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Myth of the Month: Retired myths from yesteryear
I appreciate the opportunity to share medical myths each month, hopefully to highlight topics where new knowledge and data may help change ways we approach common problems in medicine. I have been researching medical myths since the early 1990s, and some have actually evolved in such a way that they are no longer myths – that is, accepted practice now is very different than it was decades ago, and has incorporated updated research.
Some myths are timeless. The vitamin B12 myth I shared in this column last year continues to this day, despite evidence that has been present since the 1960s.
I will share with you two of my all-time favorite myths that have now been retired, where current practice now does not perpetuate these myths.
When I was in medical school, I was taught that the best way to treat a corneal abrasion was to patch the affected eye.1 Pretty much everyone who was seen in an emergency department for a corneal abrasion before the 1990s left the ED with an eye patch. This standard approach was not based on any evidence of benefit of healing or decreased pain.
Dr. Harold Jackson reported in a study of patients with corneal abrasions published in 1960 that there was no difference in healing between eyes that were patched and eyes that were left unpatched.2 The largest published study on eye patches for corneal abrasions involved 201 patients who were evaluated for corneal abrasions.3 The patients who did not receive an eye patch had less pain and quicker healing of the corneal abrasions. Other studies all showed no benefit to eye patches.4,5
A Cochrane Review published in 2006 concluded: “Treating simple corneal abrasions with a patch does not improve healing rates on the first day post-injury and does not reduce pain. In addition, use of patches results in a loss of binocular vision. Therefore, it is recommended that patches should not be used for simple corneal abrasions.”6
A more recent study by Dr. Moreno Menghini and colleagues showed no differences in healing of traumatic corneal abrasions between groups who received an eye patch, a contact lens, or no eye covering.7
Another longstanding myth that is less commonly seen now is the avoidance of use of narcotics for the treatment of acute, severe abdominal pain.
The long-term teaching was that by treating abdominal pain with narcotics, you could mask the important physical exam findings in patients presenting with an acute abdomen. The source of this myth wasn’t hard to uncover. The following are quotes from Cope’s Early Diagnosis of the Acute Abdomen 15th and 16th editions (these were the editions available back when I was a medical student in the early 1980s).
From the 15th edition: “If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the elusive hope.”8
An even stronger position was taken in the next edition of Cope’s text: “The patient cried out for relief, the relatives are insistent that something should be done, and the humane disciple of Aesculapius may think it is his first duty to diminish or banish the too obvious agony by administering a narcotic. Such a policy is a mistake. Though it may appear cruel, it is really kind to withhold morphine until a reasonable diagnosis has been made.”9
No controlled trials ever questioned this long-held belief until a study done by Dr. Alex Attard and colleagues published in 1992.10 In this study, 100 patients were evaluated by an admitting officer and given an intramuscular injection of either a narcotic or saline. Surgeons who subsequently followed the patients felt equally confident in diagnosis and management in both groups. The decision to operate or observe was incorrect in two patients in the narcotic group and nine in the saline group.
Dr. H. A. Amoli and colleagues studied whether administering morphine changed exam findings in patients with acute appendiciits.11 In a randomized, double-blind study design, half the patients received morphine and half received saline. Patients were examined by surgeons not involved in their care before and after drug administration, and their pain intensity and signs were recorded at each visit. The administration of morphine did not alter clinical signs or physician management plans.
In a study by Dr. Steven Pace and colleagues of patients presenting with acute abdominal pain, intravenous morphine or placebo was administered in 71 patients early in their presentation to the ED.12 There were no differences in accuracy of diagnosis between groups. Three diagnostic or management errors were made in each group.
I think the standard of care now for corneal abrasion treatment does not include eye patching. I also believe that the old teaching of no pain medication until the surgeon has examined the patient has also been replaced with appropriate pain management occurring early in the care plan for patients presenting with acute abdominal pain.
In the case of corneal abrasions, overwhelming data showing no benefit won out. I believe that the change in the management of acute abdominal pain was a combination of data along with advances in diagnostic imaging.
References
1. Wilkins. Emergency Medicine. 1989 Williams and Wilkins, Baltimore, Md.
2. Br Med J. 1960 Sep 3;2(5200):713.
3. Ophthalmology. 1995 Dec;102(12):1936-42.
4. Lancet. 1991 Mar 16;337(8742):643.
6. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004764.
7. Ophthalmic Res. 2013;50(1):13-8.
8. Cope’s Early Diagnosis of the Acute Abdomen, 15th Edition, Oxford University Press, 1979.
9. Cope’s Early Diagnosis of the Acute Abdomen, 16th Edition, Oxford University Press, 1983.
10. BMJ. 1992 Sep 5;305(6853):554-6.
11. Emerg Med J. 2008 Sep;25(9):586-9.
12. Acad Emerg Med. 1996 Dec;3(12):1086-92.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
I appreciate the opportunity to share medical myths each month, hopefully to highlight topics where new knowledge and data may help change ways we approach common problems in medicine. I have been researching medical myths since the early 1990s, and some have actually evolved in such a way that they are no longer myths – that is, accepted practice now is very different than it was decades ago, and has incorporated updated research.
Some myths are timeless. The vitamin B12 myth I shared in this column last year continues to this day, despite evidence that has been present since the 1960s.
I will share with you two of my all-time favorite myths that have now been retired, where current practice now does not perpetuate these myths.
When I was in medical school, I was taught that the best way to treat a corneal abrasion was to patch the affected eye.1 Pretty much everyone who was seen in an emergency department for a corneal abrasion before the 1990s left the ED with an eye patch. This standard approach was not based on any evidence of benefit of healing or decreased pain.
Dr. Harold Jackson reported in a study of patients with corneal abrasions published in 1960 that there was no difference in healing between eyes that were patched and eyes that were left unpatched.2 The largest published study on eye patches for corneal abrasions involved 201 patients who were evaluated for corneal abrasions.3 The patients who did not receive an eye patch had less pain and quicker healing of the corneal abrasions. Other studies all showed no benefit to eye patches.4,5
A Cochrane Review published in 2006 concluded: “Treating simple corneal abrasions with a patch does not improve healing rates on the first day post-injury and does not reduce pain. In addition, use of patches results in a loss of binocular vision. Therefore, it is recommended that patches should not be used for simple corneal abrasions.”6
A more recent study by Dr. Moreno Menghini and colleagues showed no differences in healing of traumatic corneal abrasions between groups who received an eye patch, a contact lens, or no eye covering.7
Another longstanding myth that is less commonly seen now is the avoidance of use of narcotics for the treatment of acute, severe abdominal pain.
The long-term teaching was that by treating abdominal pain with narcotics, you could mask the important physical exam findings in patients presenting with an acute abdomen. The source of this myth wasn’t hard to uncover. The following are quotes from Cope’s Early Diagnosis of the Acute Abdomen 15th and 16th editions (these were the editions available back when I was a medical student in the early 1980s).
From the 15th edition: “If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the elusive hope.”8
An even stronger position was taken in the next edition of Cope’s text: “The patient cried out for relief, the relatives are insistent that something should be done, and the humane disciple of Aesculapius may think it is his first duty to diminish or banish the too obvious agony by administering a narcotic. Such a policy is a mistake. Though it may appear cruel, it is really kind to withhold morphine until a reasonable diagnosis has been made.”9
No controlled trials ever questioned this long-held belief until a study done by Dr. Alex Attard and colleagues published in 1992.10 In this study, 100 patients were evaluated by an admitting officer and given an intramuscular injection of either a narcotic or saline. Surgeons who subsequently followed the patients felt equally confident in diagnosis and management in both groups. The decision to operate or observe was incorrect in two patients in the narcotic group and nine in the saline group.
Dr. H. A. Amoli and colleagues studied whether administering morphine changed exam findings in patients with acute appendiciits.11 In a randomized, double-blind study design, half the patients received morphine and half received saline. Patients were examined by surgeons not involved in their care before and after drug administration, and their pain intensity and signs were recorded at each visit. The administration of morphine did not alter clinical signs or physician management plans.
In a study by Dr. Steven Pace and colleagues of patients presenting with acute abdominal pain, intravenous morphine or placebo was administered in 71 patients early in their presentation to the ED.12 There were no differences in accuracy of diagnosis between groups. Three diagnostic or management errors were made in each group.
I think the standard of care now for corneal abrasion treatment does not include eye patching. I also believe that the old teaching of no pain medication until the surgeon has examined the patient has also been replaced with appropriate pain management occurring early in the care plan for patients presenting with acute abdominal pain.
In the case of corneal abrasions, overwhelming data showing no benefit won out. I believe that the change in the management of acute abdominal pain was a combination of data along with advances in diagnostic imaging.
References
1. Wilkins. Emergency Medicine. 1989 Williams and Wilkins, Baltimore, Md.
2. Br Med J. 1960 Sep 3;2(5200):713.
3. Ophthalmology. 1995 Dec;102(12):1936-42.
4. Lancet. 1991 Mar 16;337(8742):643.
6. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004764.
7. Ophthalmic Res. 2013;50(1):13-8.
8. Cope’s Early Diagnosis of the Acute Abdomen, 15th Edition, Oxford University Press, 1979.
9. Cope’s Early Diagnosis of the Acute Abdomen, 16th Edition, Oxford University Press, 1983.
10. BMJ. 1992 Sep 5;305(6853):554-6.
11. Emerg Med J. 2008 Sep;25(9):586-9.
12. Acad Emerg Med. 1996 Dec;3(12):1086-92.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
I appreciate the opportunity to share medical myths each month, hopefully to highlight topics where new knowledge and data may help change ways we approach common problems in medicine. I have been researching medical myths since the early 1990s, and some have actually evolved in such a way that they are no longer myths – that is, accepted practice now is very different than it was decades ago, and has incorporated updated research.
Some myths are timeless. The vitamin B12 myth I shared in this column last year continues to this day, despite evidence that has been present since the 1960s.
I will share with you two of my all-time favorite myths that have now been retired, where current practice now does not perpetuate these myths.
When I was in medical school, I was taught that the best way to treat a corneal abrasion was to patch the affected eye.1 Pretty much everyone who was seen in an emergency department for a corneal abrasion before the 1990s left the ED with an eye patch. This standard approach was not based on any evidence of benefit of healing or decreased pain.
Dr. Harold Jackson reported in a study of patients with corneal abrasions published in 1960 that there was no difference in healing between eyes that were patched and eyes that were left unpatched.2 The largest published study on eye patches for corneal abrasions involved 201 patients who were evaluated for corneal abrasions.3 The patients who did not receive an eye patch had less pain and quicker healing of the corneal abrasions. Other studies all showed no benefit to eye patches.4,5
A Cochrane Review published in 2006 concluded: “Treating simple corneal abrasions with a patch does not improve healing rates on the first day post-injury and does not reduce pain. In addition, use of patches results in a loss of binocular vision. Therefore, it is recommended that patches should not be used for simple corneal abrasions.”6
A more recent study by Dr. Moreno Menghini and colleagues showed no differences in healing of traumatic corneal abrasions between groups who received an eye patch, a contact lens, or no eye covering.7
Another longstanding myth that is less commonly seen now is the avoidance of use of narcotics for the treatment of acute, severe abdominal pain.
The long-term teaching was that by treating abdominal pain with narcotics, you could mask the important physical exam findings in patients presenting with an acute abdomen. The source of this myth wasn’t hard to uncover. The following are quotes from Cope’s Early Diagnosis of the Acute Abdomen 15th and 16th editions (these were the editions available back when I was a medical student in the early 1980s).
