Commentary

Question: Which of the following choices is best?

A. Controversy exists over whether defensive medicine is widely practiced and whether it raises health care costs.

B. Everyone agrees that defensive medicine is widely practiced.

C. Doctors who spend more for their hospitalized patients have been reported to face a lower malpractice risk.

D. A and C.

E. B and C.

Answer: D. Virtually all doctors admit they practice defensive medicine, which describes medical care specifically directed to attenuate the threat of malpractice liability rather than for a proper medical indication. Survey studies generally put the prevalence at greater than 90%, but what separates true defensive medicine from careful practice or patient expectation/demand remains controversial.

A mail survey of 824 physicians in high-risk specialties in Pennsylvania, a state where doctors pay high malpractice premiums, revealed that nearly all reported practicing defensive medicine. The respondents admitted to both assurance behavior – such as ordering more tests, especially imaging studies – as well as avoidance behavior – that is, restricting or eliminating complex procedures or perceived litigious patients.¹

In another study, emergency physicians in the upper third of “malpractice fear” used more diagnostic tests and were more likely to hospitalize patients at low risk for coronary artery disease.²

On the other hand, a report using simulated clinical scenarios concluded that the extent of defensive medicine was at most 8%, and another found no correlation between individual malpractice claims experience and resource use, physician concern about malpractice, tolerance for uncertainty, or perception of risk.³

Another area of contention is whether some of our soaring health care costs may reflect defensive medicine at play.

A recent survey of 2,000 U.S. orthopedic surgeons found that 96% admitted practicing defensive medicine, with 24% of all ordered tests being for defensive reasons. The authors estimated that this amounted to about $100,000 per surgeon per year, or a total annual sum of $2 billion for the 20,400 orthopedic surgeons in the U.S.⁴

By correlating professional liability insurance with cost of services, the AMA estimated that in the 1980s, defensive medicine cost $12.1 billion to $13.7 billion each year.⁵ In an oft-cited study by Kessler and McClellan, the authors measured the effects of malpractice liability reforms using data from elderly Medicare beneficiaries treated for serious heart disease.⁶ They found that reforms that directly reduced provider liability pressure led to reductions of 5%-9% in medical expenditures. If such Medicare savings, which amounted to $600 million per year for cardiac disease, were extrapolated across the health care system, the annual savings would total $50 billion.

A more conservative study estimated that systemwide savings from aggressive malpractice reform would approach $41 billion over 5 years.⁷

Dr. Anupam B. Jena and his coauthors are the latest investigators seeking to clarify the correlation between defensive medicine and health care costs.⁸ Using Florida hospital admission data from 2000-2009, which covered some 24,000 physicians in seven separate specialties, the authors found that higher spending by physicians was associated with reduced malpractice claims the following year. This pattern held true for six of the seven specialties, family practitioners being the sole exception.

For example, among internists, the malpractice risk probability was reduced from 1.5% in the bottom spending fifth ($19,725 per admission) to 0.3% in the top fifth ($39,379 per admission). Among obstetricians, a separate subgroup analysis of cesarean-section rates revealed that malpractice claims were approximately halved among obstetricians with rates in the highest fifth, compared with the lowest fifth. These results comport with previous reports of higher C-section rates in obstetricians who perceived themselves at higher malpractice risk, although other studies have found no correlation or an actual lower rate.

In concluding that higher resource use by physicians was associated with fewer malpractice claims, the authors acknowledged that a principal limitation of the study was the lack of information on illness severity. Importantly, they were unable to state whether higher spending was defensively motivated. A companion editorial questioned whether increased resource expenditure was a bona fide reflection of defensive medicine or may simply have resulted in fewer errors and adverse events.⁹

Unfortunately, the past malpractice experience of the doctors, which could provide insight into more defensive postures, better communication, etc., was not measured in the study. In addition, claims made just 1 year after an incident may not accurately reflect the real-world situation, where the filing of a lawsuit may lag any alleged negligence by a much longer period, especially in obstetric cases.

Worryingly, the results of this timely study may be used to imply that the more doctors spend, the less likely they are to be sued – a troubling notion in our current race to stem rising health care costs.

References

1. JAMA. 2005 Jun 1;293(21):2609-17.

2. Ann Emerg Med. 2005 Dec;46(6):525-33.

3. J Health Polit Policy Law. 1996 Summer;21(2):267-88.

4. Am J Orthop (Belle Mead NJ). 2012 Feb;41(2):69-73.

5. JAMA. 1987 May 22-29;257(20):2776-81.

6. Q J Econ. 1996 May; 111(2):353-90.

7. J Am Health Policy. 1994 Jul-Aug;4(4):7-15.

8. BMJ. 2015 Nov 4;351:h5516.

9. BMJ. 2015 Nov 4;351:h5786.

Dr. Tan is emeritus professor 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: Which of the following choices is best?

A. Controversy exists over whether defensive medicine is widely practiced and whether it raises health care costs.

B. Everyone agrees that defensive medicine is widely practiced.

C. Doctors who spend more for their hospitalized patients have been reported to face a lower malpractice risk.

D. A and C.

E. B and C.

Answer: D. Virtually all doctors admit they practice defensive medicine, which describes medical care specifically directed to attenuate the threat of malpractice liability rather than for a proper medical indication. Survey studies generally put the prevalence at greater than 90%, but what separates true defensive medicine from careful practice or patient expectation/demand remains controversial.

