Commentary

Mechanical valve is the best choice

BY THORALF M. SUNDT III, M.D.

It’s not very sexy to talk about mechanical valves, but the reasons for placing a mechanical valve in a 50-year-old patient with rheumatic disease are obvious: Mechanical valves provide outstanding hemodynamics, they are beautifully engineered devices, their durability is beyond question, and, importantly, there’s no survival advantage to a biological prosthesis although one incurs the penalty of reoperation, which in a 50-year-old is going to be inevitable.

While this patient will have to continue on anticoagulation therapy with a mechanical valve, many patients who receive a biological valve, especially those with rheumatic disease, need anticoagulation for atrial fibrillation anyway. One can argue that a maze procedure might convert them to sinus rhythm, but this is least reproducible in the subset of patients with rheumatic disease. What’s more, the American Heart Association/American College of Cardiology Guideline for the Management of Patients With Valvular Heart Disease states that a mechanical prosthesis is reasonable for aortic or mitral valve replacement in patients aged 60 and younger with no contraindication to anticoagulation.

The fact that you have to use Coumadin (warfarin, Bristol-Myers Squibb), is not a condemnation of the mechanical valve; it just means we need to get smarter and better about how we manage anticoagulation in people with these prostheses.

While neither option is desirable, surprisingly morbidity with mechanical and biological valves is not demonstrably different. Stroke, embolic events, and bleeding complications have been found to be similar in numerous studies including a recent one authored by Dr. Vinay Badhwar and colleagues. Among 469 patients aged 65 years or younger who received a bileaflet mechanical prostheses or tissue valves, researchers found nearly identical rates of bleeding and thromboembolic complications when the anticoagulation was closely monitored (Ann. Thorac. Surg. 2012;93:748-53) Indeed, they even identified a mortality benefit among those with mechanical valves.

It’s also worth noting that the risk of anticoagulation-related complications is higher when the patient’s INR (international normalized ratio) is poorly controlled; up to 60% of INR values are outside the therapeutic range when thromboembolic complications occur. One can anticipate home INR testing and home management as ways to help patients stay within therapeutic range and reduce these risks. If the issue is anticoagulation, let’s improve it.

In summary, if you implant a biological valve in a 50-year-old patient, I guarantee that patient is going to be back for a reoperation and the prosthesis is going to deteriorate. For the surgeon, a biological valve can be an annuity of sorts. The mechanical valve has a clear advantage in durability, especially in younger patients.

Neither one is perfect, but there is no difference in morbidity between the two. A tissue prosthesis just buys you a reoperation – maybe valve-in-valve transcatheter valve. Maybe.

Dr. Sundt is chief of the division of cardiac surgery, Massachusetts General Hospital, Harvard Medical School, Boston. He is an adviser to Thrasos Innovation, but has no relevant relationships to disclose.

Why biological valve is the better choice

BY ANELECHI C. ANYANWU, M.D.

The reality is that whether you implant a mechanical or biological valve for mitral regurgitation, neither is good. The survival is poor. The half-life or median survival of a patient after either valve is about 15-20 years. The death rates are about 3% per year. The morbidity is high whether you have mechanical or biological valve, and none of them are good mitral substitutes.

Yet the biological valve is often a reasonable choice for a 50-year-old patient, despite studies that have shown a higher reoperation rate and decreased survival rate after biological mitral valve repair when compared to mechanical valve implantation in patients aged 65 and younger. But those study results may be skewed.

Dr. Tsuyoshi Kaneko and colleagues at Brigham and Women’s Hospital, Boston, showed that survival at about 20 years was much better with the mechanical valve. (J. Thorac. Cardiovasc. Surg. 2014;147:117-26). However, the difference in survival is greatest immediately after surgery. By 1 year the survival difference between mechanical valve and a tissue valve was more than 10%.

Why is this? I would argue this is a function of patient selection. We know in the United States that a patient with no insurance or low socioeconomic status does poorly compared to one who does have insurance. With a mechanical valve, they can thrombose; but with a biological valve, if they don’t take care of their health, of course they can die early. The reality is surgeons tend to use biological valves in patients of lower socioeconomic status and those with questionable compliance. None of these factors were considered in the propensity matching used in this study.

Dr. Joanna Chikwe and colleagues at Mount Sinai recently compared outcomes in several thousand patients who underwent biological or mechanical mitral valve replacement in New York State (JAMA 2015:323:1435-42). They found no survival difference in the first 30 or 90 days after surgery, or even at 15 years among patients aged 50-69 years. Indeed, a critical review of any study that has shown a survival advantage of the mechanical valve would find that the advantage occurred within the first few months after surgery, making it likely that such differences are due to patient selection, or other systematic bias, rather than a prostheses effect.

Mayo Clinic investigators, including Dr. Thoralf M. Sundt III, reported that among a cohort that received a mechanical valve, with an average age of 65 years, 16% had had a stroke at 5 years, compared with 8% of the biological valve group (J. Am. Coll. Cardiol. 2008;51:1203-11). You can only imagine what would happen at 10 or 20 years. They followed the data out to 10 years for thromboembolic events; that rate was 30% in the mechanical valve group. They concluded, “the mechanical valve is the least desirable correction of mitral regurgitation.”

As for managing anticoagulation, the literature provides no evidence that self-testing is superior to clinic testing. A trial published in the New England Journal of Medicine involving more than 2,000 patients, 700 of whom had a mechanical valve, showed a higher rate of stroke in patients who were randomized to home-INR monitoring compared with INR in the clinic. (N. Engl. J. Med. 2010;363:1608-20). Self-testing did not delay the time to first stroke, bleeding, or death.

Anticoagulation can be problematic if the patient needs to undergo another operation or medical procedure later, especially on an emergent basis. If the patient with a mechanical valve stops anticoagulation for even a short period of time, the risk of valve thrombosis is great. A patient with a biological valve can stop anticoagulation for a week or more without any consequence.

Finally, I relate the story of a man who could not bear the clicking sound of his mechanical valve. He asked for a new valve, but the surgeon would not take his request seriously. The man was taking drugs and started treatment for posttraumatic stress disorder. After 3 years, he killed himself. How many times have we sat down and talked to patients about what the clicking sound can do to them? Why don’t we make more of this? The patient should be given more choice.

Dr. Anyanwu is with the department of cardiac surgery, Mount Sinai Medical Center, New York. He has no relationships to disclose.

Mechanical valve is the best choice

BY THORALF M. SUNDT III, M.D.

It’s not very sexy to talk about mechanical valves, but the reasons for placing a mechanical valve in a 50-year-old patient with rheumatic disease are obvious: Mechanical valves provide outstanding hemodynamics, they are beautifully engineered devices, their durability is beyond question, and, importantly, there’s no survival advantage to a biological prosthesis although one incurs the penalty of reoperation, which in a 50-year-old is going to be inevitable.

While this patient will have to continue on anticoagulation therapy with a mechanical valve, many patients who receive a biological valve, especially those with rheumatic disease, need anticoagulation for atrial fibrillation anyway. One can argue that a maze procedure might convert them to sinus rhythm, but this is least reproducible in the subset of patients with rheumatic disease. What’s more, the American Heart Association/American College of Cardiology Guideline for the Management of Patients With Valvular Heart Disease states that a mechanical prosthesis is reasonable for aortic or mitral valve replacement in patients aged 60 and younger with no contraindication to anticoagulation.

The fact that you have to use Coumadin (warfarin, Bristol-Myers Squibb), is not a condemnation of the mechanical valve; it just means we need to get smarter and better about how we manage anticoagulation in people with these prostheses.

While neither option is desirable, surprisingly morbidity with mechanical and biological valves is not demonstrably different. Stroke, embolic events, and bleeding complications have been found to be similar in numerous studies including a recent one authored by Dr. Vinay Badhwar and colleagues. Among 469 patients aged 65 years or younger who received a bileaflet mechanical prostheses or tissue valves, researchers found nearly identical rates of bleeding and thromboembolic complications when the anticoagulation was closely monitored (Ann. Thorac. Surg. 2012;93:748-53) Indeed, they even identified a mortality benefit among those with mechanical valves.

It’s also worth noting that the risk of anticoagulation-related complications is higher when the patient’s INR (international normalized ratio) is poorly controlled; up to 60% of INR values are outside the therapeutic range when thromboembolic complications occur. One can anticipate home INR testing and home management as ways to help patients stay within therapeutic range and reduce these risks. If the issue is anticoagulation, let’s improve it.

In summary, if you implant a biological valve in a 50-year-old patient, I guarantee that patient is going to be back for a reoperation and the prosthesis is going to deteriorate. For the surgeon, a biological valve can be an annuity of sorts. The mechanical valve has a clear advantage in durability, especially in younger patients.

Neither one is perfect, but there is no difference in morbidity between the two. A tissue prosthesis just buys you a reoperation – maybe valve-in-valve transcatheter valve. Maybe.

Dr. Sundt is chief of the division of cardiac surgery, Massachusetts General Hospital, Harvard Medical School, Boston. He is an adviser to Thrasos Innovation, but has no relevant relationships to disclose.

Why biological valve is the better choice

BY ANELECHI C. ANYANWU, M.D.

The reality is that whether you implant a mechanical or biological valve for mitral regurgitation, neither is good. The survival is poor. The half-life or median survival of a patient after either valve is about 15-20 years. The death rates are about 3% per year. The morbidity is high whether you have mechanical or biological valve, and none of them are good mitral substitutes.

Yet the biological valve is often a reasonable choice for a 50-year-old patient, despite studies that have shown a higher reoperation rate and decreased survival rate after biological mitral valve repair when compared to mechanical valve implantation in patients aged 65 and younger. But those study results may be skewed.

Dr. Tsuyoshi Kaneko and colleagues at Brigham and Women’s Hospital, Boston, showed that survival at about 20 years was much better with the mechanical valve. (J. Thorac. Cardiovasc. Surg. 2014;147:117-26). However, the difference in survival is greatest immediately after surgery. By 1 year the survival difference between mechanical valve and a tissue valve was more than 10%.

Why is this? I would argue this is a function of patient selection. We know in the United States that a patient with no insurance or low socioeconomic status does poorly compared to one who does have insurance. With a mechanical valve, they can thrombose; but with a biological valve, if they don’t take care of their health, of course they can die early. The reality is surgeons tend to use biological valves in patients of lower socioeconomic status and those with questionable compliance. None of these factors were considered in the propensity matching used in this study.