From the 15th edition: “If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the elusive hope.”8
An even stronger position was taken in the next edition of Cope’s text: “The patient cried out for relief, the relatives are insistent that something should be done, and the humane disciple of Aesculapius may think it is his first duty to diminish or banish the too obvious agony by administering a narcotic. Such a policy is a mistake. Though it may appear cruel, it is really kind to withhold morphine until a reasonable diagnosis has been made.”9
No controlled trials ever questioned this long-held belief until a study done by Dr. Alex Attard and colleagues published in 1992.10 In this study, 100 patients were evaluated by an admitting officer and given an intramuscular injection of either a narcotic or saline. Surgeons who subsequently followed the patients felt equally confident in diagnosis and management in both groups. The decision to operate or observe was incorrect in two patients in the narcotic group and nine in the saline group.
Dr. H. A. Amoli and colleagues studied whether administering morphine changed exam findings in patients with acute appendiciits.11 In a randomized, double-blind study design, half the patients received morphine and half received saline. Patients were examined by surgeons not involved in their care before and after drug administration, and their pain intensity and signs were recorded at each visit. The administration of morphine did not alter clinical signs or physician management plans.
In a study by Dr. Steven Pace and colleagues of patients presenting with acute abdominal pain, intravenous morphine or placebo was administered in 71 patients early in their presentation to the ED.12 There were no differences in accuracy of diagnosis between groups. Three diagnostic or management errors were made in each group.
I think the standard of care now for corneal abrasion treatment does not include eye patching. I also believe that the old teaching of no pain medication until the surgeon has examined the patient has also been replaced with appropriate pain management occurring early in the care plan for patients presenting with acute abdominal pain.
In the case of corneal abrasions, overwhelming data showing no benefit won out. I believe that the change in the management of acute abdominal pain was a combination of data along with advances in diagnostic imaging.
References
1. Wilkins. Emergency Medicine. 1989 Williams and Wilkins, Baltimore, Md.
2. Br Med J. 1960 Sep 3;2(5200):713.
3. Ophthalmology. 1995 Dec;102(12):1936-42.
4. Lancet. 1991 Mar 16;337(8742):643.
6. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004764.
7. Ophthalmic Res. 2013;50(1):13-8.
8. Cope’s Early Diagnosis of the Acute Abdomen, 15th Edition, Oxford University Press, 1979.
9. Cope’s Early Diagnosis of the Acute Abdomen, 16th Edition, Oxford University Press, 1983.
10. BMJ. 1992 Sep 5;305(6853):554-6.
11. Emerg Med J. 2008 Sep;25(9):586-9.
12. Acad Emerg Med. 1996 Dec;3(12):1086-92.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
Your online reputation
Have you ever run across a negative or even malicious comment about you or your practice on the web, in full view of the world? You’re certainly not alone.
Chances are it was on one of those doctor rating sites, whose supposedly “objective” evaluations are anything but fair or accurate; one curmudgeon, angry about something that usually has nothing to do with your clinical skills, can use his First Amendment–protected right to trash you unfairly, as thousands of satisfied patients remain silent.
What to do? You could hire one of the many companies in the rapidly burgeoning field of online reputation management; but that can cost hundreds to thousands of dollars per month for monitoring and intervention, and there are no guarantees of success.
A better solution is to generate your own search results – positive ones – that will overwhelm any negative comments that search engines might find. Start with the social networking sites. However you feel about networking, there’s no getting around the fact that personal pages on Facebook, LinkedIn, and Twitter rank very high on major search engines. (Some consultants say a favorable LinkedIn profile is particularly helpful because of that site’s reputation as a “professional” network.) Your community activities, charitable work, interesting hobbies – anything that casts you in a favorable light – need to be mentioned prominently in your network profiles.
You can also use Google’s profiling tool (https://plus.google.com/up/accounts/) to create a sterling bio, complete with links to URLs, photos, and anything else that shows you in the best possible light. And your Google profile will be at or near the top of any Google search.
Wikipedia articles also go to the top of most searches, so if you’re notable enough to merit mention in one – or to have one of your own – see that it is done, and updated regularly. You can’t do that yourself, however; Wikipedia’s conflict of interest rules forbid writing or editing content about yourself. Someone with a theoretically “neutral point of view” will have to do it.
If you don’t yet have a website, now would be a good time. As I’ve discussed many times, a professionally designed site will be far more attractive and polished than anything you could build yourself. Furthermore, an experienced designer will employ “search engine optimization” (SEO), meaning that content will be created in a way that is readily visible to search engine users.
Leave design and SEO to the pros, but don’t delegate the content itself; as captain of the ship you are responsible for all the facts and opinions on your site. And remember that once it’s online, it’s online forever; consider the ramifications of anything you post on any site (yours or others) before hitting the “send” button. “The most damaging item about you,” one consultant told me, “could well be something you posted yourself.” Just ask any of several prominent politicians who have famously sabotaged their own careers online.
That said, don’t be shy about creating content. Make your (noncontroversial) opinions known on Facebook and Twitter. If social networks are not your thing, add a blog to your web site and write about what you know, and what interests you. If you have expertise in a particular field, write about that.
Incidentally, if the URL for your web site is not your name, you should also register your name as a separate domain name – if only to be sure that a trickster, or someone with the same name and a bad reputation, doesn’t get it.
Set up an RSS news feed for yourself, so you’ll know immediately anytime your name pops up in news or gossip sites, or on blogs. If something untrue is posted about you, take action. Reputable news sites and blogs have their own reputations to protect, and so can usually be persuaded to correct anything that is demonstrably false. Try to get the error removed entirely, or corrected within the original article. An erratum on the last page of the next edition will be ignored, and will leave the false information online, intact.
Unfair comments on doctor rating sites are unlikely to be removed unless they are blatantly libelous; but there is nothing wrong with encouraging happy patients to write favorable reviews. Turnabout is fair play.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Have you ever run across a negative or even malicious comment about you or your practice on the web, in full view of the world? You’re certainly not alone.
Chances are it was on one of those doctor rating sites, whose supposedly “objective” evaluations are anything but fair or accurate; one curmudgeon, angry about something that usually has nothing to do with your clinical skills, can use his First Amendment–protected right to trash you unfairly, as thousands of satisfied patients remain silent.
What to do? You could hire one of the many companies in the rapidly burgeoning field of online reputation management; but that can cost hundreds to thousands of dollars per month for monitoring and intervention, and there are no guarantees of success.
A better solution is to generate your own search results – positive ones – that will overwhelm any negative comments that search engines might find. Start with the social networking sites. However you feel about networking, there’s no getting around the fact that personal pages on Facebook, LinkedIn, and Twitter rank very high on major search engines. (Some consultants say a favorable LinkedIn profile is particularly helpful because of that site’s reputation as a “professional” network.) Your community activities, charitable work, interesting hobbies – anything that casts you in a favorable light – need to be mentioned prominently in your network profiles.
You can also use Google’s profiling tool (https://plus.google.com/up/accounts/) to create a sterling bio, complete with links to URLs, photos, and anything else that shows you in the best possible light. And your Google profile will be at or near the top of any Google search.
Wikipedia articles also go to the top of most searches, so if you’re notable enough to merit mention in one – or to have one of your own – see that it is done, and updated regularly. You can’t do that yourself, however; Wikipedia’s conflict of interest rules forbid writing or editing content about yourself. Someone with a theoretically “neutral point of view” will have to do it.
If you don’t yet have a website, now would be a good time. As I’ve discussed many times, a professionally designed site will be far more attractive and polished than anything you could build yourself. Furthermore, an experienced designer will employ “search engine optimization” (SEO), meaning that content will be created in a way that is readily visible to search engine users.
Leave design and SEO to the pros, but don’t delegate the content itself; as captain of the ship you are responsible for all the facts and opinions on your site. And remember that once it’s online, it’s online forever; consider the ramifications of anything you post on any site (yours or others) before hitting the “send” button. “The most damaging item about you,” one consultant told me, “could well be something you posted yourself.” Just ask any of several prominent politicians who have famously sabotaged their own careers online.
That said, don’t be shy about creating content. Make your (noncontroversial) opinions known on Facebook and Twitter. If social networks are not your thing, add a blog to your web site and write about what you know, and what interests you. If you have expertise in a particular field, write about that.
Incidentally, if the URL for your web site is not your name, you should also register your name as a separate domain name – if only to be sure that a trickster, or someone with the same name and a bad reputation, doesn’t get it.
Set up an RSS news feed for yourself, so you’ll know immediately anytime your name pops up in news or gossip sites, or on blogs. If something untrue is posted about you, take action. Reputable news sites and blogs have their own reputations to protect, and so can usually be persuaded to correct anything that is demonstrably false. Try to get the error removed entirely, or corrected within the original article. An erratum on the last page of the next edition will be ignored, and will leave the false information online, intact.
Unfair comments on doctor rating sites are unlikely to be removed unless they are blatantly libelous; but there is nothing wrong with encouraging happy patients to write favorable reviews. Turnabout is fair play.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Have you ever run across a negative or even malicious comment about you or your practice on the web, in full view of the world? You’re certainly not alone.
Chances are it was on one of those doctor rating sites, whose supposedly “objective” evaluations are anything but fair or accurate; one curmudgeon, angry about something that usually has nothing to do with your clinical skills, can use his First Amendment–protected right to trash you unfairly, as thousands of satisfied patients remain silent.
What to do? You could hire one of the many companies in the rapidly burgeoning field of online reputation management; but that can cost hundreds to thousands of dollars per month for monitoring and intervention, and there are no guarantees of success.
A better solution is to generate your own search results – positive ones – that will overwhelm any negative comments that search engines might find. Start with the social networking sites. However you feel about networking, there’s no getting around the fact that personal pages on Facebook, LinkedIn, and Twitter rank very high on major search engines. (Some consultants say a favorable LinkedIn profile is particularly helpful because of that site’s reputation as a “professional” network.) Your community activities, charitable work, interesting hobbies – anything that casts you in a favorable light – need to be mentioned prominently in your network profiles.
You can also use Google’s profiling tool (https://plus.google.com/up/accounts/) to create a sterling bio, complete with links to URLs, photos, and anything else that shows you in the best possible light. And your Google profile will be at or near the top of any Google search.
Wikipedia articles also go to the top of most searches, so if you’re notable enough to merit mention in one – or to have one of your own – see that it is done, and updated regularly. You can’t do that yourself, however; Wikipedia’s conflict of interest rules forbid writing or editing content about yourself. Someone with a theoretically “neutral point of view” will have to do it.
If you don’t yet have a website, now would be a good time. As I’ve discussed many times, a professionally designed site will be far more attractive and polished than anything you could build yourself. Furthermore, an experienced designer will employ “search engine optimization” (SEO), meaning that content will be created in a way that is readily visible to search engine users.
Leave design and SEO to the pros, but don’t delegate the content itself; as captain of the ship you are responsible for all the facts and opinions on your site. And remember that once it’s online, it’s online forever; consider the ramifications of anything you post on any site (yours or others) before hitting the “send” button. “The most damaging item about you,” one consultant told me, “could well be something you posted yourself.” Just ask any of several prominent politicians who have famously sabotaged their own careers online.
That said, don’t be shy about creating content. Make your (noncontroversial) opinions known on Facebook and Twitter. If social networks are not your thing, add a blog to your web site and write about what you know, and what interests you. If you have expertise in a particular field, write about that.
Incidentally, if the URL for your web site is not your name, you should also register your name as a separate domain name – if only to be sure that a trickster, or someone with the same name and a bad reputation, doesn’t get it.
Set up an RSS news feed for yourself, so you’ll know immediately anytime your name pops up in news or gossip sites, or on blogs. If something untrue is posted about you, take action. Reputable news sites and blogs have their own reputations to protect, and so can usually be persuaded to correct anything that is demonstrably false. Try to get the error removed entirely, or corrected within the original article. An erratum on the last page of the next edition will be ignored, and will leave the false information online, intact.
