Commentary

I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.

My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.

Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).

Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.

Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.

Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”

My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.

What is the difference between sex and gender?

Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.

What is gender identity?

Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.

Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.

What is sexual orientation?

Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.

Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.

This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.

I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.

My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.

Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).

Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.

Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.

Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”

My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.

What is the difference between sex and gender?

Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.

What is gender identity?

Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.

Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.

What is sexual orientation?

Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.

Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.

This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.

I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.

My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.

Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).

Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.

Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.

Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”

My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.

What is the difference between sex and gender?

Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.

What is gender identity?

Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.

Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.

What is sexual orientation?

Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.

Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.

This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.

I just returned from the American Academy of Dermatology’s Washington “fly-in” and wanted to share some of my experiences. Every year, 180 or so dermatologists (all are invited!) and patient advocates spend 3 days in D.C., getting informed, trained, and organized to deliver our message to Congress. Each year, members and AAD staff winnow our many “wants” down to three reasonable “asks.” Background is given and our message rehearsed, for delivery in congressional and Senate offices. On the third day, appointments are kept with your representatives, and you get to try and convince them that your particular ask is beneficial to the country and, most importantly, patients.

This year, our “asks” were for better access to medications, specifically the ability to compound medications in the office (think diluting Kenalog for injection, come on!), which new Food and Drug Administration rules will interfere with; emphasizing the unfairness of narrow Medicare advantage networks; and our last, and usually annual, request for increased research funding for skin disease research.

The fly-in is a fascinating, and often fun, experience, which does affect how the U.S. government works. Truly, the squeaky (and most coherent and organized, thanks to AAD staff) wheel gets the grease.

This year, we had the additional weapon of a Government Accountability Office report released the day before our Hill visit, which independently confirmed our allegations regarding the unfairness of narrow networks to patients.

You may recall that last year, the Center for Medicare & Medicaid Services published detailed rules on increasing the accuracy of provider networks, which would have corrected many of the current problems we face. The only deficiency was that CMS has no procedures to review, audit, or enforce the rules they wrote. At the prodding of the AAD, the GAO took CMS to the mat and pummeled them, including such choice quotes as “99% of current provider networks have never been reviewed for accuracy” and “exemptions to insurers with inadequate provider access are approved routinely and never reviewed again.” The GAO made several sweeping recommendations for increased accountability, and the Department of Health & Human Services agreed with all of them.

Boring? Hardly. Think of this as taking the wooden stake created by your AAD, which was adopted by one government agency, and having it driven through the heart of insurance company deceit by another. It made for great emphasis on the Hill, and I expect big changes (and moaning and groaning from Medicare advantage plan insurance providers) in the coming months.

We also made great progress (you can tell by the interest by the staffers and members in our topics) on our other issues. I want to emphasize how effective our patient advocates were in explaining how expensive generics and cost of new drugs adversely affects them, how they have seen their doctors “delisted” from their insurance because their care is expensive, and why research into skin disease is so important to them. They “tie it all together” and bring it home.

I often talk about my “Washington Epiphany,” which can be summarized as, “politicians don’t worry about doctors, but they do about patients.” When you talk to politicians, bureaucrats, policy wonks, or the public about the woes of medical practice, always align it with the needs of patients, and you will be well received. In short, take care of your patients and they will take care of you.

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

I just returned from the American Academy of Dermatology’s Washington “fly-in” and wanted to share some of my experiences. Every year, 180 or so dermatologists (all are invited!) and patient advocates spend 3 days in D.C., getting informed, trained, and organized to deliver our message to Congress. Each year, members and AAD staff winnow our many “wants” down to three reasonable “asks.” Background is given and our message rehearsed, for delivery in congressional and Senate offices. On the third day, appointments are kept with your representatives, and you get to try and convince them that your particular ask is beneficial to the country and, most importantly, patients.

This year, our “asks” were for better access to medications, specifically the ability to compound medications in the office (think diluting Kenalog for injection, come on!), which new Food and Drug Administration rules will interfere with; emphasizing the unfairness of narrow Medicare advantage networks; and our last, and usually annual, request for increased research funding for skin disease research.

The fly-in is a fascinating, and often fun, experience, which does affect how the U.S. government works. Truly, the squeaky (and most coherent and organized, thanks to AAD staff) wheel gets the grease.

This year, we had the additional weapon of a Government Accountability Office report released the day before our Hill visit, which independently confirmed our allegations regarding the unfairness of narrow networks to patients.

