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Providing ambivalent medical advice
When did some doctors become so wishy-washy?
A large part of what we do is guide people through an often-confusing maze of test results and treatment options. I respect patients’ right to make their own decisions, but it came as a surprise to me to find that some doctors are turning such things over to the patients. After all, doctors are the ones who went through over a decade of training to understand the risks, benefits, and goals of each step for them. Granted, I live in Arizona, where you don’t need a doctor’s order to have labs done. You can research whatever you want on Google, decide what work-up you need, and go get whatever labs you want done.
But back to my original point. Recently, one of my patients was admitted to the hospital, then followed up with me in the office. I looked through his test results and told him what I felt the next step should be, ordered a few things, and wrote an instruction sheet to start daily aspirin. I commented that it surprised me the last hadn’t been done as an inpatient.
His answer? “They said I could if I wanted to, but didn’t make a clear suggestion.” I figured this was a simple miscommunication, so I pulled up the hospital chart on my computer. There I found a note from the attending that said, “The patient was told he may or may not want to take a daily aspirin, and that doing so might or might not be to his benefit.” What on Earth?
I understand there are no guarantees in this job. There’s no crystal ball to know for sure that what we’re doing is right. Any drug can cause serious and unexpected complications. We take calculated risks and hope we come out ahead. But to phrase it like this? Where the patient isn’t given the guidance we’re supposed to provide? What’s the point of even being a doctor?
Since then, I’ve noticed similar phrasing in other charts: “We discussed doing a brain MRI, and she’ll let me know what she decides” and “I told her that starting Lamictal may or may not prevent seizures, and to consider it as something she should or shouldn’t do.”
I’m sure some of it is part of the hurried flight-of-ideas dictations we all do when we’re busy at the hospital. There’s also a component of legalese to make sure that we documented discussing risks with the patient.
But I still don’t get the ambivalence. In similar situations, I provide guidance and advice and tell people what I think they should do. I’m not going to force anyone to do anything they don’t want to. If they disagree, I note it and make whatever suggestions I think will help. In the end, it’s their decision. I get that.
When I take my car to get fixed, I don’t want the mechanic to tell me what may or may not need to be repaired, and I hope patients see me the same way.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
When did some doctors become so wishy-washy?
A large part of what we do is guide people through an often-confusing maze of test results and treatment options. I respect patients’ right to make their own decisions, but it came as a surprise to me to find that some doctors are turning such things over to the patients. After all, doctors are the ones who went through over a decade of training to understand the risks, benefits, and goals of each step for them. Granted, I live in Arizona, where you don’t need a doctor’s order to have labs done. You can research whatever you want on Google, decide what work-up you need, and go get whatever labs you want done.
But back to my original point. Recently, one of my patients was admitted to the hospital, then followed up with me in the office. I looked through his test results and told him what I felt the next step should be, ordered a few things, and wrote an instruction sheet to start daily aspirin. I commented that it surprised me the last hadn’t been done as an inpatient.
His answer? “They said I could if I wanted to, but didn’t make a clear suggestion.” I figured this was a simple miscommunication, so I pulled up the hospital chart on my computer. There I found a note from the attending that said, “The patient was told he may or may not want to take a daily aspirin, and that doing so might or might not be to his benefit.” What on Earth?
I understand there are no guarantees in this job. There’s no crystal ball to know for sure that what we’re doing is right. Any drug can cause serious and unexpected complications. We take calculated risks and hope we come out ahead. But to phrase it like this? Where the patient isn’t given the guidance we’re supposed to provide? What’s the point of even being a doctor?
Since then, I’ve noticed similar phrasing in other charts: “We discussed doing a brain MRI, and she’ll let me know what she decides” and “I told her that starting Lamictal may or may not prevent seizures, and to consider it as something she should or shouldn’t do.”
I’m sure some of it is part of the hurried flight-of-ideas dictations we all do when we’re busy at the hospital. There’s also a component of legalese to make sure that we documented discussing risks with the patient.
But I still don’t get the ambivalence. In similar situations, I provide guidance and advice and tell people what I think they should do. I’m not going to force anyone to do anything they don’t want to. If they disagree, I note it and make whatever suggestions I think will help. In the end, it’s their decision. I get that.
When I take my car to get fixed, I don’t want the mechanic to tell me what may or may not need to be repaired, and I hope patients see me the same way.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
When did some doctors become so wishy-washy?
A large part of what we do is guide people through an often-confusing maze of test results and treatment options. I respect patients’ right to make their own decisions, but it came as a surprise to me to find that some doctors are turning such things over to the patients. After all, doctors are the ones who went through over a decade of training to understand the risks, benefits, and goals of each step for them. Granted, I live in Arizona, where you don’t need a doctor’s order to have labs done. You can research whatever you want on Google, decide what work-up you need, and go get whatever labs you want done.
But back to my original point. Recently, one of my patients was admitted to the hospital, then followed up with me in the office. I looked through his test results and told him what I felt the next step should be, ordered a few things, and wrote an instruction sheet to start daily aspirin. I commented that it surprised me the last hadn’t been done as an inpatient.
His answer? “They said I could if I wanted to, but didn’t make a clear suggestion.” I figured this was a simple miscommunication, so I pulled up the hospital chart on my computer. There I found a note from the attending that said, “The patient was told he may or may not want to take a daily aspirin, and that doing so might or might not be to his benefit.” What on Earth?
I understand there are no guarantees in this job. There’s no crystal ball to know for sure that what we’re doing is right. Any drug can cause serious and unexpected complications. We take calculated risks and hope we come out ahead. But to phrase it like this? Where the patient isn’t given the guidance we’re supposed to provide? What’s the point of even being a doctor?
Since then, I’ve noticed similar phrasing in other charts: “We discussed doing a brain MRI, and she’ll let me know what she decides” and “I told her that starting Lamictal may or may not prevent seizures, and to consider it as something she should or shouldn’t do.”
I’m sure some of it is part of the hurried flight-of-ideas dictations we all do when we’re busy at the hospital. There’s also a component of legalese to make sure that we documented discussing risks with the patient.
But I still don’t get the ambivalence. In similar situations, I provide guidance and advice and tell people what I think they should do. I’m not going to force anyone to do anything they don’t want to. If they disagree, I note it and make whatever suggestions I think will help. In the end, it’s their decision. I get that.
When I take my car to get fixed, I don’t want the mechanic to tell me what may or may not need to be repaired, and I hope patients see me the same way.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Antidepressants for functional dyspepsia
Functional, a.k.a. “nonulcer,” dyspepsia is a challenging diagnosis and likely afflicts many more patients than we have identified in our practices. Functional dyspepsia (FD) is defined by the presence of postprandial fullness, early satiety, epigastric pain or burning, and no evidence of structural disease. These are the patients who do not get better with proton pump inhibitors or feel better after a bowel movement.
After a negative upper endoscopy and Helicobacter pylori stool antigen test, the task turns to symptom control. But what’s the best treatment?
Dr. Nicholas J. Talley of the University of Newcastle in Callaghan, Australia, and colleagues conducted a multicenter, randomized trial evaluating the comparative efficacy of amitriptyline or escitalopram for symptom control, gastric emptying, and meal-induced satiety in patients with FD (Gastroenterology. 2015;149(2):340-9.e2).
Participants were enrolled if they met Rome II criteria for FD requiring that folks in the preceding 12 months have at least 12 weeks of dyspepsia, absence of organic disease, and no relationship to defecation. Patients were randomized to placebo, amitriptyline 50 mg (titrated), or escitalopram 10 mg. Medication was given for 10 weeks. The primary endpoint was adequate relief of symptoms for at least 5 weeks.
A total of 292 patients (most of whom [75%] were female) with an average age of 44 years were randomized. Seventy percent had dysmotility-like FD and 30% had ulcer-like FD.
Patients with ulcer-like FD receiving amitriptyline were more likely to report adequate relief (odds ratio, 3.1; 95% confidence interval, 1.1-9.0). Neither medication affected gastric emptying or meal-induced satiety. Both medications improved overall quality of life.
The data support the use of amitriptyline for ulcer-like FD. Some of these patients may have comorbid psychiatric illness that may be improved with escitalopram. Perhaps this is what is impacting the quality-of-life metric that taps into dimensions above and beyond relief of symptoms (such as sleep disturbance or work/study).
Proton pump inhibitors tend to be overused, and many of our patients take them indefinitely without trying to see how they do off of them. Some patients for whom we have not considered a diagnosis of FD may be on PPIs because we have had nothing else to offer them. Maybe they felt better because of a PPI placebo effect and we have continued them.
If we can, we should review the diagnosis of dyspepsia, consider FD as a possibility etiology for gastrointestinal distress, stop the PPIs, and try amitriptyline.
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. Follow him on Twitter @jonebbert.
Functional, a.k.a. “nonulcer,” dyspepsia is a challenging diagnosis and likely afflicts many more patients than we have identified in our practices. Functional dyspepsia (FD) is defined by the presence of postprandial fullness, early satiety, epigastric pain or burning, and no evidence of structural disease. These are the patients who do not get better with proton pump inhibitors or feel better after a bowel movement.
After a negative upper endoscopy and Helicobacter pylori stool antigen test, the task turns to symptom control. But what’s the best treatment?
Dr. Nicholas J. Talley of the University of Newcastle in Callaghan, Australia, and colleagues conducted a multicenter, randomized trial evaluating the comparative efficacy of amitriptyline or escitalopram for symptom control, gastric emptying, and meal-induced satiety in patients with FD (Gastroenterology. 2015;149(2):340-9.e2).
Participants were enrolled if they met Rome II criteria for FD requiring that folks in the preceding 12 months have at least 12 weeks of dyspepsia, absence of organic disease, and no relationship to defecation. Patients were randomized to placebo, amitriptyline 50 mg (titrated), or escitalopram 10 mg. Medication was given for 10 weeks. The primary endpoint was adequate relief of symptoms for at least 5 weeks.
A total of 292 patients (most of whom [75%] were female) with an average age of 44 years were randomized. Seventy percent had dysmotility-like FD and 30% had ulcer-like FD.
Patients with ulcer-like FD receiving amitriptyline were more likely to report adequate relief (odds ratio, 3.1; 95% confidence interval, 1.1-9.0). Neither medication affected gastric emptying or meal-induced satiety. Both medications improved overall quality of life.
The data support the use of amitriptyline for ulcer-like FD. Some of these patients may have comorbid psychiatric illness that may be improved with escitalopram. Perhaps this is what is impacting the quality-of-life metric that taps into dimensions above and beyond relief of symptoms (such as sleep disturbance or work/study).
Proton pump inhibitors tend to be overused, and many of our patients take them indefinitely without trying to see how they do off of them. Some patients for whom we have not considered a diagnosis of FD may be on PPIs because we have had nothing else to offer them. Maybe they felt better because of a PPI placebo effect and we have continued them.
If we can, we should review the diagnosis of dyspepsia, consider FD as a possibility etiology for gastrointestinal distress, stop the PPIs, and try amitriptyline.
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. Follow him on Twitter @jonebbert.
Functional, a.k.a. “nonulcer,” dyspepsia is a challenging diagnosis and likely afflicts many more patients than we have identified in our practices. Functional dyspepsia (FD) is defined by the presence of postprandial fullness, early satiety, epigastric pain or burning, and no evidence of structural disease. These are the patients who do not get better with proton pump inhibitors or feel better after a bowel movement.
After a negative upper endoscopy and Helicobacter pylori stool antigen test, the task turns to symptom control. But what’s the best treatment?
Dr. Nicholas J. Talley of the University of Newcastle in Callaghan, Australia, and colleagues conducted a multicenter, randomized trial evaluating the comparative efficacy of amitriptyline or escitalopram for symptom control, gastric emptying, and meal-induced satiety in patients with FD (Gastroenterology. 2015;149(2):340-9.e2).
Participants were enrolled if they met Rome II criteria for FD requiring that folks in the preceding 12 months have at least 12 weeks of dyspepsia, absence of organic disease, and no relationship to defecation. Patients were randomized to placebo, amitriptyline 50 mg (titrated), or escitalopram 10 mg. Medication was given for 10 weeks. The primary endpoint was adequate relief of symptoms for at least 5 weeks.
