walk-in appointments, after-hours availability in some locations, and secure messaging.

Electronic medical record and telehealth initiatives. The VA Computerized Patient Record System, has been around for some time and provides an excellent (although not perfect) system for documenting patient care. Each VA is linked to other VAs across the nation so patients don’t have to reinvent their story when they move and can actually get down to the business of being treated. Prior interventions, hospitalizations, medication trials, diagnostic impressions, imaging, lab work, etc, are all available at the touch of a button! And the VA’s telehealth initiative is all about access.

Veteran suicide prevention and opioid prescribing. Suicide is disproportionately high among veterans in the U.S. Recent data show that in 2014, an average of 20 veterans died by suicide per day.¹ This accounted for 18% of all U.S. adult suicide deaths, even though veterans represent only 8.5% of the population. And while these recent statistics represent some improvement over prior research, prevention and care coordination remain major priorities in the VA. Veterans have access to same-day care (at least in Boise, Idaho) and a 24-hour crisis line that gives feedback to the patient’s local VA and can help coordinate follow-up care. The VA has specialized suicide prevention coordinators who attend to the needs of patients assessed to be at high risk for suicide and also disseminate training to providers in a variety of disciplines. All of this as the VA moves to ensure that suicide prevention remains a priority across disciplines and treatment sites.

Additionally, the VA is directly addressing the nationwide crisis of overprescription of opioids, beginning with education for both patients and staff and systemic encouragement of responsible prescribing via the national Opioid Safety Initiative and increased emphasis on providing at-risk veterans with naloxone kits.⁹

Research. VA research endeavors are wide ranging. The VA has been involved in pioneering clinical research in a substantial way since at least the 1920s and has contributed to important innovations in treatment, ranging from prosthetics to imaging, neuromodulation to medication intervention for a broad array of pathology.¹⁰

Drawing in professionals who want to work with veterans. The reason that many health care providers work at the VA is the veterans themselves. Veterans by and large represent a segment of our population who have demonstrated dedication, commitment to a shared goal, and the willingness to sacrifice their health or their lives for a greater good. The veteran identity and sacrifice has drawn many of us to want to serve them. My father’s and cousin’s service are truly inspirational on a personal level. I am not alone in this.

I recently had a veteran in my office who, once seated, pulled his chair closer to mine than I ordinarily prefer. He then gave me a penetrating stare, moved well within the comfort zone of even the closest of close-talkers, and began to scream about the wrongs he had heard about in the VA system. When he finished screaming (and once the other clinicians in the building realized that I wasn’t being physically attacked), he freely acknowledged that he had never actually experienced any of the VA shortcomings personally but, nonetheless, learned how reprehensible the VA is through the media. Our veterans deserve the best care that we as a nation can provide, and they also deserve to know the truth about the quality of VA care. But too often the negative media attention does not tell the whole story that directly impacts the well-being of our veterans.

I sit on the disruptive behavior committee at the Boise VAMC and see firsthand the stress that our veterans and staff are under. We review reports of veterans who disrupt the environment, sometimes by direct threats to shoot or in some way physically harm those taking care of them. Some of this is over pain medications or other specific health care issues. Some is due to frustration in trying to navigate an increasingly complex and nonintuitive system as the VA scrambles to implement congressional directives that sometimes clash with what is clinically appropriate and evidence-based. Some of the disruptive behavior, however, is fueled by the negative national discourse against the political establishment and its nearest representative—in this case, the VA. And again, this is often fueled, in my opinion, by incomplete media coverage.

The VA has problems. It would be delusional to argue otherwise. It is rightly open to public scrutiny as a tax-funded governmental agency, and lives are literally at stake as we grapple nationally with how best to deliver on Lincoln’s promise to “care for those who have borne the battle.”

As I reflect on my friend’s skepticism at my taking a VA position, I can answer that yes, the VA needs work. It has some major issues. But I no longer feel the need to cringe, because I now know firsthand the kind of care that is being delivered (at least to the veterans in Boise).

Wherever you stand on the quality of VA care, the movement to privatize, or the politicizing inevitable during an election year, to indiscriminately excoriate the VA is to risk marginalizing the superlative care that many currently receive by the thousands of physicians and other health care providers and administrators throughout the VA. Our veterans are a national treasure that deserve excellent care and real solutions to the problems that exist in the VA, not overwhelming negative rhetoric.

Just over 2 years ago, I finished a psychiatry residency at the Mayo Clinic, turned down an offer to stay on staff, and topped it off by taking a position at the VA. Not one of my brighter moments—or so one of my friends thought. “Are you off your rocker? Don’t you know that the VA is terrible? Why would you go work there?” he jabbed incredulously. I cringed, knowing that I had passed up an opportunity to stay in arguably the best hospital system in the nation, possibly the world, to work at what some (maybe even a lot) view as a corpulent and recalcitrant bastion of ineptitude bound by the dictates of a fickle Congress.

In the wake of the Phoenix wait-time scandal (and no, it’s not like Disneyland), the suicide by self-immolation of Charles Richard Ingram III outside a VA facility in New Jersey, the new data on veteran suicide showing progress but continued significant concern, and the ongoing VA privatization discussion, the prevailing discourse about the VA is largely negative.^1,2 And in a high-voltage election cycle where public outrage can serve as an efficient tool to garner support, the VA risks getting pummeled.

Add to this the shocking research that shows nearly half of VA psychiatrists are considering leaving the VA within the next 2 years, and it’s clear that dissatisfaction within and outside the VA is high.³ This does not bode well for veterans at a time when suicide and mental health care needs are so critically important. But while the bureaucracy of the VA is often the focus of negative press, it also filters down and unfortunately has the potential to directly affect VA practitioners and veterans. When we lose sight of what the VA does well, we risk being caught up in a vortex of negativity and a profound sense of inadequacy and helplessness. More attention to what is already being done well can help us as a nation more realistically chart a path forward rather than being fueled by negative rhetoric and rage.