Dr. Joanna Chikwe and colleagues at Mount Sinai recently compared outcomes in several thousand patients who underwent biological or mechanical mitral valve replacement in New York State (JAMA 2015:323:1435-42). They found no survival difference in the first 30 or 90 days after surgery, or even at 15 years among patients aged 50-69 years. Indeed, a critical review of any study that has shown a survival advantage of the mechanical valve would find that the advantage occurred within the first few months after surgery, making it likely that such differences are due to patient selection, or other systematic bias, rather than a prostheses effect.

Mayo Clinic investigators, including Dr. Thoralf M. Sundt III, reported that among a cohort that received a mechanical valve, with an average age of 65 years, 16% had had a stroke at 5 years, compared with 8% of the biological valve group (J. Am. Coll. Cardiol. 2008;51:1203-11). You can only imagine what would happen at 10 or 20 years. They followed the data out to 10 years for thromboembolic events; that rate was 30% in the mechanical valve group. They concluded, “the mechanical valve is the least desirable correction of mitral regurgitation.”

As for managing anticoagulation, the literature provides no evidence that self-testing is superior to clinic testing. A trial published in the New England Journal of Medicine involving more than 2,000 patients, 700 of whom had a mechanical valve, showed a higher rate of stroke in patients who were randomized to home-INR monitoring compared with INR in the clinic. (N. Engl. J. Med. 2010;363:1608-20). Self-testing did not delay the time to first stroke, bleeding, or death.

Anticoagulation can be problematic if the patient needs to undergo another operation or medical procedure later, especially on an emergent basis. If the patient with a mechanical valve stops anticoagulation for even a short period of time, the risk of valve thrombosis is great. A patient with a biological valve can stop anticoagulation for a week or more without any consequence.

Finally, I relate the story of a man who could not bear the clicking sound of his mechanical valve. He asked for a new valve, but the surgeon would not take his request seriously. The man was taking drugs and started treatment for posttraumatic stress disorder. After 3 years, he killed himself. How many times have we sat down and talked to patients about what the clicking sound can do to them? Why don’t we make more of this? The patient should be given more choice.

Dr. Anyanwu is with the department of cardiac surgery, Mount Sinai Medical Center, New York. He has no relationships to disclose.

Mechanical valve is the best choice

BY THORALF M. SUNDT III, M.D.

It’s not very sexy to talk about mechanical valves, but the reasons for placing a mechanical valve in a 50-year-old patient with rheumatic disease are obvious: Mechanical valves provide outstanding hemodynamics, they are beautifully engineered devices, their durability is beyond question, and, importantly, there’s no survival advantage to a biological prosthesis although one incurs the penalty of reoperation, which in a 50-year-old is going to be inevitable.

While this patient will have to continue on anticoagulation therapy with a mechanical valve, many patients who receive a biological valve, especially those with rheumatic disease, need anticoagulation for atrial fibrillation anyway. One can argue that a maze procedure might convert them to sinus rhythm, but this is least reproducible in the subset of patients with rheumatic disease. What’s more, the American Heart Association/American College of Cardiology Guideline for the Management of Patients With Valvular Heart Disease states that a mechanical prosthesis is reasonable for aortic or mitral valve replacement in patients aged 60 and younger with no contraindication to anticoagulation.

The fact that you have to use Coumadin (warfarin, Bristol-Myers Squibb), is not a condemnation of the mechanical valve; it just means we need to get smarter and better about how we manage anticoagulation in people with these prostheses.

While neither option is desirable, surprisingly morbidity with mechanical and biological valves is not demonstrably different. Stroke, embolic events, and bleeding complications have been found to be similar in numerous studies including a recent one authored by Dr. Vinay Badhwar and colleagues. Among 469 patients aged 65 years or younger who received a bileaflet mechanical prostheses or tissue valves, researchers found nearly identical rates of bleeding and thromboembolic complications when the anticoagulation was closely monitored (Ann. Thorac. Surg. 2012;93:748-53) Indeed, they even identified a mortality benefit among those with mechanical valves.

It’s also worth noting that the risk of anticoagulation-related complications is higher when the patient’s INR (international normalized ratio) is poorly controlled; up to 60% of INR values are outside the therapeutic range when thromboembolic complications occur. One can anticipate home INR testing and home management as ways to help patients stay within therapeutic range and reduce these risks. If the issue is anticoagulation, let’s improve it.

In summary, if you implant a biological valve in a 50-year-old patient, I guarantee that patient is going to be back for a reoperation and the prosthesis is going to deteriorate. For the surgeon, a biological valve can be an annuity of sorts. The mechanical valve has a clear advantage in durability, especially in younger patients.

Neither one is perfect, but there is no difference in morbidity between the two. A tissue prosthesis just buys you a reoperation – maybe valve-in-valve transcatheter valve. Maybe.

Dr. Sundt is chief of the division of cardiac surgery, Massachusetts General Hospital, Harvard Medical School, Boston. He is an adviser to Thrasos Innovation, but has no relevant relationships to disclose.

Why biological valve is the better choice

BY ANELECHI C. ANYANWU, M.D.

The reality is that whether you implant a mechanical or biological valve for mitral regurgitation, neither is good. The survival is poor. The half-life or median survival of a patient after either valve is about 15-20 years. The death rates are about 3% per year. The morbidity is high whether you have mechanical or biological valve, and none of them are good mitral substitutes.

Yet the biological valve is often a reasonable choice for a 50-year-old patient, despite studies that have shown a higher reoperation rate and decreased survival rate after biological mitral valve repair when compared to mechanical valve implantation in patients aged 65 and younger. But those study results may be skewed.

Dr. Tsuyoshi Kaneko and colleagues at Brigham and Women’s Hospital, Boston, showed that survival at about 20 years was much better with the mechanical valve. (J. Thorac. Cardiovasc. Surg. 2014;147:117-26). However, the difference in survival is greatest immediately after surgery. By 1 year the survival difference between mechanical valve and a tissue valve was more than 10%.

Why is this? I would argue this is a function of patient selection. We know in the United States that a patient with no insurance or low socioeconomic status does poorly compared to one who does have insurance. With a mechanical valve, they can thrombose; but with a biological valve, if they don’t take care of their health, of course they can die early. The reality is surgeons tend to use biological valves in patients of lower socioeconomic status and those with questionable compliance. None of these factors were considered in the propensity matching used in this study.

Dr. Joanna Chikwe and colleagues at Mount Sinai recently compared outcomes in several thousand patients who underwent biological or mechanical mitral valve replacement in New York State (JAMA 2015:323:1435-42). They found no survival difference in the first 30 or 90 days after surgery, or even at 15 years among patients aged 50-69 years. Indeed, a critical review of any study that has shown a survival advantage of the mechanical valve would find that the advantage occurred within the first few months after surgery, making it likely that such differences are due to patient selection, or other systematic bias, rather than a prostheses effect.

Mayo Clinic investigators, including Dr. Thoralf M. Sundt III, reported that among a cohort that received a mechanical valve, with an average age of 65 years, 16% had had a stroke at 5 years, compared with 8% of the biological valve group (J. Am. Coll. Cardiol. 2008;51:1203-11). You can only imagine what would happen at 10 or 20 years. They followed the data out to 10 years for thromboembolic events; that rate was 30% in the mechanical valve group. They concluded, “the mechanical valve is the least desirable correction of mitral regurgitation.”

As for managing anticoagulation, the literature provides no evidence that self-testing is superior to clinic testing. A trial published in the New England Journal of Medicine involving more than 2,000 patients, 700 of whom had a mechanical valve, showed a higher rate of stroke in patients who were randomized to home-INR monitoring compared with INR in the clinic. (N. Engl. J. Med. 2010;363:1608-20). Self-testing did not delay the time to first stroke, bleeding, or death.

Anticoagulation can be problematic if the patient needs to undergo another operation or medical procedure later, especially on an emergent basis. If the patient with a mechanical valve stops anticoagulation for even a short period of time, the risk of valve thrombosis is great. A patient with a biological valve can stop anticoagulation for a week or more without any consequence.

Finally, I relate the story of a man who could not bear the clicking sound of his mechanical valve. He asked for a new valve, but the surgeon would not take his request seriously. The man was taking drugs and started treatment for posttraumatic stress disorder. After 3 years, he killed himself. How many times have we sat down and talked to patients about what the clicking sound can do to them? Why don’t we make more of this? The patient should be given more choice.

Dr. Anyanwu is with the department of cardiac surgery, Mount Sinai Medical Center, New York. He has no relationships to disclose.

I consider my role as an editorialist to be to inform, persuade, or—sometimes—just comment on current issues that affect PAs and NPs. There have been many opportunities in recent years to address “hot” topics, and this is certainly one of them: the rise of distance entry-level education for health professions students.

The catalyst for this discussion? Earlier this year, Yale University announced it was launching an online entry-level PA program.¹ Within minutes of that announcement, there was a conflagration of criticism from the profession, alumni, and the general public. Most of the backlash centered on concerns about adequate delivery of such intense content—including how to instill or enhance professional behaviors and attitudes, or teach hands-on procedures, objective structured clinical examinations (OSCEs), and physical exam techniques—from a distance.

See also: Letter to the Editor from Janet Evans Emery, RN, MSN, CFNP

Share YOUR thoughts with us!

In our professions, we tend to be fairly conservative when it comes to change—particularly in terms of innovations in our education programs. But as e-learning, simulations, and distance education modalities become ever more prevalent across the spectrum of higher learning, we require an improved understanding of how these methods will transform ­entry-level education for health care providers.

Until recently, there has been minimal data on the impact of these technologic advances and teaching methods in health professions education, although this is changing.² We do have a research gap when it comes to the effect of learning style on NP and PA students’ perceptions of online instruction (despite the rapidly increasing use of it). We also have not firmly established how this delivery method affects professional development (ie, how effectively it prepares clinicians to provide care to patients). None of this has prevented the proliferation of these concepts.

While many were stunned by the Yale venture, it should be ­noted that the idea is not new. Rather, such programs have steadily ­become part of health professions education (particularly nursing) in recent years.³ Yale itself was an early adopter of “bridge” programs; for example, someone with a Bachelor of Science in any field could enter the NP program, becoming an RN in one year and an NP in the second.

As far as “distance learning,” offering graduate degrees in a health profession to remote students dates back to at least the early 1990s, when the University of Pennsylvania offered a ­videoconference-based master’s in nurse-midwifery. Since then, of course, technology has advanced to a level that allows individuals to view videos and “conference” online via personal electronic devices of one kind or another—a vast improvement on the expensive and inflexible room-scale video presentations of 20 years ago.