A mail survey of 824 physicians in high-risk specialties in Pennsylvania, a state where doctors pay high malpractice premiums, revealed that nearly all reported practicing defensive medicine. The respondents admitted to both assurance behavior – such as ordering more tests, especially imaging studies – as well as avoidance behavior – that is, restricting or eliminating complex procedures or perceived litigious patients.¹

In another study, emergency physicians in the upper third of “malpractice fear” used more diagnostic tests and were more likely to hospitalize patients at low risk for coronary artery disease.²

On the other hand, a report using simulated clinical scenarios concluded that the extent of defensive medicine was at most 8%, and another found no correlation between individual malpractice claims experience and resource use, physician concern about malpractice, tolerance for uncertainty, or perception of risk.³

Another area of contention is whether some of our soaring health care costs may reflect defensive medicine at play.

A recent survey of 2,000 U.S. orthopedic surgeons found that 96% admitted practicing defensive medicine, with 24% of all ordered tests being for defensive reasons. The authors estimated that this amounted to about $100,000 per surgeon per year, or a total annual sum of $2 billion for the 20,400 orthopedic surgeons in the U.S.⁴

By correlating professional liability insurance with cost of services, the AMA estimated that in the 1980s, defensive medicine cost $12.1 billion to $13.7 billion each year.⁵ In an oft-cited study by Kessler and McClellan, the authors measured the effects of malpractice liability reforms using data from elderly Medicare beneficiaries treated for serious heart disease.⁶ They found that reforms that directly reduced provider liability pressure led to reductions of 5%-9% in medical expenditures. If such Medicare savings, which amounted to $600 million per year for cardiac disease, were extrapolated across the health care system, the annual savings would total $50 billion.

A more conservative study estimated that systemwide savings from aggressive malpractice reform would approach $41 billion over 5 years.⁷

Dr. Anupam B. Jena and his coauthors are the latest investigators seeking to clarify the correlation between defensive medicine and health care costs.⁸ Using Florida hospital admission data from 2000-2009, which covered some 24,000 physicians in seven separate specialties, the authors found that higher spending by physicians was associated with reduced malpractice claims the following year. This pattern held true for six of the seven specialties, family practitioners being the sole exception.

For example, among internists, the malpractice risk probability was reduced from 1.5% in the bottom spending fifth ($19,725 per admission) to 0.3% in the top fifth ($39,379 per admission). Among obstetricians, a separate subgroup analysis of cesarean-section rates revealed that malpractice claims were approximately halved among obstetricians with rates in the highest fifth, compared with the lowest fifth. These results comport with previous reports of higher C-section rates in obstetricians who perceived themselves at higher malpractice risk, although other studies have found no correlation or an actual lower rate.

In concluding that higher resource use by physicians was associated with fewer malpractice claims, the authors acknowledged that a principal limitation of the study was the lack of information on illness severity. Importantly, they were unable to state whether higher spending was defensively motivated. A companion editorial questioned whether increased resource expenditure was a bona fide reflection of defensive medicine or may simply have resulted in fewer errors and adverse events.⁹

Unfortunately, the past malpractice experience of the doctors, which could provide insight into more defensive postures, better communication, etc., was not measured in the study. In addition, claims made just 1 year after an incident may not accurately reflect the real-world situation, where the filing of a lawsuit may lag any alleged negligence by a much longer period, especially in obstetric cases.

Worryingly, the results of this timely study may be used to imply that the more doctors spend, the less likely they are to be sued – a troubling notion in our current race to stem rising health care costs.

References

1. JAMA. 2005 Jun 1;293(21):2609-17.

2. Ann Emerg Med. 2005 Dec;46(6):525-33.

3. J Health Polit Policy Law. 1996 Summer;21(2):267-88.

4. Am J Orthop (Belle Mead NJ). 2012 Feb;41(2):69-73.

5. JAMA. 1987 May 22-29;257(20):2776-81.

6. Q J Econ. 1996 May; 111(2):353-90.

7. J Am Health Policy. 1994 Jul-Aug;4(4):7-15.

8. BMJ. 2015 Nov 4;351:h5516.

9. BMJ. 2015 Nov 4;351:h5786.

Dr. Tan is emeritus professor 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: Which of the following choices is best?

A. Controversy exists over whether defensive medicine is widely practiced and whether it raises health care costs.

B. Everyone agrees that defensive medicine is widely practiced.

C. Doctors who spend more for their hospitalized patients have been reported to face a lower malpractice risk.

D. A and C.

E. B and C.

Answer: D. Virtually all doctors admit they practice defensive medicine, which describes medical care specifically directed to attenuate the threat of malpractice liability rather than for a proper medical indication. Survey studies generally put the prevalence at greater than 90%, but what separates true defensive medicine from careful practice or patient expectation/demand remains controversial.

A mail survey of 824 physicians in high-risk specialties in Pennsylvania, a state where doctors pay high malpractice premiums, revealed that nearly all reported practicing defensive medicine. The respondents admitted to both assurance behavior – such as ordering more tests, especially imaging studies – as well as avoidance behavior – that is, restricting or eliminating complex procedures or perceived litigious patients.¹

In another study, emergency physicians in the upper third of “malpractice fear” used more diagnostic tests and were more likely to hospitalize patients at low risk for coronary artery disease.²

On the other hand, a report using simulated clinical scenarios concluded that the extent of defensive medicine was at most 8%, and another found no correlation between individual malpractice claims experience and resource use, physician concern about malpractice, tolerance for uncertainty, or perception of risk.³

Another area of contention is whether some of our soaring health care costs may reflect defensive medicine at play.