Despite the challenges, the VA is currently succeeding in a number of areas that deserve recognition:

Medical school and resident education and collaboration with VA. In 2014, > 41,000 medical residents and nearly 23,000 medical students had some or all of their training in a VA setting. More than 95% of allopathic medical schools and nearly 90% of osteopathic medical schools had affiliation agreements with the VA in 2014.⁴ Suffice it to say, if the educational endeavors of the VA were curtailed, there would be an unholy scramble to provide well-trained physicians for our nation. (This does not include the dentists, psychologists, pharmacists, social workers, nurses, and other health care professionals whose training involves the VA in some capacity.) In addition, the VA often provides loan repayment assistance, which is very important given that many young professionals carry substantial school debt after completing training.

Mental health and primary care integration. Medical care overall is changing, and there is an increasing shift away from volume-based, fee-for-service care to integrated, team-based models. The VA is one of several successful leaders at a time when most U.S. health care providers are being scrutinized for their use of health care dollars and overall national health outcomes.⁵ In addition to primary care integration, the VA uses home-based primary care and mental health intensive case management teams for vulnerable veterans, adding flexibility, continuity, and access for many.

Overall excellent mental health care. A recent study by Watkins and colleagues found that when comparing quality measures for medication evaluation and management for schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, and substance use disorders, “In every case, VA performance was superior to that of the private sector by more than 30%.”⁶ This is not an aberration and not limited to mental health care. It is a consistent finding about which books have been written.⁷ However, the availability of evidence-based care may not be consistent across all VA facilities nationally, depending on demand and staffing.

Despite the rumors, VA has high customer satisfaction. According to the American Customer Satisfaction Index, the VA has consistently performed well in measures of customer satisfaction compared with those of the private sector health care providers.⁸ Let’s not ignore what veterans have actually said and continue to say about their care.

Once in, you’re in! I recently missed an initial appointment with a private sector pediatrician for one of my sons. I was tersely invited to find another doctor. This seemed scandalous since I have become accustomed in my role as a VA physician to reaching out, sometimes incessantly, to patients who do not come in for either a new or follow-up appointment. Yes, I call my patients; personally, directly, and often. In many clinics, patients receive reminder letters about upcoming appointments and then phone calls and sometimes letters when appointments are missed. My colleagues and I have jokingly referred to this practice as “benign stalking.”

Further, if a veteran is dissatisfied with care, there is a process to review and make adjustments if necessary, including transfer to a different doctor. Additionally, and sometimes alarmingly, veterans are not “fired” (and actually can’t be) for bad behavior (including direct threats to VA staff). Time, place, and manner of care can be tailored based on assessed risk, and VA police may be involved, but veterans continue to get care. I can assure you that if I made a threat to one of my doctors in private practice, I would very quickly be searching for a new doctor and answering some tough questions from law enforcement. Unlike many patients in private care, veterans have consistent access via phone (though admittedly not always user-friendly), walk-in appointments, after-hours availability in some locations, and secure messaging.

Electronic medical record and telehealth initiatives. The VA Computerized Patient Record System, has been around for some time and provides an excellent (although not perfect) system for documenting patient care. Each VA is linked to other VAs across the nation so patients don’t have to reinvent their story when they move and can actually get down to the business of being treated. Prior interventions, hospitalizations, medication trials, diagnostic impressions, imaging, lab work, etc, are all available at the touch of a button! And the VA’s telehealth initiative is all about access.

Veteran suicide prevention and opioid prescribing. Suicide is disproportionately high among veterans in the U.S. Recent data show that in 2014, an average of 20 veterans died by suicide per day.¹ This accounted for 18% of all U.S. adult suicide deaths, even though veterans represent only 8.5% of the population. And while these recent statistics represent some improvement over prior research, prevention and care coordination remain major priorities in the VA. Veterans have access to same-day care (at least in Boise, Idaho) and a 24-hour crisis line that gives feedback to the patient’s local VA and can help coordinate follow-up care. The VA has specialized suicide prevention coordinators who attend to the needs of patients assessed to be at high risk for suicide and also disseminate training to providers in a variety of disciplines. All of this as the VA moves to ensure that suicide prevention remains a priority across disciplines and treatment sites.

Additionally, the VA is directly addressing the nationwide crisis of overprescription of opioids, beginning with education for both patients and staff and systemic encouragement of responsible prescribing via the national Opioid Safety Initiative and increased emphasis on providing at-risk veterans with naloxone kits.⁹

Research. VA research endeavors are wide ranging. The VA has been involved in pioneering clinical research in a substantial way since at least the 1920s and has contributed to important innovations in treatment, ranging from prosthetics to imaging, neuromodulation to medication intervention for a broad array of pathology.¹⁰

Drawing in professionals who want to work with veterans. The reason that many health care providers work at the VA is the veterans themselves. Veterans by and large represent a segment of our population who have demonstrated dedication, commitment to a shared goal, and the willingness to sacrifice their health or their lives for a greater good. The veteran identity and sacrifice has drawn many of us to want to serve them. My father’s and cousin’s service are truly inspirational on a personal level. I am not alone in this.