As these technologic limitations have fallen by the wayside and alterations to our educational structure have become more feasible, more colleges and universities are exploring their options. The PA programs at the University of North Dakota and the University of Wisconsin–Madison have experimented with blended online learning environments. My own university has an interest in moving to ever-higher levels of distant interaction.

Major criticism of distance education includes the perception that it is a “watered-down” version of the “real thing.” There is also concern that educational institutions might be motivated purely by money, if the sole impetus for distance learning is to significantly increase enrollment. And some critics, while not opposed to online courses per se, do not want an NP or PA seeing patients if his/her degree was earned online—not even in part!

Perhaps the larger issue we’re struggling with is that a new paradigm of teaching is emerging: We are moving away from the traditional Socratic method to more interactive modalities, such as flipped classrooms (settings in which students collaborate via online discussion). Synchronous classes can be delivered ­seminar-style, with each student able to hear the others and instructors able to share content and even give control of a class to a student for questions or presentations. Asynchronous courses offer opportunities for students to study on their own time and at their own pace. Many suggest that more comprehensive learning, including the development of critical thinking skills, occurs in programs of this design than in traditional education programs.⁴

I think there is little argument that the educational content (didactics) of a program can be successfully delivered through a nonresidential venue. The concern, rightly so, in health professional education is how to adequately deliver the practical and cocurricular experiences at a distance. Some of us may have a difficult time understanding how this new method of teaching can create the kind of clinicians that are needed, particularly in the relatively short period in which PAs and NPs are prepared for their roles.

Proponents insist that these programs can be successful, as long as they are accredited by the appropriate agency and demonstrate high educational standards (comparable to traditional programs). Programs also need to provide clinical experiences in which the students observe and actually work with patients in order to develop skills in the art of history taking and physical examination, establishment of a differential diagnosis, creation of a plan of action, and appropriate ­decision-making with regard to available tests and treatment options. Advocates of distance learning also agree that students must be observed by peer clinicians who can confirm that they are ethical and competent to practice, have good bedside manners, and demonstrate respect for the profession and for life.

And who knows? Distance learning may create opportunities to improve access to care in remote, rural, and underserved areas, as these could become fertile training grounds for NPs and PAs (a return to our roots, in a sense). In this age of successful telemedicine, why shouldn’t “tele-education” be the next success story? Although the jury is still out on this concept, the proverbial cat has already been let out of the bag! Only time will tell what results we will see. But I think with the significant enhancement of technology, and participation of committed educators who are willing to step into the arena to ensure that competency-based education persists, we will be pleasantly surprised by the success of this venture.

I would be interested in your views. Please email me at [email protected].

REFERENCES
1. Monir M. Yale to offer full-time master’s program online. USA Today. www.usatoday.com/story/news/nation/2015/03/12/yale-full-time-online-masters-program/70163994. Accessed May 2, 2015.
2. Kushniruk AW. Advances in health education applying e-learning, simulations and distance technologies [editorial]. Knowledge Manage E-Learning Int J. 2011;3(1):1-4.
3. Robley LR, Farnsworth BJ, Flynn JB, Horne CD. This new house: building knowledge through online learning. J Prof Nurs. 2004;20(5):333-343.
4. Yang YTC, Chou HA. Beyond critical thinking skills: investigating the relationship between critical thinking skills and dispositions through different online instructional strategies. Br J Educ Technol. 2008;39(4):666-684.

I consider my role as an editorialist to be to inform, persuade, or—sometimes—just comment on current issues that affect PAs and NPs. There have been many opportunities in recent years to address “hot” topics, and this is certainly one of them: the rise of distance entry-level education for health professions students.

The catalyst for this discussion? Earlier this year, Yale University announced it was launching an online entry-level PA program.¹ Within minutes of that announcement, there was a conflagration of criticism from the profession, alumni, and the general public. Most of the backlash centered on concerns about adequate delivery of such intense content—including how to instill or enhance professional behaviors and attitudes, or teach hands-on procedures, objective structured clinical examinations (OSCEs), and physical exam techniques—from a distance.

See also: Letter to the Editor from Janet Evans Emery, RN, MSN, CFNP

Share YOUR thoughts with us!

In our professions, we tend to be fairly conservative when it comes to change—particularly in terms of innovations in our education programs. But as e-learning, simulations, and distance education modalities become ever more prevalent across the spectrum of higher learning, we require an improved understanding of how these methods will transform ­entry-level education for health care providers.

Until recently, there has been minimal data on the impact of these technologic advances and teaching methods in health professions education, although this is changing.² We do have a research gap when it comes to the effect of learning style on NP and PA students’ perceptions of online instruction (despite the rapidly increasing use of it). We also have not firmly established how this delivery method affects professional development (ie, how effectively it prepares clinicians to provide care to patients). None of this has prevented the proliferation of these concepts.

While many were stunned by the Yale venture, it should be ­noted that the idea is not new. Rather, such programs have steadily ­become part of health professions education (particularly nursing) in recent years.³ Yale itself was an early adopter of “bridge” programs; for example, someone with a Bachelor of Science in any field could enter the NP program, becoming an RN in one year and an NP in the second.

As far as “distance learning,” offering graduate degrees in a health profession to remote students dates back to at least the early 1990s, when the University of Pennsylvania offered a ­videoconference-based master’s in nurse-midwifery. Since then, of course, technology has advanced to a level that allows individuals to view videos and “conference” online via personal electronic devices of one kind or another—a vast improvement on the expensive and inflexible room-scale video presentations of 20 years ago.

As these technologic limitations have fallen by the wayside and alterations to our educational structure have become more feasible, more colleges and universities are exploring their options. The PA programs at the University of North Dakota and the University of Wisconsin–Madison have experimented with blended online learning environments. My own university has an interest in moving to ever-higher levels of distant interaction.

Major criticism of distance education includes the perception that it is a “watered-down” version of the “real thing.” There is also concern that educational institutions might be motivated purely by money, if the sole impetus for distance learning is to significantly increase enrollment. And some critics, while not opposed to online courses per se, do not want an NP or PA seeing patients if his/her degree was earned online—not even in part!

Perhaps the larger issue we’re struggling with is that a new paradigm of teaching is emerging: We are moving away from the traditional Socratic method to more interactive modalities, such as flipped classrooms (settings in which students collaborate via online discussion). Synchronous classes can be delivered ­seminar-style, with each student able to hear the others and instructors able to share content and even give control of a class to a student for questions or presentations. Asynchronous courses offer opportunities for students to study on their own time and at their own pace. Many suggest that more comprehensive learning, including the development of critical thinking skills, occurs in programs of this design than in traditional education programs.⁴

I think there is little argument that the educational content (didactics) of a program can be successfully delivered through a nonresidential venue. The concern, rightly so, in health professional education is how to adequately deliver the practical and cocurricular experiences at a distance. Some of us may have a difficult time understanding how this new method of teaching can create the kind of clinicians that are needed, particularly in the relatively short period in which PAs and NPs are prepared for their roles.

Proponents insist that these programs can be successful, as long as they are accredited by the appropriate agency and demonstrate high educational standards (comparable to traditional programs). Programs also need to provide clinical experiences in which the students observe and actually work with patients in order to develop skills in the art of history taking and physical examination, establishment of a differential diagnosis, creation of a plan of action, and appropriate ­decision-making with regard to available tests and treatment options. Advocates of distance learning also agree that students must be observed by peer clinicians who can confirm that they are ethical and competent to practice, have good bedside manners, and demonstrate respect for the profession and for life.

And who knows? Distance learning may create opportunities to improve access to care in remote, rural, and underserved areas, as these could become fertile training grounds for NPs and PAs (a return to our roots, in a sense). In this age of successful telemedicine, why shouldn’t “tele-education” be the next success story? Although the jury is still out on this concept, the proverbial cat has already been let out of the bag! Only time will tell what results we will see. But I think with the significant enhancement of technology, and participation of committed educators who are willing to step into the arena to ensure that competency-based education persists, we will be pleasantly surprised by the success of this venture.

I would be interested in your views. Please email me at [email protected].

REFERENCES
1. Monir M. Yale to offer full-time master’s program online. USA Today. www.usatoday.com/story/news/nation/2015/03/12/yale-full-time-online-masters-program/70163994. Accessed May 2, 2015.
2. Kushniruk AW. Advances in health education applying e-learning, simulations and distance technologies [editorial]. Knowledge Manage E-Learning Int J. 2011;3(1):1-4.
3. Robley LR, Farnsworth BJ, Flynn JB, Horne CD. This new house: building knowledge through online learning. J Prof Nurs. 2004;20(5):333-343.
4. Yang YTC, Chou HA. Beyond critical thinking skills: investigating the relationship between critical thinking skills and dispositions through different online instructional strategies. Br J Educ Technol. 2008;39(4):666-684.

I consider my role as an editorialist to be to inform, persuade, or—sometimes—just comment on current issues that affect PAs and NPs. There have been many opportunities in recent years to address “hot” topics, and this is certainly one of them: the rise of distance entry-level education for health professions students.

The catalyst for this discussion? Earlier this year, Yale University announced it was launching an online entry-level PA program.¹ Within minutes of that announcement, there was a conflagration of criticism from the profession, alumni, and the general public. Most of the backlash centered on concerns about adequate delivery of such intense content—including how to instill or enhance professional behaviors and attitudes, or teach hands-on procedures, objective structured clinical examinations (OSCEs), and physical exam techniques—from a distance.

See also: Letter to the Editor from Janet Evans Emery, RN, MSN, CFNP

Share YOUR thoughts with us!

In our professions, we tend to be fairly conservative when it comes to change—particularly in terms of innovations in our education programs. But as e-learning, simulations, and distance education modalities become ever more prevalent across the spectrum of higher learning, we require an improved understanding of how these methods will transform ­entry-level education for health care providers.

Until recently, there has been minimal data on the impact of these technologic advances and teaching methods in health professions education, although this is changing.² We do have a research gap when it comes to the effect of learning style on NP and PA students’ perceptions of online instruction (despite the rapidly increasing use of it). We also have not firmly established how this delivery method affects professional development (ie, how effectively it prepares clinicians to provide care to patients). None of this has prevented the proliferation of these concepts.

While many were stunned by the Yale venture, it should be ­noted that the idea is not new. Rather, such programs have steadily ­become part of health professions education (particularly nursing) in recent years.³ Yale itself was an early adopter of “bridge” programs; for example, someone with a Bachelor of Science in any field could enter the NP program, becoming an RN in one year and an NP in the second.

As far as “distance learning,” offering graduate degrees in a health profession to remote students dates back to at least the early 1990s, when the University of Pennsylvania offered a ­videoconference-based master’s in nurse-midwifery. Since then, of course, technology has advanced to a level that allows individuals to view videos and “conference” online via personal electronic devices of one kind or another—a vast improvement on the expensive and inflexible room-scale video presentations of 20 years ago.