Unfair comments on doctor rating sites are unlikely to be removed unless they are blatantly libelous; but there is nothing wrong with encouraging happy patients to write favorable reviews. Turnabout is fair play.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Can’t we be friends?
Can’t we just be friends? This is the disquieting question we ask someone when we want to set boundaries. It is meant to define expectation, level of trust and intimacy in a relationship.
We are capable of forming an astonishing variety of relationships with others. We form deep emotional connections with romantic partners, close family, and dear friends. We create more superficial ties with colleagues, distant family, and professionals. Understanding the nature of our relationships is important. There are reasons why professors should not engage in romantic relationships with their students: mixing relationships can lead to confusion and destroy trust. The risk for misunderstanding and harm to one or both parties increases as the intensity of the relationship increases. Can a professor who has a personal relationship with a student be objective? Does the student really want to be kissed or is she feigning interest for a better grade?
The stakes are even higher for us physicians. Forming inappropriate relationships with patients can result in the loss of your medical license. This seems obvious to most of us, but when we examine the appropriateness of other nonprofessional connections, it becomes less clear.
What if you have an intimate but nonsexual relationship with a patient? What about having a family member or close friend as a patient? Most medical ethicists say that any relationship other than the straightforward, professional doctor/patient one is improper. This strict definition exists primarily to protect our patients but also to help us. The highest levels of quality and service can only come from the sterile yet compassionate trust that occurs only in doctor/patient connections.
As a male dermatologist, something as seemingly innocuous as my following a female patient on Instagram puts our professional relationship at risk. If a patient views you as a friend as well as a doctor, would he hesitate to divulge things that are important to his health but inappropriate for a friend to know? Moreover, if I have such knowledge, won’t that impair the trust we share as friends? Such conundrums might hinder your ability to care for your patients and limit the quality of service they receive.
Social media have added many more levels to the already complex ways we can relate to our patients. There are Facebook friends, Snapchat buddies, and Twitter followers. Most of these are diminishingly shallow in terms of the depth and seriousness of the relationship, but they can be misconstrued. In most instances, keep it simple: I’m your doctor. You’re my patient.
When patients ask me to friend them, as they sometime do, I remind them: I’m not your brother or your son. I am not your friend. You pay me to provide a service, yet what I give cannot be bought. I work for you when I’m home. I worry about you when I drive to the office. Someday, I may save your life.
I’m your doctor. No, we cannot be Facebook friends.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter.
Can’t we just be friends? This is the disquieting question we ask someone when we want to set boundaries. It is meant to define expectation, level of trust and intimacy in a relationship.
We are capable of forming an astonishing variety of relationships with others. We form deep emotional connections with romantic partners, close family, and dear friends. We create more superficial ties with colleagues, distant family, and professionals. Understanding the nature of our relationships is important. There are reasons why professors should not engage in romantic relationships with their students: mixing relationships can lead to confusion and destroy trust. The risk for misunderstanding and harm to one or both parties increases as the intensity of the relationship increases. Can a professor who has a personal relationship with a student be objective? Does the student really want to be kissed or is she feigning interest for a better grade?
The stakes are even higher for us physicians. Forming inappropriate relationships with patients can result in the loss of your medical license. This seems obvious to most of us, but when we examine the appropriateness of other nonprofessional connections, it becomes less clear.
What if you have an intimate but nonsexual relationship with a patient? What about having a family member or close friend as a patient? Most medical ethicists say that any relationship other than the straightforward, professional doctor/patient one is improper. This strict definition exists primarily to protect our patients but also to help us. The highest levels of quality and service can only come from the sterile yet compassionate trust that occurs only in doctor/patient connections.
As a male dermatologist, something as seemingly innocuous as my following a female patient on Instagram puts our professional relationship at risk. If a patient views you as a friend as well as a doctor, would he hesitate to divulge things that are important to his health but inappropriate for a friend to know? Moreover, if I have such knowledge, won’t that impair the trust we share as friends? Such conundrums might hinder your ability to care for your patients and limit the quality of service they receive.
Social media have added many more levels to the already complex ways we can relate to our patients. There are Facebook friends, Snapchat buddies, and Twitter followers. Most of these are diminishingly shallow in terms of the depth and seriousness of the relationship, but they can be misconstrued. In most instances, keep it simple: I’m your doctor. You’re my patient.
When patients ask me to friend them, as they sometime do, I remind them: I’m not your brother or your son. I am not your friend. You pay me to provide a service, yet what I give cannot be bought. I work for you when I’m home. I worry about you when I drive to the office. Someday, I may save your life.
I’m your doctor. No, we cannot be Facebook friends.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter.
Can’t we just be friends? This is the disquieting question we ask someone when we want to set boundaries. It is meant to define expectation, level of trust and intimacy in a relationship.
We are capable of forming an astonishing variety of relationships with others. We form deep emotional connections with romantic partners, close family, and dear friends. We create more superficial ties with colleagues, distant family, and professionals. Understanding the nature of our relationships is important. There are reasons why professors should not engage in romantic relationships with their students: mixing relationships can lead to confusion and destroy trust. The risk for misunderstanding and harm to one or both parties increases as the intensity of the relationship increases. Can a professor who has a personal relationship with a student be objective? Does the student really want to be kissed or is she feigning interest for a better grade?
The stakes are even higher for us physicians. Forming inappropriate relationships with patients can result in the loss of your medical license. This seems obvious to most of us, but when we examine the appropriateness of other nonprofessional connections, it becomes less clear.
What if you have an intimate but nonsexual relationship with a patient? What about having a family member or close friend as a patient? Most medical ethicists say that any relationship other than the straightforward, professional doctor/patient one is improper. This strict definition exists primarily to protect our patients but also to help us. The highest levels of quality and service can only come from the sterile yet compassionate trust that occurs only in doctor/patient connections.
As a male dermatologist, something as seemingly innocuous as my following a female patient on Instagram puts our professional relationship at risk. If a patient views you as a friend as well as a doctor, would he hesitate to divulge things that are important to his health but inappropriate for a friend to know? Moreover, if I have such knowledge, won’t that impair the trust we share as friends? Such conundrums might hinder your ability to care for your patients and limit the quality of service they receive.
Social media have added many more levels to the already complex ways we can relate to our patients. There are Facebook friends, Snapchat buddies, and Twitter followers. Most of these are diminishingly shallow in terms of the depth and seriousness of the relationship, but they can be misconstrued. In most instances, keep it simple: I’m your doctor. You’re my patient.
When patients ask me to friend them, as they sometime do, I remind them: I’m not your brother or your son. I am not your friend. You pay me to provide a service, yet what I give cannot be bought. I work for you when I’m home. I worry about you when I drive to the office. Someday, I may save your life.
I’m your doctor. No, we cannot be Facebook friends.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter.
Dispensing with expert testimony
Question: When a doctor could not find a dislodged biopsy guide wire, he abandoned his search after informing the patient of his intention to retrieve it at a later date. Two months later, he was successful in locating and removing the foreign body, but the patient alleged she suffered pain and anxiety in the interim. She filed a negligence lawsuit and, based on the “obvious” nature of her injuries, called no expert witness to testify on her behalf.
Which of the following choices is best?
A. Expert testimony is always needed to establish the applicable standard of care in medical negligence lawsuits.
B. Although a plaintiff is not qualified to expound on medical matters, he/she can offer evidence from learned treatises and medical texts.
C. The jury is the one who determines whether a plaintiff can invoke either the res ipsa loquitur doctrine or the “common knowledge” rule to obviate the need for an expert witness.
D. This patient will likely win her case.
E. All are incorrect.
Answer: E. It is well-established law that the question of negligence must be decided by reference to relevant medical standards of care for which the plaintiff carries the burden of proving through expert medical testimony. Only a professional, duly qualified by the court as an expert witness, is allowed to offer medical testimony – whereas the plaintiff typically will be disqualified from playing this role because of the complexity of issues involved.
However, under either the doctrine of res ipsa loquitur (“the thing speaks for itself”) or the “common knowledge” rule, a court (i.e., the judge) may allow the jury to infer negligence in the absence of expert testimony.
The res doctrine is invoked where there is only circumstantial but no direct evidence, and three conditions are met: 1) The injury would not have occurred in the absence of someone’s negligence; 2) the plaintiff was not at fault; and 3) the defendant had total control of the instrumentality that led to the injury.
The closely related “common knowledge” rule relies on the everyday knowledge and experience of the layperson to identify plain and obvious negligent conduct, which then allows the judge to waive the expert requirement.
The two principles are frequently used interchangeably, ultimately favoring the plaintiff by dispensing with the difficult and expensive task of securing a qualified expert willing to testify against a doctor defendant.
The best example of res in action is the surgeon who inadvertently leaves behind a sponge or instrument inside a body cavity. Other successfully litigated examples include a cardiac arrest in the operating room, hypoxia in the recovery room, burns to the buttock, gangrene after the accidental injection of penicillin into an artery, air trapped subcutaneously from a displaced needle, and a pierced eyeball during a procedure.
A particularly well-known example is Ybarra v. Spangard, in which the patient developed shoulder injuries during an appendectomy.1 The Supreme Court of California felt it was appropriate to place the burden on the operating room defendants to explain how the patient, unconscious under general anesthesia throughout the procedure, sustained the shoulder injury.
The scenario provided in the opening question is taken from a 2013 New York case, James v. Wormuth, in which the plaintiff relied on the res doctrine.2 The defendant doctor had left a guide wire in the plaintiff’s chest following a biopsy and was unable to locate it after a 20-minute search. However, he was able to retrieve the wire 2 months later under C-arm imaging.
The plaintiff sued the doctor for pain and anxiety, but did not call any expert witness, relying instead on the “foreign object” basis for invoking the res doctrine. The lower court ruled for the doctor, and the court of appeals affirmed.
It reasoned that the object was left behind deliberately, not unintentionally, and that under the circumstances of the case, an expert witness was needed to set out the applicable standard of care, without which a jury could not determine whether the doctor’s professional judgment breached the requisite standard. The court also ruled that the plaintiff failed to satisfy the “exclusive control” requirement of the res doctrine, because several other individuals participated to an extent in the medical procedure.
Hawaii’s case of Barbee v. Queen’s Medical Center is illustrative of the “common knowledge” rule.3 Mr. Barbee, age 75 years, underwent laparoscopic nephrectomy for a malignancy. Massive bleeding complicated his postoperative course, the hemoglobin falling into the 3 range, and he required emergent reoperation. Over the next 18 months, the patient progressively deteriorated, eventually requiring dialysis and dying from a stroke and intestinal volvulus.
Notwithstanding an initial jury verdict in favor of the plaintiff’s children, awarding each of the three children $365,000, the defendants filed a so-called JNOV motion (current term is “judgment as a matter of law”) to negate the jury verdict, on the basis that the plaintiffs failed to present competent expert testimony at trial to prove causation.
The plaintiffs countered that the cause of death was within the realm of common knowledge, thus no expert was necessary. They asserted that “any lay person can easily grasp the concept that a person dies from losing so much blood that multiple organs fail to perform their functions.” Mr. Barbee’s death thus was not “of such a technical nature that lay persons are incompetent to draw their own conclusions from facts presented without aid.”
Hawaii’s Intermediate Court of Appeals disagreed with the plaintiffs, holding that although “Hawaii does recognize a ‘common knowledge’ exception to the requirement that a plaintiff must introduce expert medical testimony on causation … this exception is rare in application.” The court asserted that the causal link between any alleged negligence and Mr. Barbee’s death 17 months later is not within the realm of common knowledge.