You may recall that last year, the Center for Medicare & Medicaid Services published detailed rules on increasing the accuracy of provider networks, which would have corrected many of the current problems we face. The only deficiency was that CMS has no procedures to review, audit, or enforce the rules they wrote. At the prodding of the AAD, the GAO took CMS to the mat and pummeled them, including such choice quotes as “99% of current provider networks have never been reviewed for accuracy” and “exemptions to insurers with inadequate provider access are approved routinely and never reviewed again.” The GAO made several sweeping recommendations for increased accountability, and the Department of Health & Human Services agreed with all of them.

Boring? Hardly. Think of this as taking the wooden stake created by your AAD, which was adopted by one government agency, and having it driven through the heart of insurance company deceit by another. It made for great emphasis on the Hill, and I expect big changes (and moaning and groaning from Medicare advantage plan insurance providers) in the coming months.

We also made great progress (you can tell by the interest by the staffers and members in our topics) on our other issues. I want to emphasize how effective our patient advocates were in explaining how expensive generics and cost of new drugs adversely affects them, how they have seen their doctors “delisted” from their insurance because their care is expensive, and why research into skin disease is so important to them. They “tie it all together” and bring it home.

I often talk about my “Washington Epiphany,” which can be summarized as, “politicians don’t worry about doctors, but they do about patients.” When you talk to politicians, bureaucrats, policy wonks, or the public about the woes of medical practice, always align it with the needs of patients, and you will be well received. In short, take care of your patients and they will take care of you.

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

I just returned from the American Academy of Dermatology’s Washington “fly-in” and wanted to share some of my experiences. Every year, 180 or so dermatologists (all are invited!) and patient advocates spend 3 days in D.C., getting informed, trained, and organized to deliver our message to Congress. Each year, members and AAD staff winnow our many “wants” down to three reasonable “asks.” Background is given and our message rehearsed, for delivery in congressional and Senate offices. On the third day, appointments are kept with your representatives, and you get to try and convince them that your particular ask is beneficial to the country and, most importantly, patients.

This year, our “asks” were for better access to medications, specifically the ability to compound medications in the office (think diluting Kenalog for injection, come on!), which new Food and Drug Administration rules will interfere with; emphasizing the unfairness of narrow Medicare advantage networks; and our last, and usually annual, request for increased research funding for skin disease research.

The fly-in is a fascinating, and often fun, experience, which does affect how the U.S. government works. Truly, the squeaky (and most coherent and organized, thanks to AAD staff) wheel gets the grease.

This year, we had the additional weapon of a Government Accountability Office report released the day before our Hill visit, which independently confirmed our allegations regarding the unfairness of narrow networks to patients.

You may recall that last year, the Center for Medicare & Medicaid Services published detailed rules on increasing the accuracy of provider networks, which would have corrected many of the current problems we face. The only deficiency was that CMS has no procedures to review, audit, or enforce the rules they wrote. At the prodding of the AAD, the GAO took CMS to the mat and pummeled them, including such choice quotes as “99% of current provider networks have never been reviewed for accuracy” and “exemptions to insurers with inadequate provider access are approved routinely and never reviewed again.” The GAO made several sweeping recommendations for increased accountability, and the Department of Health & Human Services agreed with all of them.

Boring? Hardly. Think of this as taking the wooden stake created by your AAD, which was adopted by one government agency, and having it driven through the heart of insurance company deceit by another. It made for great emphasis on the Hill, and I expect big changes (and moaning and groaning from Medicare advantage plan insurance providers) in the coming months.

We also made great progress (you can tell by the interest by the staffers and members in our topics) on our other issues. I want to emphasize how effective our patient advocates were in explaining how expensive generics and cost of new drugs adversely affects them, how they have seen their doctors “delisted” from their insurance because their care is expensive, and why research into skin disease is so important to them. They “tie it all together” and bring it home.

I often talk about my “Washington Epiphany,” which can be summarized as, “politicians don’t worry about doctors, but they do about patients.” When you talk to politicians, bureaucrats, policy wonks, or the public about the woes of medical practice, always align it with the needs of patients, and you will be well received. In short, take care of your patients and they will take care of you.