I recently had a veteran in my office who, once seated, pulled his chair closer to mine than I ordinarily prefer. He then gave me a penetrating stare, moved well within the comfort zone of even the closest of close-talkers, and began to scream about the wrongs he had heard about in the VA system. When he finished screaming (and once the other clinicians in the building realized that I wasn’t being physically attacked), he freely acknowledged that he had never actually experienced any of the VA shortcomings personally but, nonetheless, learned how reprehensible the VA is through the media. Our veterans deserve the best care that we as a nation can provide, and they also deserve to know the truth about the quality of VA care. But too often the negative media attention does not tell the whole story that directly impacts the well-being of our veterans.

I sit on the disruptive behavior committee at the Boise VAMC and see firsthand the stress that our veterans and staff are under. We review reports of veterans who disrupt the environment, sometimes by direct threats to shoot or in some way physically harm those taking care of them. Some of this is over pain medications or other specific health care issues. Some is due to frustration in trying to navigate an increasingly complex and nonintuitive system as the VA scrambles to implement congressional directives that sometimes clash with what is clinically appropriate and evidence-based. Some of the disruptive behavior, however, is fueled by the negative national discourse against the political establishment and its nearest representative—in this case, the VA. And again, this is often fueled, in my opinion, by incomplete media coverage.

The VA has problems. It would be delusional to argue otherwise. It is rightly open to public scrutiny as a tax-funded governmental agency, and lives are literally at stake as we grapple nationally with how best to deliver on Lincoln’s promise to “care for those who have borne the battle.”

As I reflect on my friend’s skepticism at my taking a VA position, I can answer that yes, the VA needs work. It has some major issues. But I no longer feel the need to cringe, because I now know firsthand the kind of care that is being delivered (at least to the veterans in Boise).

Wherever you stand on the quality of VA care, the movement to privatize, or the politicizing inevitable during an election year, to indiscriminately excoriate the VA is to risk marginalizing the superlative care that many currently receive by the thousands of physicians and other health care providers and administrators throughout the VA. Our veterans are a national treasure that deserve excellent care and real solutions to the problems that exist in the VA, not overwhelming negative rhetoric.

Just over 2 years ago, I finished a psychiatry residency at the Mayo Clinic, turned down an offer to stay on staff, and topped it off by taking a position at the VA. Not one of my brighter moments—or so one of my friends thought. “Are you off your rocker? Don’t you know that the VA is terrible? Why would you go work there?” he jabbed incredulously. I cringed, knowing that I had passed up an opportunity to stay in arguably the best hospital system in the nation, possibly the world, to work at what some (maybe even a lot) view as a corpulent and recalcitrant bastion of ineptitude bound by the dictates of a fickle Congress.

In the wake of the Phoenix wait-time scandal (and no, it’s not like Disneyland), the suicide by self-immolation of Charles Richard Ingram III outside a VA facility in New Jersey, the new data on veteran suicide showing progress but continued significant concern, and the ongoing VA privatization discussion, the prevailing discourse about the VA is largely negative.^1,2 And in a high-voltage election cycle where public outrage can serve as an efficient tool to garner support, the VA risks getting pummeled.

Add to this the shocking research that shows nearly half of VA psychiatrists are considering leaving the VA within the next 2 years, and it’s clear that dissatisfaction within and outside the VA is high.³ This does not bode well for veterans at a time when suicide and mental health care needs are so critically important. But while the bureaucracy of the VA is often the focus of negative press, it also filters down and unfortunately has the potential to directly affect VA practitioners and veterans. When we lose sight of what the VA does well, we risk being caught up in a vortex of negativity and a profound sense of inadequacy and helplessness. More attention to what is already being done well can help us as a nation more realistically chart a path forward rather than being fueled by negative rhetoric and rage.

Despite the challenges, the VA is currently succeeding in a number of areas that deserve recognition:

Medical school and resident education and collaboration with VA. In 2014, > 41,000 medical residents and nearly 23,000 medical students had some or all of their training in a VA setting. More than 95% of allopathic medical schools and nearly 90% of osteopathic medical schools had affiliation agreements with the VA in 2014.⁴ Suffice it to say, if the educational endeavors of the VA were curtailed, there would be an unholy scramble to provide well-trained physicians for our nation. (This does not include the dentists, psychologists, pharmacists, social workers, nurses, and other health care professionals whose training involves the VA in some capacity.) In addition, the VA often provides loan repayment assistance, which is very important given that many young professionals carry substantial school debt after completing training.

Mental health and primary care integration. Medical care overall is changing, and there is an increasing shift away from volume-based, fee-for-service care to integrated, team-based models. The VA is one of several successful leaders at a time when most U.S. health care providers are being scrutinized for their use of health care dollars and overall national health outcomes.⁵ In addition to primary care integration, the VA uses home-based primary care and mental health intensive case management teams for vulnerable veterans, adding flexibility, continuity, and access for many.

Overall excellent mental health care. A recent study by Watkins and colleagues found that when comparing quality measures for medication evaluation and management for schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, and substance use disorders, “In every case, VA performance was superior to that of the private sector by more than 30%.”⁶ This is not an aberration and not limited to mental health care. It is a consistent finding about which books have been written.⁷ However, the availability of evidence-based care may not be consistent across all VA facilities nationally, depending on demand and staffing.

Despite the rumors, VA has high customer satisfaction. According to the American Customer Satisfaction Index, the VA has consistently performed well in measures of customer satisfaction compared with those of the private sector health care providers.⁸ Let’s not ignore what veterans have actually said and continue to say about their care.

Once in, you’re in! I recently missed an initial appointment with a private sector pediatrician for one of my sons. I was tersely invited to find another doctor. This seemed scandalous since I have become accustomed in my role as a VA physician to reaching out, sometimes incessantly, to patients who do not come in for either a new or follow-up appointment. Yes, I call my patients; personally, directly, and often. In many clinics, patients receive reminder letters about upcoming appointments and then phone calls and sometimes letters when appointments are missed. My colleagues and I have jokingly referred to this practice as “benign stalking.”