As these technologic limitations have fallen by the wayside and alterations to our educational structure have become more feasible, more colleges and universities are exploring their options. The PA programs at the University of North Dakota and the University of Wisconsin–Madison have experimented with blended online learning environments. My own university has an interest in moving to ever-higher levels of distant interaction.

Major criticism of distance education includes the perception that it is a “watered-down” version of the “real thing.” There is also concern that educational institutions might be motivated purely by money, if the sole impetus for distance learning is to significantly increase enrollment. And some critics, while not opposed to online courses per se, do not want an NP or PA seeing patients if his/her degree was earned online—not even in part!

Perhaps the larger issue we’re struggling with is that a new paradigm of teaching is emerging: We are moving away from the traditional Socratic method to more interactive modalities, such as flipped classrooms (settings in which students collaborate via online discussion). Synchronous classes can be delivered ­seminar-style, with each student able to hear the others and instructors able to share content and even give control of a class to a student for questions or presentations. Asynchronous courses offer opportunities for students to study on their own time and at their own pace. Many suggest that more comprehensive learning, including the development of critical thinking skills, occurs in programs of this design than in traditional education programs.⁴

I think there is little argument that the educational content (didactics) of a program can be successfully delivered through a nonresidential venue. The concern, rightly so, in health professional education is how to adequately deliver the practical and cocurricular experiences at a distance. Some of us may have a difficult time understanding how this new method of teaching can create the kind of clinicians that are needed, particularly in the relatively short period in which PAs and NPs are prepared for their roles.

Proponents insist that these programs can be successful, as long as they are accredited by the appropriate agency and demonstrate high educational standards (comparable to traditional programs). Programs also need to provide clinical experiences in which the students observe and actually work with patients in order to develop skills in the art of history taking and physical examination, establishment of a differential diagnosis, creation of a plan of action, and appropriate ­decision-making with regard to available tests and treatment options. Advocates of distance learning also agree that students must be observed by peer clinicians who can confirm that they are ethical and competent to practice, have good bedside manners, and demonstrate respect for the profession and for life.

And who knows? Distance learning may create opportunities to improve access to care in remote, rural, and underserved areas, as these could become fertile training grounds for NPs and PAs (a return to our roots, in a sense). In this age of successful telemedicine, why shouldn’t “tele-education” be the next success story? Although the jury is still out on this concept, the proverbial cat has already been let out of the bag! Only time will tell what results we will see. But I think with the significant enhancement of technology, and participation of committed educators who are willing to step into the arena to ensure that competency-based education persists, we will be pleasantly surprised by the success of this venture.

I would be interested in your views. Please email me at [email protected].

REFERENCES
1. Monir M. Yale to offer full-time master’s program online. USA Today. www.usatoday.com/story/news/nation/2015/03/12/yale-full-time-online-masters-program/70163994. Accessed May 2, 2015.
2. Kushniruk AW. Advances in health education applying e-learning, simulations and distance technologies [editorial]. Knowledge Manage E-Learning Int J. 2011;3(1):1-4.
3. Robley LR, Farnsworth BJ, Flynn JB, Horne CD. This new house: building knowledge through online learning. J Prof Nurs. 2004;20(5):333-343.
4. Yang YTC, Chou HA. Beyond critical thinking skills: investigating the relationship between critical thinking skills and dispositions through different online instructional strategies. Br J Educ Technol. 2008;39(4):666-684.

As Medicare celebrates its 50th anniversary, federal officials are beginning one of the most significant shifts in the program’s history – paying physicians based on quality and efficiency rather than for the volume of services they provide. The shift to so-called value-based payment will be phased in, but it is coming soon.

Earlier this year, federal officials announced their goal to tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018, relying heavily on the use of alternative payment models such as Accountable Care Organizations (ACOs) and bundled payments. The shift also is being driven by the recent repeal of Medicare’s Sustainable Growth Rate formula. The law that removed the SGR from physicians’ lives also created alternative payment pathways that tie payments to performance on certain quality metrics or successful participation as part of an ACO.

How will these changes affect how physicians deliver care in the future? We invited physicians in various practice settings to offer their perspectives on how the new payment paradigm will drive practice changes.

‘Value’ payment system is arbitrary

BY JOSEPH S. EASTERN, M.D.

While much has been written about the Centers for Medicare & Medicaid Services’ plan to shift its payment system away from fee-for-service and toward a “value-based” structure, most physicians in small and solo private settings have given little if any thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS’s plan is something called the value-based payment modifier (VBPM), a component of the Affordable Care Act. The VBPM has not been on the radar of smaller private practices because up until now it has only applied to groups with more than 10 providers. Beginning this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBPM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBPM “score.”

It will adjust your reimbursements based on quality of care as defined by the CMS and cost, compared to other physicians. Your “score” will have a quality component and a cost component, and will be calculated based on measures reported through the Physician Quality Reporting System (PQRS). And the ACA requires that the program be budget neutral, which means that all rewards to physicians who pull the highest scores must be offset by penalties, or “negative adjustments,” to those who don’t score as well. In essence, the VBPM establishes arbitrary practice standards and spending ceilings; physicians who have the temerity to practice medicine as they see fit, or spend too much relative to their peers, will be punished.

Beyond the obvious and very real possibility of significant financial hardship, there are serious potential consequences inherent in this unprecedented new system. Health care is already among the most regulated industries in the country; the VBPM creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. The inevitable result will be compromised care and further limitation of patient access.

The VBPM’s potential effects on physician-patient relations and legal liability are additional serious concerns. Many patients will object to their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs; and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

The already strained relationship between physicians and their hospitals will likely deteriorate as well. Hospital administrators will be scrutinizing each medical decision from admission to discharge, particularly in those institutions already in financial trouble, as is all too often the case. The constant necessity of justifying every significant order and consult will not be in anyone’s best interest, least of all that of patients.

For all the talk that the transition from fee-for-service to value-based reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing. Conversely, there are plenty of warning signs that physicians in small private practices who can’t meet the new performance standards may face a significant financial burden because of the resulting penalties and lower reimbursements.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.

Staying independent may prove costly

BY PETER M.G. DEANE, M.D.

The changes announced for Medicare and Medicaid, to be implemented over the next few years, are breathtaking in scope and ambition. A system based on payment for services is to become a system based on payment for individual health and population health outcomes. This will require enormous changes in the way health care is delivered, and this is an intended effect. Private payers will certainly desire the same results and savings.

I am a partner in a multiphysician, single-specialty private group practice. We have two hospital systems locally. Both of these are now health systems, in that they either employ or closely interact with many physicians.

Just a few years ago, our practice could comfortably make decisions about how we went about delivering care without much consideration of the plans of larger local institutions. Then came the rise of our local accountable care networks. These were created by the local health care systems to provide the overall organizational infrastructure to move from the current payment model to the coming one. We delayed for awhile but have now signed up with both. It can only be a matter of months before each of them pursues a meaningful degree of clinical integration. In other words, they will be analyzing data from our electronic medical record about our individual practice patterns and results, and giving us the results along with feedback on how to improve care.

For this to happen, our EMR system needs to be up to the task. We are unsure it will be. It has been difficult for some of us to adapt to electronic records systems. Now we need to see if our existing system can interoperate effectively. If not, we may be paying quite a bit for another one soon.

Our physicians are not accustomed to seeing report cards about their practice patterns. It will be a shock to see comparisons and rankings. But patients will be enrolled in and referred to us by the networks, and it will not be possible to ignore the reports we get.

Likely this radical change in the practice of medicine will drive some to retire, affecting the size of our group. We intend to remain in private practice, but independence may prove increasingly costly.

Already, patients see that their physicians make less eye contact with them and more time documenting care. This will likely get worse. We worry that if increased expenses cause staff cuts, the personal service we provide will suffer.

Redesigning medical practice will be a serious challenge for us. But our goal has always been to provide the best care, and in a value-based system, that should be what sustains us all.

Dr. Deane specializes in allergy, immunology, and rheumatology and is a partner in a private group practice with eight physicians and five offices in greater Rochester, N.Y. He is also the chief of allergy, immunology, and rheumatology at Unity Hospital in Rochester.

Value shift brings irreparable change to private practice

BY ROBERT SHOR, M.D.

The simple truth is that we are in transition. The current health system, for the most part, rewards “making widgets” (volume). That is, being paid for units of work actually being done. The more patients you see, the more procedures you do, the more you are compensated. We are moving from “volume” to “value” as we try to move away from “widgets” to management of population health. How do we get there? What can we as physicians and providers do?

I am part of a 40-person, single-specialty private cardiology practice in the Washington, D.C., suburbs. In the coming years, the CMS will reward (the euphemism for payment) practices that meet their definitions for quality and penalize those that don’t meet those metrics.

We have participated in PQRS/PQRI, Meaningful Use (MU), and other Medicare programs for which we are compensated. But how do you truly determine what are quality metrics and what is truly meaningful use of health system resources? How do we impact health on an individual and population view?

For us to be compliant with the Medicare rules and get paid, we have had to heavily invest in not only EHRs (we were an early adopter around 2000), but personnel costs to make sure all of the paperwork is completed appropriately for submission and for the audit that precedes the CMS payment for MU.

So how do we proceed going forward? In my opinion, what is clear is that private practice has been irreparably changed. The notion of an individual physician or a small practice surviving without some arrangement with a health system, an ACO, or a Clinical Integrated Network (CIN) is rapidly dwindling.

I have seen a variety of actions taken as providers try to survive and jockey for position to their advantage and we have explored a wide range of options. For an ACO to succeed in the shared risk model, it usually is part of a larger health care system. Thus many practices – primary care and subspecialty – have integrated with these health systems. Indeed, about 70% of the cardiology community is now integrated. To manage costs, you need to know your costs and most of the cost remains in the hospital care.

What do you do if you want to stay independent or do not feel you have a reliable health system with which you can integrate? Many practices may merge in a formal or looser network of practices to create a CIN where EHR access to patient records within the network is streamlined and care can be more effectively given. This has benefits, but also limitations. I believe that any future in which cost is contained on a larger scale will require close collaboration with hospitals given the disproportionate cost incurred during hospital care. Some practices have decided to form Physician Service Agreements with hospital systems to help manage product lines within the health system and to establish more meaningful relationships in an effort to coordinate care more effectively. This provides an opportunity to impact inpatient care, to contribute to programs that reduce hospital readmissions, and to reach the holy grail of preventing disease by better outpatient care. This would truly help with population health care management.