A recent survey of 2,000 U.S. orthopedic surgeons found that 96% admitted practicing defensive medicine, with 24% of all ordered tests being for defensive reasons. The authors estimated that this amounted to about $100,000 per surgeon per year, or a total annual sum of $2 billion for the 20,400 orthopedic surgeons in the U.S.⁴

By correlating professional liability insurance with cost of services, the AMA estimated that in the 1980s, defensive medicine cost $12.1 billion to $13.7 billion each year.⁵ In an oft-cited study by Kessler and McClellan, the authors measured the effects of malpractice liability reforms using data from elderly Medicare beneficiaries treated for serious heart disease.⁶ They found that reforms that directly reduced provider liability pressure led to reductions of 5%-9% in medical expenditures. If such Medicare savings, which amounted to $600 million per year for cardiac disease, were extrapolated across the health care system, the annual savings would total $50 billion.

A more conservative study estimated that systemwide savings from aggressive malpractice reform would approach $41 billion over 5 years.⁷

Dr. Anupam B. Jena and his coauthors are the latest investigators seeking to clarify the correlation between defensive medicine and health care costs.⁸ Using Florida hospital admission data from 2000-2009, which covered some 24,000 physicians in seven separate specialties, the authors found that higher spending by physicians was associated with reduced malpractice claims the following year. This pattern held true for six of the seven specialties, family practitioners being the sole exception.

For example, among internists, the malpractice risk probability was reduced from 1.5% in the bottom spending fifth ($19,725 per admission) to 0.3% in the top fifth ($39,379 per admission). Among obstetricians, a separate subgroup analysis of cesarean-section rates revealed that malpractice claims were approximately halved among obstetricians with rates in the highest fifth, compared with the lowest fifth. These results comport with previous reports of higher C-section rates in obstetricians who perceived themselves at higher malpractice risk, although other studies have found no correlation or an actual lower rate.

In concluding that higher resource use by physicians was associated with fewer malpractice claims, the authors acknowledged that a principal limitation of the study was the lack of information on illness severity. Importantly, they were unable to state whether higher spending was defensively motivated. A companion editorial questioned whether increased resource expenditure was a bona fide reflection of defensive medicine or may simply have resulted in fewer errors and adverse events.⁹

Unfortunately, the past malpractice experience of the doctors, which could provide insight into more defensive postures, better communication, etc., was not measured in the study. In addition, claims made just 1 year after an incident may not accurately reflect the real-world situation, where the filing of a lawsuit may lag any alleged negligence by a much longer period, especially in obstetric cases.

Worryingly, the results of this timely study may be used to imply that the more doctors spend, the less likely they are to be sued – a troubling notion in our current race to stem rising health care costs.

References

1. JAMA. 2005 Jun 1;293(21):2609-17.

2. Ann Emerg Med. 2005 Dec;46(6):525-33.

3. J Health Polit Policy Law. 1996 Summer;21(2):267-88.

4. Am J Orthop (Belle Mead NJ). 2012 Feb;41(2):69-73.

5. JAMA. 1987 May 22-29;257(20):2776-81.

6. Q J Econ. 1996 May; 111(2):353-90.

7. J Am Health Policy. 1994 Jul-Aug;4(4):7-15.

8. BMJ. 2015 Nov 4;351:h5516.

9. BMJ. 2015 Nov 4;351:h5786.

Dr. Tan is emeritus professor 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].

In a letter dated Nov. 20, 2015, a particular insurance company reminded me that I need to think about healthcare costs. I got a breakdown of how often in the quarter I used proprietary vs. generic drugs, how I compared to other rheumatologists, and how I compared to other physicians. I also got a list of the drugs that I used and alternatives that I should be thinking about instead. In principle, this is not a terrible idea. But let me describe some glaring mistakes that show that these letters are in fact a contradiction in themselves. They are a huge waste of resources.

The letter suggested that my number one “prescribed brand drug with potential member savings opportunities” was Uloric, costing an average of $302 per prescription. The suggested “generic” alternative was Colcrys, leading to a “potential annual cost savings” of $600.

Third drug on my list? Colcrys, coming in at $165 per prescription with a potential annual savings of $300. Listed alternative: allopurinol.

We rheumatologists know that Colcrys is not an alternative to Uloric, and allopurinol is not an alternative to Colcrys. Also, suggesting an alternative only to suggest an alternative to that alternative is idiotic. Obviously, the letter is generated by a data-crunching algorithm. But an algorithm can only be as good as the programmer creating it.

As for my other proprietary prescriptions: Lyrica was the second on my list, and Celebrex the fourth. Let me explain why this is both annoying and inefficient. Before I could prescribe those drugs, this insurer made me jump through hoops to get them. In other words, there already exists in their database proof that I had already tried their recommended alternatives.

I can only conclude that within the bowels of health insurance corporate offices, and probably in more places than I care to imagine, there are people who are either incompetent or lazy, or both, making healthcare decisions.

So, to the health insurer: Forgive me if I ignore your reminder. I already know that healthcare costs are bloated. I am already quite conscientious about my prescribing practices. I think I can speak for all rheumatologists who receive these notices: You’re barking up the wrong tree.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In a letter dated Nov. 20, 2015, a particular insurance company reminded me that I need to think about healthcare costs. I got a breakdown of how often in the quarter I used proprietary vs. generic drugs, how I compared to other rheumatologists, and how I compared to other physicians. I also got a list of the drugs that I used and alternatives that I should be thinking about instead. In principle, this is not a terrible idea. But let me describe some glaring mistakes that show that these letters are in fact a contradiction in themselves. They are a huge waste of resources.