Further, if a veteran is dissatisfied with care, there is a process to review and make adjustments if necessary, including transfer to a different doctor. Additionally, and sometimes alarmingly, veterans are not “fired” (and actually can’t be) for bad behavior (including direct threats to VA staff). Time, place, and manner of care can be tailored based on assessed risk, and VA police may be involved, but veterans continue to get care. I can assure you that if I made a threat to one of my doctors in private practice, I would very quickly be searching for a new doctor and answering some tough questions from law enforcement. Unlike many patients in private care, veterans have consistent access via phone (though admittedly not always user-friendly), walk-in appointments, after-hours availability in some locations, and secure messaging.

Electronic medical record and telehealth initiatives. The VA Computerized Patient Record System, has been around for some time and provides an excellent (although not perfect) system for documenting patient care. Each VA is linked to other VAs across the nation so patients don’t have to reinvent their story when they move and can actually get down to the business of being treated. Prior interventions, hospitalizations, medication trials, diagnostic impressions, imaging, lab work, etc, are all available at the touch of a button! And the VA’s telehealth initiative is all about access.

Veteran suicide prevention and opioid prescribing. Suicide is disproportionately high among veterans in the U.S. Recent data show that in 2014, an average of 20 veterans died by suicide per day.¹ This accounted for 18% of all U.S. adult suicide deaths, even though veterans represent only 8.5% of the population. And while these recent statistics represent some improvement over prior research, prevention and care coordination remain major priorities in the VA. Veterans have access to same-day care (at least in Boise, Idaho) and a 24-hour crisis line that gives feedback to the patient’s local VA and can help coordinate follow-up care. The VA has specialized suicide prevention coordinators who attend to the needs of patients assessed to be at high risk for suicide and also disseminate training to providers in a variety of disciplines. All of this as the VA moves to ensure that suicide prevention remains a priority across disciplines and treatment sites.

Additionally, the VA is directly addressing the nationwide crisis of overprescription of opioids, beginning with education for both patients and staff and systemic encouragement of responsible prescribing via the national Opioid Safety Initiative and increased emphasis on providing at-risk veterans with naloxone kits.⁹

Research. VA research endeavors are wide ranging. The VA has been involved in pioneering clinical research in a substantial way since at least the 1920s and has contributed to important innovations in treatment, ranging from prosthetics to imaging, neuromodulation to medication intervention for a broad array of pathology.¹⁰

Drawing in professionals who want to work with veterans. The reason that many health care providers work at the VA is the veterans themselves. Veterans by and large represent a segment of our population who have demonstrated dedication, commitment to a shared goal, and the willingness to sacrifice their health or their lives for a greater good. The veteran identity and sacrifice has drawn many of us to want to serve them. My father’s and cousin’s service are truly inspirational on a personal level. I am not alone in this.

I recently had a veteran in my office who, once seated, pulled his chair closer to mine than I ordinarily prefer. He then gave me a penetrating stare, moved well within the comfort zone of even the closest of close-talkers, and began to scream about the wrongs he had heard about in the VA system. When he finished screaming (and once the other clinicians in the building realized that I wasn’t being physically attacked), he freely acknowledged that he had never actually experienced any of the VA shortcomings personally but, nonetheless, learned how reprehensible the VA is through the media. Our veterans deserve the best care that we as a nation can provide, and they also deserve to know the truth about the quality of VA care. But too often the negative media attention does not tell the whole story that directly impacts the well-being of our veterans.

I sit on the disruptive behavior committee at the Boise VAMC and see firsthand the stress that our veterans and staff are under. We review reports of veterans who disrupt the environment, sometimes by direct threats to shoot or in some way physically harm those taking care of them. Some of this is over pain medications or other specific health care issues. Some is due to frustration in trying to navigate an increasingly complex and nonintuitive system as the VA scrambles to implement congressional directives that sometimes clash with what is clinically appropriate and evidence-based. Some of the disruptive behavior, however, is fueled by the negative national discourse against the political establishment and its nearest representative—in this case, the VA. And again, this is often fueled, in my opinion, by incomplete media coverage.

The VA has problems. It would be delusional to argue otherwise. It is rightly open to public scrutiny as a tax-funded governmental agency, and lives are literally at stake as we grapple nationally with how best to deliver on Lincoln’s promise to “care for those who have borne the battle.”

As I reflect on my friend’s skepticism at my taking a VA position, I can answer that yes, the VA needs work. It has some major issues. But I no longer feel the need to cringe, because I now know firsthand the kind of care that is being delivered (at least to the veterans in Boise).

Wherever you stand on the quality of VA care, the movement to privatize, or the politicizing inevitable during an election year, to indiscriminately excoriate the VA is to risk marginalizing the superlative care that many currently receive by the thousands of physicians and other health care providers and administrators throughout the VA. Our veterans are a national treasure that deserve excellent care and real solutions to the problems that exist in the VA, not overwhelming negative rhetoric.

In “What’s Hot and What’s Not in Our National Organizations, An Emergency Medicine Panel, Parts 1 and 2” (Emergency Medicine, April 2016 and May 2016, respectively), we published highlights from a panel discussion that took place at the annual retreat of the Association of Academic Chairs in Emergency Medicine in Tempe, Arizona in February 2016. That discussion included seven EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Residency Directors in Emergency Medicine (CORD), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM). In this issue, we follow up with reports from the American College of Osteopathic Emergency Physicians (ACOEP) and the American Osteopathic Board of Emergency Medicine (AOBEM).