Some of the challenges, at least in large metropolitan areas, are that practices may work at several hospitals with different health systems. They may want to continue providing care at all of the hospitals in their community, but may be forced to choose. This does not appear to me to be in the best interest of our patients, many of whom we have cared for many years. However, the choice may be forced upon them as the health systems force the issue and make the decision for us.

The future holds much uncertainty, but also opportunity. Will our practice survive in its current form in 5 years? For now we are trying to read the tea leaves, like so many others, to make the best decisions on behalf of our patients to allow us to be able to continue to provide care in our community.

We are still reading the tea leaves.

Dr. Shor is vice president of Virginia Heart, which has nine offices in the northern Virginia region. He is the chair of the board of governors of the American College of Cardiology.

Leaving behind fee-for-service battles

BY ROBERT FIELDS, M.D.

Many of us in health care received with a mix of excitement and fear the recent news from the CMS regarding the transition to 90% value-based payments by 2018. For me, an employed family medicine physician and medical director of a new ACO in western North Carolina, I applaud the ambitious goal and understand the sentiment behind it. But, I also worry about the ability of most providers to adapt to this change in such a short time span.

The rationale behind value-based payments couldn’t be clearer – we spend too much on health care. Way too much. So much, that if we continue on this track our country will break under the financial pressures of providing care in a fee-for-service system. In addition, U.S. medical outcomes lag behind most other industrialized nations, which leads to the conclusion that the system at large is not providing the value it should.

As I put on my rose-colored glasses, I hope this restructuring encourages the system at large to coordinate care better, to improve our information systems to share relevant clinical data, and to encourage quality improvement at the practice level so that we move toward improved outcomes for our patient populations.

When talking to providers about our ACO and adding value in health care, they think we are saying that THEY are not delivering high value care. I keep reiterating, and will continue to do so, that value-based payments are not a criticism of our individual abilities as physicians or a comment on our interactions with our patients, but acknowledgment that how we communicate with and manage our populations as a network of hospitals, providers, and agencies lacks the efficiencies and coordination of services that patients deserve.

Ultimately, we are moving toward a patient-centered health care system that requires a fundamental transformation in how we pay for and deliver care. Measurement and quality improvement, although new to health care, has existed in every other industry for years.

In the end, I hope patients feel they are getting more efficient, coordinated care and that providers can start to see improvements in outcomes without the daily battle of the fee-for-service world.

Dr. Fields is a family physician and the medical director of Mission Health Partners, a physician led ACO in Asheville, N.C.

As Medicare celebrates its 50th anniversary, federal officials are beginning one of the most significant shifts in the program’s history – paying physicians based on quality and efficiency rather than for the volume of services they provide. The shift to so-called value-based payment will be phased in, but it is coming soon.

Earlier this year, federal officials announced their goal to tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018, relying heavily on the use of alternative payment models such as Accountable Care Organizations (ACOs) and bundled payments. The shift also is being driven by the recent repeal of Medicare’s Sustainable Growth Rate formula. The law that removed the SGR from physicians’ lives also created alternative payment pathways that tie payments to performance on certain quality metrics or successful participation as part of an ACO.

How will these changes affect how physicians deliver care in the future? We invited physicians in various practice settings to offer their perspectives on how the new payment paradigm will drive practice changes.

‘Value’ payment system is arbitrary

BY JOSEPH S. EASTERN, M.D.

While much has been written about the Centers for Medicare & Medicaid Services’ plan to shift its payment system away from fee-for-service and toward a “value-based” structure, most physicians in small and solo private settings have given little if any thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS’s plan is something called the value-based payment modifier (VBPM), a component of the Affordable Care Act. The VBPM has not been on the radar of smaller private practices because up until now it has only applied to groups with more than 10 providers. Beginning this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBPM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBPM “score.”

It will adjust your reimbursements based on quality of care as defined by the CMS and cost, compared to other physicians. Your “score” will have a quality component and a cost component, and will be calculated based on measures reported through the Physician Quality Reporting System (PQRS). And the ACA requires that the program be budget neutral, which means that all rewards to physicians who pull the highest scores must be offset by penalties, or “negative adjustments,” to those who don’t score as well. In essence, the VBPM establishes arbitrary practice standards and spending ceilings; physicians who have the temerity to practice medicine as they see fit, or spend too much relative to their peers, will be punished.

Beyond the obvious and very real possibility of significant financial hardship, there are serious potential consequences inherent in this unprecedented new system. Health care is already among the most regulated industries in the country; the VBPM creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. The inevitable result will be compromised care and further limitation of patient access.

The VBPM’s potential effects on physician-patient relations and legal liability are additional serious concerns. Many patients will object to their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs; and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

The already strained relationship between physicians and their hospitals will likely deteriorate as well. Hospital administrators will be scrutinizing each medical decision from admission to discharge, particularly in those institutions already in financial trouble, as is all too often the case. The constant necessity of justifying every significant order and consult will not be in anyone’s best interest, least of all that of patients.

For all the talk that the transition from fee-for-service to value-based reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing. Conversely, there are plenty of warning signs that physicians in small private practices who can’t meet the new performance standards may face a significant financial burden because of the resulting penalties and lower reimbursements.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.

Staying independent may prove costly

BY PETER M.G. DEANE, M.D.

The changes announced for Medicare and Medicaid, to be implemented over the next few years, are breathtaking in scope and ambition. A system based on payment for services is to become a system based on payment for individual health and population health outcomes. This will require enormous changes in the way health care is delivered, and this is an intended effect. Private payers will certainly desire the same results and savings.

I am a partner in a multiphysician, single-specialty private group practice. We have two hospital systems locally. Both of these are now health systems, in that they either employ or closely interact with many physicians.

Just a few years ago, our practice could comfortably make decisions about how we went about delivering care without much consideration of the plans of larger local institutions. Then came the rise of our local accountable care networks. These were created by the local health care systems to provide the overall organizational infrastructure to move from the current payment model to the coming one. We delayed for awhile but have now signed up with both. It can only be a matter of months before each of them pursues a meaningful degree of clinical integration. In other words, they will be analyzing data from our electronic medical record about our individual practice patterns and results, and giving us the results along with feedback on how to improve care.

For this to happen, our EMR system needs to be up to the task. We are unsure it will be. It has been difficult for some of us to adapt to electronic records systems. Now we need to see if our existing system can interoperate effectively. If not, we may be paying quite a bit for another one soon.

Our physicians are not accustomed to seeing report cards about their practice patterns. It will be a shock to see comparisons and rankings. But patients will be enrolled in and referred to us by the networks, and it will not be possible to ignore the reports we get.

Likely this radical change in the practice of medicine will drive some to retire, affecting the size of our group. We intend to remain in private practice, but independence may prove increasingly costly.

Already, patients see that their physicians make less eye contact with them and more time documenting care. This will likely get worse. We worry that if increased expenses cause staff cuts, the personal service we provide will suffer.

Redesigning medical practice will be a serious challenge for us. But our goal has always been to provide the best care, and in a value-based system, that should be what sustains us all.

Dr. Deane specializes in allergy, immunology, and rheumatology and is a partner in a private group practice with eight physicians and five offices in greater Rochester, N.Y. He is also the chief of allergy, immunology, and rheumatology at Unity Hospital in Rochester.

Value shift brings irreparable change to private practice

BY ROBERT SHOR, M.D.

The simple truth is that we are in transition. The current health system, for the most part, rewards “making widgets” (volume). That is, being paid for units of work actually being done. The more patients you see, the more procedures you do, the more you are compensated. We are moving from “volume” to “value” as we try to move away from “widgets” to management of population health. How do we get there? What can we as physicians and providers do?

I am part of a 40-person, single-specialty private cardiology practice in the Washington, D.C., suburbs. In the coming years, the CMS will reward (the euphemism for payment) practices that meet their definitions for quality and penalize those that don’t meet those metrics.

We have participated in PQRS/PQRI, Meaningful Use (MU), and other Medicare programs for which we are compensated. But how do you truly determine what are quality metrics and what is truly meaningful use of health system resources? How do we impact health on an individual and population view?

For us to be compliant with the Medicare rules and get paid, we have had to heavily invest in not only EHRs (we were an early adopter around 2000), but personnel costs to make sure all of the paperwork is completed appropriately for submission and for the audit that precedes the CMS payment for MU.

So how do we proceed going forward? In my opinion, what is clear is that private practice has been irreparably changed. The notion of an individual physician or a small practice surviving without some arrangement with a health system, an ACO, or a Clinical Integrated Network (CIN) is rapidly dwindling.

I have seen a variety of actions taken as providers try to survive and jockey for position to their advantage and we have explored a wide range of options. For an ACO to succeed in the shared risk model, it usually is part of a larger health care system. Thus many practices – primary care and subspecialty – have integrated with these health systems. Indeed, about 70% of the cardiology community is now integrated. To manage costs, you need to know your costs and most of the cost remains in the hospital care.

What do you do if you want to stay independent or do not feel you have a reliable health system with which you can integrate? Many practices may merge in a formal or looser network of practices to create a CIN where EHR access to patient records within the network is streamlined and care can be more effectively given. This has benefits, but also limitations. I believe that any future in which cost is contained on a larger scale will require close collaboration with hospitals given the disproportionate cost incurred during hospital care. Some practices have decided to form Physician Service Agreements with hospital systems to help manage product lines within the health system and to establish more meaningful relationships in an effort to coordinate care more effectively. This provides an opportunity to impact inpatient care, to contribute to programs that reduce hospital readmissions, and to reach the holy grail of preventing disease by better outpatient care. This would truly help with population health care management.

Some of the challenges, at least in large metropolitan areas, are that practices may work at several hospitals with different health systems. They may want to continue providing care at all of the hospitals in their community, but may be forced to choose. This does not appear to me to be in the best interest of our patients, many of whom we have cared for many years. However, the choice may be forced upon them as the health systems force the issue and make the decision for us.

The future holds much uncertainty, but also opportunity. Will our practice survive in its current form in 5 years? For now we are trying to read the tea leaves, like so many others, to make the best decisions on behalf of our patients to allow us to be able to continue to provide care in our community.

We are still reading the tea leaves.

Dr. Shor is vice president of Virginia Heart, which has nine offices in the northern Virginia region. He is the chair of the board of governors of the American College of Cardiology.

Leaving behind fee-for-service battles

BY ROBERT FIELDS, M.D.