It reasoned that the long-term effects of internal bleeding are not so widely known as to be analogous to leaving a sponge within a patient or removing the wrong limb during an amputation. Moreover, Mr. Barbee had a long history of preexisting conditions, including hypertension, diabetes, and cancer. He also suffered numerous and serious postoperative medical conditions, including a stroke and surgery to remove part of his intestine, which had become gangrenous.
Thus, the role that preexisting conditions and/or the subsequent complications of this type played in Mr. Barbee’s death was not within the knowledge of the average layperson.
The “common knowledge” rule is aligned with, though not identical to, the res doctrine, but courts are known to conflate the two legal principles, often using them interchangeably.4
Strictly speaking, the “common knowledge” waiver comes into play where direct evidence of negligent conduct lies within the realm of everyday lay knowledge that the physician had deviated from common practice. It may or may not address the causation issue.
On the other hand, res is successfully invoked when, despite no direct evidence of negligence and causation, the circumstances surrounding the injury are such that the plaintiff’s case can go to the jury without expert testimony.
References
1. Ybarra v. Spangard, 154 P.2d 687 (Cal. 1944).
2. James v. Wormuth, 997 N.E.2d 133 (N.Y. 2013).
3. Barbee v. Queen’s Medical Center, 119 Haw 136 (2008).
4. Spinner, Amanda E. Common Ignorance: Medical Malpractice Law and the Misconceived Application of the “Common Knowledge” and “Res Ipsa Loquitur” Doctrines.” Touro Law Review: Vol. 31: No. 3, Article 15. Available at http://digitalcommons.tourolaw.edu/lawreview/vol31/iss3/15.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: When a doctor could not find a dislodged biopsy guide wire, he abandoned his search after informing the patient of his intention to retrieve it at a later date. Two months later, he was successful in locating and removing the foreign body, but the patient alleged she suffered pain and anxiety in the interim. She filed a negligence lawsuit and, based on the “obvious” nature of her injuries, called no expert witness to testify on her behalf.
Which of the following choices is best?
A. Expert testimony is always needed to establish the applicable standard of care in medical negligence lawsuits.
B. Although a plaintiff is not qualified to expound on medical matters, he/she can offer evidence from learned treatises and medical texts.
C. The jury is the one who determines whether a plaintiff can invoke either the res ipsa loquitur doctrine or the “common knowledge” rule to obviate the need for an expert witness.
D. This patient will likely win her case.
E. All are incorrect.
Answer: E. It is well-established law that the question of negligence must be decided by reference to relevant medical standards of care for which the plaintiff carries the burden of proving through expert medical testimony. Only a professional, duly qualified by the court as an expert witness, is allowed to offer medical testimony – whereas the plaintiff typically will be disqualified from playing this role because of the complexity of issues involved.
However, under either the doctrine of res ipsa loquitur (“the thing speaks for itself”) or the “common knowledge” rule, a court (i.e., the judge) may allow the jury to infer negligence in the absence of expert testimony.
The res doctrine is invoked where there is only circumstantial but no direct evidence, and three conditions are met: 1) The injury would not have occurred in the absence of someone’s negligence; 2) the plaintiff was not at fault; and 3) the defendant had total control of the instrumentality that led to the injury.
The closely related “common knowledge” rule relies on the everyday knowledge and experience of the layperson to identify plain and obvious negligent conduct, which then allows the judge to waive the expert requirement.
The two principles are frequently used interchangeably, ultimately favoring the plaintiff by dispensing with the difficult and expensive task of securing a qualified expert willing to testify against a doctor defendant.
The best example of res in action is the surgeon who inadvertently leaves behind a sponge or instrument inside a body cavity. Other successfully litigated examples include a cardiac arrest in the operating room, hypoxia in the recovery room, burns to the buttock, gangrene after the accidental injection of penicillin into an artery, air trapped subcutaneously from a displaced needle, and a pierced eyeball during a procedure.
A particularly well-known example is Ybarra v. Spangard, in which the patient developed shoulder injuries during an appendectomy.1 The Supreme Court of California felt it was appropriate to place the burden on the operating room defendants to explain how the patient, unconscious under general anesthesia throughout the procedure, sustained the shoulder injury.
The scenario provided in the opening question is taken from a 2013 New York case, James v. Wormuth, in which the plaintiff relied on the res doctrine.2 The defendant doctor had left a guide wire in the plaintiff’s chest following a biopsy and was unable to locate it after a 20-minute search. However, he was able to retrieve the wire 2 months later under C-arm imaging.
The plaintiff sued the doctor for pain and anxiety, but did not call any expert witness, relying instead on the “foreign object” basis for invoking the res doctrine. The lower court ruled for the doctor, and the court of appeals affirmed.
It reasoned that the object was left behind deliberately, not unintentionally, and that under the circumstances of the case, an expert witness was needed to set out the applicable standard of care, without which a jury could not determine whether the doctor’s professional judgment breached the requisite standard. The court also ruled that the plaintiff failed to satisfy the “exclusive control” requirement of the res doctrine, because several other individuals participated to an extent in the medical procedure.
Hawaii’s case of Barbee v. Queen’s Medical Center is illustrative of the “common knowledge” rule.3 Mr. Barbee, age 75 years, underwent laparoscopic nephrectomy for a malignancy. Massive bleeding complicated his postoperative course, the hemoglobin falling into the 3 range, and he required emergent reoperation. Over the next 18 months, the patient progressively deteriorated, eventually requiring dialysis and dying from a stroke and intestinal volvulus.
Notwithstanding an initial jury verdict in favor of the plaintiff’s children, awarding each of the three children $365,000, the defendants filed a so-called JNOV motion (current term is “judgment as a matter of law”) to negate the jury verdict, on the basis that the plaintiffs failed to present competent expert testimony at trial to prove causation.
The plaintiffs countered that the cause of death was within the realm of common knowledge, thus no expert was necessary. They asserted that “any lay person can easily grasp the concept that a person dies from losing so much blood that multiple organs fail to perform their functions.” Mr. Barbee’s death thus was not “of such a technical nature that lay persons are incompetent to draw their own conclusions from facts presented without aid.”
Hawaii’s Intermediate Court of Appeals disagreed with the plaintiffs, holding that although “Hawaii does recognize a ‘common knowledge’ exception to the requirement that a plaintiff must introduce expert medical testimony on causation … this exception is rare in application.” The court asserted that the causal link between any alleged negligence and Mr. Barbee’s death 17 months later is not within the realm of common knowledge.
It reasoned that the long-term effects of internal bleeding are not so widely known as to be analogous to leaving a sponge within a patient or removing the wrong limb during an amputation. Moreover, Mr. Barbee had a long history of preexisting conditions, including hypertension, diabetes, and cancer. He also suffered numerous and serious postoperative medical conditions, including a stroke and surgery to remove part of his intestine, which had become gangrenous.
Thus, the role that preexisting conditions and/or the subsequent complications of this type played in Mr. Barbee’s death was not within the knowledge of the average layperson.
The “common knowledge” rule is aligned with, though not identical to, the res doctrine, but courts are known to conflate the two legal principles, often using them interchangeably.4
Strictly speaking, the “common knowledge” waiver comes into play where direct evidence of negligent conduct lies within the realm of everyday lay knowledge that the physician had deviated from common practice. It may or may not address the causation issue.
On the other hand, res is successfully invoked when, despite no direct evidence of negligence and causation, the circumstances surrounding the injury are such that the plaintiff’s case can go to the jury without expert testimony.
References
1. Ybarra v. Spangard, 154 P.2d 687 (Cal. 1944).
2. James v. Wormuth, 997 N.E.2d 133 (N.Y. 2013).
3. Barbee v. Queen’s Medical Center, 119 Haw 136 (2008).
4. Spinner, Amanda E. Common Ignorance: Medical Malpractice Law and the Misconceived Application of the “Common Knowledge” and “Res Ipsa Loquitur” Doctrines.” Touro Law Review: Vol. 31: No. 3, Article 15. Available at http://digitalcommons.tourolaw.edu/lawreview/vol31/iss3/15.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: When a doctor could not find a dislodged biopsy guide wire, he abandoned his search after informing the patient of his intention to retrieve it at a later date. Two months later, he was successful in locating and removing the foreign body, but the patient alleged she suffered pain and anxiety in the interim. She filed a negligence lawsuit and, based on the “obvious” nature of her injuries, called no expert witness to testify on her behalf.
Which of the following choices is best?
A. Expert testimony is always needed to establish the applicable standard of care in medical negligence lawsuits.
B. Although a plaintiff is not qualified to expound on medical matters, he/she can offer evidence from learned treatises and medical texts.
C. The jury is the one who determines whether a plaintiff can invoke either the res ipsa loquitur doctrine or the “common knowledge” rule to obviate the need for an expert witness.
D. This patient will likely win her case.
E. All are incorrect.
Answer: E. It is well-established law that the question of negligence must be decided by reference to relevant medical standards of care for which the plaintiff carries the burden of proving through expert medical testimony. Only a professional, duly qualified by the court as an expert witness, is allowed to offer medical testimony – whereas the plaintiff typically will be disqualified from playing this role because of the complexity of issues involved.
However, under either the doctrine of res ipsa loquitur (“the thing speaks for itself”) or the “common knowledge” rule, a court (i.e., the judge) may allow the jury to infer negligence in the absence of expert testimony.
The res doctrine is invoked where there is only circumstantial but no direct evidence, and three conditions are met: 1) The injury would not have occurred in the absence of someone’s negligence; 2) the plaintiff was not at fault; and 3) the defendant had total control of the instrumentality that led to the injury.
The closely related “common knowledge” rule relies on the everyday knowledge and experience of the layperson to identify plain and obvious negligent conduct, which then allows the judge to waive the expert requirement.
The two principles are frequently used interchangeably, ultimately favoring the plaintiff by dispensing with the difficult and expensive task of securing a qualified expert willing to testify against a doctor defendant.
The best example of res in action is the surgeon who inadvertently leaves behind a sponge or instrument inside a body cavity. Other successfully litigated examples include a cardiac arrest in the operating room, hypoxia in the recovery room, burns to the buttock, gangrene after the accidental injection of penicillin into an artery, air trapped subcutaneously from a displaced needle, and a pierced eyeball during a procedure.
A particularly well-known example is Ybarra v. Spangard, in which the patient developed shoulder injuries during an appendectomy.1 The Supreme Court of California felt it was appropriate to place the burden on the operating room defendants to explain how the patient, unconscious under general anesthesia throughout the procedure, sustained the shoulder injury.
The scenario provided in the opening question is taken from a 2013 New York case, James v. Wormuth, in which the plaintiff relied on the res doctrine.2 The defendant doctor had left a guide wire in the plaintiff’s chest following a biopsy and was unable to locate it after a 20-minute search. However, he was able to retrieve the wire 2 months later under C-arm imaging.
The plaintiff sued the doctor for pain and anxiety, but did not call any expert witness, relying instead on the “foreign object” basis for invoking the res doctrine. The lower court ruled for the doctor, and the court of appeals affirmed.
It reasoned that the object was left behind deliberately, not unintentionally, and that under the circumstances of the case, an expert witness was needed to set out the applicable standard of care, without which a jury could not determine whether the doctor’s professional judgment breached the requisite standard. The court also ruled that the plaintiff failed to satisfy the “exclusive control” requirement of the res doctrine, because several other individuals participated to an extent in the medical procedure.
Hawaii’s case of Barbee v. Queen’s Medical Center is illustrative of the “common knowledge” rule.3 Mr. Barbee, age 75 years, underwent laparoscopic nephrectomy for a malignancy. Massive bleeding complicated his postoperative course, the hemoglobin falling into the 3 range, and he required emergent reoperation. Over the next 18 months, the patient progressively deteriorated, eventually requiring dialysis and dying from a stroke and intestinal volvulus.