American College of Osteopathic Emergency Physicians

John C. Prestosh, DO, FACOEP-DPresident, ACOEP

Strategic Planning. The Board of Directors of ACOEP has recently adopted a revised mission statement and goals for the organization. The ACOEP “promotes patient-centric, holistic emergency care consistent with the osteopathic philosophy practiced by all emergency medicine professionals.” This statement is based on the belief that many non-osteopathic professionals practice aspects of holistic medicine, and will allow ACOEP to be a “home” for these practitioners. ACOEP’s goals are member engagement and value, advocacy and involvement, education and knowledge, improving awareness, and college strength and sustainability.

Workplace Issues. The ACOEP is aware of the issues emergency physicians (EPs) and professionals face every day. Therefore, we are including items for EPs on these issues in our educational programs. Upcoming events will include workshops on dealing with an active shooter scenario, ultrasound, and advanced airway management, which will be included in our Scientific Assembly in November.

The ACOEP is also a member of the White House Task Force addressing the opioid epidemic. Realizing there are times when opiates are necessary adjuncts to patient care, we also want to help educate physicians on the usage of alternative pain-relieving treatment plans when indicated.

Single Accreditation System and College Sustainability. Graduate medical education is undergoing an unprecedented change. The Single Accreditation System is currently being implemented with a target date of July 1, 2020 for all residency programs to fall under the jurisdiction of the Accreditation Council for Graduate Medical Education (ACGME) for accreditation. There is much anticipation regarding the changes that will occur.

We anticipate some American Osteopathic Association-accredited EM programs will become 3-year programs, thus precluding graduating residents from AOBEM certification. However, we expect a number of ACGME-accredited EM programs to establish “osteopathic-focused” tracks in which both DOs and MDs will learn osteopathic tenets and procedures to broaden their practice of EM. We anticipate this will allow residents to be certified by the AOBEM.

We believe the ACOEP can be a “home” for MD residents graduating from “osteopathic-focused” ACGME programs. Furthermore, the ACOEP is ready to amend its bylaws to offer active membership with full voting rights to MDs. We do not want to remain a closed organization, but are striving to have both DO and MD EPs belong to our College.

American Osteopathic Board of Emergency Medicine

Donald Phillips, DO, FACOEP-D, Executive Physician Director, AOBEM

Primary Certification News. The date for the 2017 Part I Examination (written examination) has been published. All candidates are advised that the examination has been moved from March to September beginning in 2017. Applications for Part I will be available on January 2, 2017. The deadline to submit the application is April 1, 2017. The examination will be administered at Prometric Testing Centers nationwide on September 12, 2017. Part II Examinations (oral examinations) are in March and November. Please refer to the AOBEM Web page at www.aobem.org for dates.

Subspecialty Certifications. AOBEM offers subspecialty certification opportunities to its diplomates in the following areas:

• Emergency medical services
• Hospice and palliative medicine
• Medical toxicology
• Sports medicine
• Undersea and hyperbaric medicine
• Internal medicine critical care
• Surgical critical care.

AOBEM and the American Osteopathic Board of Pediatrics are also engaged in the development of a pediatric EM subspecialty examination.

Osteopathic Continuous Certification (OCC). AOBEM continues to refine and evolve the OCC process. The Board has received approval to begin allowing group data for the Practice Performance Assessment portion of OCC. Diplomates may submit group data provided at least 30% of the charts reviewed are patients that the diplomate cared for personally. Diplomates may also submit unique projects that are not on the list of “preapproved” projects. It is recognized that many of our diplomates are involved in very advanced care systems. Many times, these systems have useful projects that will meet criteria for this component. If you wish to submit data for a unique project, they will be welcomed, but the Board asks that you contact us to have them approved before beginning the project.

Continuous Osteopathic Learning Assessments (COLAs) are a vital component. They demonstrate the diplomate is maintaining currency across the entire specialty of EM. We invite diplomates and candidates to submit journal articles they feel are significant to a topic for potential inclusion in the official list of COLA articles.

Candidates and diplomates are advised to keep apprised of important dates and announcements via the AOBEM Web page at www.aobem.org.

In “What’s Hot and What’s Not in Our National Organizations, An Emergency Medicine Panel, Parts 1 and 2” (Emergency Medicine, April 2016 and May 2016, respectively), we published highlights from a panel discussion that took place at the annual retreat of the Association of Academic Chairs in Emergency Medicine in Tempe, Arizona in February 2016. That discussion included seven EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Residency Directors in Emergency Medicine (CORD), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM). In this issue, we follow up with reports from the American College of Osteopathic Emergency Physicians (ACOEP) and the American Osteopathic Board of Emergency Medicine (AOBEM).

American College of Osteopathic Emergency Physicians

John C. Prestosh, DO, FACOEP-DPresident, ACOEP

Strategic Planning. The Board of Directors of ACOEP has recently adopted a revised mission statement and goals for the organization. The ACOEP “promotes patient-centric, holistic emergency care consistent with the osteopathic philosophy practiced by all emergency medicine professionals.” This statement is based on the belief that many non-osteopathic professionals practice aspects of holistic medicine, and will allow ACOEP to be a “home” for these practitioners. ACOEP’s goals are member engagement and value, advocacy and involvement, education and knowledge, improving awareness, and college strength and sustainability.

Workplace Issues. The ACOEP is aware of the issues emergency physicians (EPs) and professionals face every day. Therefore, we are including items for EPs on these issues in our educational programs. Upcoming events will include workshops on dealing with an active shooter scenario, ultrasound, and advanced airway management, which will be included in our Scientific Assembly in November.

The ACOEP is also a member of the White House Task Force addressing the opioid epidemic. Realizing there are times when opiates are necessary adjuncts to patient care, we also want to help educate physicians on the usage of alternative pain-relieving treatment plans when indicated.