The letter suggested that my number one “prescribed brand drug with potential member savings opportunities” was Uloric, costing an average of $302 per prescription. The suggested “generic” alternative was Colcrys, leading to a “potential annual cost savings” of $600.

Third drug on my list? Colcrys, coming in at $165 per prescription with a potential annual savings of $300. Listed alternative: allopurinol.

We rheumatologists know that Colcrys is not an alternative to Uloric, and allopurinol is not an alternative to Colcrys. Also, suggesting an alternative only to suggest an alternative to that alternative is idiotic. Obviously, the letter is generated by a data-crunching algorithm. But an algorithm can only be as good as the programmer creating it.

As for my other proprietary prescriptions: Lyrica was the second on my list, and Celebrex the fourth. Let me explain why this is both annoying and inefficient. Before I could prescribe those drugs, this insurer made me jump through hoops to get them. In other words, there already exists in their database proof that I had already tried their recommended alternatives.

I can only conclude that within the bowels of health insurance corporate offices, and probably in more places than I care to imagine, there are people who are either incompetent or lazy, or both, making healthcare decisions.

So, to the health insurer: Forgive me if I ignore your reminder. I already know that healthcare costs are bloated. I am already quite conscientious about my prescribing practices. I think I can speak for all rheumatologists who receive these notices: You’re barking up the wrong tree.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In a letter dated Nov. 20, 2015, a particular insurance company reminded me that I need to think about healthcare costs. I got a breakdown of how often in the quarter I used proprietary vs. generic drugs, how I compared to other rheumatologists, and how I compared to other physicians. I also got a list of the drugs that I used and alternatives that I should be thinking about instead. In principle, this is not a terrible idea. But let me describe some glaring mistakes that show that these letters are in fact a contradiction in themselves. They are a huge waste of resources.

The letter suggested that my number one “prescribed brand drug with potential member savings opportunities” was Uloric, costing an average of $302 per prescription. The suggested “generic” alternative was Colcrys, leading to a “potential annual cost savings” of $600.

Third drug on my list? Colcrys, coming in at $165 per prescription with a potential annual savings of $300. Listed alternative: allopurinol.

We rheumatologists know that Colcrys is not an alternative to Uloric, and allopurinol is not an alternative to Colcrys. Also, suggesting an alternative only to suggest an alternative to that alternative is idiotic. Obviously, the letter is generated by a data-crunching algorithm. But an algorithm can only be as good as the programmer creating it.

As for my other proprietary prescriptions: Lyrica was the second on my list, and Celebrex the fourth. Let me explain why this is both annoying and inefficient. Before I could prescribe those drugs, this insurer made me jump through hoops to get them. In other words, there already exists in their database proof that I had already tried their recommended alternatives.

I can only conclude that within the bowels of health insurance corporate offices, and probably in more places than I care to imagine, there are people who are either incompetent or lazy, or both, making healthcare decisions.

So, to the health insurer: Forgive me if I ignore your reminder. I already know that healthcare costs are bloated. I am already quite conscientious about my prescribing practices. I think I can speak for all rheumatologists who receive these notices: You’re barking up the wrong tree.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Years ago, I had a colleague who’d once worked for the prison system, treating people who were some of the more dangerous elements of society.

Once I asked if he’d ever gotten curious about what they were in for. He answered that, while he was always curious, he never asked. He felt as if knowing might prejudice his care. Since a key part of being a doctor is being impartial and objective, he was afraid that knowing about their previous heinous behavior would make him less concerned about treating them properly. And I agree.

When I was a younger doctor, I’d sometimes Google patients. I’d be curious about their backgrounds, or I wanted to see if there was anything on their social media I should be aware of they hadn’t told me. Maybe something like “I scored 20 percs off a neurologist today!”

I stopped after a while, and haven’t done it since. I never saw anything that would affect my treatment plan. I did, however, often learn about their political and religious views, some of which were distasteful to me. I respect anyone’s right to have an opinion, but that doesn’t mean I have to agree with them.

Like I’ve written before, I specifically avoid any discussion of religion or politics with my patients because doing so can lead to antagonism and dislike, with the potential to impact my objectivity.

The same can be said about what else you might learn online: their habits and hobbies, unflattering pictures, stories about their backgrounds, etc. All of those things can, in the right circumstances, lead to a bias against them. Perhaps it may just exist subconsciously, but it’s still there. A recent Medscape report noted the number of physicians who admitted having biases against patients, as well as the things that can trigger our visceral reactions: emotional state, weight, and intelligence, to name a few. We try hard to overcome negative feelings to provide proper care, but are still human and 100% objectivity is often difficult.

To me, Googling a patient became the same thing as asking inmates what they’d been locked up for: You learn things about them that might change how you view and care for them.

The only way to effectively treat patients is to see them as just people, like yourself. Knowing too much about their background that isn’t medically relevant is just asking for trouble.

I’d rather know less and be more objective.

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

Years ago, I had a colleague who’d once worked for the prison system, treating people who were some of the more dangerous elements of society.

Once I asked if he’d ever gotten curious about what they were in for. He answered that, while he was always curious, he never asked. He felt as if knowing might prejudice his care. Since a key part of being a doctor is being impartial and objective, he was afraid that knowing about their previous heinous behavior would make him less concerned about treating them properly. And I agree.