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

Apparently, it is well known among canine behavior specialists that under similar situations dogs will look at human faces while wolves continue about their business – usually eating (“Why Is That Dog Looking at Me?” by James Gorman, New York Times, Sept. 15, 2015).

It also has been shown that when presented with the challenge of opening a food container that has been sealed shut, dogs will give up quickly and look to a nearby human, presumably for help. On the other hand, wolves raised by humans don’t look for help, suggesting that this looking to humans for help behavior may have a genetic component.

If the container of food has been altered so that it can be opened, but only with significant effort, the wolves will persist until they succeed. The adult dogs give up too quickly to succeed and instead look to humans. But, it is very interesting that in some preexperiment trials, at least one 8-month-old puppy kept at it until he was able to open the container, suggesting that in addition to some genetic influence, hanging around humans may foster what we might consider learned helplessness.

This observation wouldn’t surprise the product engineers tasked with developing child-resistant closures that can be easily opened by an adult. And I’m sure this evidence of learned helplessness in an animal wouldn’t surprise those who believe that welfare in any form is an abomination. As a card-carrying centrist, I will leave that argument to the polarizers on both ends of the political spectrum.

But I think this observation is most interesting because it raises the question of how often today’s parents are contributing to their children’s sense of helplessness. You only have to watch a child or grandchild tackle and construct a Lego project to realize that children are natural problem solvers. They get the trial-and-error thing. The problem is that too often we adults intervene at the first hint of failure, and in doing so, screw up the beautiful simplicity of the trial-and-error method of learning.

Watching someone struggle with a challenge for which you know the solution is difficult, particularly difficult if the struggler is your child or spouse. It is tempting to step forward and offer, “Here, let me show you how to do it.” Or, even worse, “Let me do it for you.”

To return to the canine world, consider the dog that brings a ball or stick to his/her master and then sits patiently waiting for the object to be tossed. If nothing is thrown, the dog will eventually give up and curl up for a nap. Puppies, on the other hand, don’t expect someone to initiate the game. They will paw at the ball until it moves or chase some unsuspecting insect playmate.

While offering children the chance to participate in organized sports is preferable to having them sit inside watching television or glued to a computer screen, the pendulum has swung a little too far toward the “organized” side of things. Too many parents seem unaware that if children are placed in an environment with room to run, a ball or two, and a few older children from whom they can model behavior, the children will organize themselves. They will figure out how to choose teams, make rules, and settle disputes.

The sad thing is that too many children have been offered so few opportunities to exercise their own powers of invention that they believe they are helpless to organize themselves. To them a sport is just a miniature version of what they see on television and comes complete with full uniforms, organized teams, sidelines lined with adoring fans ... and – of course – team pictures and trophies for everyone at the end of the season.

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].

Apparently, it is well known among canine behavior specialists that under similar situations dogs will look at human faces while wolves continue about their business – usually eating (“Why Is That Dog Looking at Me?” by James Gorman, New York Times, Sept. 15, 2015).

It also has been shown that when presented with the challenge of opening a food container that has been sealed shut, dogs will give up quickly and look to a nearby human, presumably for help. On the other hand, wolves raised by humans don’t look for help, suggesting that this looking to humans for help behavior may have a genetic component.

If the container of food has been altered so that it can be opened, but only with significant effort, the wolves will persist until they succeed. The adult dogs give up too quickly to succeed and instead look to humans. But, it is very interesting that in some preexperiment trials, at least one 8-month-old puppy kept at it until he was able to open the container, suggesting that in addition to some genetic influence, hanging around humans may foster what we might consider learned helplessness.

This observation wouldn’t surprise the product engineers tasked with developing child-resistant closures that can be easily opened by an adult. And I’m sure this evidence of learned helplessness in an animal wouldn’t surprise those who believe that welfare in any form is an abomination. As a card-carrying centrist, I will leave that argument to the polarizers on both ends of the political spectrum.

But I think this observation is most interesting because it raises the question of how often today’s parents are contributing to their children’s sense of helplessness. You only have to watch a child or grandchild tackle and construct a Lego project to realize that children are natural problem solvers. They get the trial-and-error thing. The problem is that too often we adults intervene at the first hint of failure, and in doing so, screw up the beautiful simplicity of the trial-and-error method of learning.

Watching someone struggle with a challenge for which you know the solution is difficult, particularly difficult if the struggler is your child or spouse. It is tempting to step forward and offer, “Here, let me show you how to do it.” Or, even worse, “Let me do it for you.”