Notwithstanding an initial jury verdict in favor of the plaintiff’s children, awarding each of the three children $365,000, the defendants filed a so-called JNOV motion (current term is “judgment as a matter of law”) to negate the jury verdict, on the basis that the plaintiffs failed to present competent expert testimony at trial to prove causation.
The plaintiffs countered that the cause of death was within the realm of common knowledge, thus no expert was necessary. They asserted that “any lay person can easily grasp the concept that a person dies from losing so much blood that multiple organs fail to perform their functions.” Mr. Barbee’s death thus was not “of such a technical nature that lay persons are incompetent to draw their own conclusions from facts presented without aid.”
Hawaii’s Intermediate Court of Appeals disagreed with the plaintiffs, holding that although “Hawaii does recognize a ‘common knowledge’ exception to the requirement that a plaintiff must introduce expert medical testimony on causation … this exception is rare in application.” The court asserted that the causal link between any alleged negligence and Mr. Barbee’s death 17 months later is not within the realm of common knowledge.
It reasoned that the long-term effects of internal bleeding are not so widely known as to be analogous to leaving a sponge within a patient or removing the wrong limb during an amputation. Moreover, Mr. Barbee had a long history of preexisting conditions, including hypertension, diabetes, and cancer. He also suffered numerous and serious postoperative medical conditions, including a stroke and surgery to remove part of his intestine, which had become gangrenous.
Thus, the role that preexisting conditions and/or the subsequent complications of this type played in Mr. Barbee’s death was not within the knowledge of the average layperson.
The “common knowledge” rule is aligned with, though not identical to, the res doctrine, but courts are known to conflate the two legal principles, often using them interchangeably.4
Strictly speaking, the “common knowledge” waiver comes into play where direct evidence of negligent conduct lies within the realm of everyday lay knowledge that the physician had deviated from common practice. It may or may not address the causation issue.
On the other hand, res is successfully invoked when, despite no direct evidence of negligence and causation, the circumstances surrounding the injury are such that the plaintiff’s case can go to the jury without expert testimony.
References
1. Ybarra v. Spangard, 154 P.2d 687 (Cal. 1944).
2. James v. Wormuth, 997 N.E.2d 133 (N.Y. 2013).
3. Barbee v. Queen’s Medical Center, 119 Haw 136 (2008).
4. Spinner, Amanda E. Common Ignorance: Medical Malpractice Law and the Misconceived Application of the “Common Knowledge” and “Res Ipsa Loquitur” Doctrines.” Touro Law Review: Vol. 31: No. 3, Article 15. Available at http://digitalcommons.tourolaw.edu/lawreview/vol31/iss3/15.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
The Power of Quiet
In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.
In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.
Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.
Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.
Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?
First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”
However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.
During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.
Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.
Dr. Rikkers is Editor in Chief of ACS Surgery News.
In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.
In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.
Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.
Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.
Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?
First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”
However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.
During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.
Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.
Dr. Rikkers is Editor in Chief of ACS Surgery News.
In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.
In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.
Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.
Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.
Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?
First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”
However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.
During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.
Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.
Dr. Rikkers is Editor in Chief of ACS Surgery News.
From the Washington Office: A guide to in-district meetings with your representatives and senators
WHY should surgeons take time out of their busy schedules to meet with legislators?
To become an effective surgeon advocate, nothing is more important than establishing a personal relationship with your legislators. Conversely, to a legislator, there is nothing more valuable than the input and support of constituents. After all, constituents are VOTERS. Meeting with policy makers and/or their staff is extremely valuable in advancing the overall advocacy agenda of The American College of Surgeons and provides surgeons with the opportunity to develop key contacts in the offices of their legislators.
WHERE do such meetings take place?
All U.S. Representatives and Senators have one or more offices for constituent service in their home districts or states. These offices serve as a readily accessible meeting point. As an alternative, legislators frequently will schedule meetings with constituents in mutually convenient locations such as a coffee shop, or during a local legislative event such as a town hall.
WHEN is it most feasible to schedule in-district meetings?
You might be surprised to discover how much time is allotted by both the House and Senate for in-district work periods. Typical times include periods around President’s Day in February, Easter/Passover in March/April, Memorial Day, Independence Day, and summer recess (late July and the month of August). If Congress does not officially adjourn in early October, additional work periods include time around Columbus Day in October, Veteran’s Day in November, and Thanksgiving. Congress will usually adjourn for the year in December. A specific schedule for each legislative body for the year 2016 can be found at:
House of Representatives: http://www.majorityleader.gov/wp-content/uploads/2011/07/2016_ANNUAL_CALENDAR.pdf
Senate: http://www.senate.gov/legislative/resources/pdf/2016_calendar.pdf
HOW does one schedule an in-district meeting?
To set up a meeting you should first search the websites of your representatives (www.house.gov) and senators (www.senate.gov) for information as to the preferred scheduling procedures. Expect each office’s procedure to be a bit different. You will be asked to provide your name, address, and basic contact information as well as to briefly describe what issue(s) you wish to discuss. Be sure to mention that you are a surgeon and also whether you have previously met with the representative or senator.
If several days pass and staff from the office have not followed up, you should not hesitate to call or contact the office again. Remember, persistence is key! Keep in mind that legislators typically maintain busy schedules during the in-district work period and accordingly, the scheduled appointment time will be brief and subject to change, perhaps on short notice.
If you experience difficulty or simply would like to have assistance in scheduling an in-district meeting, staff in the ACS Division of Advocacy and Health Policy are available to assist and may be contacted by e-mail at surgeonsvoice.org.
WHAT should one discuss?
As a surgeon advocate, your most powerful tool is frequent contact and meetings with your elected officials. Meetings provide an opportunity to offer knowledge and perspective to educate legislators on key topics important to ensuring access to quality surgical care. Your personal experience brings a personal, human touch to issues about which legislators only have knowledge based upon raw numbers and impersonal policy jargon. Most legislators, as well as their staff, will be grateful to have the reliable resource of a constituent’s experience and perspective on complicated medical issues.
To maximize the opportunity for a successful meeting and thereby lay the foundation for the development of a mutually beneficial future relationship, I would offer the following three tips:
1) KNOW YOUR LEGISLATOR: Visit your legislators’ websites, read their biographies, ascertain to what congressional committees they are assigned, and what leadership roles they may have. All of this serves to help determine what issues are important to them and what positions they have previously taken on such issues.
2) KNOW YOUR ISSUE and be able to FRAME IT: Nothing substitutes for a solid knowledge base of the issue and the position you are trying to convey. Be focused and resist the temptation to try to cover too many topics in any one visit. When presenting your argument, “frame it” in layman’s terms much as you would explain it to a patient. Including examples of real-life, anecdotal experiences demonstrating how the status quo or the proposed legislation (depending upon the circumstance) is impacting providers and patients is particularly important.
3) HAVE AN ASK: It is imperative that you always be clear with your legislators about what you want them to do. This serves to reinforce the importance of your having taken time out of your schedule to communicate with them and also serves to hold the legislator accountable. “Asks” can be as specific as a request to cosponsor and support legislation or simply making the offer to serve as a resource to them as a constituent with expertise in health care.
Lastly, I would respectfully request that when surgeons meet with their legislators they inform the ACS Division of Advocacy and Health Policy. Having basic information about the outcome of the meeting, whether knowing that the legislator committed to taking a specific action or knowing that the legislator has requested additional information, is incredibly valuable to us in our ongoing advocacy efforts on behalf of surgeons and their patients here in Washington, DC.
Until next month ….
Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
WHY should surgeons take time out of their busy schedules to meet with legislators?
To become an effective surgeon advocate, nothing is more important than establishing a personal relationship with your legislators. Conversely, to a legislator, there is nothing more valuable than the input and support of constituents. After all, constituents are VOTERS. Meeting with policy makers and/or their staff is extremely valuable in advancing the overall advocacy agenda of The American College of Surgeons and provides surgeons with the opportunity to develop key contacts in the offices of their legislators.
WHERE do such meetings take place?
All U.S. Representatives and Senators have one or more offices for constituent service in their home districts or states. These offices serve as a readily accessible meeting point. As an alternative, legislators frequently will schedule meetings with constituents in mutually convenient locations such as a coffee shop, or during a local legislative event such as a town hall.
WHEN is it most feasible to schedule in-district meetings?
You might be surprised to discover how much time is allotted by both the House and Senate for in-district work periods. Typical times include periods around President’s Day in February, Easter/Passover in March/April, Memorial Day, Independence Day, and summer recess (late July and the month of August). If Congress does not officially adjourn in early October, additional work periods include time around Columbus Day in October, Veteran’s Day in November, and Thanksgiving. Congress will usually adjourn for the year in December. A specific schedule for each legislative body for the year 2016 can be found at:
House of Representatives: http://www.majorityleader.gov/wp-content/uploads/2011/07/2016_ANNUAL_CALENDAR.pdf
Senate: http://www.senate.gov/legislative/resources/pdf/2016_calendar.pdf
HOW does one schedule an in-district meeting?
To set up a meeting you should first search the websites of your representatives (www.house.gov) and senators (www.senate.gov) for information as to the preferred scheduling procedures. Expect each office’s procedure to be a bit different. You will be asked to provide your name, address, and basic contact information as well as to briefly describe what issue(s) you wish to discuss. Be sure to mention that you are a surgeon and also whether you have previously met with the representative or senator.
If several days pass and staff from the office have not followed up, you should not hesitate to call or contact the office again. Remember, persistence is key! Keep in mind that legislators typically maintain busy schedules during the in-district work period and accordingly, the scheduled appointment time will be brief and subject to change, perhaps on short notice.
If you experience difficulty or simply would like to have assistance in scheduling an in-district meeting, staff in the ACS Division of Advocacy and Health Policy are available to assist and may be contacted by e-mail at surgeonsvoice.org.
WHAT should one discuss?
As a surgeon advocate, your most powerful tool is frequent contact and meetings with your elected officials. Meetings provide an opportunity to offer knowledge and perspective to educate legislators on key topics important to ensuring access to quality surgical care. Your personal experience brings a personal, human touch to issues about which legislators only have knowledge based upon raw numbers and impersonal policy jargon. Most legislators, as well as their staff, will be grateful to have the reliable resource of a constituent’s experience and perspective on complicated medical issues.
To maximize the opportunity for a successful meeting and thereby lay the foundation for the development of a mutually beneficial future relationship, I would offer the following three tips:
1) KNOW YOUR LEGISLATOR: Visit your legislators’ websites, read their biographies, ascertain to what congressional committees they are assigned, and what leadership roles they may have. All of this serves to help determine what issues are important to them and what positions they have previously taken on such issues.
2) KNOW YOUR ISSUE and be able to FRAME IT: Nothing substitutes for a solid knowledge base of the issue and the position you are trying to convey. Be focused and resist the temptation to try to cover too many topics in any one visit. When presenting your argument, “frame it” in layman’s terms much as you would explain it to a patient. Including examples of real-life, anecdotal experiences demonstrating how the status quo or the proposed legislation (depending upon the circumstance) is impacting providers and patients is particularly important.
3) HAVE AN ASK: It is imperative that you always be clear with your legislators about what you want them to do. This serves to reinforce the importance of your having taken time out of your schedule to communicate with them and also serves to hold the legislator accountable. “Asks” can be as specific as a request to cosponsor and support legislation or simply making the offer to serve as a resource to them as a constituent with expertise in health care.
Lastly, I would respectfully request that when surgeons meet with their legislators they inform the ACS Division of Advocacy and Health Policy. Having basic information about the outcome of the meeting, whether knowing that the legislator committed to taking a specific action or knowing that the legislator has requested additional information, is incredibly valuable to us in our ongoing advocacy efforts on behalf of surgeons and their patients here in Washington, DC.