Single Accreditation System and College Sustainability. Graduate medical education is undergoing an unprecedented change. The Single Accreditation System is currently being implemented with a target date of July 1, 2020 for all residency programs to fall under the jurisdiction of the Accreditation Council for Graduate Medical Education (ACGME) for accreditation. There is much anticipation regarding the changes that will occur.

We anticipate some American Osteopathic Association-accredited EM programs will become 3-year programs, thus precluding graduating residents from AOBEM certification. However, we expect a number of ACGME-accredited EM programs to establish “osteopathic-focused” tracks in which both DOs and MDs will learn osteopathic tenets and procedures to broaden their practice of EM. We anticipate this will allow residents to be certified by the AOBEM.

We believe the ACOEP can be a “home” for MD residents graduating from “osteopathic-focused” ACGME programs. Furthermore, the ACOEP is ready to amend its bylaws to offer active membership with full voting rights to MDs. We do not want to remain a closed organization, but are striving to have both DO and MD EPs belong to our College.

American Osteopathic Board of Emergency Medicine

Donald Phillips, DO, FACOEP-D, Executive Physician Director, AOBEM

Primary Certification News. The date for the 2017 Part I Examination (written examination) has been published. All candidates are advised that the examination has been moved from March to September beginning in 2017. Applications for Part I will be available on January 2, 2017. The deadline to submit the application is April 1, 2017. The examination will be administered at Prometric Testing Centers nationwide on September 12, 2017. Part II Examinations (oral examinations) are in March and November. Please refer to the AOBEM Web page at www.aobem.org for dates.

Subspecialty Certifications. AOBEM offers subspecialty certification opportunities to its diplomates in the following areas:

• Emergency medical services
• Hospice and palliative medicine
• Medical toxicology
• Sports medicine
• Undersea and hyperbaric medicine
• Internal medicine critical care
• Surgical critical care.

AOBEM and the American Osteopathic Board of Pediatrics are also engaged in the development of a pediatric EM subspecialty examination.

Osteopathic Continuous Certification (OCC). AOBEM continues to refine and evolve the OCC process. The Board has received approval to begin allowing group data for the Practice Performance Assessment portion of OCC. Diplomates may submit group data provided at least 30% of the charts reviewed are patients that the diplomate cared for personally. Diplomates may also submit unique projects that are not on the list of “preapproved” projects. It is recognized that many of our diplomates are involved in very advanced care systems. Many times, these systems have useful projects that will meet criteria for this component. If you wish to submit data for a unique project, they will be welcomed, but the Board asks that you contact us to have them approved before beginning the project.

Continuous Osteopathic Learning Assessments (COLAs) are a vital component. They demonstrate the diplomate is maintaining currency across the entire specialty of EM. We invite diplomates and candidates to submit journal articles they feel are significant to a topic for potential inclusion in the official list of COLA articles.

Candidates and diplomates are advised to keep apprised of important dates and announcements via the AOBEM Web page at www.aobem.org.

In “What’s Hot and What’s Not in Our National Organizations, An Emergency Medicine Panel, Parts 1 and 2” (Emergency Medicine, April 2016 and May 2016, respectively), we published highlights from a panel discussion that took place at the annual retreat of the Association of Academic Chairs in Emergency Medicine in Tempe, Arizona in February 2016. That discussion included seven EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Residency Directors in Emergency Medicine (CORD), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM). In this issue, we follow up with reports from the American College of Osteopathic Emergency Physicians (ACOEP) and the American Osteopathic Board of Emergency Medicine (AOBEM).

American College of Osteopathic Emergency Physicians

John C. Prestosh, DO, FACOEP-DPresident, ACOEP

Strategic Planning. The Board of Directors of ACOEP has recently adopted a revised mission statement and goals for the organization. The ACOEP “promotes patient-centric, holistic emergency care consistent with the osteopathic philosophy practiced by all emergency medicine professionals.” This statement is based on the belief that many non-osteopathic professionals practice aspects of holistic medicine, and will allow ACOEP to be a “home” for these practitioners. ACOEP’s goals are member engagement and value, advocacy and involvement, education and knowledge, improving awareness, and college strength and sustainability.

Workplace Issues. The ACOEP is aware of the issues emergency physicians (EPs) and professionals face every day. Therefore, we are including items for EPs on these issues in our educational programs. Upcoming events will include workshops on dealing with an active shooter scenario, ultrasound, and advanced airway management, which will be included in our Scientific Assembly in November.

The ACOEP is also a member of the White House Task Force addressing the opioid epidemic. Realizing there are times when opiates are necessary adjuncts to patient care, we also want to help educate physicians on the usage of alternative pain-relieving treatment plans when indicated.

Single Accreditation System and College Sustainability. Graduate medical education is undergoing an unprecedented change. The Single Accreditation System is currently being implemented with a target date of July 1, 2020 for all residency programs to fall under the jurisdiction of the Accreditation Council for Graduate Medical Education (ACGME) for accreditation. There is much anticipation regarding the changes that will occur.

We anticipate some American Osteopathic Association-accredited EM programs will become 3-year programs, thus precluding graduating residents from AOBEM certification. However, we expect a number of ACGME-accredited EM programs to establish “osteopathic-focused” tracks in which both DOs and MDs will learn osteopathic tenets and procedures to broaden their practice of EM. We anticipate this will allow residents to be certified by the AOBEM.

We believe the ACOEP can be a “home” for MD residents graduating from “osteopathic-focused” ACGME programs. Furthermore, the ACOEP is ready to amend its bylaws to offer active membership with full voting rights to MDs. We do not want to remain a closed organization, but are striving to have both DO and MD EPs belong to our College.