When I was a younger doctor, I’d sometimes Google patients. I’d be curious about their backgrounds, or I wanted to see if there was anything on their social media I should be aware of they hadn’t told me. Maybe something like “I scored 20 percs off a neurologist today!”

I stopped after a while, and haven’t done it since. I never saw anything that would affect my treatment plan. I did, however, often learn about their political and religious views, some of which were distasteful to me. I respect anyone’s right to have an opinion, but that doesn’t mean I have to agree with them.

Like I’ve written before, I specifically avoid any discussion of religion or politics with my patients because doing so can lead to antagonism and dislike, with the potential to impact my objectivity.

The same can be said about what else you might learn online: their habits and hobbies, unflattering pictures, stories about their backgrounds, etc. All of those things can, in the right circumstances, lead to a bias against them. Perhaps it may just exist subconsciously, but it’s still there. A recent Medscape report noted the number of physicians who admitted having biases against patients, as well as the things that can trigger our visceral reactions: emotional state, weight, and intelligence, to name a few. We try hard to overcome negative feelings to provide proper care, but are still human and 100% objectivity is often difficult.

To me, Googling a patient became the same thing as asking inmates what they’d been locked up for: You learn things about them that might change how you view and care for them.

The only way to effectively treat patients is to see them as just people, like yourself. Knowing too much about their background that isn’t medically relevant is just asking for trouble.

I’d rather know less and be more objective.

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

Years ago, I had a colleague who’d once worked for the prison system, treating people who were some of the more dangerous elements of society.

Once I asked if he’d ever gotten curious about what they were in for. He answered that, while he was always curious, he never asked. He felt as if knowing might prejudice his care. Since a key part of being a doctor is being impartial and objective, he was afraid that knowing about their previous heinous behavior would make him less concerned about treating them properly. And I agree.

When I was a younger doctor, I’d sometimes Google patients. I’d be curious about their backgrounds, or I wanted to see if there was anything on their social media I should be aware of they hadn’t told me. Maybe something like “I scored 20 percs off a neurologist today!”

I stopped after a while, and haven’t done it since. I never saw anything that would affect my treatment plan. I did, however, often learn about their political and religious views, some of which were distasteful to me. I respect anyone’s right to have an opinion, but that doesn’t mean I have to agree with them.

Like I’ve written before, I specifically avoid any discussion of religion or politics with my patients because doing so can lead to antagonism and dislike, with the potential to impact my objectivity.

The same can be said about what else you might learn online: their habits and hobbies, unflattering pictures, stories about their backgrounds, etc. All of those things can, in the right circumstances, lead to a bias against them. Perhaps it may just exist subconsciously, but it’s still there. A recent Medscape report noted the number of physicians who admitted having biases against patients, as well as the things that can trigger our visceral reactions: emotional state, weight, and intelligence, to name a few. We try hard to overcome negative feelings to provide proper care, but are still human and 100% objectivity is often difficult.

To me, Googling a patient became the same thing as asking inmates what they’d been locked up for: You learn things about them that might change how you view and care for them.

The only way to effectively treat patients is to see them as just people, like yourself. Knowing too much about their background that isn’t medically relevant is just asking for trouble.

I’d rather know less and be more objective.

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

Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.

Is there another way?

Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.

Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).

In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.

However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.

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

Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.

Is there another way?

Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.

Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).

In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.

However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.

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

Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.

Is there another way?

Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.

Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).

In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.

However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.

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

It’s a great day for our patients! The Food and Drug Administration has proposed new tanning bed restrictions that would not allow those under 18 years old to use tanning beds and would require adults to sign a written acknowledgment that certifies that they have been warned of the risks of tanning beds. These are proposed rules, so it is important for you to write and support them (or ask for even more). The rule is available for review and comments are accepted through March 21, 2016, at www.regulations.gov.

The American Academy of Dermatology and numerous state dermatology societies have been advocating for such restrictions for many years.

The real question is why has it taken so long. At a meeting almost 6 years ago, an FDA advisory committee agreed that these devices were hazardous and recommended greater restrictions. The answer is multifactorial, long, but an important one for dermatologists who have been patient advocates on this issue for many long years.

First, we had to establish a scientific basis for our efforts. Many contributed to this, from establishing basic science of ultraviolet injury, to demonstration of ultraviolet carcinogenesis in an animal model (a fish no less!), to publishing compelling numbers confirming the epidemic of skin cancer (for which I will take some credit). Once the literature was in place, we had the good fortune to have a dermatologist (a former resident of mine and good friend) who was acting surgeon general (Dr. Boris Lushniak) and brought the Centers for Disease Control and Prevention on board and declared ultraviolet radiation exposure a national health crisis.

During this time, the tanning industry was not idle. They were not highly organized and were caught off guard by the imposition of a federal tanning tax several years ago. Since then, they have become more organized and have hired lobbyists (reportedly the same ones who represented big tobacco) and petitioned congress for relief as small businesses. They claim they provide something that is healthful (vitamin D is good, right?), are small businesses, and sell something that people can get by walking outside, but in a timelier manner. Never mind that they are clustered around high school and college campuses and sell their carcinogenic wares to unsuspecting teenage girls. I remember arguing with a tanning lobbyist at a state hearing who claimed that dermatologists were trying to line their pockets because we sell ultraviolet radiation in our offices.