Many of us in health care received with a mix of excitement and fear the recent news from the CMS regarding the transition to 90% value-based payments by 2018. For me, an employed family medicine physician and medical director of a new ACO in western North Carolina, I applaud the ambitious goal and understand the sentiment behind it. But, I also worry about the ability of most providers to adapt to this change in such a short time span.

The rationale behind value-based payments couldn’t be clearer – we spend too much on health care. Way too much. So much, that if we continue on this track our country will break under the financial pressures of providing care in a fee-for-service system. In addition, U.S. medical outcomes lag behind most other industrialized nations, which leads to the conclusion that the system at large is not providing the value it should.

As I put on my rose-colored glasses, I hope this restructuring encourages the system at large to coordinate care better, to improve our information systems to share relevant clinical data, and to encourage quality improvement at the practice level so that we move toward improved outcomes for our patient populations.

When talking to providers about our ACO and adding value in health care, they think we are saying that THEY are not delivering high value care. I keep reiterating, and will continue to do so, that value-based payments are not a criticism of our individual abilities as physicians or a comment on our interactions with our patients, but acknowledgment that how we communicate with and manage our populations as a network of hospitals, providers, and agencies lacks the efficiencies and coordination of services that patients deserve.

Ultimately, we are moving toward a patient-centered health care system that requires a fundamental transformation in how we pay for and deliver care. Measurement and quality improvement, although new to health care, has existed in every other industry for years.

In the end, I hope patients feel they are getting more efficient, coordinated care and that providers can start to see improvements in outcomes without the daily battle of the fee-for-service world.

Dr. Fields is a family physician and the medical director of Mission Health Partners, a physician led ACO in Asheville, N.C.

As Medicare celebrates its 50th anniversary, federal officials are beginning one of the most significant shifts in the program’s history – paying physicians based on quality and efficiency rather than for the volume of services they provide. The shift to so-called value-based payment will be phased in, but it is coming soon.

Earlier this year, federal officials announced their goal to tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018, relying heavily on the use of alternative payment models such as Accountable Care Organizations (ACOs) and bundled payments. The shift also is being driven by the recent repeal of Medicare’s Sustainable Growth Rate formula. The law that removed the SGR from physicians’ lives also created alternative payment pathways that tie payments to performance on certain quality metrics or successful participation as part of an ACO.

How will these changes affect how physicians deliver care in the future? We invited physicians in various practice settings to offer their perspectives on how the new payment paradigm will drive practice changes.

‘Value’ payment system is arbitrary

BY JOSEPH S. EASTERN, M.D.

While much has been written about the Centers for Medicare & Medicaid Services’ plan to shift its payment system away from fee-for-service and toward a “value-based” structure, most physicians in small and solo private settings have given little if any thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS’s plan is something called the value-based payment modifier (VBPM), a component of the Affordable Care Act. The VBPM has not been on the radar of smaller private practices because up until now it has only applied to groups with more than 10 providers. Beginning this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBPM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBPM “score.”

It will adjust your reimbursements based on quality of care as defined by the CMS and cost, compared to other physicians. Your “score” will have a quality component and a cost component, and will be calculated based on measures reported through the Physician Quality Reporting System (PQRS). And the ACA requires that the program be budget neutral, which means that all rewards to physicians who pull the highest scores must be offset by penalties, or “negative adjustments,” to those who don’t score as well. In essence, the VBPM establishes arbitrary practice standards and spending ceilings; physicians who have the temerity to practice medicine as they see fit, or spend too much relative to their peers, will be punished.

Beyond the obvious and very real possibility of significant financial hardship, there are serious potential consequences inherent in this unprecedented new system. Health care is already among the most regulated industries in the country; the VBPM creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. The inevitable result will be compromised care and further limitation of patient access.

The VBPM’s potential effects on physician-patient relations and legal liability are additional serious concerns. Many patients will object to their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs; and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

The already strained relationship between physicians and their hospitals will likely deteriorate as well. Hospital administrators will be scrutinizing each medical decision from admission to discharge, particularly in those institutions already in financial trouble, as is all too often the case. The constant necessity of justifying every significant order and consult will not be in anyone’s best interest, least of all that of patients.

For all the talk that the transition from fee-for-service to value-based reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing. Conversely, there are plenty of warning signs that physicians in small private practices who can’t meet the new performance standards may face a significant financial burden because of the resulting penalties and lower reimbursements.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.

Staying independent may prove costly

BY PETER M.G. DEANE, M.D.

The changes announced for Medicare and Medicaid, to be implemented over the next few years, are breathtaking in scope and ambition. A system based on payment for services is to become a system based on payment for individual health and population health outcomes. This will require enormous changes in the way health care is delivered, and this is an intended effect. Private payers will certainly desire the same results and savings.

I am a partner in a multiphysician, single-specialty private group practice. We have two hospital systems locally. Both of these are now health systems, in that they either employ or closely interact with many physicians.

Just a few years ago, our practice could comfortably make decisions about how we went about delivering care without much consideration of the plans of larger local institutions. Then came the rise of our local accountable care networks. These were created by the local health care systems to provide the overall organizational infrastructure to move from the current payment model to the coming one. We delayed for awhile but have now signed up with both. It can only be a matter of months before each of them pursues a meaningful degree of clinical integration. In other words, they will be analyzing data from our electronic medical record about our individual practice patterns and results, and giving us the results along with feedback on how to improve care.

For this to happen, our EMR system needs to be up to the task. We are unsure it will be. It has been difficult for some of us to adapt to electronic records systems. Now we need to see if our existing system can interoperate effectively. If not, we may be paying quite a bit for another one soon.

Our physicians are not accustomed to seeing report cards about their practice patterns. It will be a shock to see comparisons and rankings. But patients will be enrolled in and referred to us by the networks, and it will not be possible to ignore the reports we get.

Likely this radical change in the practice of medicine will drive some to retire, affecting the size of our group. We intend to remain in private practice, but independence may prove increasingly costly.

Already, patients see that their physicians make less eye contact with them and more time documenting care. This will likely get worse. We worry that if increased expenses cause staff cuts, the personal service we provide will suffer.

Redesigning medical practice will be a serious challenge for us. But our goal has always been to provide the best care, and in a value-based system, that should be what sustains us all.

Dr. Deane specializes in allergy, immunology, and rheumatology and is a partner in a private group practice with eight physicians and five offices in greater Rochester, N.Y. He is also the chief of allergy, immunology, and rheumatology at Unity Hospital in Rochester.

Value shift brings irreparable change to private practice

BY ROBERT SHOR, M.D.

The simple truth is that we are in transition. The current health system, for the most part, rewards “making widgets” (volume). That is, being paid for units of work actually being done. The more patients you see, the more procedures you do, the more you are compensated. We are moving from “volume” to “value” as we try to move away from “widgets” to management of population health. How do we get there? What can we as physicians and providers do?

I am part of a 40-person, single-specialty private cardiology practice in the Washington, D.C., suburbs. In the coming years, the CMS will reward (the euphemism for payment) practices that meet their definitions for quality and penalize those that don’t meet those metrics.

We have participated in PQRS/PQRI, Meaningful Use (MU), and other Medicare programs for which we are compensated. But how do you truly determine what are quality metrics and what is truly meaningful use of health system resources? How do we impact health on an individual and population view?

For us to be compliant with the Medicare rules and get paid, we have had to heavily invest in not only EHRs (we were an early adopter around 2000), but personnel costs to make sure all of the paperwork is completed appropriately for submission and for the audit that precedes the CMS payment for MU.

So how do we proceed going forward? In my opinion, what is clear is that private practice has been irreparably changed. The notion of an individual physician or a small practice surviving without some arrangement with a health system, an ACO, or a Clinical Integrated Network (CIN) is rapidly dwindling.

I have seen a variety of actions taken as providers try to survive and jockey for position to their advantage and we have explored a wide range of options. For an ACO to succeed in the shared risk model, it usually is part of a larger health care system. Thus many practices – primary care and subspecialty – have integrated with these health systems. Indeed, about 70% of the cardiology community is now integrated. To manage costs, you need to know your costs and most of the cost remains in the hospital care.

What do you do if you want to stay independent or do not feel you have a reliable health system with which you can integrate? Many practices may merge in a formal or looser network of practices to create a CIN where EHR access to patient records within the network is streamlined and care can be more effectively given. This has benefits, but also limitations. I believe that any future in which cost is contained on a larger scale will require close collaboration with hospitals given the disproportionate cost incurred during hospital care. Some practices have decided to form Physician Service Agreements with hospital systems to help manage product lines within the health system and to establish more meaningful relationships in an effort to coordinate care more effectively. This provides an opportunity to impact inpatient care, to contribute to programs that reduce hospital readmissions, and to reach the holy grail of preventing disease by better outpatient care. This would truly help with population health care management.

Some of the challenges, at least in large metropolitan areas, are that practices may work at several hospitals with different health systems. They may want to continue providing care at all of the hospitals in their community, but may be forced to choose. This does not appear to me to be in the best interest of our patients, many of whom we have cared for many years. However, the choice may be forced upon them as the health systems force the issue and make the decision for us.

The future holds much uncertainty, but also opportunity. Will our practice survive in its current form in 5 years? For now we are trying to read the tea leaves, like so many others, to make the best decisions on behalf of our patients to allow us to be able to continue to provide care in our community.

We are still reading the tea leaves.

Dr. Shor is vice president of Virginia Heart, which has nine offices in the northern Virginia region. He is the chair of the board of governors of the American College of Cardiology.

Leaving behind fee-for-service battles

BY ROBERT FIELDS, M.D.

Many of us in health care received with a mix of excitement and fear the recent news from the CMS regarding the transition to 90% value-based payments by 2018. For me, an employed family medicine physician and medical director of a new ACO in western North Carolina, I applaud the ambitious goal and understand the sentiment behind it. But, I also worry about the ability of most providers to adapt to this change in such a short time span.

The rationale behind value-based payments couldn’t be clearer – we spend too much on health care. Way too much. So much, that if we continue on this track our country will break under the financial pressures of providing care in a fee-for-service system. In addition, U.S. medical outcomes lag behind most other industrialized nations, which leads to the conclusion that the system at large is not providing the value it should.

As I put on my rose-colored glasses, I hope this restructuring encourages the system at large to coordinate care better, to improve our information systems to share relevant clinical data, and to encourage quality improvement at the practice level so that we move toward improved outcomes for our patient populations.

When talking to providers about our ACO and adding value in health care, they think we are saying that THEY are not delivering high value care. I keep reiterating, and will continue to do so, that value-based payments are not a criticism of our individual abilities as physicians or a comment on our interactions with our patients, but acknowledgment that how we communicate with and manage our populations as a network of hospitals, providers, and agencies lacks the efficiencies and coordination of services that patients deserve.