A total of 292 patients (most of whom [75%] were female) with an average age of 44 years were randomized. Seventy percent had dysmotility-like FD and 30% had ulcer-like FD.
Patients with ulcer-like FD receiving amitriptyline were more likely to report adequate relief (odds ratio, 3.1; 95% confidence interval, 1.1-9.0). Neither medication affected gastric emptying or meal-induced satiety. Both medications improved overall quality of life.
The data support the use of amitriptyline for ulcer-like FD. Some of these patients may have comorbid psychiatric illness that may be improved with escitalopram. Perhaps this is what is impacting the quality-of-life metric that taps into dimensions above and beyond relief of symptoms (such as sleep disturbance or work/study).
Proton pump inhibitors tend to be overused, and many of our patients take them indefinitely without trying to see how they do off of them. Some patients for whom we have not considered a diagnosis of FD may be on PPIs because we have had nothing else to offer them. Maybe they felt better because of a PPI placebo effect and we have continued them.
If we can, we should review the diagnosis of dyspepsia, consider FD as a possibility etiology for gastrointestinal distress, stop the PPIs, and try amitriptyline.
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. Follow him on Twitter @jonebbert.
Commentary: Red meat and cancer risk – what your patients should know
It may have come as a surprise to the approximately 60% of Americans who consume red or processed meat that the International Agency for Research on Cancer (IARC), a part of the World Health Organization, recently reported that processed meat is a carcinogen, and red meat is probably a carcinogen to humans.2
This report was based on a review of the world’s body of human and laboratory research by an international working group of experts convened for the IARC Monographs Programme. Since 1971, the IARC Monographs Programme has specifically sought to evaluate the potential carcinogenic effects of a range of exposures – from specific chemicals, complex chemical mixtures, and occupational exposures to physical and biological agents – and lifestyle factors, including dietary factors.
Because of the growing evidence on the potential carcinogenic effects of processed meat and red meat intake, it was not surprising that in 2014, an IARC advisory committee recommended the evaluation of processed and red meat.
While the new report has generated considerable media attention, and many questions about whether or not it is safe to consume processed meat (for example, hot dogs, bacon, sausage, deli meats, etc.) and red meat (e.g., mammalian muscle meat such as beef, pork, and lamb), the working group’s conclusions were not unexpected.
Based on review of earlier studies, the American Cancer Society first recommended limiting consumption of red and processed meat in 20023 and has maintained this recommendation in its latest (2012) Guidelines on Nutrition and Physical Activity for Cancer Prevention.4
The conclusions also are consistent with the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) Continuous Update Project,5 which found the evidence “convincing” that diets high in red meat and processed meat are associated with increased risk of colorectal cancer.5 Moreover, the IARC conclusions support the United States 2015 Dietary Guidelines for Americans Advisory Committee’s recommendation to consume a healthful dietary pattern that is “lower in red and processed meat.”6
The classifications for both red and processed meats are based primarily on evidence showing an increased risk of colorectal cancer, the third most commonly diagnosed cancer among men and among women in the United States.
In the IARC report, it was noted that a meta-analysis of 10 prospective studies showed a statistically significant 18% (95% confidence interval, 1.10-1.28) increased risk of colorectal cancer per 50 g (about 1.75 ounces) per day of processed meat consumption, and a 17% (95% CI, 1.05-1.31) increased risk of colorectal cancer per 100 g (about 3.5 ounces) per day of red meat.7
In terms of lifetime risk, this means that eating an extra 50 g of processed meat per day would be expected to increase the average person’s risk of ever developing colorectal cancer from about 5% to about 6%. A similar excess risk would be observed for 100 g of red meat consumption.
While this increased risk is modest, for heavy meat eaters and for those at high risk of colorectal cancer, limiting processed and red meat consumption is one way to help reduce their risk of colorectal cancer.
Some mechanisms thought to be responsible include consumption of N-nitroso compounds formed during meat processing, and the endogenous formation of N-nitroso compounds in the gut, which can be catalyzed by heme iron in red meat. High-heat cooking methods such as pan frying or barbecuing produce high concentrations of known or suspected carcinogens, including heterocyclic amines and polycyclic aromatic hydrocarbons.8,9
The data for other cancers are more limited, but positive associations were also seen for processed meat consumption and stomach cancer, and for red meat and cancers of the pancreas and prostate (advanced prostate cancer in particular).2
It is worth keeping in mind that preventing smoking initiation and improving smoking cessation rates remain the most important ways to reduce cancer mortality rates worldwide. In addition, there is considerable evidence that other healthful lifestyle habits also are important for minimizing cancer risk, including limiting alcohol consumption, maintaining a healthy body weight throughout adulthood, being physically active, and consuming a mostly plant-based diet.
Our own research,10 using data from the Cancer Prevention Study II and that of others,11,12 has shown that a lifestyle most consistent with following the American Cancer Society’s Guidelines on Nutrition and Physical Activity for Cancer Prevention13 has marked impact on reducing the risk of developing many types of cancer, as well as dying from cancer, cardiovascular disease, and all causes.
In terms of meat consumption, the American Cancer Society’s guidelines emphasize choosing fish, poultry, or beans as alternatives to processed and red meat. For those who choose to eat red meat, selecting lean cuts and eating smaller portions are recommended.4 The guidelines also recommend preparing meat, poultry, and fish by baking, broiling, or poaching, rather than frying or charbroiling, to reduce the formation of carcinogens during the cooking process.
When discussing behavioral approaches to reduce cancer risk with their patients, physicians, dietitians, and other health care providers may find the WHO classification of processed meat as a carcinogen and red meat as a probable carcinogen helpful in motivating patients to make healthier dietary choices.
References
1. Public Health Nutr. 2011 Apr;14(4):575-83.
2. Lancet Oncol. 2015 Oct 26(doi:10.1016/S1470-2045(15)00444-1).
3. CA Cancer J Clin. 2002 Mar-Apr;52(2):92-119.
4. CA Cancer J Clin. 2012 Jan-Feb;62(1):30-67.
5. World Cancer Research Fund, American Institute for Cancer Research. Colorectal Cancer 2011 Continuous Update Project Report WCRF/AICR;2011.
6. 2015 Dietary Guidelines Scientific Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. USDA;2015.
7. PLoS One. 2011;6(6):e20456.
8. Meat Sci. 2014 Aug;97(4):583-96.
9. Nutr Res. 2013 Dec;33(12):983-94.
10. Cancer Epidemiol Biomarkers Prev. 2011 Jun;20(6):1089-97.
11. Cancer Prev Res (Phila). 2014 Jan;7(1):42-53.
12. Am J Clin Nutr. 2015 Mar;101(3):558-69.
13. CA Cancer J Clin. 2006 Sep-Oct;56(5):254-81; quiz 313-4.
Dr. Gapstur is the American Cancer Society’s vice president of epidemiology. Dr. McCullough is the American Cancer Society’s strategic director of nutritional epidemiology. Dr. McCullough attended the IARC evaluation as an observer.
It may have come as a surprise to the approximately 60% of Americans who consume red or processed meat that the International Agency for Research on Cancer (IARC), a part of the World Health Organization, recently reported that processed meat is a carcinogen, and red meat is probably a carcinogen to humans.2
This report was based on a review of the world’s body of human and laboratory research by an international working group of experts convened for the IARC Monographs Programme. Since 1971, the IARC Monographs Programme has specifically sought to evaluate the potential carcinogenic effects of a range of exposures – from specific chemicals, complex chemical mixtures, and occupational exposures to physical and biological agents – and lifestyle factors, including dietary factors.
Because of the growing evidence on the potential carcinogenic effects of processed meat and red meat intake, it was not surprising that in 2014, an IARC advisory committee recommended the evaluation of processed and red meat.
While the new report has generated considerable media attention, and many questions about whether or not it is safe to consume processed meat (for example, hot dogs, bacon, sausage, deli meats, etc.) and red meat (e.g., mammalian muscle meat such as beef, pork, and lamb), the working group’s conclusions were not unexpected.
Based on review of earlier studies, the American Cancer Society first recommended limiting consumption of red and processed meat in 20023 and has maintained this recommendation in its latest (2012) Guidelines on Nutrition and Physical Activity for Cancer Prevention.4
The conclusions also are consistent with the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) Continuous Update Project,5 which found the evidence “convincing” that diets high in red meat and processed meat are associated with increased risk of colorectal cancer.5 Moreover, the IARC conclusions support the United States 2015 Dietary Guidelines for Americans Advisory Committee’s recommendation to consume a healthful dietary pattern that is “lower in red and processed meat.”6
The classifications for both red and processed meats are based primarily on evidence showing an increased risk of colorectal cancer, the third most commonly diagnosed cancer among men and among women in the United States.
In the IARC report, it was noted that a meta-analysis of 10 prospective studies showed a statistically significant 18% (95% confidence interval, 1.10-1.28) increased risk of colorectal cancer per 50 g (about 1.75 ounces) per day of processed meat consumption, and a 17% (95% CI, 1.05-1.31) increased risk of colorectal cancer per 100 g (about 3.5 ounces) per day of red meat.7
In terms of lifetime risk, this means that eating an extra 50 g of processed meat per day would be expected to increase the average person’s risk of ever developing colorectal cancer from about 5% to about 6%. A similar excess risk would be observed for 100 g of red meat consumption.
While this increased risk is modest, for heavy meat eaters and for those at high risk of colorectal cancer, limiting processed and red meat consumption is one way to help reduce their risk of colorectal cancer.
Some mechanisms thought to be responsible include consumption of N-nitroso compounds formed during meat processing, and the endogenous formation of N-nitroso compounds in the gut, which can be catalyzed by heme iron in red meat. High-heat cooking methods such as pan frying or barbecuing produce high concentrations of known or suspected carcinogens, including heterocyclic amines and polycyclic aromatic hydrocarbons.8,9
The data for other cancers are more limited, but positive associations were also seen for processed meat consumption and stomach cancer, and for red meat and cancers of the pancreas and prostate (advanced prostate cancer in particular).2
It is worth keeping in mind that preventing smoking initiation and improving smoking cessation rates remain the most important ways to reduce cancer mortality rates worldwide. In addition, there is considerable evidence that other healthful lifestyle habits also are important for minimizing cancer risk, including limiting alcohol consumption, maintaining a healthy body weight throughout adulthood, being physically active, and consuming a mostly plant-based diet.
Our own research,10 using data from the Cancer Prevention Study II and that of others,11,12 has shown that a lifestyle most consistent with following the American Cancer Society’s Guidelines on Nutrition and Physical Activity for Cancer Prevention13 has marked impact on reducing the risk of developing many types of cancer, as well as dying from cancer, cardiovascular disease, and all causes.
In terms of meat consumption, the American Cancer Society’s guidelines emphasize choosing fish, poultry, or beans as alternatives to processed and red meat. For those who choose to eat red meat, selecting lean cuts and eating smaller portions are recommended.4 The guidelines also recommend preparing meat, poultry, and fish by baking, broiling, or poaching, rather than frying or charbroiling, to reduce the formation of carcinogens during the cooking process.
When discussing behavioral approaches to reduce cancer risk with their patients, physicians, dietitians, and other health care providers may find the WHO classification of processed meat as a carcinogen and red meat as a probable carcinogen helpful in motivating patients to make healthier dietary choices.
References
1. Public Health Nutr. 2011 Apr;14(4):575-83.
2. Lancet Oncol. 2015 Oct 26(doi:10.1016/S1470-2045(15)00444-1).
3. CA Cancer J Clin. 2002 Mar-Apr;52(2):92-119.
4. CA Cancer J Clin. 2012 Jan-Feb;62(1):30-67.
5. World Cancer Research Fund, American Institute for Cancer Research. Colorectal Cancer 2011 Continuous Update Project Report WCRF/AICR;2011.
6. 2015 Dietary Guidelines Scientific Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. USDA;2015.