To return to the canine world, consider the dog that brings a ball or stick to his/her master and then sits patiently waiting for the object to be tossed. If nothing is thrown, the dog will eventually give up and curl up for a nap. Puppies, on the other hand, don’t expect someone to initiate the game. They will paw at the ball until it moves or chase some unsuspecting insect playmate.

While offering children the chance to participate in organized sports is preferable to having them sit inside watching television or glued to a computer screen, the pendulum has swung a little too far toward the “organized” side of things. Too many parents seem unaware that if children are placed in an environment with room to run, a ball or two, and a few older children from whom they can model behavior, the children will organize themselves. They will figure out how to choose teams, make rules, and settle disputes.

The sad thing is that too many children have been offered so few opportunities to exercise their own powers of invention that they believe they are helpless to organize themselves. To them a sport is just a miniature version of what they see on television and comes complete with full uniforms, organized teams, sidelines lined with adoring fans ... and – of course – team pictures and trophies for everyone at the end of the season.

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].

Apparently, it is well known among canine behavior specialists that under similar situations dogs will look at human faces while wolves continue about their business – usually eating (“Why Is That Dog Looking at Me?” by James Gorman, New York Times, Sept. 15, 2015).

It also has been shown that when presented with the challenge of opening a food container that has been sealed shut, dogs will give up quickly and look to a nearby human, presumably for help. On the other hand, wolves raised by humans don’t look for help, suggesting that this looking to humans for help behavior may have a genetic component.

If the container of food has been altered so that it can be opened, but only with significant effort, the wolves will persist until they succeed. The adult dogs give up too quickly to succeed and instead look to humans. But, it is very interesting that in some preexperiment trials, at least one 8-month-old puppy kept at it until he was able to open the container, suggesting that in addition to some genetic influence, hanging around humans may foster what we might consider learned helplessness.

This observation wouldn’t surprise the product engineers tasked with developing child-resistant closures that can be easily opened by an adult. And I’m sure this evidence of learned helplessness in an animal wouldn’t surprise those who believe that welfare in any form is an abomination. As a card-carrying centrist, I will leave that argument to the polarizers on both ends of the political spectrum.

But I think this observation is most interesting because it raises the question of how often today’s parents are contributing to their children’s sense of helplessness. You only have to watch a child or grandchild tackle and construct a Lego project to realize that children are natural problem solvers. They get the trial-and-error thing. The problem is that too often we adults intervene at the first hint of failure, and in doing so, screw up the beautiful simplicity of the trial-and-error method of learning.

Watching someone struggle with a challenge for which you know the solution is difficult, particularly difficult if the struggler is your child or spouse. It is tempting to step forward and offer, “Here, let me show you how to do it.” Or, even worse, “Let me do it for you.”

To return to the canine world, consider the dog that brings a ball or stick to his/her master and then sits patiently waiting for the object to be tossed. If nothing is thrown, the dog will eventually give up and curl up for a nap. Puppies, on the other hand, don’t expect someone to initiate the game. They will paw at the ball until it moves or chase some unsuspecting insect playmate.

While offering children the chance to participate in organized sports is preferable to having them sit inside watching television or glued to a computer screen, the pendulum has swung a little too far toward the “organized” side of things. Too many parents seem unaware that if children are placed in an environment with room to run, a ball or two, and a few older children from whom they can model behavior, the children will organize themselves. They will figure out how to choose teams, make rules, and settle disputes.

The sad thing is that too many children have been offered so few opportunities to exercise their own powers of invention that they believe they are helpless to organize themselves. To them a sport is just a miniature version of what they see on television and comes complete with full uniforms, organized teams, sidelines lined with adoring fans ... and – of course – team pictures and trophies for everyone at the end of the season.

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].

I am, apparently, not a very good doctor. At least, that’s what some mailings I get from insurance companies make me think.

You probably get the same ones. They tell me what guidelines I’m not following or drug interactions I’m not mindful of. I suppose I should be grateful for their efforts to protect patients.

Letters I’ve gotten in the last week have reminded me that:

• Patients with elevated fasting blood sugars should be started on metformin.

• A lady on Eliquis (apixaban) after developing a deep-vein thrombosis should be considered for a less costly alternative, such as warfarin, to help her save money.