Ultimately, we are moving toward a patient-centered health care system that requires a fundamental transformation in how we pay for and deliver care. Measurement and quality improvement, although new to health care, has existed in every other industry for years.

In the end, I hope patients feel they are getting more efficient, coordinated care and that providers can start to see improvements in outcomes without the daily battle of the fee-for-service world.

Dr. Fields is a family physician and the medical director of Mission Health Partners, a physician led ACO in Asheville, N.C.

In a May 2, 2015 editorial “Stroke of Fate,” respected Times columnist Maureen Dowd wrote about her niece’s experience after suffering a vertebral artery dissection that had been “diagnosed correctly and acted on in the ED,” according to a subsequent letter written by neurologist Louis R. Caplan, MD, who was quoted extensively in the column. Noting that the incidence of strokes has been rising among younger adults, the column took issue with the advice of doctors who told her niece to cut back on physical activity. Dr Caplan was consulted for a second opinion and determined that the imaging studies had been misinterpreted and that the vertebral artery had only narrowed, not closed, allowing the patient to resume her active lifestyle.

Though the column did not specify which doctors had misinterpreted the studies or who had given the unnecessarily restrictive advice, it is difficult to imagine that EPs were responsible for either. Nevertheless, Dr Caplan was subsequently quoted as saying that “stroke experts have had a hard time getting the message across to ER personnel that if a stroke is suspected, a vascular image must be taken as well as a brain image” and that going to an “ER” because of a neurological problem is similar to “run[ning] your Rolls-Royce into the local gas station.” He also said that he is afraid to go to the “emergency room” because he thinks it’s dangerous, and that patients have to “worry about the quality of treatment” there.

In a letter to emergency medicine colleagues after the column appeared, Dr Caplan apologized for quotes taken out of context, and wrote “feel free to convey…to your colleagues” that he did not mean to throw stones at EPs, but wanted to point out that undue limitations on activities can become more disabling than the stroke itself and that system issues, such as long waits and lack of access to past records, not the competency of EPs, made patients afraid. He added that he did “not think being in an ED is dangerous, but is frightening to many patients.”

Clearly, we can all agree on the need for vascular as well as other types of imaging for certain stroke presentations, and that statements in the column were not intended to be understood exactly as written— though to date, no clarifications have since appeared in the column or newspaper. But when such criticism appears in a powerful, respected, and widely disseminated media source, it is almost impossible to undo whatever damage may have been done to public perceptions of ED safety and quality of care. Although many EPs have read or learned of the subsequent clarifying letter, few nonphysicians will ever see or appreciate the disclaimers and clarifications.

To avoid such unfortunate situations in the future, all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed “in context,” or nuanced as they intended. Most important, is to not disparage entire specialties or use slang terms such as “ER docs” to indicate lesser expertise than one’s own specialty. Doing so can only unnecessarily heighten patients’ fears.  

In a May 2, 2015 editorial “Stroke of Fate,” respected Times columnist Maureen Dowd wrote about her niece’s experience after suffering a vertebral artery dissection that had been “diagnosed correctly and acted on in the ED,” according to a subsequent letter written by neurologist Louis R. Caplan, MD, who was quoted extensively in the column. Noting that the incidence of strokes has been rising among younger adults, the column took issue with the advice of doctors who told her niece to cut back on physical activity. Dr Caplan was consulted for a second opinion and determined that the imaging studies had been misinterpreted and that the vertebral artery had only narrowed, not closed, allowing the patient to resume her active lifestyle.

Though the column did not specify which doctors had misinterpreted the studies or who had given the unnecessarily restrictive advice, it is difficult to imagine that EPs were responsible for either. Nevertheless, Dr Caplan was subsequently quoted as saying that “stroke experts have had a hard time getting the message across to ER personnel that if a stroke is suspected, a vascular image must be taken as well as a brain image” and that going to an “ER” because of a neurological problem is similar to “run[ning] your Rolls-Royce into the local gas station.” He also said that he is afraid to go to the “emergency room” because he thinks it’s dangerous, and that patients have to “worry about the quality of treatment” there.

In a letter to emergency medicine colleagues after the column appeared, Dr Caplan apologized for quotes taken out of context, and wrote “feel free to convey…to your colleagues” that he did not mean to throw stones at EPs, but wanted to point out that undue limitations on activities can become more disabling than the stroke itself and that system issues, such as long waits and lack of access to past records, not the competency of EPs, made patients afraid. He added that he did “not think being in an ED is dangerous, but is frightening to many patients.”

Clearly, we can all agree on the need for vascular as well as other types of imaging for certain stroke presentations, and that statements in the column were not intended to be understood exactly as written— though to date, no clarifications have since appeared in the column or newspaper. But when such criticism appears in a powerful, respected, and widely disseminated media source, it is almost impossible to undo whatever damage may have been done to public perceptions of ED safety and quality of care. Although many EPs have read or learned of the subsequent clarifying letter, few nonphysicians will ever see or appreciate the disclaimers and clarifications.

To avoid such unfortunate situations in the future, all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed “in context,” or nuanced as they intended. Most important, is to not disparage entire specialties or use slang terms such as “ER docs” to indicate lesser expertise than one’s own specialty. Doing so can only unnecessarily heighten patients’ fears.  

In a May 2, 2015 editorial “Stroke of Fate,” respected Times columnist Maureen Dowd wrote about her niece’s experience after suffering a vertebral artery dissection that had been “diagnosed correctly and acted on in the ED,” according to a subsequent letter written by neurologist Louis R. Caplan, MD, who was quoted extensively in the column. Noting that the incidence of strokes has been rising among younger adults, the column took issue with the advice of doctors who told her niece to cut back on physical activity. Dr Caplan was consulted for a second opinion and determined that the imaging studies had been misinterpreted and that the vertebral artery had only narrowed, not closed, allowing the patient to resume her active lifestyle.

Though the column did not specify which doctors had misinterpreted the studies or who had given the unnecessarily restrictive advice, it is difficult to imagine that EPs were responsible for either. Nevertheless, Dr Caplan was subsequently quoted as saying that “stroke experts have had a hard time getting the message across to ER personnel that if a stroke is suspected, a vascular image must be taken as well as a brain image” and that going to an “ER” because of a neurological problem is similar to “run[ning] your Rolls-Royce into the local gas station.” He also said that he is afraid to go to the “emergency room” because he thinks it’s dangerous, and that patients have to “worry about the quality of treatment” there.

In a letter to emergency medicine colleagues after the column appeared, Dr Caplan apologized for quotes taken out of context, and wrote “feel free to convey…to your colleagues” that he did not mean to throw stones at EPs, but wanted to point out that undue limitations on activities can become more disabling than the stroke itself and that system issues, such as long waits and lack of access to past records, not the competency of EPs, made patients afraid. He added that he did “not think being in an ED is dangerous, but is frightening to many patients.”

Clearly, we can all agree on the need for vascular as well as other types of imaging for certain stroke presentations, and that statements in the column were not intended to be understood exactly as written— though to date, no clarifications have since appeared in the column or newspaper. But when such criticism appears in a powerful, respected, and widely disseminated media source, it is almost impossible to undo whatever damage may have been done to public perceptions of ED safety and quality of care. Although many EPs have read or learned of the subsequent clarifying letter, few nonphysicians will ever see or appreciate the disclaimers and clarifications.

To avoid such unfortunate situations in the future, all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed “in context,” or nuanced as they intended. Most important, is to not disparage entire specialties or use slang terms such as “ER docs” to indicate lesser expertise than one’s own specialty. Doing so can only unnecessarily heighten patients’ fears.  

Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.

Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.

Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!

Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.

While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.

Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)

Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.

I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.

“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.

Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.

Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.

Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!

Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.

While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.

Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)

Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.

I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.

“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.

Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.

Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.

Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!

Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.

While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.

Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)

Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.

I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.

“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.

Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

On a recent rerun of the 1960s TV series, “The Addams Family,” Thing, the disembodied hand that lived without a body, came down with a cold. So Morticia Addams contacted a doctor who agreed to see Thing during a house call. While the need for convenient access to a physician has not changed in 50 years, technology is offering new solutions to fill the need for patient/physician interaction that range from e-mail to text messaging to video chat, offering both promises and pitfalls. In this article we will explore some of the emerging liability issues that these new forms of patient evaluation present.

Today, there are essentially three types of interactions between patients and physicians: in office/hospital visits, telephone conferences, and electronic communications. The first two interactions have been long practiced and physicians have a good sense of the parameters of their use. Electronic communication is new and has become popular within the past few years. Clinicians often do not have a well-honed sense of the boundaries of interaction with these new mediums and, unfortunately, electronic communications have created another avenue for physician liability.

When a physician sees a patient in person, the physician assesses the patient’s subjective complaints and objectively evaluates the patient. While it has been said that 90% of the diagnosis is arrived at through the taking of a careful history, I think we would all agree that a physical exam is an important part of a complete evaluation, and, depending upon the presenting problem and the differential diagnosis, it may be an essential part of the evaluation. When a physician interacts with a patient over the phone, that physician’s ability to evaluate the patient’s complaints through physical contact is removed, but the physician still has the ability to hear the patient’s voice and engage the patient. Voice inflections – a slight tremor in the voice of a tearful patient, the sense of heightened concern from the mother of a sick 5-year-old – can give insight into the severity of illness beyond what was conveyed by the words themselves. The conversation, in person or on the phone, allows for an iterative exchange of information, with one piece of information allowing the physician to ask the next important question, and so on. When a physician interacts with a patient through electronic communication via e-mail or text message, the tools that the physician uses to evaluate the patient objectively are removed.

Though patients are pushing for fewer in-person interactions with health care providers and have become used to electronic communications, clinicians need to be careful not to relinquish the opportunity for robust two-way conversations that allow them to obtain the information necessary to formulate a thoughtful diagnosis and plan. Recently, we have seen an important increase in lawsuits stemming from electronic interactions. In most cases, liability stems from the lack of an objective evaluation of the patient or perception of a lack of caring by the health care provider.

In a lawsuit we (G.C.) recently defended, a husband and wife had been seeing their primary care physician for 15 years. During one of the husband’s visits with the physician, the husband complained of weight loss and fatigue. The husband’s initial complaints were not concerning. However, at the next visit, the husband complained of new symptoms including chills, cramping, fatigue, and a poor appetite. A urinalysis did not point to a clear diagnosis. Thereafter, all communications between the husband and physician were conducted solely through e-mail. In those correspondences, the husband continued to make ambiguous complaints of the same symptoms. Without asking the patient to come into the office, the physician diagnosed the husband with a viral infection. Multiple e-mail exchanges ensued thereafter and, without ever setting eyes on the patient, the physician continued to assure the couple that the husband would get better over time. Meanwhile, the husband was developing endocarditis during the course of these e-mail exchanges that eventually led to his death.