7. PLoS One. 2011;6(6):e20456.
8. Meat Sci. 2014 Aug;97(4):583-96.
9. Nutr Res. 2013 Dec;33(12):983-94.
10. Cancer Epidemiol Biomarkers Prev. 2011 Jun;20(6):1089-97.
11. Cancer Prev Res (Phila). 2014 Jan;7(1):42-53.
12. Am J Clin Nutr. 2015 Mar;101(3):558-69.
13. CA Cancer J Clin. 2006 Sep-Oct;56(5):254-81; quiz 313-4.
Dr. Gapstur is the American Cancer Society’s vice president of epidemiology. Dr. McCullough is the American Cancer Society’s strategic director of nutritional epidemiology. Dr. McCullough attended the IARC evaluation as an observer.
It may have come as a surprise to the approximately 60% of Americans who consume red or processed meat that the International Agency for Research on Cancer (IARC), a part of the World Health Organization, recently reported that processed meat is a carcinogen, and red meat is probably a carcinogen to humans.2
This report was based on a review of the world’s body of human and laboratory research by an international working group of experts convened for the IARC Monographs Programme. Since 1971, the IARC Monographs Programme has specifically sought to evaluate the potential carcinogenic effects of a range of exposures – from specific chemicals, complex chemical mixtures, and occupational exposures to physical and biological agents – and lifestyle factors, including dietary factors.
Because of the growing evidence on the potential carcinogenic effects of processed meat and red meat intake, it was not surprising that in 2014, an IARC advisory committee recommended the evaluation of processed and red meat.
While the new report has generated considerable media attention, and many questions about whether or not it is safe to consume processed meat (for example, hot dogs, bacon, sausage, deli meats, etc.) and red meat (e.g., mammalian muscle meat such as beef, pork, and lamb), the working group’s conclusions were not unexpected.
Based on review of earlier studies, the American Cancer Society first recommended limiting consumption of red and processed meat in 20023 and has maintained this recommendation in its latest (2012) Guidelines on Nutrition and Physical Activity for Cancer Prevention.4
The conclusions also are consistent with the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) Continuous Update Project,5 which found the evidence “convincing” that diets high in red meat and processed meat are associated with increased risk of colorectal cancer.5 Moreover, the IARC conclusions support the United States 2015 Dietary Guidelines for Americans Advisory Committee’s recommendation to consume a healthful dietary pattern that is “lower in red and processed meat.”6
The classifications for both red and processed meats are based primarily on evidence showing an increased risk of colorectal cancer, the third most commonly diagnosed cancer among men and among women in the United States.
In the IARC report, it was noted that a meta-analysis of 10 prospective studies showed a statistically significant 18% (95% confidence interval, 1.10-1.28) increased risk of colorectal cancer per 50 g (about 1.75 ounces) per day of processed meat consumption, and a 17% (95% CI, 1.05-1.31) increased risk of colorectal cancer per 100 g (about 3.5 ounces) per day of red meat.7
In terms of lifetime risk, this means that eating an extra 50 g of processed meat per day would be expected to increase the average person’s risk of ever developing colorectal cancer from about 5% to about 6%. A similar excess risk would be observed for 100 g of red meat consumption.
While this increased risk is modest, for heavy meat eaters and for those at high risk of colorectal cancer, limiting processed and red meat consumption is one way to help reduce their risk of colorectal cancer.
Some mechanisms thought to be responsible include consumption of N-nitroso compounds formed during meat processing, and the endogenous formation of N-nitroso compounds in the gut, which can be catalyzed by heme iron in red meat. High-heat cooking methods such as pan frying or barbecuing produce high concentrations of known or suspected carcinogens, including heterocyclic amines and polycyclic aromatic hydrocarbons.8,9
The data for other cancers are more limited, but positive associations were also seen for processed meat consumption and stomach cancer, and for red meat and cancers of the pancreas and prostate (advanced prostate cancer in particular).2
It is worth keeping in mind that preventing smoking initiation and improving smoking cessation rates remain the most important ways to reduce cancer mortality rates worldwide. In addition, there is considerable evidence that other healthful lifestyle habits also are important for minimizing cancer risk, including limiting alcohol consumption, maintaining a healthy body weight throughout adulthood, being physically active, and consuming a mostly plant-based diet.
Our own research,10 using data from the Cancer Prevention Study II and that of others,11,12 has shown that a lifestyle most consistent with following the American Cancer Society’s Guidelines on Nutrition and Physical Activity for Cancer Prevention13 has marked impact on reducing the risk of developing many types of cancer, as well as dying from cancer, cardiovascular disease, and all causes.
In terms of meat consumption, the American Cancer Society’s guidelines emphasize choosing fish, poultry, or beans as alternatives to processed and red meat. For those who choose to eat red meat, selecting lean cuts and eating smaller portions are recommended.4 The guidelines also recommend preparing meat, poultry, and fish by baking, broiling, or poaching, rather than frying or charbroiling, to reduce the formation of carcinogens during the cooking process.
When discussing behavioral approaches to reduce cancer risk with their patients, physicians, dietitians, and other health care providers may find the WHO classification of processed meat as a carcinogen and red meat as a probable carcinogen helpful in motivating patients to make healthier dietary choices.
References
1. Public Health Nutr. 2011 Apr;14(4):575-83.
2. Lancet Oncol. 2015 Oct 26(doi:10.1016/S1470-2045(15)00444-1).
3. CA Cancer J Clin. 2002 Mar-Apr;52(2):92-119.
4. CA Cancer J Clin. 2012 Jan-Feb;62(1):30-67.
5. World Cancer Research Fund, American Institute for Cancer Research. Colorectal Cancer 2011 Continuous Update Project Report WCRF/AICR;2011.
6. 2015 Dietary Guidelines Scientific Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. USDA;2015.
7. PLoS One. 2011;6(6):e20456.
8. Meat Sci. 2014 Aug;97(4):583-96.
9. Nutr Res. 2013 Dec;33(12):983-94.
10. Cancer Epidemiol Biomarkers Prev. 2011 Jun;20(6):1089-97.
11. Cancer Prev Res (Phila). 2014 Jan;7(1):42-53.
12. Am J Clin Nutr. 2015 Mar;101(3):558-69.
13. CA Cancer J Clin. 2006 Sep-Oct;56(5):254-81; quiz 313-4.
Dr. Gapstur is the American Cancer Society’s vice president of epidemiology. Dr. McCullough is the American Cancer Society’s strategic director of nutritional epidemiology. Dr. McCullough attended the IARC evaluation as an observer.
Primum Non Nocere
In 1995, because of an inadvertent overdose of chemotherapy, a mother of two and beloved Boston Globe health reporter died.1 In 2001, an 18-month-old daughter and sister died of dehydration and an erroneously administered narcotic.2 In 2003, a father of two and award-winning producer for CBS died from a potentially deadly mix of drugs given with dangerous frequency.3
These are a mere representation of the number of medication errors that occur daily. In fact, on average, a hospitalized patient is subject to at least one medication error per day, which is a sobering statistic.1 These events and well-documented evidence of inadequate treatments have fueled research on prevention of medication errors—but those are but one component of the ongoing issue of patient safety in health care.
Patient safety has been on the agenda of the Institute of Medicine (IOM) for decades. Since the initial publication in 2000, the focus of To Err Is Human: Building a Safer Health System and the subsequent Quality Chasm series has been on how health care organizations emphasize patient safety, prevent medical errors, mitigate health care–associated infections and postoperative complications, and tackle breaches in safety when they occur. All these efforts concentrated primarily on medication-use processes, prescribing, packaging and education, and improving the “processes of care to ensure that patients are safe from accidental injury.”4 However, we have consistently overlooked another major problem in patient safety: diagnostic errors.
One aim of the Harvard Medical Practice Study I (1991) was developing contemporary and more reliable estimates of adverse events and negligence in hospitalized patients. The researchers defined negligence as “care that fell below the standard expected of physicians in their community.”5 In that study, the rate of adverse events due to negligence was 27.6%. In the subsequent Harvard Medical Practice Study II, researchers identified 1,276 adverse events and noted that 13.8% of them were the result of diagnostic errors.6 Further, in a systematic review of autopsy studies conducted over 40 years, data revealed that roughly 9% of subjects had a major health problem that went undetected while they were alive.6
The results of these studies are evidence that thousands of hospitalized patients die every year due to diagnostic errors. Despite data from autopsy and malpractice claims that identify diagnostic errors as preventable causes of morbidity and mortality, and the frequency with which misdiagnosis occurs, this matter has not received much consideration.7
In 2009, Newman-Toker and colleagues called attention to this oversight, recommending that diagnostic errors become the next focus of patient safety initiatives.7 Sadly, in a recent report from the IOM, we read that “most Americans will encounter at least one diagnostic error in their lifetime, sometimes with severe consequences for their physical and mental health.”8
And so we again turn our attention to improving how we deliver health care. The latest IOM report in the Quality Chasm series, Improving Diagnosis in Health Care, emphasizes the grave category of medical errors: errors of diagnosis, which include inaccurate or delayed diagnoses.8 We all know that correct and timely diagnosis is crucial to the ability to clarify a health problem, and it provides the basis for all decisions on how to solve that problem. While cure may not be possible in every situation, at the very least, our plan of care should not result in harm. What we also know is that we are members of a team, and it is within that team that we can take up the gauntlet of improving diagnosis and reducing the incidence of diagnostic errors.
The IOM Committee members who developed this report provided the following eight goals to achieve the outcome of improved diagnosis and reduced errors:
• Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families
• Enhance health care professional education and training in the diagnostic process
• Ensure that health information technologies support patients and health care professionals in the diagnostic process
• Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
• Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
• Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses
• Design a payment and care delivery environment that supports the diagnostic process
• Provide dedicated funding for research on the diagnostic process and diagnostic errors.8
NPs and PAs are integral to the success of this initiative. Our responsibility, as key stakeholders in our health care system, is to identify situations that might result in these types of errors and be proactive in mitigating them. Moreover, it is our professional and moral obligation to take an active, even a leadership, role in this critical endeavor.
Read the report (available at www.nap.edu/21794) and lead the charge in your setting. I am interested in how you think this initiative will evolve, and what role you will take in advancing it as a priority in your setting; let me know by writing to [email protected].
REFERENCES
1. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds; Committee on Identifying and Preventing Medication Errors, Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007:27.
2. Institute for Healthcare Improvement. What happened to Josie? www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx. Accessed October 5, 2015.
3. Andrzejczak OV. “60 Minutes” ace’s death echoes his own investigations. Houston Chronicle. July 30, 2009. www.chron.com/news/article/60-Minutes-ace-s-death-echoes-his-own-1747718.php. Accessed October 5, 2015.
4. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients—results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-376.
6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients—results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324: 377-384.
7. Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301(10):1060-1062.
8. Balogh EP, Miller BT, Ball JR, eds; Committee on Diagnostic Error in Health Care, Institute of Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015.
In 1995, because of an inadvertent overdose of chemotherapy, a mother of two and beloved Boston Globe health reporter died.1 In 2001, an 18-month-old daughter and sister died of dehydration and an erroneously administered narcotic.2 In 2003, a father of two and award-winning producer for CBS died from a potentially deadly mix of drugs given with dangerous frequency.3
These are a mere representation of the number of medication errors that occur daily. In fact, on average, a hospitalized patient is subject to at least one medication error per day, which is a sobering statistic.1 These events and well-documented evidence of inadequate treatments have fueled research on prevention of medication errors—but those are but one component of the ongoing issue of patient safety in health care.
Patient safety has been on the agenda of the Institute of Medicine (IOM) for decades. Since the initial publication in 2000, the focus of To Err Is Human: Building a Safer Health System and the subsequent Quality Chasm series has been on how health care organizations emphasize patient safety, prevent medical errors, mitigate health care–associated infections and postoperative complications, and tackle breaches in safety when they occur. All these efforts concentrated primarily on medication-use processes, prescribing, packaging and education, and improving the “processes of care to ensure that patients are safe from accidental injury.”4 However, we have consistently overlooked another major problem in patient safety: diagnostic errors.