Until next month ….
Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
WHY should surgeons take time out of their busy schedules to meet with legislators?
To become an effective surgeon advocate, nothing is more important than establishing a personal relationship with your legislators. Conversely, to a legislator, there is nothing more valuable than the input and support of constituents. After all, constituents are VOTERS. Meeting with policy makers and/or their staff is extremely valuable in advancing the overall advocacy agenda of The American College of Surgeons and provides surgeons with the opportunity to develop key contacts in the offices of their legislators.
WHERE do such meetings take place?
All U.S. Representatives and Senators have one or more offices for constituent service in their home districts or states. These offices serve as a readily accessible meeting point. As an alternative, legislators frequently will schedule meetings with constituents in mutually convenient locations such as a coffee shop, or during a local legislative event such as a town hall.
WHEN is it most feasible to schedule in-district meetings?
You might be surprised to discover how much time is allotted by both the House and Senate for in-district work periods. Typical times include periods around President’s Day in February, Easter/Passover in March/April, Memorial Day, Independence Day, and summer recess (late July and the month of August). If Congress does not officially adjourn in early October, additional work periods include time around Columbus Day in October, Veteran’s Day in November, and Thanksgiving. Congress will usually adjourn for the year in December. A specific schedule for each legislative body for the year 2016 can be found at:
House of Representatives: http://www.majorityleader.gov/wp-content/uploads/2011/07/2016_ANNUAL_CALENDAR.pdf
Senate: http://www.senate.gov/legislative/resources/pdf/2016_calendar.pdf
HOW does one schedule an in-district meeting?
To set up a meeting you should first search the websites of your representatives (www.house.gov) and senators (www.senate.gov) for information as to the preferred scheduling procedures. Expect each office’s procedure to be a bit different. You will be asked to provide your name, address, and basic contact information as well as to briefly describe what issue(s) you wish to discuss. Be sure to mention that you are a surgeon and also whether you have previously met with the representative or senator.
If several days pass and staff from the office have not followed up, you should not hesitate to call or contact the office again. Remember, persistence is key! Keep in mind that legislators typically maintain busy schedules during the in-district work period and accordingly, the scheduled appointment time will be brief and subject to change, perhaps on short notice.
If you experience difficulty or simply would like to have assistance in scheduling an in-district meeting, staff in the ACS Division of Advocacy and Health Policy are available to assist and may be contacted by e-mail at surgeonsvoice.org.
WHAT should one discuss?
As a surgeon advocate, your most powerful tool is frequent contact and meetings with your elected officials. Meetings provide an opportunity to offer knowledge and perspective to educate legislators on key topics important to ensuring access to quality surgical care. Your personal experience brings a personal, human touch to issues about which legislators only have knowledge based upon raw numbers and impersonal policy jargon. Most legislators, as well as their staff, will be grateful to have the reliable resource of a constituent’s experience and perspective on complicated medical issues.
To maximize the opportunity for a successful meeting and thereby lay the foundation for the development of a mutually beneficial future relationship, I would offer the following three tips:
1) KNOW YOUR LEGISLATOR: Visit your legislators’ websites, read their biographies, ascertain to what congressional committees they are assigned, and what leadership roles they may have. All of this serves to help determine what issues are important to them and what positions they have previously taken on such issues.
2) KNOW YOUR ISSUE and be able to FRAME IT: Nothing substitutes for a solid knowledge base of the issue and the position you are trying to convey. Be focused and resist the temptation to try to cover too many topics in any one visit. When presenting your argument, “frame it” in layman’s terms much as you would explain it to a patient. Including examples of real-life, anecdotal experiences demonstrating how the status quo or the proposed legislation (depending upon the circumstance) is impacting providers and patients is particularly important.
3) HAVE AN ASK: It is imperative that you always be clear with your legislators about what you want them to do. This serves to reinforce the importance of your having taken time out of your schedule to communicate with them and also serves to hold the legislator accountable. “Asks” can be as specific as a request to cosponsor and support legislation or simply making the offer to serve as a resource to them as a constituent with expertise in health care.
Lastly, I would respectfully request that when surgeons meet with their legislators they inform the ACS Division of Advocacy and Health Policy. Having basic information about the outcome of the meeting, whether knowing that the legislator committed to taking a specific action or knowing that the legislator has requested additional information, is incredibly valuable to us in our ongoing advocacy efforts on behalf of surgeons and their patients here in Washington, DC.
Until next month ….
Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
Conflicts in the physician-patient relationship
The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.
One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.
Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?
On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.
Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.
If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.
Dr. Chan practices rheumatology in Pawtucket, R.I.
The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.
One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.
Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?
On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.
Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.
If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.
Dr. Chan practices rheumatology in Pawtucket, R.I.
The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.
One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.
Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?
On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.
Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.
If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.
Dr. Chan practices rheumatology in Pawtucket, R.I.
CASE REPORTS: Transient neutrophilia in acute mania
A description of two bipolar I disorder cases presents examples of the phenomenon of transient neutrophilia that occurred during admission into a state psychiatric hospital. A brief review of the mechanisms that may explain this hematologic response is included.
Background
In 1889, the U.S. territory of New Mexico established the New Mexico Insane Asylum, and it was known as such until 1955, when it became the State Hospital. In 1970, it became the Las Vegas Medical Center but changed its name in 2005 to the New Mexico Behavioral Health Institute (NMBHI), which services the entire state for inpatient and long-term care patients. On average, it accepts two admissions per day, of which two patients per month present with neutrophilia (white blood cell [WBC] count greater than 11,000), which resolves after 1-4 days in the hospital.
Case presentations
Case one. A 21-year-old Native American man presented with multiple psychiatric admissions for bipolar I disorder and major depression with suicidal ideation. He was brought into the local emergency department by police, who found him walking down the interstate highway trying to hitch a ride back to his native pueblo after a disagreement with a fellow resident at a local boarding home. He had discontinued his Seroquel and lithium 2 weeks earlier because he felt he no longer needed them and required medical clearance for admission.1 His presenting hemogram in the ED was normal except for an elevated WBC count of 20,000. His vital signs were normal except for tachycardia of 110 beats per minute. On exam the patient demonstrated a flat affect and anxiety but other than mild ingrown toenails and tachycardia, there were no abnormal findings.
He received a chest x-ray and abdominal computed tomography scan that were both normal, and the patient was cleared for admission. He was cooperative with staff and restarted his lithium. A repeat WBC at day 5 was 9,700.
Case two. A 24-year-old white man with a history of bipolar I disorder and dependency on benzodiazepines and Ritalin was transferred from a distant county jail after 10 days of incarceration. He started screaming in his cell, praying, and perseverating that he “needed to kill himself,” which triggered his transfer to the NMBHI. His aggressive behavior upon arrival necessitated a transfer to the local ED for sedation and four-point restraints. He received Versed and Ativan IVP before allowing a blood collection, which revealed dehydration and a WBC count of 17,100. After 4 L of normal saline, his labs normalized with a WBC of 10,100, and he was admitted for a 7-day committal.
Discussion
Neutrophilia can result from granulocytes moving from pericapillary tissue margins into the circulating pool.2 It may occur in association with vigorous exercise, seizures, paroxysmal tachycardia, and adrenergic stress.3 The duration is fewer than 30 minutes and usually results in WBC counts of 15,000-20,000.4 Beta receptors on endothelial cells may mediate neutrophil adherence and release from marginal sites. A left shift is absent, because there is no change of the inflow of cells from the marrow.
In these two cases, a transient neutrophilia and tachycardia were observed. Neither case was febrile, and the platelet count remained normal. Both patients voluntarily stopped taking their lithium about 2 weeks before decompensating from bipolar I disorders. Stress was evident in both cases, one from walking on a cold December night after a disagreement, while the other patient in case two was highly agitated and aggressive requiring four-point restraints and intravenous sedation in the ED before admission to NMBHI. Past histories of psychiatric admissions were noted in both cases, and neither subject smoked tobacco – which can increase WBC by 25%-50% with the use of one-two packs per day, respectively.5
These two cases show that clinicians should consider stress in its many permutations to the long list of causes to explain elevated WBC, particularly in the ED. They also illustrate the power of antianxiety medications for some patients with acute mania who present to the ED.
References
1. J Emerg Med. 2012;43(5):866-70.
2. “Wintrobe’s Clinical Hematology,” Philadelphia: Lea & Febiger, 1981, p.1292.
3. “Diagnostic Hematology,” London: Springer, 2009, p. 324.
4. Gen Hosp Psychiatry. 2005;27(6):454-56.
5. Euro Heart J. 2003 Jul;24(14)1365-72.
Dr. Taylor is a staff physician affiliated with the New Mexico Behavioral Health Institute, New Mexico Department of Health, Santa Fe. He reports no financial disclosures or conflicts of interest. The author wishes to thank Dr. Dan Collins from the NMBHI for recommending that he research and write about this topic. In addition, document access was greatly aided by Lisa Apodaca and Mary Bunker, CNP, from the NMBHI, and Karen Ebler and Dr. Irwin Hoffman from Christus St. Vincent Hospital in Santa Fe. Finally, the following colleagues helped by proofreading the manuscript: Dr. Wendy Dimmette, Dr. Richard Nail, and Dr. Matt Streicherz. Eva Romero and Dr. Troy Jones provided useful historical documentation.
A description of two bipolar I disorder cases presents examples of the phenomenon of transient neutrophilia that occurred during admission into a state psychiatric hospital. A brief review of the mechanisms that may explain this hematologic response is included.
Background
In 1889, the U.S. territory of New Mexico established the New Mexico Insane Asylum, and it was known as such until 1955, when it became the State Hospital. In 1970, it became the Las Vegas Medical Center but changed its name in 2005 to the New Mexico Behavioral Health Institute (NMBHI), which services the entire state for inpatient and long-term care patients. On average, it accepts two admissions per day, of which two patients per month present with neutrophilia (white blood cell [WBC] count greater than 11,000), which resolves after 1-4 days in the hospital.
Case presentations
Case one. A 21-year-old Native American man presented with multiple psychiatric admissions for bipolar I disorder and major depression with suicidal ideation. He was brought into the local emergency department by police, who found him walking down the interstate highway trying to hitch a ride back to his native pueblo after a disagreement with a fellow resident at a local boarding home. He had discontinued his Seroquel and lithium 2 weeks earlier because he felt he no longer needed them and required medical clearance for admission.1 His presenting hemogram in the ED was normal except for an elevated WBC count of 20,000. His vital signs were normal except for tachycardia of 110 beats per minute. On exam the patient demonstrated a flat affect and anxiety but other than mild ingrown toenails and tachycardia, there were no abnormal findings.
He received a chest x-ray and abdominal computed tomography scan that were both normal, and the patient was cleared for admission. He was cooperative with staff and restarted his lithium. A repeat WBC at day 5 was 9,700.
Case two. A 24-year-old white man with a history of bipolar I disorder and dependency on benzodiazepines and Ritalin was transferred from a distant county jail after 10 days of incarceration. He started screaming in his cell, praying, and perseverating that he “needed to kill himself,” which triggered his transfer to the NMBHI. His aggressive behavior upon arrival necessitated a transfer to the local ED for sedation and four-point restraints. He received Versed and Ativan IVP before allowing a blood collection, which revealed dehydration and a WBC count of 17,100. After 4 L of normal saline, his labs normalized with a WBC of 10,100, and he was admitted for a 7-day committal.