• An antihypertensive agent is recommended for a young man with persistently elevated blood pressures.

• An older gentleman’s lipid-lowering agent may interfere with his diabetes medication.

What do these have to do with anything that I, as a neurologist, am doing for the patient? Nothing.

Why are they being sent to me, as opposed to an internist or cardiologist? I have no idea. Of course, for all I know, the other docs might be getting recommendations on how to manage Parkinson’s disease or multiple sclerosis.

The insurance companies pay the bills. They obviously know which doctors are seeing who and prescribing what. Their billing systems track who practices what specialty. If I were to try submitting a claim for pulmonary evaluation, I’m sure they’d immediately notice and deny it.

So why can’t they get this straight? It seems like a big waste of time, paper, and postage all around.

On rare occasions, they actually get it right … sort of. About a month ago, I received a letter about a migraine patient, telling me that, for those with frequent migraines, a preventive medication should be considered. It even listed her current prescriptions to help me understand.

I absolutely agree with the letter, but it completely ignored that her medication list already included topiramate and nortriptyline, both commonly used for migraine prophylaxis. Since she has no other reason to be on either, I have no idea why they thought I’d use them. These kinds of notes all end with some generic comment that these are just suggestions, and only I and my patient can make the correct decisions about treatment, etc. etc.

That letter may be well intentioned, perhaps, but it is also inaccurate, unnecessary, and – to me – even a little demeaning. If you don’t think I know what I’m doing, then why are you sending patients to me? Maybe the software you’re using to screen charts and send these letters should open its own practice instead.

If the real goal of these letters is to save money (and we all know it is), then why is the company wasting it on redundant and inaccurate letters, usually not even sent to the correct doctor?

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

I am, apparently, not a very good doctor. At least, that’s what some mailings I get from insurance companies make me think.

You probably get the same ones. They tell me what guidelines I’m not following or drug interactions I’m not mindful of. I suppose I should be grateful for their efforts to protect patients.

Letters I’ve gotten in the last week have reminded me that:

• Patients with elevated fasting blood sugars should be started on metformin.

• A lady on Eliquis (apixaban) after developing a deep-vein thrombosis should be considered for a less costly alternative, such as warfarin, to help her save money.

• An antihypertensive agent is recommended for a young man with persistently elevated blood pressures.

• An older gentleman’s lipid-lowering agent may interfere with his diabetes medication.

What do these have to do with anything that I, as a neurologist, am doing for the patient? Nothing.

Why are they being sent to me, as opposed to an internist or cardiologist? I have no idea. Of course, for all I know, the other docs might be getting recommendations on how to manage Parkinson’s disease or multiple sclerosis.

The insurance companies pay the bills. They obviously know which doctors are seeing who and prescribing what. Their billing systems track who practices what specialty. If I were to try submitting a claim for pulmonary evaluation, I’m sure they’d immediately notice and deny it.

So why can’t they get this straight? It seems like a big waste of time, paper, and postage all around.

On rare occasions, they actually get it right … sort of. About a month ago, I received a letter about a migraine patient, telling me that, for those with frequent migraines, a preventive medication should be considered. It even listed her current prescriptions to help me understand.

I absolutely agree with the letter, but it completely ignored that her medication list already included topiramate and nortriptyline, both commonly used for migraine prophylaxis. Since she has no other reason to be on either, I have no idea why they thought I’d use them. These kinds of notes all end with some generic comment that these are just suggestions, and only I and my patient can make the correct decisions about treatment, etc. etc.

That letter may be well intentioned, perhaps, but it is also inaccurate, unnecessary, and – to me – even a little demeaning. If you don’t think I know what I’m doing, then why are you sending patients to me? Maybe the software you’re using to screen charts and send these letters should open its own practice instead.

If the real goal of these letters is to save money (and we all know it is), then why is the company wasting it on redundant and inaccurate letters, usually not even sent to the correct doctor?

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

I am, apparently, not a very good doctor. At least, that’s what some mailings I get from insurance companies make me think.

You probably get the same ones. They tell me what guidelines I’m not following or drug interactions I’m not mindful of. I suppose I should be grateful for their efforts to protect patients.

Letters I’ve gotten in the last week have reminded me that:

• Patients with elevated fasting blood sugars should be started on metformin.

• A lady on Eliquis (apixaban) after developing a deep-vein thrombosis should be considered for a less costly alternative, such as warfarin, to help her save money.