One aim of the Harvard Medical Practice Study I (1991) was developing contemporary and more reliable estimates of adverse events and negligence in hospitalized patients. The researchers defined negligence as “care that fell below the standard expected of physicians in their community.”5 In that study, the rate of adverse events due to negligence was 27.6%. In the subsequent Harvard Medical Practice Study II, researchers identified 1,276 adverse events and noted that 13.8% of them were the result of diagnostic errors.6 Further, in a systematic review of autopsy studies conducted over 40 years, data revealed that roughly 9% of subjects had a major health problem that went undetected while they were alive.6
The results of these studies are evidence that thousands of hospitalized patients die every year due to diagnostic errors. Despite data from autopsy and malpractice claims that identify diagnostic errors as preventable causes of morbidity and mortality, and the frequency with which misdiagnosis occurs, this matter has not received much consideration.7
In 2009, Newman-Toker and colleagues called attention to this oversight, recommending that diagnostic errors become the next focus of patient safety initiatives.7 Sadly, in a recent report from the IOM, we read that “most Americans will encounter at least one diagnostic error in their lifetime, sometimes with severe consequences for their physical and mental health.”8
And so we again turn our attention to improving how we deliver health care. The latest IOM report in the Quality Chasm series, Improving Diagnosis in Health Care, emphasizes the grave category of medical errors: errors of diagnosis, which include inaccurate or delayed diagnoses.8 We all know that correct and timely diagnosis is crucial to the ability to clarify a health problem, and it provides the basis for all decisions on how to solve that problem. While cure may not be possible in every situation, at the very least, our plan of care should not result in harm. What we also know is that we are members of a team, and it is within that team that we can take up the gauntlet of improving diagnosis and reducing the incidence of diagnostic errors.
The IOM Committee members who developed this report provided the following eight goals to achieve the outcome of improved diagnosis and reduced errors:
• Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families
• Enhance health care professional education and training in the diagnostic process
• Ensure that health information technologies support patients and health care professionals in the diagnostic process
• Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
• Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
• Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses
• Design a payment and care delivery environment that supports the diagnostic process
• Provide dedicated funding for research on the diagnostic process and diagnostic errors.8
NPs and PAs are integral to the success of this initiative. Our responsibility, as key stakeholders in our health care system, is to identify situations that might result in these types of errors and be proactive in mitigating them. Moreover, it is our professional and moral obligation to take an active, even a leadership, role in this critical endeavor.
Read the report (available at www.nap.edu/21794) and lead the charge in your setting. I am interested in how you think this initiative will evolve, and what role you will take in advancing it as a priority in your setting; let me know by writing to [email protected].
REFERENCES
1. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds; Committee on Identifying and Preventing Medication Errors, Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007:27.
2. Institute for Healthcare Improvement. What happened to Josie? www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx. Accessed October 5, 2015.
3. Andrzejczak OV. “60 Minutes” ace’s death echoes his own investigations. Houston Chronicle. July 30, 2009. www.chron.com/news/article/60-Minutes-ace-s-death-echoes-his-own-1747718.php. Accessed October 5, 2015.
4. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients—results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-376.
6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients—results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324: 377-384.
7. Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301(10):1060-1062.
8. Balogh EP, Miller BT, Ball JR, eds; Committee on Diagnostic Error in Health Care, Institute of Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015.
In 1995, because of an inadvertent overdose of chemotherapy, a mother of two and beloved Boston Globe health reporter died.1 In 2001, an 18-month-old daughter and sister died of dehydration and an erroneously administered narcotic.2 In 2003, a father of two and award-winning producer for CBS died from a potentially deadly mix of drugs given with dangerous frequency.3
These are a mere representation of the number of medication errors that occur daily. In fact, on average, a hospitalized patient is subject to at least one medication error per day, which is a sobering statistic.1 These events and well-documented evidence of inadequate treatments have fueled research on prevention of medication errors—but those are but one component of the ongoing issue of patient safety in health care.
Patient safety has been on the agenda of the Institute of Medicine (IOM) for decades. Since the initial publication in 2000, the focus of To Err Is Human: Building a Safer Health System and the subsequent Quality Chasm series has been on how health care organizations emphasize patient safety, prevent medical errors, mitigate health care–associated infections and postoperative complications, and tackle breaches in safety when they occur. All these efforts concentrated primarily on medication-use processes, prescribing, packaging and education, and improving the “processes of care to ensure that patients are safe from accidental injury.”4 However, we have consistently overlooked another major problem in patient safety: diagnostic errors.
One aim of the Harvard Medical Practice Study I (1991) was developing contemporary and more reliable estimates of adverse events and negligence in hospitalized patients. The researchers defined negligence as “care that fell below the standard expected of physicians in their community.”5 In that study, the rate of adverse events due to negligence was 27.6%. In the subsequent Harvard Medical Practice Study II, researchers identified 1,276 adverse events and noted that 13.8% of them were the result of diagnostic errors.6 Further, in a systematic review of autopsy studies conducted over 40 years, data revealed that roughly 9% of subjects had a major health problem that went undetected while they were alive.6
The results of these studies are evidence that thousands of hospitalized patients die every year due to diagnostic errors. Despite data from autopsy and malpractice claims that identify diagnostic errors as preventable causes of morbidity and mortality, and the frequency with which misdiagnosis occurs, this matter has not received much consideration.7
In 2009, Newman-Toker and colleagues called attention to this oversight, recommending that diagnostic errors become the next focus of patient safety initiatives.7 Sadly, in a recent report from the IOM, we read that “most Americans will encounter at least one diagnostic error in their lifetime, sometimes with severe consequences for their physical and mental health.”8
And so we again turn our attention to improving how we deliver health care. The latest IOM report in the Quality Chasm series, Improving Diagnosis in Health Care, emphasizes the grave category of medical errors: errors of diagnosis, which include inaccurate or delayed diagnoses.8 We all know that correct and timely diagnosis is crucial to the ability to clarify a health problem, and it provides the basis for all decisions on how to solve that problem. While cure may not be possible in every situation, at the very least, our plan of care should not result in harm. What we also know is that we are members of a team, and it is within that team that we can take up the gauntlet of improving diagnosis and reducing the incidence of diagnostic errors.
The IOM Committee members who developed this report provided the following eight goals to achieve the outcome of improved diagnosis and reduced errors:
• Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families
• Enhance health care professional education and training in the diagnostic process
• Ensure that health information technologies support patients and health care professionals in the diagnostic process
• Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
• Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
• Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses
• Design a payment and care delivery environment that supports the diagnostic process
• Provide dedicated funding for research on the diagnostic process and diagnostic errors.8
NPs and PAs are integral to the success of this initiative. Our responsibility, as key stakeholders in our health care system, is to identify situations that might result in these types of errors and be proactive in mitigating them. Moreover, it is our professional and moral obligation to take an active, even a leadership, role in this critical endeavor.
Read the report (available at www.nap.edu/21794) and lead the charge in your setting. I am interested in how you think this initiative will evolve, and what role you will take in advancing it as a priority in your setting; let me know by writing to [email protected].
REFERENCES
1. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds; Committee on Identifying and Preventing Medication Errors, Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007:27.
2. Institute for Healthcare Improvement. What happened to Josie? www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx. Accessed October 5, 2015.
3. Andrzejczak OV. “60 Minutes” ace’s death echoes his own investigations. Houston Chronicle. July 30, 2009. www.chron.com/news/article/60-Minutes-ace-s-death-echoes-his-own-1747718.php. Accessed October 5, 2015.
4. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients—results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-376.
6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients—results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324: 377-384.
7. Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301(10):1060-1062.
8. Balogh EP, Miller BT, Ball JR, eds; Committee on Diagnostic Error in Health Care, Institute of Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015.
Time or content?
In May 2015, the American Academy of Pediatrics convened an invitation-only symposium titled Growing Up Digital. Its goal was to reconsider the Academy’s advice on “screen time” and make sure that its policies were “science-driven, not based merely on the precautionary principle.” (“Beyond ‘turn it off’: How to advice families on media use,” Brown et al. AAP News, October 2015). Driven by the concern that the current AAP advice was becoming obsolete and as a result likely to be ignored by parents faced with the realities of our digital culture, the participants investigated the available data on “early learning, game-based learning, social/emotional and developmental concerns, and strategies to foster digital citizenship.”
Their findings have been distilled into a collection of “key messages” for parents published in the October, 2015 AAP News. It’s hard to argue with most of the common sense advice that includes “Role modeling is critical; playtime is important; co-engagement counts; set limits; and create tech-free zones.” A set of formal recommendations is in the works and will be published at a later date.
It is comforting to learn of the academy’s concern to keep its advice current and evidence-based. It is frustrating for those of us expected to deliver the party line when we suspect that parents are muttering to themselves, “Really?” I assume that most pediatricians at the parent/doctor interface will join me in welcoming much of the more nuanced advice in the final recommendations, particularly those for older children and adolescents.
However, if the new document is not carefully worded and promoted, I fear that the potent message of “no screen time under age 2” will be lost or diluted. While the symposium participants may have uncovered some evidence of benefit or at least no serious harm from some digital platforms, does this warrant softening the catchy and clear advice of “no screen time under 2?” I have to ask myself when would a child under the age of 2 being raised in a healthy environment have time for electronic distraction?
As Dr. Ari Brown, Dr. Donald L. Shifrin, and Dr. David L. Hill ask parents in their AAP News piece, “Does your child’s technology use help or hinder participation in other activities?” Just doing a little quick math: Wake up at 7 a.m., breakfast, playground time, maybe a midmorning nap, snack, lunch, afternoon nap, afternoon playground time, maybe another snack, dinner, bedtime story and lights out at 7 p.m. I don’t see a spot to shoehorn in some screen time without eliminating a developmentally and socially important activity. You could replace the hard cover book at bedtime with an electronic one on a tablet, but in my experience that runs the risk of replacing a soporific activity with one that is too visually stimulating.
One could argue that depriving a young child of screen time is going to put him behind his peers who have become masterful web navigators by the time they are 18 months. Rubbish. The learning curve for most electronic devices is so short that the “deprived” child will catch up in a couple of dozen clicks. However, screens require little more than a moving and tapping index finger. What about those other manipulative skills and the strength and coordination of the muscles sitting unused during screen time?
Unfortunately, the crafters of these new guidelines have repeated the same mistake the academy has made before when they observe, “The quality of the content is more important than the platform or time spent with media.” In my opinion, if the time spent on a screen is kept sufficiently short, children won’t squander it on bad stuff for very long nor will what they see be that harmful. Burdening parents with the task of determining quality is unrealistic. However, setting a time limit is far more workable and enforceable.
Finally, when it comes to parents enforcing no screen time under 2, everyone knows that Skyping with Grandma and Grandpa gets a free pass.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].
In May 2015, the American Academy of Pediatrics convened an invitation-only symposium titled Growing Up Digital. Its goal was to reconsider the Academy’s advice on “screen time” and make sure that its policies were “science-driven, not based merely on the precautionary principle.” (“Beyond ‘turn it off’: How to advice families on media use,” Brown et al. AAP News, October 2015). Driven by the concern that the current AAP advice was becoming obsolete and as a result likely to be ignored by parents faced with the realities of our digital culture, the participants investigated the available data on “early learning, game-based learning, social/emotional and developmental concerns, and strategies to foster digital citizenship.”
Their findings have been distilled into a collection of “key messages” for parents published in the October, 2015 AAP News. It’s hard to argue with most of the common sense advice that includes “Role modeling is critical; playtime is important; co-engagement counts; set limits; and create tech-free zones.” A set of formal recommendations is in the works and will be published at a later date.
It is comforting to learn of the academy’s concern to keep its advice current and evidence-based. It is frustrating for those of us expected to deliver the party line when we suspect that parents are muttering to themselves, “Really?” I assume that most pediatricians at the parent/doctor interface will join me in welcoming much of the more nuanced advice in the final recommendations, particularly those for older children and adolescents.
However, if the new document is not carefully worded and promoted, I fear that the potent message of “no screen time under age 2” will be lost or diluted. While the symposium participants may have uncovered some evidence of benefit or at least no serious harm from some digital platforms, does this warrant softening the catchy and clear advice of “no screen time under 2?” I have to ask myself when would a child under the age of 2 being raised in a healthy environment have time for electronic distraction?