There are powerful social drivers behind tanning bed use. A tan in our office cubicle-based work force implies wealth and success since no one really has time to sit around a pool and cultivate one. The young are healthy and indestructible and haven’t seen or won’t believe the carnage wrought by skin cancer. Some do buy the pictures of resultant wrinkling. The good news is that tanning is nowhere as nearly addictive as tobacco and should be easier to vanquish. As the data continue to roll in, and as more movie stars go under the knife for skin cancer, the momentum builds. We are making progress and we will continue the campaign because prevention efforts will save more anguish and lives than an army of dermatologists.

It has taken 50 years to turn the tide on cigarette smoking and with a similarly long cancer latency, tanning will take persistent effort. The problem, however, has been identified, the solution obvious, and an ultimate victory for our patients inevitable. Dermatologists everywhere should take great pride in this victory at the FDA. Remember, tanning is the new tobacco!

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

It’s a great day for our patients! The Food and Drug Administration has proposed new tanning bed restrictions that would not allow those under 18 years old to use tanning beds and would require adults to sign a written acknowledgment that certifies that they have been warned of the risks of tanning beds. These are proposed rules, so it is important for you to write and support them (or ask for even more). The rule is available for review and comments are accepted through March 21, 2016, at www.regulations.gov.

The American Academy of Dermatology and numerous state dermatology societies have been advocating for such restrictions for many years.

The real question is why has it taken so long. At a meeting almost 6 years ago, an FDA advisory committee agreed that these devices were hazardous and recommended greater restrictions. The answer is multifactorial, long, but an important one for dermatologists who have been patient advocates on this issue for many long years.

First, we had to establish a scientific basis for our efforts. Many contributed to this, from establishing basic science of ultraviolet injury, to demonstration of ultraviolet carcinogenesis in an animal model (a fish no less!), to publishing compelling numbers confirming the epidemic of skin cancer (for which I will take some credit). Once the literature was in place, we had the good fortune to have a dermatologist (a former resident of mine and good friend) who was acting surgeon general (Dr. Boris Lushniak) and brought the Centers for Disease Control and Prevention on board and declared ultraviolet radiation exposure a national health crisis.

During this time, the tanning industry was not idle. They were not highly organized and were caught off guard by the imposition of a federal tanning tax several years ago. Since then, they have become more organized and have hired lobbyists (reportedly the same ones who represented big tobacco) and petitioned congress for relief as small businesses. They claim they provide something that is healthful (vitamin D is good, right?), are small businesses, and sell something that people can get by walking outside, but in a timelier manner. Never mind that they are clustered around high school and college campuses and sell their carcinogenic wares to unsuspecting teenage girls. I remember arguing with a tanning lobbyist at a state hearing who claimed that dermatologists were trying to line their pockets because we sell ultraviolet radiation in our offices.

There are powerful social drivers behind tanning bed use. A tan in our office cubicle-based work force implies wealth and success since no one really has time to sit around a pool and cultivate one. The young are healthy and indestructible and haven’t seen or won’t believe the carnage wrought by skin cancer. Some do buy the pictures of resultant wrinkling. The good news is that tanning is nowhere as nearly addictive as tobacco and should be easier to vanquish. As the data continue to roll in, and as more movie stars go under the knife for skin cancer, the momentum builds. We are making progress and we will continue the campaign because prevention efforts will save more anguish and lives than an army of dermatologists.

It has taken 50 years to turn the tide on cigarette smoking and with a similarly long cancer latency, tanning will take persistent effort. The problem, however, has been identified, the solution obvious, and an ultimate victory for our patients inevitable. Dermatologists everywhere should take great pride in this victory at the FDA. Remember, tanning is the new tobacco!

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

It’s a great day for our patients! The Food and Drug Administration has proposed new tanning bed restrictions that would not allow those under 18 years old to use tanning beds and would require adults to sign a written acknowledgment that certifies that they have been warned of the risks of tanning beds. These are proposed rules, so it is important for you to write and support them (or ask for even more). The rule is available for review and comments are accepted through March 21, 2016, at www.regulations.gov.

The American Academy of Dermatology and numerous state dermatology societies have been advocating for such restrictions for many years.

The real question is why has it taken so long. At a meeting almost 6 years ago, an FDA advisory committee agreed that these devices were hazardous and recommended greater restrictions. The answer is multifactorial, long, but an important one for dermatologists who have been patient advocates on this issue for many long years.

First, we had to establish a scientific basis for our efforts. Many contributed to this, from establishing basic science of ultraviolet injury, to demonstration of ultraviolet carcinogenesis in an animal model (a fish no less!), to publishing compelling numbers confirming the epidemic of skin cancer (for which I will take some credit). Once the literature was in place, we had the good fortune to have a dermatologist (a former resident of mine and good friend) who was acting surgeon general (Dr. Boris Lushniak) and brought the Centers for Disease Control and Prevention on board and declared ultraviolet radiation exposure a national health crisis.

During this time, the tanning industry was not idle. They were not highly organized and were caught off guard by the imposition of a federal tanning tax several years ago. Since then, they have become more organized and have hired lobbyists (reportedly the same ones who represented big tobacco) and petitioned congress for relief as small businesses. They claim they provide something that is healthful (vitamin D is good, right?), are small businesses, and sell something that people can get by walking outside, but in a timelier manner. Never mind that they are clustered around high school and college campuses and sell their carcinogenic wares to unsuspecting teenage girls. I remember arguing with a tanning lobbyist at a state hearing who claimed that dermatologists were trying to line their pockets because we sell ultraviolet radiation in our offices.