• An antihypertensive agent is recommended for a young man with persistently elevated blood pressures.

• An older gentleman’s lipid-lowering agent may interfere with his diabetes medication.

What do these have to do with anything that I, as a neurologist, am doing for the patient? Nothing.

Why are they being sent to me, as opposed to an internist or cardiologist? I have no idea. Of course, for all I know, the other docs might be getting recommendations on how to manage Parkinson’s disease or multiple sclerosis.

The insurance companies pay the bills. They obviously know which doctors are seeing who and prescribing what. Their billing systems track who practices what specialty. If I were to try submitting a claim for pulmonary evaluation, I’m sure they’d immediately notice and deny it.

So why can’t they get this straight? It seems like a big waste of time, paper, and postage all around.

On rare occasions, they actually get it right … sort of. About a month ago, I received a letter about a migraine patient, telling me that, for those with frequent migraines, a preventive medication should be considered. It even listed her current prescriptions to help me understand.

I absolutely agree with the letter, but it completely ignored that her medication list already included topiramate and nortriptyline, both commonly used for migraine prophylaxis. Since she has no other reason to be on either, I have no idea why they thought I’d use them. These kinds of notes all end with some generic comment that these are just suggestions, and only I and my patient can make the correct decisions about treatment, etc. etc.

That letter may be well intentioned, perhaps, but it is also inaccurate, unnecessary, and – to me – even a little demeaning. If you don’t think I know what I’m doing, then why are you sending patients to me? Maybe the software you’re using to screen charts and send these letters should open its own practice instead.

If the real goal of these letters is to save money (and we all know it is), then why is the company wasting it on redundant and inaccurate letters, usually not even sent to the correct doctor?

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

I am, apparently, not a very good doctor. At least, that’s what some mailings I get from insurance companies make me think.

You probably get the same ones. They tell me what guidelines I’m not following or drug interactions I’m not mindful of. I suppose I should be grateful for their efforts to protect patients.

Letters I’ve gotten in the last week have reminded me that:

• Patients with elevated fasting blood sugars should be started on metformin.

• A lady on Eliquis (apixaban) after developing a deep-vein thrombosis should be considered for a less costly alternative, such as warfarin, to help her save money.

• An antihypertensive agent is recommended for a young man with persistently elevated blood pressures.

• An older gentleman’s lipid-lowering agent may interfere with his diabetes medication.

What do these have to do with anything that I, as a neurologist, am doing for the patient? Nothing.

Why are they being sent to me, as opposed to an internist or cardiologist? I have no idea. Of course, for all I know, the other docs might be getting recommendations on how to manage Parkinson’s disease or multiple sclerosis.

The insurance companies pay the bills. They obviously know which doctors are seeing who and prescribing what. Their billing systems track who practices what specialty. If I were to try submitting a claim for pulmonary evaluation, I’m sure they’d immediately notice and deny it.

So why can’t they get this straight? It seems like a big waste of time, paper, and postage all around.

On rare occasions, they actually get it right … sort of. About a month ago, I received a letter about a migraine patient, telling me that, for those with frequent migraines, a preventive medication should be considered. It even listed her current prescriptions to help me understand.

I absolutely agree with the letter, but it completely ignored that her medication list already included topiramate and nortriptyline, both commonly used for migraine prophylaxis. Since she has no other reason to be on either, I have no idea why they thought I’d use them. These kinds of notes all end with some generic comment that these are just suggestions, and only I and my patient can make the correct decisions about treatment, etc. etc.

That letter may be well intentioned, perhaps, but it is also inaccurate, unnecessary, and – to me – even a little demeaning. If you don’t think I know what I’m doing, then why are you sending patients to me? Maybe the software you’re using to screen charts and send these letters should open its own practice instead.

If the real goal of these letters is to save money (and we all know it is), then why is the company wasting it on redundant and inaccurate letters, usually not even sent to the correct doctor?

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

I am, apparently, not a very good doctor. At least, that’s what some mailings I get from insurance companies make me think.

You probably get the same ones. They tell me what guidelines I’m not following or drug interactions I’m not mindful of. I suppose I should be grateful for their efforts to protect patients.

Letters I’ve gotten in the last week have reminded me that:

• Patients with elevated fasting blood sugars should be started on metformin.