As Dr. Ari Brown, Dr. Donald L. Shifrin, and Dr. David L. Hill ask parents in their AAP News piece, “Does your child’s technology use help or hinder participation in other activities?” Just doing a little quick math: Wake up at 7 a.m., breakfast, playground time, maybe a midmorning nap, snack, lunch, afternoon nap, afternoon playground time, maybe another snack, dinner, bedtime story and lights out at 7 p.m. I don’t see a spot to shoehorn in some screen time without eliminating a developmentally and socially important activity. You could replace the hard cover book at bedtime with an electronic one on a tablet, but in my experience that runs the risk of replacing a soporific activity with one that is too visually stimulating.
One could argue that depriving a young child of screen time is going to put him behind his peers who have become masterful web navigators by the time they are 18 months. Rubbish. The learning curve for most electronic devices is so short that the “deprived” child will catch up in a couple of dozen clicks. However, screens require little more than a moving and tapping index finger. What about those other manipulative skills and the strength and coordination of the muscles sitting unused during screen time?
Unfortunately, the crafters of these new guidelines have repeated the same mistake the academy has made before when they observe, “The quality of the content is more important than the platform or time spent with media.” In my opinion, if the time spent on a screen is kept sufficiently short, children won’t squander it on bad stuff for very long nor will what they see be that harmful. Burdening parents with the task of determining quality is unrealistic. However, setting a time limit is far more workable and enforceable.
Finally, when it comes to parents enforcing no screen time under 2, everyone knows that Skyping with Grandma and Grandpa gets a free pass.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].
In May 2015, the American Academy of Pediatrics convened an invitation-only symposium titled Growing Up Digital. Its goal was to reconsider the Academy’s advice on “screen time” and make sure that its policies were “science-driven, not based merely on the precautionary principle.” (“Beyond ‘turn it off’: How to advice families on media use,” Brown et al. AAP News, October 2015). Driven by the concern that the current AAP advice was becoming obsolete and as a result likely to be ignored by parents faced with the realities of our digital culture, the participants investigated the available data on “early learning, game-based learning, social/emotional and developmental concerns, and strategies to foster digital citizenship.”
Their findings have been distilled into a collection of “key messages” for parents published in the October, 2015 AAP News. It’s hard to argue with most of the common sense advice that includes “Role modeling is critical; playtime is important; co-engagement counts; set limits; and create tech-free zones.” A set of formal recommendations is in the works and will be published at a later date.
It is comforting to learn of the academy’s concern to keep its advice current and evidence-based. It is frustrating for those of us expected to deliver the party line when we suspect that parents are muttering to themselves, “Really?” I assume that most pediatricians at the parent/doctor interface will join me in welcoming much of the more nuanced advice in the final recommendations, particularly those for older children and adolescents.
However, if the new document is not carefully worded and promoted, I fear that the potent message of “no screen time under age 2” will be lost or diluted. While the symposium participants may have uncovered some evidence of benefit or at least no serious harm from some digital platforms, does this warrant softening the catchy and clear advice of “no screen time under 2?” I have to ask myself when would a child under the age of 2 being raised in a healthy environment have time for electronic distraction?
As Dr. Ari Brown, Dr. Donald L. Shifrin, and Dr. David L. Hill ask parents in their AAP News piece, “Does your child’s technology use help or hinder participation in other activities?” Just doing a little quick math: Wake up at 7 a.m., breakfast, playground time, maybe a midmorning nap, snack, lunch, afternoon nap, afternoon playground time, maybe another snack, dinner, bedtime story and lights out at 7 p.m. I don’t see a spot to shoehorn in some screen time without eliminating a developmentally and socially important activity. You could replace the hard cover book at bedtime with an electronic one on a tablet, but in my experience that runs the risk of replacing a soporific activity with one that is too visually stimulating.
One could argue that depriving a young child of screen time is going to put him behind his peers who have become masterful web navigators by the time they are 18 months. Rubbish. The learning curve for most electronic devices is so short that the “deprived” child will catch up in a couple of dozen clicks. However, screens require little more than a moving and tapping index finger. What about those other manipulative skills and the strength and coordination of the muscles sitting unused during screen time?
Unfortunately, the crafters of these new guidelines have repeated the same mistake the academy has made before when they observe, “The quality of the content is more important than the platform or time spent with media.” In my opinion, if the time spent on a screen is kept sufficiently short, children won’t squander it on bad stuff for very long nor will what they see be that harmful. Burdening parents with the task of determining quality is unrealistic. However, setting a time limit is far more workable and enforceable.
Finally, when it comes to parents enforcing no screen time under 2, everyone knows that Skyping with Grandma and Grandpa gets a free pass.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].
What does the evidence really say about acupuncture for IBS?
Dr. Hickner’s conclusion from his editorial, “The mainstreaming of alternative therapies” (J Fam Pract. 2015;64:451) that acupuncture “can relieve symptoms” of irritable bowel syndrome (IBS) is not based on “solid evidence.” I read the same abstract from the Cochrane database on acupuncture for IBS that he cited in his editorial but came to a different conclusion.
According to the Cochrane authors’ conclusions, “Sham-controlled RCTs have found no benefits of acupuncture…for IBS symptom severity or IBS-related quality of life.” The authors noted a risk of “high” bias in all of the other studies in the Cochrane database. This important caveat should serve as a caution to any physician seeking to draw a conclusion from those other studies.
Paul D. Fuchs, MD
Laurel Hill, NC
Author’s response:
Dr. Fuchs is right in calling me to task on this particular meta-analysis. I based my comment on the finding that acupuncture was better than 2 pharmacologic therapies that have shown benefit for patients with IBS, but the quality of the studies was not high, as Dr. Fuchs points out.
John Hickner, MD, MSc
Editor-in-chief, The Journal of Family Practice
Dr. Hickner’s conclusion from his editorial, “The mainstreaming of alternative therapies” (J Fam Pract. 2015;64:451) that acupuncture “can relieve symptoms” of irritable bowel syndrome (IBS) is not based on “solid evidence.” I read the same abstract from the Cochrane database on acupuncture for IBS that he cited in his editorial but came to a different conclusion.
According to the Cochrane authors’ conclusions, “Sham-controlled RCTs have found no benefits of acupuncture…for IBS symptom severity or IBS-related quality of life.” The authors noted a risk of “high” bias in all of the other studies in the Cochrane database. This important caveat should serve as a caution to any physician seeking to draw a conclusion from those other studies.
Paul D. Fuchs, MD
Laurel Hill, NC
Author’s response:
Dr. Fuchs is right in calling me to task on this particular meta-analysis. I based my comment on the finding that acupuncture was better than 2 pharmacologic therapies that have shown benefit for patients with IBS, but the quality of the studies was not high, as Dr. Fuchs points out.
John Hickner, MD, MSc
Editor-in-chief, The Journal of Family Practice
Dr. Hickner’s conclusion from his editorial, “The mainstreaming of alternative therapies” (J Fam Pract. 2015;64:451) that acupuncture “can relieve symptoms” of irritable bowel syndrome (IBS) is not based on “solid evidence.” I read the same abstract from the Cochrane database on acupuncture for IBS that he cited in his editorial but came to a different conclusion.
According to the Cochrane authors’ conclusions, “Sham-controlled RCTs have found no benefits of acupuncture…for IBS symptom severity or IBS-related quality of life.” The authors noted a risk of “high” bias in all of the other studies in the Cochrane database. This important caveat should serve as a caution to any physician seeking to draw a conclusion from those other studies.
Paul D. Fuchs, MD
Laurel Hill, NC
Author’s response:
Dr. Fuchs is right in calling me to task on this particular meta-analysis. I based my comment on the finding that acupuncture was better than 2 pharmacologic therapies that have shown benefit for patients with IBS, but the quality of the studies was not high, as Dr. Fuchs points out.
John Hickner, MD, MSc
Editor-in-chief, The Journal of Family Practice
Sizing up EMRs and patient care from the other side of the bed rail
Dr. Unger’s guest editorial, “Med students: Look up from your EMRs” (J Fam Pract. 2015;64:517-518), vividly describes what those who have been paying attention see quite clearly: Not only has the widespread implementation of electronic medical records (EMRs) failed to deliver all it has promised, but it has made patient care worse. Many students and members of the health care team spend as little time as possible talking and listening to patients. Instead, the goal is to complete every box in our EMRs to qualify for meaningful use payments and whatever “quality” incentives are available in our local environment.
That said, I believe EMRs are very good at doing the things computers do well, and I hope I never again have to rifle through a paper chart the size of a phone book to find a critical piece of information. The problem lies in the myriad inappropriate ways the EMR is used in place of accurately telling the patient’s story, and the resulting diversion of the entire health care team away from caring for the patients we are supposedly here to serve.
I am tired of complaining to my patients, partners, family, friends, and anyone else who will listen. It is time for family medicine to reclaim its role as “counterculture” and lead the charge for comprehensive, continuous, compassionate care—whose centerpiece is actually talking to, listening to, and examining patients.
David A. Silverstein, MD
Buffalo, NY
While I agree with Dr. Unger about EMRs, I respectfully disagree with his approach when he suspected he had appendicitis. When he initially ordered his own computed tomography scan, rather than seeing his own doctor or going to the emergency department, he (inadvertently) “assigned” himself as his own doctor. He then should have at least offered his history in the hospital, rather than making it a test for the student and the hospital. It sounds like an adversarial situation developed, which did not help matters. Good that he’s doing OK!
Michael Kelly, MD
Minneapolis, Minn
Dr. Unger’s guest editorial, “Med students: Look up from your EMRs” (J Fam Pract. 2015;64:517-518), vividly describes what those who have been paying attention see quite clearly: Not only has the widespread implementation of electronic medical records (EMRs) failed to deliver all it has promised, but it has made patient care worse. Many students and members of the health care team spend as little time as possible talking and listening to patients. Instead, the goal is to complete every box in our EMRs to qualify for meaningful use payments and whatever “quality” incentives are available in our local environment.
That said, I believe EMRs are very good at doing the things computers do well, and I hope I never again have to rifle through a paper chart the size of a phone book to find a critical piece of information. The problem lies in the myriad inappropriate ways the EMR is used in place of accurately telling the patient’s story, and the resulting diversion of the entire health care team away from caring for the patients we are supposedly here to serve.
I am tired of complaining to my patients, partners, family, friends, and anyone else who will listen. It is time for family medicine to reclaim its role as “counterculture” and lead the charge for comprehensive, continuous, compassionate care—whose centerpiece is actually talking to, listening to, and examining patients.
David A. Silverstein, MD
Buffalo, NY
While I agree with Dr. Unger about EMRs, I respectfully disagree with his approach when he suspected he had appendicitis. When he initially ordered his own computed tomography scan, rather than seeing his own doctor or going to the emergency department, he (inadvertently) “assigned” himself as his own doctor. He then should have at least offered his history in the hospital, rather than making it a test for the student and the hospital. It sounds like an adversarial situation developed, which did not help matters. Good that he’s doing OK!
Michael Kelly, MD
Minneapolis, Minn
Dr. Unger’s guest editorial, “Med students: Look up from your EMRs” (J Fam Pract. 2015;64:517-518), vividly describes what those who have been paying attention see quite clearly: Not only has the widespread implementation of electronic medical records (EMRs) failed to deliver all it has promised, but it has made patient care worse. Many students and members of the health care team spend as little time as possible talking and listening to patients. Instead, the goal is to complete every box in our EMRs to qualify for meaningful use payments and whatever “quality” incentives are available in our local environment.
That said, I believe EMRs are very good at doing the things computers do well, and I hope I never again have to rifle through a paper chart the size of a phone book to find a critical piece of information. The problem lies in the myriad inappropriate ways the EMR is used in place of accurately telling the patient’s story, and the resulting diversion of the entire health care team away from caring for the patients we are supposedly here to serve.
I am tired of complaining to my patients, partners, family, friends, and anyone else who will listen. It is time for family medicine to reclaim its role as “counterculture” and lead the charge for comprehensive, continuous, compassionate care—whose centerpiece is actually talking to, listening to, and examining patients.
David A. Silverstein, MD
Buffalo, NY
While I agree with Dr. Unger about EMRs, I respectfully disagree with his approach when he suspected he had appendicitis. When he initially ordered his own computed tomography scan, rather than seeing his own doctor or going to the emergency department, he (inadvertently) “assigned” himself as his own doctor. He then should have at least offered his history in the hospital, rather than making it a test for the student and the hospital. It sounds like an adversarial situation developed, which did not help matters. Good that he’s doing OK!