American Osteopathic Board of Emergency Medicine

Donald Phillips, DO, FACOEP-D, Executive Physician Director, AOBEM

Primary Certification News. The date for the 2017 Part I Examination (written examination) has been published. All candidates are advised that the examination has been moved from March to September beginning in 2017. Applications for Part I will be available on January 2, 2017. The deadline to submit the application is April 1, 2017. The examination will be administered at Prometric Testing Centers nationwide on September 12, 2017. Part II Examinations (oral examinations) are in March and November. Please refer to the AOBEM Web page at www.aobem.org for dates.

Subspecialty Certifications. AOBEM offers subspecialty certification opportunities to its diplomates in the following areas:

• Emergency medical services
• Hospice and palliative medicine
• Medical toxicology
• Sports medicine
• Undersea and hyperbaric medicine
• Internal medicine critical care
• Surgical critical care.

AOBEM and the American Osteopathic Board of Pediatrics are also engaged in the development of a pediatric EM subspecialty examination.

Osteopathic Continuous Certification (OCC). AOBEM continues to refine and evolve the OCC process. The Board has received approval to begin allowing group data for the Practice Performance Assessment portion of OCC. Diplomates may submit group data provided at least 30% of the charts reviewed are patients that the diplomate cared for personally. Diplomates may also submit unique projects that are not on the list of “preapproved” projects. It is recognized that many of our diplomates are involved in very advanced care systems. Many times, these systems have useful projects that will meet criteria for this component. If you wish to submit data for a unique project, they will be welcomed, but the Board asks that you contact us to have them approved before beginning the project.

Continuous Osteopathic Learning Assessments (COLAs) are a vital component. They demonstrate the diplomate is maintaining currency across the entire specialty of EM. We invite diplomates and candidates to submit journal articles they feel are significant to a topic for potential inclusion in the official list of COLA articles.

Candidates and diplomates are advised to keep apprised of important dates and announcements via the AOBEM Web page at www.aobem.org.

During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.

On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”

As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”

Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.

Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.

Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at [email protected].

During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.

On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”

As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”

Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.

Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.

Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at [email protected].

During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.

On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”

As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”

Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.

Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.

Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at [email protected].

Improving medication accuracy, transitions of care, health information technology, and other ED patient-safety strategies are offered in this month’s Emergency Medicine cover article, “Patient Safety in the Emergency Department,” by emergency physician (EP)/toxicologist Brenna M. Farmer, MD, a colleague for many years.

As Dr Farmer notes in her introduction, patient safety—in the ED and elsewhere—has received a great deal of attention since the publication of the two landmark Institute of Medicine (IOM) studies in 1999 and 2001 that documented an enormous number of medical errors and recommended improvements in medical care. More than a decade and a half after their publication, is there any evidence that these reports have led to a reduction in the number of serious adverse effects and deaths due to medical errors?

Although most EPs believe that ED safety measures have reduced the overall number of errors, there is a scarcity of published data demonstrating a direct cause-and-effect relationship in reducing the number of adverse events and deaths. A recent analysis of National Hospital Ambulatory Medical Care Survey data by EPs Kanzaria, Probst, and Hsia (Health Aff [Millwood]. 2016;35[7]:1303-1308) found that ED death rates dropped by nearly 50% between 1997 and 2011. Most of this reporting period includes the years following the IOM reports before the implementation of the Affordable Care Act measures. One might reasonably assume that the decrease in ED death rates since 1997 is at least partly due to the safety measures described by Dr Farmer. However, Kanzaria et al hypothesize that the reduction is probably due to palliative and prehospital care efforts which “shift the locus of deaths,” to recent advances in emergency critical care, and to public health successes in smoking cessation, motor vehicle safety, etc. Conspicuously absent from their list of possible measures responsible for the reduction in ED death rates are ED safety measures.

If Kanzaria et al are correct in attributing the reduction in ED deaths to measures taken by others to decrease the number of dying patients brought to EDs, then it may be reasonable to look for the benefit of eliminating serious ED errors to a decrease in death rates after patients leave the ED for inpatient services. Though inpatient death-rate data is available only since 2005, Kanzaria et al report no significant change in the inpatient death rate between 2005 and 2011. It is possible, however, that the improvements in ED critical care hypothesized by the authors to be partly responsible for reducing ED death rates enable sicker patients to survive longer and ultimately succumb to their serious illnesses as inpatients. If so, this could offset any evident reduction in inpatient mortality from the avoidance of serious errors in the ED.

In any case, Dr Farmer does present direct evidence that safety measures are effective in reducing morbidity, and probably mortality. For example, in one study cited, medication errors were 13.5 times less likely to occur when an ED pharmacist was present, and clearly, avoiding doubling the doses of potent cardiac medications or sedative hypnotics, avoiding dangerous drug interactions, and choosing the correct type, dose, and time of administration of antibiotics and all meds must be responsible for reducing morbidity and ultimately mortality. It is also worth recalling that with respect to patient safety, emergency medicine is undoubtedly the safest medical specialty ever created, pioneering from its inception 24/7 bedside attending presence and mandatory recertifications, years to decades before other specialties adopted these practices. Thanks to these efforts, EDs are much safer than they had been previously, and by implementing the measures described by Dr Farmer will be safer still.  

Improving medication accuracy, transitions of care, health information technology, and other ED patient-safety strategies are offered in this month’s Emergency Medicine cover article, “Patient Safety in the Emergency Department,” by emergency physician (EP)/toxicologist Brenna M. Farmer, MD, a colleague for many years.

As Dr Farmer notes in her introduction, patient safety—in the ED and elsewhere—has received a great deal of attention since the publication of the two landmark Institute of Medicine (IOM) studies in 1999 and 2001 that documented an enormous number of medical errors and recommended improvements in medical care. More than a decade and a half after their publication, is there any evidence that these reports have led to a reduction in the number of serious adverse effects and deaths due to medical errors?