There are powerful social drivers behind tanning bed use. A tan in our office cubicle-based work force implies wealth and success since no one really has time to sit around a pool and cultivate one. The young are healthy and indestructible and haven’t seen or won’t believe the carnage wrought by skin cancer. Some do buy the pictures of resultant wrinkling. The good news is that tanning is nowhere as nearly addictive as tobacco and should be easier to vanquish. As the data continue to roll in, and as more movie stars go under the knife for skin cancer, the momentum builds. We are making progress and we will continue the campaign because prevention efforts will save more anguish and lives than an army of dermatologists.

It has taken 50 years to turn the tide on cigarette smoking and with a similarly long cancer latency, tanning will take persistent effort. The problem, however, has been identified, the solution obvious, and an ultimate victory for our patients inevitable. Dermatologists everywhere should take great pride in this victory at the FDA. Remember, tanning is the new tobacco!

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

No matter how complete your insurance portfolio, there is one policy – one you probably never heard of – that you should definitely consider adding to it.

A few years ago, I spoke with a dermatologist in California who experienced every employer’s nightmare: He fired an incompetent employee who promptly sued him for wrongful termination and accused him of sexual harassment to boot. The charges were completely false, and the employee’s transgressions were well documented, but defending the lawsuit, successfully or not, would have been expensive. So the dermatologist’s lawyer persuaded him to settle it for a significant sum of money.

Disasters like that are becoming more common. Plaintiffs’ attorneys know all too well that most small businesses, including medical practices, are not insured against employees’ legal actions, and usually cannot afford to defend them in court.

Fortunately, there is a relatively inexpensive way to protect yourself: Employment Practices Liability Insurance (EPLI) provides protection against many kinds of employee lawsuits not covered by conventional liability insurance. These include wrongful termination, sexual harassment, discrimination, breach of employment contract, negligent hiring or evaluation, failure to promote, wrongful discipline, mismanagement of benefits, and the ever-popular “emotional distress.”

EPLI would have covered the California dermatologist, had he carried it, against his employee’s charges. In fact, there is a better-than-even chance that the plaintiff’s attorney would have dropped the lawsuit entirely once informed that it would be aggressively defended.

Some liability carriers are beginning to cover some employee-related issues in “umbrella” policies, so check your current insurance coverage first. Then, as with all insurance, you should shop around for the best price, and carefully read the policies on your short list. All EPLI policies cover claims against your practice and its owners and employees, but some cover claims against full-time employees only. Try to obtain the broadest coverage possible so that part-time, temporary, and seasonal employees, and if possible, even applicants for employment and former employees, also are covered.

Look for the most comprehensive policy in terms of coverage. Almost every EPLI policy covers the allegations mentioned above, but some offer a more comprehensive list of covered acts, such as invasion of privacy and defamation of character.

Also be aware of precisely what each policy does not cover. Most contain exclusions for punitive damages and court-imposed fines, as well as for criminal acts, fraud, and other clearly illegal conduct. For example, if it can be proved that you fired an employee because he or she refused to falsify insurance claims, any resulting civil suit against you will not be covered by any type of insurance.

Depending on where you practice, it may be necessary to ask an employment lawyer to evaluate your individual EPLI needs. An underwriter cannot anticipate every eventuality for you, particularly if he or she does not live in your area and is not familiar with employment conditions in your community.

Try to get a clause added that permits you to choose your own defense attorney. Better still, pick a specific attorney or firm that you trust, and have that counsel named in an endorsement to the policy. Otherwise, the insurance carrier will select an attorney from its own panel who may not consider your interests a higher priority than those of the insurer itself.

If you must accept the insurer’s choice of counsel, you should find out whether that attorney is experienced in employment law, which is a very specialized area. And, just as with your malpractice policy, you will want to maintain as much control as possible over the settlement of claims. Ideally, no claim should be settled without your expressed permission.

As with any insurance policy you buy, be sure to choose an established carrier with ample experience in the field and solid financial strength. A low premium is no bargain if the carrier is new to EPLI, or goes broke, or decides to cease covering employment practices liability.

Above all, make sure that you can live with the claims definition and exclusions in the policy you choose, and seek advice if you are unsure what your specific needs are before you sign on the dotted line.

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].

No matter how complete your insurance portfolio, there is one policy – one you probably never heard of – that you should definitely consider adding to it.

A few years ago, I spoke with a dermatologist in California who experienced every employer’s nightmare: He fired an incompetent employee who promptly sued him for wrongful termination and accused him of sexual harassment to boot. The charges were completely false, and the employee’s transgressions were well documented, but defending the lawsuit, successfully or not, would have been expensive. So the dermatologist’s lawyer persuaded him to settle it for a significant sum of money.

Disasters like that are becoming more common. Plaintiffs’ attorneys know all too well that most small businesses, including medical practices, are not insured against employees’ legal actions, and usually cannot afford to defend them in court.

Fortunately, there is a relatively inexpensive way to protect yourself: Employment Practices Liability Insurance (EPLI) provides protection against many kinds of employee lawsuits not covered by conventional liability insurance. These include wrongful termination, sexual harassment, discrimination, breach of employment contract, negligent hiring or evaluation, failure to promote, wrongful discipline, mismanagement of benefits, and the ever-popular “emotional distress.”

EPLI would have covered the California dermatologist, had he carried it, against his employee’s charges. In fact, there is a better-than-even chance that the plaintiff’s attorney would have dropped the lawsuit entirely once informed that it would be aggressively defended.