Michael Kelly, MD
Minneapolis, Minn
Seeing eye to eye
It seems like every time I ask a family physician how things are going, the electronic medical record (EMR) inevitably rears its ugly face. At the annual Illinois Academy of Family Physicians business meeting last month, one of the physicians lamented the evenings he spends finishing his charting. A family physician I consider a master user of EMRs e-mailed me recently, saying he is fed up with documentation expectations for coding, billing, meaningful use, and quality measures. He wrote, “We are challenged by good intentions but crushingly poor execution … and it is taking its toll.”
At the 2015 American Academy of Family Physicians Family Medicine Expo, keynote speaker, general internist, and bestselling author Abraham Verghese, MD, talked about the “iPatient.” He said, “The patient in the bed has become a mere icon for the ‘real patient’ who is in the computer. The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on.”
He had received this comment from a patient: “When I go to my doctor’s office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen.”
Patients don’t like us attending to the screen instead of to them. The observational study of 126 primary care encounters by Farber et al in this issue supports this assertion. Although Farber et al found that patients’ satisfaction with their primary care physician or nurse practitioner was high overall, patients were even more satisfied with their office visit when the clinician spent more time looking at them. Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.
Until clever innovators figure out a much better way to document patient visits, there are ways to overcome this patient-physician-computer screen triangle. Take my optometrist, for example. He opens my EMR at the beginning of the visit to take a quick look, but doesn’t return to the computer until the end of the visit. When he does the charting, he excuses himself and says, “I need to enter some information in the computer. It will take me a few minutes.” I pull out my cell phone to check e-mails while he types.
I follow his example, and patients regularly thank me for truly listening to them.
It seems like every time I ask a family physician how things are going, the electronic medical record (EMR) inevitably rears its ugly face. At the annual Illinois Academy of Family Physicians business meeting last month, one of the physicians lamented the evenings he spends finishing his charting. A family physician I consider a master user of EMRs e-mailed me recently, saying he is fed up with documentation expectations for coding, billing, meaningful use, and quality measures. He wrote, “We are challenged by good intentions but crushingly poor execution … and it is taking its toll.”
At the 2015 American Academy of Family Physicians Family Medicine Expo, keynote speaker, general internist, and bestselling author Abraham Verghese, MD, talked about the “iPatient.” He said, “The patient in the bed has become a mere icon for the ‘real patient’ who is in the computer. The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on.”
He had received this comment from a patient: “When I go to my doctor’s office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen.”
Patients don’t like us attending to the screen instead of to them. The observational study of 126 primary care encounters by Farber et al in this issue supports this assertion. Although Farber et al found that patients’ satisfaction with their primary care physician or nurse practitioner was high overall, patients were even more satisfied with their office visit when the clinician spent more time looking at them. Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.
Until clever innovators figure out a much better way to document patient visits, there are ways to overcome this patient-physician-computer screen triangle. Take my optometrist, for example. He opens my EMR at the beginning of the visit to take a quick look, but doesn’t return to the computer until the end of the visit. When he does the charting, he excuses himself and says, “I need to enter some information in the computer. It will take me a few minutes.” I pull out my cell phone to check e-mails while he types.
I follow his example, and patients regularly thank me for truly listening to them.
It seems like every time I ask a family physician how things are going, the electronic medical record (EMR) inevitably rears its ugly face. At the annual Illinois Academy of Family Physicians business meeting last month, one of the physicians lamented the evenings he spends finishing his charting. A family physician I consider a master user of EMRs e-mailed me recently, saying he is fed up with documentation expectations for coding, billing, meaningful use, and quality measures. He wrote, “We are challenged by good intentions but crushingly poor execution … and it is taking its toll.”
At the 2015 American Academy of Family Physicians Family Medicine Expo, keynote speaker, general internist, and bestselling author Abraham Verghese, MD, talked about the “iPatient.” He said, “The patient in the bed has become a mere icon for the ‘real patient’ who is in the computer. The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on.”
He had received this comment from a patient: “When I go to my doctor’s office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen.”
Patients don’t like us attending to the screen instead of to them. The observational study of 126 primary care encounters by Farber et al in this issue supports this assertion. Although Farber et al found that patients’ satisfaction with their primary care physician or nurse practitioner was high overall, patients were even more satisfied with their office visit when the clinician spent more time looking at them. Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.
Until clever innovators figure out a much better way to document patient visits, there are ways to overcome this patient-physician-computer screen triangle. Take my optometrist, for example. He opens my EMR at the beginning of the visit to take a quick look, but doesn’t return to the computer until the end of the visit. When he does the charting, he excuses himself and says, “I need to enter some information in the computer. It will take me a few minutes.” I pull out my cell phone to check e-mails while he types.
I follow his example, and patients regularly thank me for truly listening to them.
“Best ED”- News You Can Use*?
Among the many organizations that rate hospitals and medical care—CMS, JCAHO, and Consumer Reports, to name a few—one that has captured the public’s attention since 1990 is the US News & World Report (USNWR) annual list of best hospitals, which includes its “honor roll” of the 15 very best. Yet, emergency medicine (EM) has never been included among the ranked specialties, raising the question, should the “best hospitals” have the best EDs?
Formerly a weekly newsmagazine and now web-based, USNWR still publishes print editions of its popular annual best colleges and best hospitals listings. Widely read and widely reported in other media, the lists appear to resonate strongly with the public, as well as with college and hospital administrators. But what exactly is meant by best? In a press release accompanying its 2015-16 best hospitals list, USNWR describes the purpose of the list as “designed to help patients with life threatening or rare conditions identify hospitals that excel in treating the most difficult cases,” and its honor roll as a list that “highlights hospitals that are exceptional in 16 specialties” (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals). Specialties not included, in addition to EM, are internal medicine and surgery, which are represented by subspecialties, or service lines. The ranked list includes cardiology and heart surgery; diabetes and endocrinology; gastroenterology and GI surgery; geriatrics; nephrology; neurology and neurosurgery; pulmonology; rheumatology; and urology. Presumably, like medicine and surgery, EM is too all-encompassing a discipline, but unlike the case for the other two specialties, the need for emergency care in most locations does not allow patients to select the “best” facility for their acute problem. Nevertheless, it is interesting to speculate about the effect inclusion of EM would have on the elite institutions vying for honor roll status, as well as on EM itself.
A July 15, 2015 report on USNWR methodology (http://www.usnews.com/pubfiles/BH2015-16MethodologyReport.pdf) (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals) notes that rankings in 12 of the 16 specialties are based on data-driven analyses of volume; technology and other resources (derived principally from the American Hospital Association annual survey); reputation for developing and sustaining the delivery of high-quality care (derived from surveyed physicians); and outcomes-based mostly on CMS risk-adjusted mortality figures. Rankings in the remaining four specialties are based solely on physician surveys of hospital reputation. Hospitals eligible for inclusion on the best hospitals list must either be teaching hospitals, be affiliated with medical schools, or, generally, have 200 or more beds.
Most, if not all, of these criteria can be applied to ranking EDs, but would doing so provide a valid assessment of the best EDs, and if so, to what end? The first question is too complicated to answer here. As for the second, many have argued that the “best ED” isn’t a relevant concept, considering that standards of emergency care demanded of every ED and emergency physician by ABEM, ACEP, ABMS, JCAHO, and more recently, CMS, have been promulgated and implemented nationwide for over three-and-a-half decades. But for the select few hospitals competing for the title of “best,” inclusion of EM among ranked specialties would send a very powerful message and require increased resources to achieve and maintain top standing. Even if EM is not ranked as a discrete specialty, many of the features of a “best ED” can and should be included. Currently, hospitals receive 1 point for being a state-certified, level 1 or level 2 trauma center. Points for other ED “center” designations could also be applied to a hospital’s overall score.
In any case, should USNWR include EM in future best hospitals listings, perhaps many of the measures that will be taken by hospitals to claim the title of “best ED” could subsequently become standard operating procedure for all EDs. So, let the games begin.
*“News You Can Use” is a column that ran in USNWR beginning in 1952.
Among the many organizations that rate hospitals and medical care—CMS, JCAHO, and Consumer Reports, to name a few—one that has captured the public’s attention since 1990 is the US News & World Report (USNWR) annual list of best hospitals, which includes its “honor roll” of the 15 very best. Yet, emergency medicine (EM) has never been included among the ranked specialties, raising the question, should the “best hospitals” have the best EDs?
Formerly a weekly newsmagazine and now web-based, USNWR still publishes print editions of its popular annual best colleges and best hospitals listings. Widely read and widely reported in other media, the lists appear to resonate strongly with the public, as well as with college and hospital administrators. But what exactly is meant by best? In a press release accompanying its 2015-16 best hospitals list, USNWR describes the purpose of the list as “designed to help patients with life threatening or rare conditions identify hospitals that excel in treating the most difficult cases,” and its honor roll as a list that “highlights hospitals that are exceptional in 16 specialties” (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals). Specialties not included, in addition to EM, are internal medicine and surgery, which are represented by subspecialties, or service lines. The ranked list includes cardiology and heart surgery; diabetes and endocrinology; gastroenterology and GI surgery; geriatrics; nephrology; neurology and neurosurgery; pulmonology; rheumatology; and urology. Presumably, like medicine and surgery, EM is too all-encompassing a discipline, but unlike the case for the other two specialties, the need for emergency care in most locations does not allow patients to select the “best” facility for their acute problem. Nevertheless, it is interesting to speculate about the effect inclusion of EM would have on the elite institutions vying for honor roll status, as well as on EM itself.
A July 15, 2015 report on USNWR methodology (http://www.usnews.com/pubfiles/BH2015-16MethodologyReport.pdf) (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals) notes that rankings in 12 of the 16 specialties are based on data-driven analyses of volume; technology and other resources (derived principally from the American Hospital Association annual survey); reputation for developing and sustaining the delivery of high-quality care (derived from surveyed physicians); and outcomes-based mostly on CMS risk-adjusted mortality figures. Rankings in the remaining four specialties are based solely on physician surveys of hospital reputation. Hospitals eligible for inclusion on the best hospitals list must either be teaching hospitals, be affiliated with medical schools, or, generally, have 200 or more beds.
Most, if not all, of these criteria can be applied to ranking EDs, but would doing so provide a valid assessment of the best EDs, and if so, to what end? The first question is too complicated to answer here. As for the second, many have argued that the “best ED” isn’t a relevant concept, considering that standards of emergency care demanded of every ED and emergency physician by ABEM, ACEP, ABMS, JCAHO, and more recently, CMS, have been promulgated and implemented nationwide for over three-and-a-half decades. But for the select few hospitals competing for the title of “best,” inclusion of EM among ranked specialties would send a very powerful message and require increased resources to achieve and maintain top standing. Even if EM is not ranked as a discrete specialty, many of the features of a “best ED” can and should be included. Currently, hospitals receive 1 point for being a state-certified, level 1 or level 2 trauma center. Points for other ED “center” designations could also be applied to a hospital’s overall score.
In any case, should USNWR include EM in future best hospitals listings, perhaps many of the measures that will be taken by hospitals to claim the title of “best ED” could subsequently become standard operating procedure for all EDs. So, let the games begin.
*“News You Can Use” is a column that ran in USNWR beginning in 1952.
Among the many organizations that rate hospitals and medical care—CMS, JCAHO, and Consumer Reports, to name a few—one that has captured the public’s attention since 1990 is the US News & World Report (USNWR) annual list of best hospitals, which includes its “honor roll” of the 15 very best. Yet, emergency medicine (EM) has never been included among the ranked specialties, raising the question, should the “best hospitals” have the best EDs?