• A lady on Eliquis (apixaban) after developing a deep-vein thrombosis should be considered for a less costly alternative, such as warfarin, to help her save money.

• An antihypertensive agent is recommended for a young man with persistently elevated blood pressures.

• An older gentleman’s lipid-lowering agent may interfere with his diabetes medication.

What do these have to do with anything that I, as a neurologist, am doing for the patient? Nothing.

Why are they being sent to me, as opposed to an internist or cardiologist? I have no idea. Of course, for all I know, the other docs might be getting recommendations on how to manage Parkinson’s disease or multiple sclerosis.

The insurance companies pay the bills. They obviously know which doctors are seeing who and prescribing what. Their billing systems track who practices what specialty. If I were to try submitting a claim for pulmonary evaluation, I’m sure they’d immediately notice and deny it.

So why can’t they get this straight? It seems like a big waste of time, paper, and postage all around.

On rare occasions, they actually get it right … sort of. About a month ago, I received a letter about a migraine patient, telling me that, for those with frequent migraines, a preventive medication should be considered. It even listed her current prescriptions to help me understand.

I absolutely agree with the letter, but it completely ignored that her medication list already included topiramate and nortriptyline, both commonly used for migraine prophylaxis. Since she has no other reason to be on either, I have no idea why they thought I’d use them. These kinds of notes all end with some generic comment that these are just suggestions, and only I and my patient can make the correct decisions about treatment, etc. etc.

That letter may be well intentioned, perhaps, but it is also inaccurate, unnecessary, and – to me – even a little demeaning. If you don’t think I know what I’m doing, then why are you sending patients to me? Maybe the software you’re using to screen charts and send these letters should open its own practice instead.

If the real goal of these letters is to save money (and we all know it is), then why is the company wasting it on redundant and inaccurate letters, usually not even sent to the correct doctor?

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

I am, apparently, not a very good doctor. At least, that’s what some mailings I get from insurance companies make me think.

You probably get the same ones. They tell me what guidelines I’m not following or drug interactions I’m not mindful of. I suppose I should be grateful for their efforts to protect patients.

Letters I’ve gotten in the last week have reminded me that:

• Patients with elevated fasting blood sugars should be started on metformin.

• A lady on Eliquis (apixaban) after developing a deep-vein thrombosis should be considered for a less costly alternative, such as warfarin, to help her save money.

• An antihypertensive agent is recommended for a young man with persistently elevated blood pressures.

• An older gentleman’s lipid-lowering agent may interfere with his diabetes medication.

What do these have to do with anything that I, as a neurologist, am doing for the patient? Nothing.

Why are they being sent to me, as opposed to an internist or cardiologist? I have no idea. Of course, for all I know, the other docs might be getting recommendations on how to manage Parkinson’s disease or multiple sclerosis.

The insurance companies pay the bills. They obviously know which doctors are seeing who and prescribing what. Their billing systems track who practices what specialty. If I were to try submitting a claim for pulmonary evaluation, I’m sure they’d immediately notice and deny it.

So why can’t they get this straight? It seems like a big waste of time, paper, and postage all around.

On rare occasions, they actually get it right … sort of. About a month ago, I received a letter about a migraine patient, telling me that, for those with frequent migraines, a preventive medication should be considered. It even listed her current prescriptions to help me understand.

I absolutely agree with the letter, but it completely ignored that her medication list already included topiramate and nortriptyline, both commonly used for migraine prophylaxis. Since she has no other reason to be on either, I have no idea why they thought I’d use them. These kinds of notes all end with some generic comment that these are just suggestions, and only I and my patient can make the correct decisions about treatment, etc. etc.

That letter may be well intentioned, perhaps, but it is also inaccurate, unnecessary, and – to me – even a little demeaning. If you don’t think I know what I’m doing, then why are you sending patients to me? Maybe the software you’re using to screen charts and send these letters should open its own practice instead.

If the real goal of these letters is to save money (and we all know it is), then why is the company wasting it on redundant and inaccurate letters, usually not even sent to the correct doctor?

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

Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman¹ published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:

“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”

This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.

The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)

"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.

Holman et al¹ describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.

Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman¹ published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:

“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”

This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.

The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)

"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.

Holman et al¹ describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.

Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman¹ published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:

“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”

This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.

The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)

"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.

Holman et al¹ describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.