Some liability carriers are beginning to cover some employee-related issues in “umbrella” policies, so check your current insurance coverage first. Then, as with all insurance, you should shop around for the best price, and carefully read the policies on your short list. All EPLI policies cover claims against your practice and its owners and employees, but some cover claims against full-time employees only. Try to obtain the broadest coverage possible so that part-time, temporary, and seasonal employees, and if possible, even applicants for employment and former employees, also are covered.

Look for the most comprehensive policy in terms of coverage. Almost every EPLI policy covers the allegations mentioned above, but some offer a more comprehensive list of covered acts, such as invasion of privacy and defamation of character.

Also be aware of precisely what each policy does not cover. Most contain exclusions for punitive damages and court-imposed fines, as well as for criminal acts, fraud, and other clearly illegal conduct. For example, if it can be proved that you fired an employee because he or she refused to falsify insurance claims, any resulting civil suit against you will not be covered by any type of insurance.

Depending on where you practice, it may be necessary to ask an employment lawyer to evaluate your individual EPLI needs. An underwriter cannot anticipate every eventuality for you, particularly if he or she does not live in your area and is not familiar with employment conditions in your community.

Try to get a clause added that permits you to choose your own defense attorney. Better still, pick a specific attorney or firm that you trust, and have that counsel named in an endorsement to the policy. Otherwise, the insurance carrier will select an attorney from its own panel who may not consider your interests a higher priority than those of the insurer itself.

If you must accept the insurer’s choice of counsel, you should find out whether that attorney is experienced in employment law, which is a very specialized area. And, just as with your malpractice policy, you will want to maintain as much control as possible over the settlement of claims. Ideally, no claim should be settled without your expressed permission.

As with any insurance policy you buy, be sure to choose an established carrier with ample experience in the field and solid financial strength. A low premium is no bargain if the carrier is new to EPLI, or goes broke, or decides to cease covering employment practices liability.

Above all, make sure that you can live with the claims definition and exclusions in the policy you choose, and seek advice if you are unsure what your specific needs are before you sign on the dotted line.

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].

No matter how complete your insurance portfolio, there is one policy – one you probably never heard of – that you should definitely consider adding to it.

A few years ago, I spoke with a dermatologist in California who experienced every employer’s nightmare: He fired an incompetent employee who promptly sued him for wrongful termination and accused him of sexual harassment to boot. The charges were completely false, and the employee’s transgressions were well documented, but defending the lawsuit, successfully or not, would have been expensive. So the dermatologist’s lawyer persuaded him to settle it for a significant sum of money.

Disasters like that are becoming more common. Plaintiffs’ attorneys know all too well that most small businesses, including medical practices, are not insured against employees’ legal actions, and usually cannot afford to defend them in court.

Fortunately, there is a relatively inexpensive way to protect yourself: Employment Practices Liability Insurance (EPLI) provides protection against many kinds of employee lawsuits not covered by conventional liability insurance. These include wrongful termination, sexual harassment, discrimination, breach of employment contract, negligent hiring or evaluation, failure to promote, wrongful discipline, mismanagement of benefits, and the ever-popular “emotional distress.”

EPLI would have covered the California dermatologist, had he carried it, against his employee’s charges. In fact, there is a better-than-even chance that the plaintiff’s attorney would have dropped the lawsuit entirely once informed that it would be aggressively defended.

Some liability carriers are beginning to cover some employee-related issues in “umbrella” policies, so check your current insurance coverage first. Then, as with all insurance, you should shop around for the best price, and carefully read the policies on your short list. All EPLI policies cover claims against your practice and its owners and employees, but some cover claims against full-time employees only. Try to obtain the broadest coverage possible so that part-time, temporary, and seasonal employees, and if possible, even applicants for employment and former employees, also are covered.

Look for the most comprehensive policy in terms of coverage. Almost every EPLI policy covers the allegations mentioned above, but some offer a more comprehensive list of covered acts, such as invasion of privacy and defamation of character.

Also be aware of precisely what each policy does not cover. Most contain exclusions for punitive damages and court-imposed fines, as well as for criminal acts, fraud, and other clearly illegal conduct. For example, if it can be proved that you fired an employee because he or she refused to falsify insurance claims, any resulting civil suit against you will not be covered by any type of insurance.

Depending on where you practice, it may be necessary to ask an employment lawyer to evaluate your individual EPLI needs. An underwriter cannot anticipate every eventuality for you, particularly if he or she does not live in your area and is not familiar with employment conditions in your community.

Try to get a clause added that permits you to choose your own defense attorney. Better still, pick a specific attorney or firm that you trust, and have that counsel named in an endorsement to the policy. Otherwise, the insurance carrier will select an attorney from its own panel who may not consider your interests a higher priority than those of the insurer itself.

If you must accept the insurer’s choice of counsel, you should find out whether that attorney is experienced in employment law, which is a very specialized area. And, just as with your malpractice policy, you will want to maintain as much control as possible over the settlement of claims. Ideally, no claim should be settled without your expressed permission.

As with any insurance policy you buy, be sure to choose an established carrier with ample experience in the field and solid financial strength. A low premium is no bargain if the carrier is new to EPLI, or goes broke, or decides to cease covering employment practices liability.

Above all, make sure that you can live with the claims definition and exclusions in the policy you choose, and seek advice if you are unsure what your specific needs are before you sign on the dotted line.

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

A few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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.”

A few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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.”

A few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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.”

The dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 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.”

The dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 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.”

The dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 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.”