Formerly a weekly newsmagazine and now web-based, USNWR still publishes print editions of its popular annual best colleges and best hospitals listings. Widely read and widely reported in other media, the lists appear to resonate strongly with the public, as well as with college and hospital administrators. But what exactly is meant by best? In a press release accompanying its 2015-16 best hospitals list, USNWR describes the purpose of the list as “designed to help patients with life threatening or rare conditions identify hospitals that excel in treating the most difficult cases,” and its honor roll as a list that “highlights hospitals that are exceptional in 16 specialties” (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals). Specialties not included, in addition to EM, are internal medicine and surgery, which are represented by subspecialties, or service lines. The ranked list includes cardiology and heart surgery; diabetes and endocrinology; gastroenterology and GI surgery; geriatrics; nephrology; neurology and neurosurgery; pulmonology; rheumatology; and urology. Presumably, like medicine and surgery, EM is too all-encompassing a discipline, but unlike the case for the other two specialties, the need for emergency care in most locations does not allow patients to select the “best” facility for their acute problem. Nevertheless, it is interesting to speculate about the effect inclusion of EM would have on the elite institutions vying for honor roll status, as well as on EM itself.
A July 15, 2015 report on USNWR methodology (http://www.usnews.com/pubfiles/BH2015-16MethodologyReport.pdf) (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals) notes that rankings in 12 of the 16 specialties are based on data-driven analyses of volume; technology and other resources (derived principally from the American Hospital Association annual survey); reputation for developing and sustaining the delivery of high-quality care (derived from surveyed physicians); and outcomes-based mostly on CMS risk-adjusted mortality figures. Rankings in the remaining four specialties are based solely on physician surveys of hospital reputation. Hospitals eligible for inclusion on the best hospitals list must either be teaching hospitals, be affiliated with medical schools, or, generally, have 200 or more beds.
Most, if not all, of these criteria can be applied to ranking EDs, but would doing so provide a valid assessment of the best EDs, and if so, to what end? The first question is too complicated to answer here. As for the second, many have argued that the “best ED” isn’t a relevant concept, considering that standards of emergency care demanded of every ED and emergency physician by ABEM, ACEP, ABMS, JCAHO, and more recently, CMS, have been promulgated and implemented nationwide for over three-and-a-half decades. But for the select few hospitals competing for the title of “best,” inclusion of EM among ranked specialties would send a very powerful message and require increased resources to achieve and maintain top standing. Even if EM is not ranked as a discrete specialty, many of the features of a “best ED” can and should be included. Currently, hospitals receive 1 point for being a state-certified, level 1 or level 2 trauma center. Points for other ED “center” designations could also be applied to a hospital’s overall score.
In any case, should USNWR include EM in future best hospitals listings, perhaps many of the measures that will be taken by hospitals to claim the title of “best ED” could subsequently become standard operating procedure for all EDs. So, let the games begin.
*“News You Can Use” is a column that ran in USNWR beginning in 1952.
What does Liletta cost to non-340B providers?
“YOUR TEENAGE PATIENT AND CONTRACEPTION: THINK
‘LONG-ACTING’ FIRST”
DAVID R. KATTAN, MD, MPH, AND
RONALD T. BURKMAN, MD (SEPTEMBER 2015)
What does Liletta cost
to non-340B providers?
Drs. Kattan and Burkman state in their article: “For providers who practice in settings eligible for 340B pricing, Liletta costs $50, a fraction of the cost of alternative intrauterine devices (IUDs). The cost is slightly higher for non-340B providers but is still significantly lower than the cost of other IUDs.”
Could you provide a cost range and the source for the non-340B cost?
Sharon J. Hawthorne, MBA
St. Louis, Missouri
Drs. Kattan and Burkman respond:
Thank you for your question and for allowing us to clarify. The manufacturer of Liletta, Actavis, offers a Patient Savings Program for private insurance patients to limit their out-of-pocket cost to $75. This program will end on December 31, 2015. Information is available at http://www.lilettacard.com.
For non-340B providers, the cost per IUD is higher, although this should be reimbursed by the patient’s insurance program. After volume discounts, the price per device is as low as $537. Without volume discounts, the price per device is $600. For more information, visit: https://www.lilettahcp.com/content/pdf/LILETTA-Quick-Reference-Guide.pdf.
Medicines360, the nonprofit partner of Actavis, states the following on its Web site (http://medicines360.org/our-mission): “Through our pharmaceutical partnerships, commercial product sales help support an affordable price to public sector clinics. This allows low income women or those without insurance the opportunity to access more healthcare choices.”
“DOES PREOPERATIVE URODYNAMICS IMPROVE OUTCOMES FOR WOMEN UNDERGOING SURGERY FOR STRESS URINARY INCONTINENCE?”
CHARLES W. NAGER, MD
(EXAMINING THE EVIDENCE; AUGUST 2015)
Priorities for determining the etiology of incontinence
While I believe Dr. Nager’s approach accurately interprets current clinical evidence, it also reflects an inadequate paradigm. Whether or not incontinence surgery should be preceded by formal invasive urodynamic evaluation is not the question. As director of urodynamics at UConn, I understand that even the most advanced clinical urodynamics evaluation is limited in what it can measure. Nowhere in that data set is “determine the etiology of incontinence.” Therefore, the more appropriate question is: When should one consider
urodynamic evaluation before making a diagnosis requiring therapy? The answer: By prioritizing aspects of lower urinary tract function.
As recommended by the International Continence Society, the diagnosing physician actually must conduct the urodynamic testing. This physician’s first priority is to determine if the bladder can maintain low storage pressures. History and physical examination must include an acknowledgment of potential causes, including chronic urethral obstruction or failure of autonomic/sympathetic regulation. Yes, in an otherwise healthy 45-year-old vaginally parous woman with stress urinary incontinence (SUI) symptoms, it is unlikely that storage pressures aren’t normally regulated. It takes little office visit time to reach that conclusion.
The diagnosing physician’s second priority is to determine the actual functional size of the urinary reservoir. Only the bladder can expel urine actively. Is there a bladder diverticulum or reflux into the upper tracts augmenting the reservoir? Bladder/urethral function is about volume management, yet the sphincteric mechanism is not tolerant of very high volumes, even in “normal” patients. Knowing reservoir volumes when leakage occurs and the relationship of these volumes to perceptions of “empty” and “full” is critical to determining how to respond to sphincteric insufficiency that produces SUI symptoms. I agree that an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms will have a problem here. However, if the diagnosing physician has any reason to doubt that the urinary reservoir has the same functionality as the bladder and that operational volumes are “normal,” then videourodynamic investigation is the most direct approach.
The third priority during evaluation is to determine how the reservoir empties. What is the source of the expulsive pressure of voiding? What is the interaction of the expulsive pressure and the urethral opening? How effectively does the bladder empty? In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem, but if the physician doesn’t consider how this patient’s bladder empties, determining how the sphincter is stressed during storage and how the patient might respond to intervention is impossible. If normal efficient voiding by detrusor pressurization cannot be assured by office evaluation, then urodynamic examination, including a pressure/flow study, is necessary.
The last priority is to determine how the urine storage/emptying system is controlled. This is most important to the patient but least important for diagnosis. Often this can be deduced from a simple office evaluation that includes urinalysis, a voiding diary, standing stress test, possibly simple “office cystometry” (with a large Toomey syringe, a straight catheter, and saline solution), and the patient’s history. No aspect of this last priority requires invasive computerized urodynamics—unless the physician just cannot figure it out even after considering results of the first 3 steps.
Once these evaluative priorities have been completed, a diagnosis can be considered and treatment options determined. But only then.
Phillip P. Smith, MD
Farmington, Connecticut
Dr. Nager responds:
Dr. Smith provides a very nice review of what the bladder and urethra need to do. As he points out, the most appropriate question is: When should one consider urodynamic evaluation before making a diagnosis requiring therapy? Well, when a reliable diagnosis cannot be made by history, physical examination, and simple office tests.
The literature suggests that a neurologically normal woman without prolapse and without previous incontinence surgeries can receive a reliable diagnosis without urodynamic testing. If she demonstrates SUI on office stress testing, she is not storing urine normally and urodynamics will confirm urodynamic stress incontinence 97% of the time.1 If she voluntarily voids with a normal postvoid residual, her emptying function has been assessed and is normal.
I think Dr. Smith and I both agree that, “In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem.” We also both agree that whenever the diagnosis is unclear, or the situation is complicated, urodynamic testing is a helpful tool to assess the bladder’s storage and emptying function. I perform urodynamics regularly in my practice; it just is not necessary before surgery in a woman without prolapse and without previous incontinence surgeries who demonstrates her SUI and has a normal urinalysis and normal postvoid residual. We seem to agree on that point also.
Reference
- Nager C, Brubaker L, Litman H, et al; Urinary Incontinence Treatment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–1997.
“UPDATE ON MENOPAUSE”
ANDREW M. KAUNITZ, MD (JUNE 2015)
Should Provera still be used?
Dr. Kaunitz provided an excellent review of the Women’s Health Initiative (WHI) study and a recent testosterone trial in women in his update on hormone therapy in menopause.
After the WHI revealed differences between the estrogen-alone and estrogen–progestin study arms, implicating medroxyprogesterone acetate for increased risk of breast cancer, why is Provera still being advocated by the American College of Obstetricians and Gynecologists as a progestin safe for use in menopause?
Kathleen Norman, MD
Phoenix, Arizona
Dr. Barbieri responds:
Many insurance formularies favor the use of Provera because it is inexpensive. I try to avoid using it in my practice. Many experts do not yet diligently avoid the use of Provera; some are worried about the cost impact for patients.
For additional information on reducing the use of Provera, see my July 2014 editorial, “Hormone therapy for menopausal vasomotor symptoms,” at obgmanagement.com.
Dr. Kaunitz responds:
My preference is to use micronized oral progesterone (formulated in peanut oil) for endometrial protection in menopausal women using estrogen. I use progesterone 100 mg nightly in women taking standard-dose estrogen (estradiol patch 0.05 mg, oral estradiol 1 mg, or conjugated equine estrogen 0.625 mg). However, some patients request generic medroxyprogesterone acetate because it is so inexpensive (often $4 each month).
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“YOUR TEENAGE PATIENT AND CONTRACEPTION: THINK
‘LONG-ACTING’ FIRST”
DAVID R. KATTAN, MD, MPH, AND
RONALD T. BURKMAN, MD (SEPTEMBER 2015)
What does Liletta cost
to non-340B providers?
Drs. Kattan and Burkman state in their article: “For providers who practice in settings eligible for 340B pricing, Liletta costs $50, a fraction of the cost of alternative intrauterine devices (IUDs). The cost is slightly higher for non-340B providers but is still significantly lower than the cost of other IUDs.”
Could you provide a cost range and the source for the non-340B cost?
Sharon J. Hawthorne, MBA
St. Louis, Missouri
Drs. Kattan and Burkman respond:
Thank you for your question and for allowing us to clarify. The manufacturer of Liletta, Actavis, offers a Patient Savings Program for private insurance patients to limit their out-of-pocket cost to $75. This program will end on December 31, 2015. Information is available at http://www.lilettacard.com.
For non-340B providers, the cost per IUD is higher, although this should be reimbursed by the patient’s insurance program. After volume discounts, the price per device is as low as $537. Without volume discounts, the price per device is $600. For more information, visit: https://www.lilettahcp.com/content/pdf/LILETTA-Quick-Reference-Guide.pdf.
Medicines360, the nonprofit partner of Actavis, states the following on its Web site (http://medicines360.org/our-mission): “Through our pharmaceutical partnerships, commercial product sales help support an affordable price to public sector clinics. This allows low income women or those without insurance the opportunity to access more healthcare choices.”
“DOES PREOPERATIVE URODYNAMICS IMPROVE OUTCOMES FOR WOMEN UNDERGOING SURGERY FOR STRESS URINARY INCONTINENCE?”
CHARLES W. NAGER, MD
(EXAMINING THE EVIDENCE; AUGUST 2015)
Priorities for determining the etiology of incontinence
While I believe Dr. Nager’s approach accurately interprets current clinical evidence, it also reflects an inadequate paradigm. Whether or not incontinence surgery should be preceded by formal invasive urodynamic evaluation is not the question. As director of urodynamics at UConn, I understand that even the most advanced clinical urodynamics evaluation is limited in what it can measure. Nowhere in that data set is “determine the etiology of incontinence.” Therefore, the more appropriate question is: When should one consider
urodynamic evaluation before making a diagnosis requiring therapy? The answer: By prioritizing aspects of lower urinary tract function.