Although most EPs believe that ED safety measures have reduced the overall number of errors, there is a scarcity of published data demonstrating a direct cause-and-effect relationship in reducing the number of adverse events and deaths. A recent analysis of National Hospital Ambulatory Medical Care Survey data by EPs Kanzaria, Probst, and Hsia (Health Aff [Millwood]. 2016;35[7]:1303-1308) found that ED death rates dropped by nearly 50% between 1997 and 2011. Most of this reporting period includes the years following the IOM reports before the implementation of the Affordable Care Act measures. One might reasonably assume that the decrease in ED death rates since 1997 is at least partly due to the safety measures described by Dr Farmer. However, Kanzaria et al hypothesize that the reduction is probably due to palliative and prehospital care efforts which “shift the locus of deaths,” to recent advances in emergency critical care, and to public health successes in smoking cessation, motor vehicle safety, etc. Conspicuously absent from their list of possible measures responsible for the reduction in ED death rates are ED safety measures.

If Kanzaria et al are correct in attributing the reduction in ED deaths to measures taken by others to decrease the number of dying patients brought to EDs, then it may be reasonable to look for the benefit of eliminating serious ED errors to a decrease in death rates after patients leave the ED for inpatient services. Though inpatient death-rate data is available only since 2005, Kanzaria et al report no significant change in the inpatient death rate between 2005 and 2011. It is possible, however, that the improvements in ED critical care hypothesized by the authors to be partly responsible for reducing ED death rates enable sicker patients to survive longer and ultimately succumb to their serious illnesses as inpatients. If so, this could offset any evident reduction in inpatient mortality from the avoidance of serious errors in the ED.

In any case, Dr Farmer does present direct evidence that safety measures are effective in reducing morbidity, and probably mortality. For example, in one study cited, medication errors were 13.5 times less likely to occur when an ED pharmacist was present, and clearly, avoiding doubling the doses of potent cardiac medications or sedative hypnotics, avoiding dangerous drug interactions, and choosing the correct type, dose, and time of administration of antibiotics and all meds must be responsible for reducing morbidity and ultimately mortality. It is also worth recalling that with respect to patient safety, emergency medicine is undoubtedly the safest medical specialty ever created, pioneering from its inception 24/7 bedside attending presence and mandatory recertifications, years to decades before other specialties adopted these practices. Thanks to these efforts, EDs are much safer than they had been previously, and by implementing the measures described by Dr Farmer will be safer still.  

Improving medication accuracy, transitions of care, health information technology, and other ED patient-safety strategies are offered in this month’s Emergency Medicine cover article, “Patient Safety in the Emergency Department,” by emergency physician (EP)/toxicologist Brenna M. Farmer, MD, a colleague for many years.

As Dr Farmer notes in her introduction, patient safety—in the ED and elsewhere—has received a great deal of attention since the publication of the two landmark Institute of Medicine (IOM) studies in 1999 and 2001 that documented an enormous number of medical errors and recommended improvements in medical care. More than a decade and a half after their publication, is there any evidence that these reports have led to a reduction in the number of serious adverse effects and deaths due to medical errors?

Although most EPs believe that ED safety measures have reduced the overall number of errors, there is a scarcity of published data demonstrating a direct cause-and-effect relationship in reducing the number of adverse events and deaths. A recent analysis of National Hospital Ambulatory Medical Care Survey data by EPs Kanzaria, Probst, and Hsia (Health Aff [Millwood]. 2016;35[7]:1303-1308) found that ED death rates dropped by nearly 50% between 1997 and 2011. Most of this reporting period includes the years following the IOM reports before the implementation of the Affordable Care Act measures. One might reasonably assume that the decrease in ED death rates since 1997 is at least partly due to the safety measures described by Dr Farmer. However, Kanzaria et al hypothesize that the reduction is probably due to palliative and prehospital care efforts which “shift the locus of deaths,” to recent advances in emergency critical care, and to public health successes in smoking cessation, motor vehicle safety, etc. Conspicuously absent from their list of possible measures responsible for the reduction in ED death rates are ED safety measures.

If Kanzaria et al are correct in attributing the reduction in ED deaths to measures taken by others to decrease the number of dying patients brought to EDs, then it may be reasonable to look for the benefit of eliminating serious ED errors to a decrease in death rates after patients leave the ED for inpatient services. Though inpatient death-rate data is available only since 2005, Kanzaria et al report no significant change in the inpatient death rate between 2005 and 2011. It is possible, however, that the improvements in ED critical care hypothesized by the authors to be partly responsible for reducing ED death rates enable sicker patients to survive longer and ultimately succumb to their serious illnesses as inpatients. If so, this could offset any evident reduction in inpatient mortality from the avoidance of serious errors in the ED.

In any case, Dr Farmer does present direct evidence that safety measures are effective in reducing morbidity, and probably mortality. For example, in one study cited, medication errors were 13.5 times less likely to occur when an ED pharmacist was present, and clearly, avoiding doubling the doses of potent cardiac medications or sedative hypnotics, avoiding dangerous drug interactions, and choosing the correct type, dose, and time of administration of antibiotics and all meds must be responsible for reducing morbidity and ultimately mortality. It is also worth recalling that with respect to patient safety, emergency medicine is undoubtedly the safest medical specialty ever created, pioneering from its inception 24/7 bedside attending presence and mandatory recertifications, years to decades before other specialties adopted these practices. Thanks to these efforts, EDs are much safer than they had been previously, and by implementing the measures described by Dr Farmer will be safer still.