Discussion
Neutrophilia can result from granulocytes moving from pericapillary tissue margins into the circulating pool.2 It may occur in association with vigorous exercise, seizures, paroxysmal tachycardia, and adrenergic stress.3 The duration is fewer than 30 minutes and usually results in WBC counts of 15,000-20,000.4 Beta receptors on endothelial cells may mediate neutrophil adherence and release from marginal sites. A left shift is absent, because there is no change of the inflow of cells from the marrow.
In these two cases, a transient neutrophilia and tachycardia were observed. Neither case was febrile, and the platelet count remained normal. Both patients voluntarily stopped taking their lithium about 2 weeks before decompensating from bipolar I disorders. Stress was evident in both cases, one from walking on a cold December night after a disagreement, while the other patient in case two was highly agitated and aggressive requiring four-point restraints and intravenous sedation in the ED before admission to NMBHI. Past histories of psychiatric admissions were noted in both cases, and neither subject smoked tobacco – which can increase WBC by 25%-50% with the use of one-two packs per day, respectively.5
These two cases show that clinicians should consider stress in its many permutations to the long list of causes to explain elevated WBC, particularly in the ED. They also illustrate the power of antianxiety medications for some patients with acute mania who present to the ED.
References
1. J Emerg Med. 2012;43(5):866-70.
2. “Wintrobe’s Clinical Hematology,” Philadelphia: Lea & Febiger, 1981, p.1292.
3. “Diagnostic Hematology,” London: Springer, 2009, p. 324.
4. Gen Hosp Psychiatry. 2005;27(6):454-56.
5. Euro Heart J. 2003 Jul;24(14)1365-72.
Dr. Taylor is a staff physician affiliated with the New Mexico Behavioral Health Institute, New Mexico Department of Health, Santa Fe. He reports no financial disclosures or conflicts of interest. The author wishes to thank Dr. Dan Collins from the NMBHI for recommending that he research and write about this topic. In addition, document access was greatly aided by Lisa Apodaca and Mary Bunker, CNP, from the NMBHI, and Karen Ebler and Dr. Irwin Hoffman from Christus St. Vincent Hospital in Santa Fe. Finally, the following colleagues helped by proofreading the manuscript: Dr. Wendy Dimmette, Dr. Richard Nail, and Dr. Matt Streicherz. Eva Romero and Dr. Troy Jones provided useful historical documentation.
A description of two bipolar I disorder cases presents examples of the phenomenon of transient neutrophilia that occurred during admission into a state psychiatric hospital. A brief review of the mechanisms that may explain this hematologic response is included.
Background
In 1889, the U.S. territory of New Mexico established the New Mexico Insane Asylum, and it was known as such until 1955, when it became the State Hospital. In 1970, it became the Las Vegas Medical Center but changed its name in 2005 to the New Mexico Behavioral Health Institute (NMBHI), which services the entire state for inpatient and long-term care patients. On average, it accepts two admissions per day, of which two patients per month present with neutrophilia (white blood cell [WBC] count greater than 11,000), which resolves after 1-4 days in the hospital.
Case presentations
Case one. A 21-year-old Native American man presented with multiple psychiatric admissions for bipolar I disorder and major depression with suicidal ideation. He was brought into the local emergency department by police, who found him walking down the interstate highway trying to hitch a ride back to his native pueblo after a disagreement with a fellow resident at a local boarding home. He had discontinued his Seroquel and lithium 2 weeks earlier because he felt he no longer needed them and required medical clearance for admission.1 His presenting hemogram in the ED was normal except for an elevated WBC count of 20,000. His vital signs were normal except for tachycardia of 110 beats per minute. On exam the patient demonstrated a flat affect and anxiety but other than mild ingrown toenails and tachycardia, there were no abnormal findings.
He received a chest x-ray and abdominal computed tomography scan that were both normal, and the patient was cleared for admission. He was cooperative with staff and restarted his lithium. A repeat WBC at day 5 was 9,700.
Case two. A 24-year-old white man with a history of bipolar I disorder and dependency on benzodiazepines and Ritalin was transferred from a distant county jail after 10 days of incarceration. He started screaming in his cell, praying, and perseverating that he “needed to kill himself,” which triggered his transfer to the NMBHI. His aggressive behavior upon arrival necessitated a transfer to the local ED for sedation and four-point restraints. He received Versed and Ativan IVP before allowing a blood collection, which revealed dehydration and a WBC count of 17,100. After 4 L of normal saline, his labs normalized with a WBC of 10,100, and he was admitted for a 7-day committal.
Discussion
Neutrophilia can result from granulocytes moving from pericapillary tissue margins into the circulating pool.2 It may occur in association with vigorous exercise, seizures, paroxysmal tachycardia, and adrenergic stress.3 The duration is fewer than 30 minutes and usually results in WBC counts of 15,000-20,000.4 Beta receptors on endothelial cells may mediate neutrophil adherence and release from marginal sites. A left shift is absent, because there is no change of the inflow of cells from the marrow.
In these two cases, a transient neutrophilia and tachycardia were observed. Neither case was febrile, and the platelet count remained normal. Both patients voluntarily stopped taking their lithium about 2 weeks before decompensating from bipolar I disorders. Stress was evident in both cases, one from walking on a cold December night after a disagreement, while the other patient in case two was highly agitated and aggressive requiring four-point restraints and intravenous sedation in the ED before admission to NMBHI. Past histories of psychiatric admissions were noted in both cases, and neither subject smoked tobacco – which can increase WBC by 25%-50% with the use of one-two packs per day, respectively.5
These two cases show that clinicians should consider stress in its many permutations to the long list of causes to explain elevated WBC, particularly in the ED. They also illustrate the power of antianxiety medications for some patients with acute mania who present to the ED.
References
1. J Emerg Med. 2012;43(5):866-70.
2. “Wintrobe’s Clinical Hematology,” Philadelphia: Lea & Febiger, 1981, p.1292.
3. “Diagnostic Hematology,” London: Springer, 2009, p. 324.
4. Gen Hosp Psychiatry. 2005;27(6):454-56.
5. Euro Heart J. 2003 Jul;24(14)1365-72.
Dr. Taylor is a staff physician affiliated with the New Mexico Behavioral Health Institute, New Mexico Department of Health, Santa Fe. He reports no financial disclosures or conflicts of interest. The author wishes to thank Dr. Dan Collins from the NMBHI for recommending that he research and write about this topic. In addition, document access was greatly aided by Lisa Apodaca and Mary Bunker, CNP, from the NMBHI, and Karen Ebler and Dr. Irwin Hoffman from Christus St. Vincent Hospital in Santa Fe. Finally, the following colleagues helped by proofreading the manuscript: Dr. Wendy Dimmette, Dr. Richard Nail, and Dr. Matt Streicherz. Eva Romero and Dr. Troy Jones provided useful historical documentation.
Shiftless
I drive a 10-year-old pickup truck. The air conditioner no longer works – not a real problem here in Maine. It has hand-operated roll down windows ... a real plus should I back too far down the boat ramp and find myself in the cold waters of the Atlantic. If I ever decide to lock it, I will need to use a real key. But the pile of mismatched work gloves and rusty garden tools stashed behind the front seat hasn’t seemed to attract any burglars. Its dented body sits on a new frame, thanks to a generous recall from the manufacturer.
It’s a four-wheel drive, handy in the winter. But what I really like about it is that my old truck has a standard manual transmission. I still have that boyish enthusiasm for shifting gears. I can imagine myself driving a low-slung sports car or operating some gargantuan piece of heavy machinery.
Driving a stick shift vehicle demands a level of engagement and concentration several levels above that of simply aiming a car equipped with an automatic transmission. While I am sure some have tried, shifting gears is a serious deterrent to texting at the wheel.
The fact that our three children learned to drive on a standard shift station wagon is a tribute to their parents’ ability to tolerate repeated whiplash injuries. But it also may be one of the reasons that they survived those deadly middle teenage years. Nichole Morris, a researcher at the Human FIRST Laboratory of the University of Minnesota has said, “If you are going to have an early, untimely death, the most dangerous 2 years of your life are between 16 and 17, and the reason for that is driving” (“Teenage Drivers? Be Very Afraid,” by Bruce Feiler, New York Times, March 19, 2016). Six teenagers a day die from motor vehicle accident–related injuries, according to the Centers for Disease Control and Prevention. There are more deaths from motor vehicle accidents in this age group than from suicides, cancer, and other accidents.
An unfortunate combination of perceived invincibility and inexperience in an environment richly decorated with distractions makes those first years behind the wheel so dangerous. Charlie Klauer, a researcher at Virginia Tech’s Transportation Institute, believes that one in four teenagers will be involved in a motor vehicle crash in his or her first 6 months of driving. My personal experience supports her observation. Luckily, my daughter’s first accident was a low speed rear-ender into a giant pickup truck that sustained no obvious damage.
Given these frightening statistics, it is surprising that any parents would ever allow their teenage children to start on the path toward a driver’s license. As physicians committed to the health and safety of children, why haven’t pediatricians done more to prevent this tragic loss of life? The honest answer is simply that the motor vehicle is too tightly woven into our culture. We have tried, but we could probably do more.
Technological advances such as self-braking cars that are spinning off from the development of autonomous vehicles may save a few teenage drivers. But, watching your 17-year-old child take the wheel for the first time will continue to be an anxiety-provoking experience for the foreseeable future. We can help by reminding parents that the driving is a privilege that can easily be revoked. We must continue to urge parents to create and enforce rules about the use of cell phones behind the wheel. Many states have enacted laws that restrict teenage drivers from driving with other teens in the car, a well-known and often fatal distraction. But parents must be reminded that they are the first line of enforcement.
Enduring those neck-snapping sessions that are unavoidable when your child is learning to drive a standard shift vehicle was a sacrifice my wife and I made gladly. Manual transmissions aren’t coming back. But there are still plenty of sacrifices for today’s parents to make if they want their children to survive those deadly midteen years.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
I drive a 10-year-old pickup truck. The air conditioner no longer works – not a real problem here in Maine. It has hand-operated roll down windows ... a real plus should I back too far down the boat ramp and find myself in the cold waters of the Atlantic. If I ever decide to lock it, I will need to use a real key. But the pile of mismatched work gloves and rusty garden tools stashed behind the front seat hasn’t seemed to attract any burglars. Its dented body sits on a new frame, thanks to a generous recall from the manufacturer.
It’s a four-wheel drive, handy in the winter. But what I really like about it is that my old truck has a standard manual transmission. I still have that boyish enthusiasm for shifting gears. I can imagine myself driving a low-slung sports car or operating some gargantuan piece of heavy machinery.
Driving a stick shift vehicle demands a level of engagement and concentration several levels above that of simply aiming a car equipped with an automatic transmission. While I am sure some have tried, shifting gears is a serious deterrent to texting at the wheel.
The fact that our three children learned to drive on a standard shift station wagon is a tribute to their parents’ ability to tolerate repeated whiplash injuries. But it also may be one of the reasons that they survived those deadly middle teenage years. Nichole Morris, a researcher at the Human FIRST Laboratory of the University of Minnesota has said, “If you are going to have an early, untimely death, the most dangerous 2 years of your life are between 16 and 17, and the reason for that is driving” (“Teenage Drivers? Be Very Afraid,” by Bruce Feiler, New York Times, March 19, 2016). Six teenagers a day die from motor vehicle accident–related injuries, according to the Centers for Disease Control and Prevention. There are more deaths from motor vehicle accidents in this age group than from suicides, cancer, and other accidents.
An unfortunate combination of perceived invincibility and inexperience in an environment richly decorated with distractions makes those first years behind the wheel so dangerous. Charlie Klauer, a researcher at Virginia Tech’s Transportation Institute, believes that one in four teenagers will be involved in a motor vehicle crash in his or her first 6 months of driving. My personal experience supports her observation. Luckily, my daughter’s first accident was a low speed rear-ender into a giant pickup truck that sustained no obvious damage.