As recommended by the International Continence Society, the diagnosing physician actually must conduct the urodynamic testing. This physician’s first priority is to determine if the bladder can maintain low storage pressures. History and physical examination must include an acknowledgment of potential causes, including chronic urethral obstruction or failure of autonomic/sympathetic regulation. Yes, in an otherwise healthy 45-year-old vaginally parous woman with stress urinary incontinence (SUI) symptoms, it is unlikely that storage pressures aren’t normally regulated. It takes little office visit time to reach that conclusion.
The diagnosing physician’s second priority is to determine the actual functional size of the urinary reservoir. Only the bladder can expel urine actively. Is there a bladder diverticulum or reflux into the upper tracts augmenting the reservoir? Bladder/urethral function is about volume management, yet the sphincteric mechanism is not tolerant of very high volumes, even in “normal” patients. Knowing reservoir volumes when leakage occurs and the relationship of these volumes to perceptions of “empty” and “full” is critical to determining how to respond to sphincteric insufficiency that produces SUI symptoms. I agree that an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms will have a problem here. However, if the diagnosing physician has any reason to doubt that the urinary reservoir has the same functionality as the bladder and that operational volumes are “normal,” then videourodynamic investigation is the most direct approach.
The third priority during evaluation is to determine how the reservoir empties. What is the source of the expulsive pressure of voiding? What is the interaction of the expulsive pressure and the urethral opening? How effectively does the bladder empty? In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem, but if the physician doesn’t consider how this patient’s bladder empties, determining how the sphincter is stressed during storage and how the patient might respond to intervention is impossible. If normal efficient voiding by detrusor pressurization cannot be assured by office evaluation, then urodynamic examination, including a pressure/flow study, is necessary.
The last priority is to determine how the urine storage/emptying system is controlled. This is most important to the patient but least important for diagnosis. Often this can be deduced from a simple office evaluation that includes urinalysis, a voiding diary, standing stress test, possibly simple “office cystometry” (with a large Toomey syringe, a straight catheter, and saline solution), and the patient’s history. No aspect of this last priority requires invasive computerized urodynamics—unless the physician just cannot figure it out even after considering results of the first 3 steps.
Once these evaluative priorities have been completed, a diagnosis can be considered and treatment options determined. But only then.
Phillip P. Smith, MD
Farmington, Connecticut
Dr. Nager responds:
Dr. Smith provides a very nice review of what the bladder and urethra need to do. As he points out, the most appropriate question is: When should one consider urodynamic evaluation before making a diagnosis requiring therapy? Well, when a reliable diagnosis cannot be made by history, physical examination, and simple office tests.
The literature suggests that a neurologically normal woman without prolapse and without previous incontinence surgeries can receive a reliable diagnosis without urodynamic testing. If she demonstrates SUI on office stress testing, she is not storing urine normally and urodynamics will confirm urodynamic stress incontinence 97% of the time.1 If she voluntarily voids with a normal postvoid residual, her emptying function has been assessed and is normal.
I think Dr. Smith and I both agree that, “In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem.” We also both agree that whenever the diagnosis is unclear, or the situation is complicated, urodynamic testing is a helpful tool to assess the bladder’s storage and emptying function. I perform urodynamics regularly in my practice; it just is not necessary before surgery in a woman without prolapse and without previous incontinence surgeries who demonstrates her SUI and has a normal urinalysis and normal postvoid residual. We seem to agree on that point also.
Reference
- Nager C, Brubaker L, Litman H, et al; Urinary Incontinence Treatment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–1997.
“UPDATE ON MENOPAUSE”
ANDREW M. KAUNITZ, MD (JUNE 2015)
Should Provera still be used?
Dr. Kaunitz provided an excellent review of the Women’s Health Initiative (WHI) study and a recent testosterone trial in women in his update on hormone therapy in menopause.
After the WHI revealed differences between the estrogen-alone and estrogen–progestin study arms, implicating medroxyprogesterone acetate for increased risk of breast cancer, why is Provera still being advocated by the American College of Obstetricians and Gynecologists as a progestin safe for use in menopause?
Kathleen Norman, MD
Phoenix, Arizona
Dr. Barbieri responds:
Many insurance formularies favor the use of Provera because it is inexpensive. I try to avoid using it in my practice. Many experts do not yet diligently avoid the use of Provera; some are worried about the cost impact for patients.
For additional information on reducing the use of Provera, see my July 2014 editorial, “Hormone therapy for menopausal vasomotor symptoms,” at obgmanagement.com.
Dr. Kaunitz responds:
My preference is to use micronized oral progesterone (formulated in peanut oil) for endometrial protection in menopausal women using estrogen. I use progesterone 100 mg nightly in women taking standard-dose estrogen (estradiol patch 0.05 mg, oral estradiol 1 mg, or conjugated equine estrogen 0.625 mg). However, some patients request generic medroxyprogesterone acetate because it is so inexpensive (often $4 each month).
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“YOUR TEENAGE PATIENT AND CONTRACEPTION: THINK
‘LONG-ACTING’ FIRST”
DAVID R. KATTAN, MD, MPH, AND
RONALD T. BURKMAN, MD (SEPTEMBER 2015)
What does Liletta cost
to non-340B providers?
Drs. Kattan and Burkman state in their article: “For providers who practice in settings eligible for 340B pricing, Liletta costs $50, a fraction of the cost of alternative intrauterine devices (IUDs). The cost is slightly higher for non-340B providers but is still significantly lower than the cost of other IUDs.”
Could you provide a cost range and the source for the non-340B cost?
Sharon J. Hawthorne, MBA
St. Louis, Missouri
Drs. Kattan and Burkman respond:
Thank you for your question and for allowing us to clarify. The manufacturer of Liletta, Actavis, offers a Patient Savings Program for private insurance patients to limit their out-of-pocket cost to $75. This program will end on December 31, 2015. Information is available at http://www.lilettacard.com.
For non-340B providers, the cost per IUD is higher, although this should be reimbursed by the patient’s insurance program. After volume discounts, the price per device is as low as $537. Without volume discounts, the price per device is $600. For more information, visit: https://www.lilettahcp.com/content/pdf/LILETTA-Quick-Reference-Guide.pdf.
Medicines360, the nonprofit partner of Actavis, states the following on its Web site (http://medicines360.org/our-mission): “Through our pharmaceutical partnerships, commercial product sales help support an affordable price to public sector clinics. This allows low income women or those without insurance the opportunity to access more healthcare choices.”
“DOES PREOPERATIVE URODYNAMICS IMPROVE OUTCOMES FOR WOMEN UNDERGOING SURGERY FOR STRESS URINARY INCONTINENCE?”
CHARLES W. NAGER, MD
(EXAMINING THE EVIDENCE; AUGUST 2015)
Priorities for determining the etiology of incontinence
While I believe Dr. Nager’s approach accurately interprets current clinical evidence, it also reflects an inadequate paradigm. Whether or not incontinence surgery should be preceded by formal invasive urodynamic evaluation is not the question. As director of urodynamics at UConn, I understand that even the most advanced clinical urodynamics evaluation is limited in what it can measure. Nowhere in that data set is “determine the etiology of incontinence.” Therefore, the more appropriate question is: When should one consider
urodynamic evaluation before making a diagnosis requiring therapy? The answer: By prioritizing aspects of lower urinary tract function.
As recommended by the International Continence Society, the diagnosing physician actually must conduct the urodynamic testing. This physician’s first priority is to determine if the bladder can maintain low storage pressures. History and physical examination must include an acknowledgment of potential causes, including chronic urethral obstruction or failure of autonomic/sympathetic regulation. Yes, in an otherwise healthy 45-year-old vaginally parous woman with stress urinary incontinence (SUI) symptoms, it is unlikely that storage pressures aren’t normally regulated. It takes little office visit time to reach that conclusion.
The diagnosing physician’s second priority is to determine the actual functional size of the urinary reservoir. Only the bladder can expel urine actively. Is there a bladder diverticulum or reflux into the upper tracts augmenting the reservoir? Bladder/urethral function is about volume management, yet the sphincteric mechanism is not tolerant of very high volumes, even in “normal” patients. Knowing reservoir volumes when leakage occurs and the relationship of these volumes to perceptions of “empty” and “full” is critical to determining how to respond to sphincteric insufficiency that produces SUI symptoms. I agree that an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms will have a problem here. However, if the diagnosing physician has any reason to doubt that the urinary reservoir has the same functionality as the bladder and that operational volumes are “normal,” then videourodynamic investigation is the most direct approach.
The third priority during evaluation is to determine how the reservoir empties. What is the source of the expulsive pressure of voiding? What is the interaction of the expulsive pressure and the urethral opening? How effectively does the bladder empty? In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem, but if the physician doesn’t consider how this patient’s bladder empties, determining how the sphincter is stressed during storage and how the patient might respond to intervention is impossible. If normal efficient voiding by detrusor pressurization cannot be assured by office evaluation, then urodynamic examination, including a pressure/flow study, is necessary.
The last priority is to determine how the urine storage/emptying system is controlled. This is most important to the patient but least important for diagnosis. Often this can be deduced from a simple office evaluation that includes urinalysis, a voiding diary, standing stress test, possibly simple “office cystometry” (with a large Toomey syringe, a straight catheter, and saline solution), and the patient’s history. No aspect of this last priority requires invasive computerized urodynamics—unless the physician just cannot figure it out even after considering results of the first 3 steps.
Once these evaluative priorities have been completed, a diagnosis can be considered and treatment options determined. But only then.
Phillip P. Smith, MD
Farmington, Connecticut
Dr. Nager responds:
Dr. Smith provides a very nice review of what the bladder and urethra need to do. As he points out, the most appropriate question is: When should one consider urodynamic evaluation before making a diagnosis requiring therapy? Well, when a reliable diagnosis cannot be made by history, physical examination, and simple office tests.
The literature suggests that a neurologically normal woman without prolapse and without previous incontinence surgeries can receive a reliable diagnosis without urodynamic testing. If she demonstrates SUI on office stress testing, she is not storing urine normally and urodynamics will confirm urodynamic stress incontinence 97% of the time.1 If she voluntarily voids with a normal postvoid residual, her emptying function has been assessed and is normal.
I think Dr. Smith and I both agree that, “In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem.” We also both agree that whenever the diagnosis is unclear, or the situation is complicated, urodynamic testing is a helpful tool to assess the bladder’s storage and emptying function. I perform urodynamics regularly in my practice; it just is not necessary before surgery in a woman without prolapse and without previous incontinence surgeries who demonstrates her SUI and has a normal urinalysis and normal postvoid residual. We seem to agree on that point also.
Reference
- Nager C, Brubaker L, Litman H, et al; Urinary Incontinence Treatment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–1997.
“UPDATE ON MENOPAUSE”
ANDREW M. KAUNITZ, MD (JUNE 2015)
Should Provera still be used?
Dr. Kaunitz provided an excellent review of the Women’s Health Initiative (WHI) study and a recent testosterone trial in women in his update on hormone therapy in menopause.
After the WHI revealed differences between the estrogen-alone and estrogen–progestin study arms, implicating medroxyprogesterone acetate for increased risk of breast cancer, why is Provera still being advocated by the American College of Obstetricians and Gynecologists as a progestin safe for use in menopause?
Kathleen Norman, MD
Phoenix, Arizona
Dr. Barbieri responds:
Many insurance formularies favor the use of Provera because it is inexpensive. I try to avoid using it in my practice. Many experts do not yet diligently avoid the use of Provera; some are worried about the cost impact for patients.
For additional information on reducing the use of Provera, see my July 2014 editorial, “Hormone therapy for menopausal vasomotor symptoms,” at obgmanagement.com.
Dr. Kaunitz responds:
My preference is to use micronized oral progesterone (formulated in peanut oil) for endometrial protection in menopausal women using estrogen. I use progesterone 100 mg nightly in women taking standard-dose estrogen (estradiol patch 0.05 mg, oral estradiol 1 mg, or conjugated equine estrogen 0.625 mg). However, some patients request generic medroxyprogesterone acetate because it is so inexpensive (often $4 each month).
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.