Given these frightening statistics, it is surprising that any parents would ever allow their teenage children to start on the path toward a driver’s license. As physicians committed to the health and safety of children, why haven’t pediatricians done more to prevent this tragic loss of life? The honest answer is simply that the motor vehicle is too tightly woven into our culture. We have tried, but we could probably do more.
Technological advances such as self-braking cars that are spinning off from the development of autonomous vehicles may save a few teenage drivers. But, watching your 17-year-old child take the wheel for the first time will continue to be an anxiety-provoking experience for the foreseeable future. We can help by reminding parents that the driving is a privilege that can easily be revoked. We must continue to urge parents to create and enforce rules about the use of cell phones behind the wheel. Many states have enacted laws that restrict teenage drivers from driving with other teens in the car, a well-known and often fatal distraction. But parents must be reminded that they are the first line of enforcement.
Enduring those neck-snapping sessions that are unavoidable when your child is learning to drive a standard shift vehicle was a sacrifice my wife and I made gladly. Manual transmissions aren’t coming back. But there are still plenty of sacrifices for today’s parents to make if they want their children to survive those deadly midteen years.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
I drive a 10-year-old pickup truck. The air conditioner no longer works – not a real problem here in Maine. It has hand-operated roll down windows ... a real plus should I back too far down the boat ramp and find myself in the cold waters of the Atlantic. If I ever decide to lock it, I will need to use a real key. But the pile of mismatched work gloves and rusty garden tools stashed behind the front seat hasn’t seemed to attract any burglars. Its dented body sits on a new frame, thanks to a generous recall from the manufacturer.
It’s a four-wheel drive, handy in the winter. But what I really like about it is that my old truck has a standard manual transmission. I still have that boyish enthusiasm for shifting gears. I can imagine myself driving a low-slung sports car or operating some gargantuan piece of heavy machinery.
Driving a stick shift vehicle demands a level of engagement and concentration several levels above that of simply aiming a car equipped with an automatic transmission. While I am sure some have tried, shifting gears is a serious deterrent to texting at the wheel.
The fact that our three children learned to drive on a standard shift station wagon is a tribute to their parents’ ability to tolerate repeated whiplash injuries. But it also may be one of the reasons that they survived those deadly middle teenage years. Nichole Morris, a researcher at the Human FIRST Laboratory of the University of Minnesota has said, “If you are going to have an early, untimely death, the most dangerous 2 years of your life are between 16 and 17, and the reason for that is driving” (“Teenage Drivers? Be Very Afraid,” by Bruce Feiler, New York Times, March 19, 2016). Six teenagers a day die from motor vehicle accident–related injuries, according to the Centers for Disease Control and Prevention. There are more deaths from motor vehicle accidents in this age group than from suicides, cancer, and other accidents.
An unfortunate combination of perceived invincibility and inexperience in an environment richly decorated with distractions makes those first years behind the wheel so dangerous. Charlie Klauer, a researcher at Virginia Tech’s Transportation Institute, believes that one in four teenagers will be involved in a motor vehicle crash in his or her first 6 months of driving. My personal experience supports her observation. Luckily, my daughter’s first accident was a low speed rear-ender into a giant pickup truck that sustained no obvious damage.
Given these frightening statistics, it is surprising that any parents would ever allow their teenage children to start on the path toward a driver’s license. As physicians committed to the health and safety of children, why haven’t pediatricians done more to prevent this tragic loss of life? The honest answer is simply that the motor vehicle is too tightly woven into our culture. We have tried, but we could probably do more.
Technological advances such as self-braking cars that are spinning off from the development of autonomous vehicles may save a few teenage drivers. But, watching your 17-year-old child take the wheel for the first time will continue to be an anxiety-provoking experience for the foreseeable future. We can help by reminding parents that the driving is a privilege that can easily be revoked. We must continue to urge parents to create and enforce rules about the use of cell phones behind the wheel. Many states have enacted laws that restrict teenage drivers from driving with other teens in the car, a well-known and often fatal distraction. But parents must be reminded that they are the first line of enforcement.
Enduring those neck-snapping sessions that are unavoidable when your child is learning to drive a standard shift vehicle was a sacrifice my wife and I made gladly. Manual transmissions aren’t coming back. But there are still plenty of sacrifices for today’s parents to make if they want their children to survive those deadly midteen years.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
Lessons From History: The Ethical Foundation of VA Health Care
We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).
There are health care experts, politicians, even ethicists, who have called for either complete overhauling or dismantling of the old and swaying VHA edifice and furloughing or firing its demoralized and overworked staff. But before the wrecking crews come in and the ranks of committed and competent VA employees are sent packing, the naysayers should stop and realize that no matter what may be gained in that process, we will have profoundly changed the founding purpose and mission of the VA. The VA has one reason for existence—to care for veterans. Long before patient-centered care and medical homes were bywords in health care parlance, they were the words of ethical justification for the VHA as a health care agency. No moral agent, be it a person or an institution, can serve 2 masters. The VA is the only major health care system in the U.S. that does not have dual and often conflicting interests, whether in mission-readiness, profit, religious faith, or local and state politics.
There may be disagreements about the nature and scope of VHA’s problems and their solutions, but we should all recognize that a deeper ethical problem exists if the federal government and VHA fail to fulfill the obligation of reciprocity so eloquently described by President Lincoln. Economics can inform and empower but never fully resolve what is at the heart an ethical issue. Accountability and integrity are fundamental ethical values that are easily eroded by a singular and punitive focus on rules and rule-breaking that have guided too much of VA’s action and inaction, as well as the reaction of Congress. The military motto is to “leave no solider behind.” President Lincoln created the VA to honor this promise to veterans when they returned to civilian life. We must not allow engagement in partisan clashes to prevent us from fulfilling our moral commitment to those who actually fought and supported the nation’s battles.
Aknowledgements
The editor thanks Virginia Ashby Sharpe, PhD, for her insightful comments on an earlier draft of this editorial.
1. Shulkin DJ. Beyond the VA crises-becoming a high-performance network. N Engl J Med. 2016;374(11):1003-1005.
2. U.S. Department of Veterans Affairs. The origin of the VA motto: Lincoln’s second inaugural address. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed March 21, 2016.
3. Shi L, Singh DA. Delivering Health Care in America: A Systems Approach. 3rd ed. Sudbury, MA: Jones and Bartlett; 2004.
4. Johnson PM. A glossary of political economy terms: entitlement program. Auburn University Website. https://www.auburn.edu/~johnspm/gloss/entitlement_program. Accessed March 21, 2016.
5. Should all Americans have the right (be entitled) to health care? ProCon.org Website. http://healthcare.procon.org/view.answers.php?questionID=001602. Accessed March 21, 2016.
6. Core values and characteristics of the department. Fed Regist. 2012;77(135):41273-41276. 38 CFR Part 0.
We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).
There are health care experts, politicians, even ethicists, who have called for either complete overhauling or dismantling of the old and swaying VHA edifice and furloughing or firing its demoralized and overworked staff. But before the wrecking crews come in and the ranks of committed and competent VA employees are sent packing, the naysayers should stop and realize that no matter what may be gained in that process, we will have profoundly changed the founding purpose and mission of the VA. The VA has one reason for existence—to care for veterans. Long before patient-centered care and medical homes were bywords in health care parlance, they were the words of ethical justification for the VHA as a health care agency. No moral agent, be it a person or an institution, can serve 2 masters. The VA is the only major health care system in the U.S. that does not have dual and often conflicting interests, whether in mission-readiness, profit, religious faith, or local and state politics.
There may be disagreements about the nature and scope of VHA’s problems and their solutions, but we should all recognize that a deeper ethical problem exists if the federal government and VHA fail to fulfill the obligation of reciprocity so eloquently described by President Lincoln. Economics can inform and empower but never fully resolve what is at the heart an ethical issue. Accountability and integrity are fundamental ethical values that are easily eroded by a singular and punitive focus on rules and rule-breaking that have guided too much of VA’s action and inaction, as well as the reaction of Congress. The military motto is to “leave no solider behind.” President Lincoln created the VA to honor this promise to veterans when they returned to civilian life. We must not allow engagement in partisan clashes to prevent us from fulfilling our moral commitment to those who actually fought and supported the nation’s battles.
Aknowledgements
The editor thanks Virginia Ashby Sharpe, PhD, for her insightful comments on an earlier draft of this editorial.
We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).
There are health care experts, politicians, even ethicists, who have called for either complete overhauling or dismantling of the old and swaying VHA edifice and furloughing or firing its demoralized and overworked staff. But before the wrecking crews come in and the ranks of committed and competent VA employees are sent packing, the naysayers should stop and realize that no matter what may be gained in that process, we will have profoundly changed the founding purpose and mission of the VA. The VA has one reason for existence—to care for veterans. Long before patient-centered care and medical homes were bywords in health care parlance, they were the words of ethical justification for the VHA as a health care agency. No moral agent, be it a person or an institution, can serve 2 masters. The VA is the only major health care system in the U.S. that does not have dual and often conflicting interests, whether in mission-readiness, profit, religious faith, or local and state politics.
There may be disagreements about the nature and scope of VHA’s problems and their solutions, but we should all recognize that a deeper ethical problem exists if the federal government and VHA fail to fulfill the obligation of reciprocity so eloquently described by President Lincoln. Economics can inform and empower but never fully resolve what is at the heart an ethical issue. Accountability and integrity are fundamental ethical values that are easily eroded by a singular and punitive focus on rules and rule-breaking that have guided too much of VA’s action and inaction, as well as the reaction of Congress. The military motto is to “leave no solider behind.” President Lincoln created the VA to honor this promise to veterans when they returned to civilian life. We must not allow engagement in partisan clashes to prevent us from fulfilling our moral commitment to those who actually fought and supported the nation’s battles.
Aknowledgements
The editor thanks Virginia Ashby Sharpe, PhD, for her insightful comments on an earlier draft of this editorial.
1. Shulkin DJ. Beyond the VA crises-becoming a high-performance network. N Engl J Med. 2016;374(11):1003-1005.
2. U.S. Department of Veterans Affairs. The origin of the VA motto: Lincoln’s second inaugural address. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed March 21, 2016.
3. Shi L, Singh DA. Delivering Health Care in America: A Systems Approach. 3rd ed. Sudbury, MA: Jones and Bartlett; 2004.
4. Johnson PM. A glossary of political economy terms: entitlement program. Auburn University Website. https://www.auburn.edu/~johnspm/gloss/entitlement_program. Accessed March 21, 2016.
5. Should all Americans have the right (be entitled) to health care? ProCon.org Website. http://healthcare.procon.org/view.answers.php?questionID=001602. Accessed March 21, 2016.
6. Core values and characteristics of the department. Fed Regist. 2012;77(135):41273-41276. 38 CFR Part 0.
1. Shulkin DJ. Beyond the VA crises-becoming a high-performance network. N Engl J Med. 2016;374(11):1003-1005.
2. U.S. Department of Veterans Affairs. The origin of the VA motto: Lincoln’s second inaugural address. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed March 21, 2016.
3. Shi L, Singh DA. Delivering Health Care in America: A Systems Approach. 3rd ed. Sudbury, MA: Jones and Bartlett; 2004.
4. Johnson PM. A glossary of political economy terms: entitlement program. Auburn University Website. https://www.auburn.edu/~johnspm/gloss/entitlement_program. Accessed March 21, 2016.
5. Should all Americans have the right (be entitled) to health care? ProCon.org Website. http://healthcare.procon.org/view.answers.php?questionID=001602. Accessed March 21, 2016.
6. Core values and characteristics of the department. Fed Regist. 2012;77(135):41273-41276. 38 CFR Part 0.