What happened in this case was an unfortunate misinterpretation of the e-mails, which led to confusion, misdiagnosis, harm to the patient, and, ultimately, a lawsuit against the physician. While endocarditis is rare and difficult to diagnose under any circumstances, that physician did not ensure that he had the opportunity to evaluate the patient fully, to see with his own eyes how sick the patient might have looked, or to listen for a new murmur, or spot a Janeway lesion, all signs of more serious disease that may or may not have been apparent during a full evaluation. The uncritical use of e-mail made it easy to assume that the original diagnosis of a viral syndrome was correct, without providing the opportunity to critically reassess the patient’s concerns.

In this case, in addition to the missed diagnosis, there was an apparent violation of HIPAA. The e-mail address used by the physician was a personal e-mail account. HIPAA precludes physicians from discussing medical information through a means of communication that a non–health care provider might have access to. In an electronic age with multiple modes of communication, we have to be ever more careful to have a well thought out approach to the protection of patient privacy. It is easy to send a quick text message or e-mail to a patient, but it is important to understand that HIPAA applies even when a communication seems trivial or benign in nature.

In summary, society realizes that primary care physicians need to communicate at times other than at scheduled visits, and there is no longer an expectation that the physician will make house calls like the doctor in “The Addam’s Family” episode did 50 years ago. Society, and the courts, recognize that e-mail and text messaging are potentially useful forms of quick, convenient communication. We want to conclude with two important points. First, when using e-mails and texts to communicate with patients, use a secure HIPAA-compliant technology. Second, we need to be cautious that these convenient technologies do not creep into areas where they don’t belong, such as in making a diagnosis when doing so requires more interactive discussion and a physical exam. E-mail and text messaging are emerging as useful mediums for communication with patients, but as with any new technology, we need to be careful and thoughtful in their use.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Cannon is an attorney at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh.

On a recent rerun of the 1960s TV series, “The Addams Family,” Thing, the disembodied hand that lived without a body, came down with a cold. So Morticia Addams contacted a doctor who agreed to see Thing during a house call. While the need for convenient access to a physician has not changed in 50 years, technology is offering new solutions to fill the need for patient/physician interaction that range from e-mail to text messaging to video chat, offering both promises and pitfalls. In this article we will explore some of the emerging liability issues that these new forms of patient evaluation present.

Today, there are essentially three types of interactions between patients and physicians: in office/hospital visits, telephone conferences, and electronic communications. The first two interactions have been long practiced and physicians have a good sense of the parameters of their use. Electronic communication is new and has become popular within the past few years. Clinicians often do not have a well-honed sense of the boundaries of interaction with these new mediums and, unfortunately, electronic communications have created another avenue for physician liability.

When a physician sees a patient in person, the physician assesses the patient’s subjective complaints and objectively evaluates the patient. While it has been said that 90% of the diagnosis is arrived at through the taking of a careful history, I think we would all agree that a physical exam is an important part of a complete evaluation, and, depending upon the presenting problem and the differential diagnosis, it may be an essential part of the evaluation. When a physician interacts with a patient over the phone, that physician’s ability to evaluate the patient’s complaints through physical contact is removed, but the physician still has the ability to hear the patient’s voice and engage the patient. Voice inflections – a slight tremor in the voice of a tearful patient, the sense of heightened concern from the mother of a sick 5-year-old – can give insight into the severity of illness beyond what was conveyed by the words themselves. The conversation, in person or on the phone, allows for an iterative exchange of information, with one piece of information allowing the physician to ask the next important question, and so on. When a physician interacts with a patient through electronic communication via e-mail or text message, the tools that the physician uses to evaluate the patient objectively are removed.

Though patients are pushing for fewer in-person interactions with health care providers and have become used to electronic communications, clinicians need to be careful not to relinquish the opportunity for robust two-way conversations that allow them to obtain the information necessary to formulate a thoughtful diagnosis and plan. Recently, we have seen an important increase in lawsuits stemming from electronic interactions. In most cases, liability stems from the lack of an objective evaluation of the patient or perception of a lack of caring by the health care provider.

In a lawsuit we (G.C.) recently defended, a husband and wife had been seeing their primary care physician for 15 years. During one of the husband’s visits with the physician, the husband complained of weight loss and fatigue. The husband’s initial complaints were not concerning. However, at the next visit, the husband complained of new symptoms including chills, cramping, fatigue, and a poor appetite. A urinalysis did not point to a clear diagnosis. Thereafter, all communications between the husband and physician were conducted solely through e-mail. In those correspondences, the husband continued to make ambiguous complaints of the same symptoms. Without asking the patient to come into the office, the physician diagnosed the husband with a viral infection. Multiple e-mail exchanges ensued thereafter and, without ever setting eyes on the patient, the physician continued to assure the couple that the husband would get better over time. Meanwhile, the husband was developing endocarditis during the course of these e-mail exchanges that eventually led to his death.

What happened in this case was an unfortunate misinterpretation of the e-mails, which led to confusion, misdiagnosis, harm to the patient, and, ultimately, a lawsuit against the physician. While endocarditis is rare and difficult to diagnose under any circumstances, that physician did not ensure that he had the opportunity to evaluate the patient fully, to see with his own eyes how sick the patient might have looked, or to listen for a new murmur, or spot a Janeway lesion, all signs of more serious disease that may or may not have been apparent during a full evaluation. The uncritical use of e-mail made it easy to assume that the original diagnosis of a viral syndrome was correct, without providing the opportunity to critically reassess the patient’s concerns.

In this case, in addition to the missed diagnosis, there was an apparent violation of HIPAA. The e-mail address used by the physician was a personal e-mail account. HIPAA precludes physicians from discussing medical information through a means of communication that a non–health care provider might have access to. In an electronic age with multiple modes of communication, we have to be ever more careful to have a well thought out approach to the protection of patient privacy. It is easy to send a quick text message or e-mail to a patient, but it is important to understand that HIPAA applies even when a communication seems trivial or benign in nature.

In summary, society realizes that primary care physicians need to communicate at times other than at scheduled visits, and there is no longer an expectation that the physician will make house calls like the doctor in “The Addam’s Family” episode did 50 years ago. Society, and the courts, recognize that e-mail and text messaging are potentially useful forms of quick, convenient communication. We want to conclude with two important points. First, when using e-mails and texts to communicate with patients, use a secure HIPAA-compliant technology. Second, we need to be cautious that these convenient technologies do not creep into areas where they don’t belong, such as in making a diagnosis when doing so requires more interactive discussion and a physical exam. E-mail and text messaging are emerging as useful mediums for communication with patients, but as with any new technology, we need to be careful and thoughtful in their use.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Cannon is an attorney at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh.

On a recent rerun of the 1960s TV series, “The Addams Family,” Thing, the disembodied hand that lived without a body, came down with a cold. So Morticia Addams contacted a doctor who agreed to see Thing during a house call. While the need for convenient access to a physician has not changed in 50 years, technology is offering new solutions to fill the need for patient/physician interaction that range from e-mail to text messaging to video chat, offering both promises and pitfalls. In this article we will explore some of the emerging liability issues that these new forms of patient evaluation present.

Today, there are essentially three types of interactions between patients and physicians: in office/hospital visits, telephone conferences, and electronic communications. The first two interactions have been long practiced and physicians have a good sense of the parameters of their use. Electronic communication is new and has become popular within the past few years. Clinicians often do not have a well-honed sense of the boundaries of interaction with these new mediums and, unfortunately, electronic communications have created another avenue for physician liability.

When a physician sees a patient in person, the physician assesses the patient’s subjective complaints and objectively evaluates the patient. While it has been said that 90% of the diagnosis is arrived at through the taking of a careful history, I think we would all agree that a physical exam is an important part of a complete evaluation, and, depending upon the presenting problem and the differential diagnosis, it may be an essential part of the evaluation. When a physician interacts with a patient over the phone, that physician’s ability to evaluate the patient’s complaints through physical contact is removed, but the physician still has the ability to hear the patient’s voice and engage the patient. Voice inflections – a slight tremor in the voice of a tearful patient, the sense of heightened concern from the mother of a sick 5-year-old – can give insight into the severity of illness beyond what was conveyed by the words themselves. The conversation, in person or on the phone, allows for an iterative exchange of information, with one piece of information allowing the physician to ask the next important question, and so on. When a physician interacts with a patient through electronic communication via e-mail or text message, the tools that the physician uses to evaluate the patient objectively are removed.

Though patients are pushing for fewer in-person interactions with health care providers and have become used to electronic communications, clinicians need to be careful not to relinquish the opportunity for robust two-way conversations that allow them to obtain the information necessary to formulate a thoughtful diagnosis and plan. Recently, we have seen an important increase in lawsuits stemming from electronic interactions. In most cases, liability stems from the lack of an objective evaluation of the patient or perception of a lack of caring by the health care provider.

In a lawsuit we (G.C.) recently defended, a husband and wife had been seeing their primary care physician for 15 years. During one of the husband’s visits with the physician, the husband complained of weight loss and fatigue. The husband’s initial complaints were not concerning. However, at the next visit, the husband complained of new symptoms including chills, cramping, fatigue, and a poor appetite. A urinalysis did not point to a clear diagnosis. Thereafter, all communications between the husband and physician were conducted solely through e-mail. In those correspondences, the husband continued to make ambiguous complaints of the same symptoms. Without asking the patient to come into the office, the physician diagnosed the husband with a viral infection. Multiple e-mail exchanges ensued thereafter and, without ever setting eyes on the patient, the physician continued to assure the couple that the husband would get better over time. Meanwhile, the husband was developing endocarditis during the course of these e-mail exchanges that eventually led to his death.

What happened in this case was an unfortunate misinterpretation of the e-mails, which led to confusion, misdiagnosis, harm to the patient, and, ultimately, a lawsuit against the physician. While endocarditis is rare and difficult to diagnose under any circumstances, that physician did not ensure that he had the opportunity to evaluate the patient fully, to see with his own eyes how sick the patient might have looked, or to listen for a new murmur, or spot a Janeway lesion, all signs of more serious disease that may or may not have been apparent during a full evaluation. The uncritical use of e-mail made it easy to assume that the original diagnosis of a viral syndrome was correct, without providing the opportunity to critically reassess the patient’s concerns.

In this case, in addition to the missed diagnosis, there was an apparent violation of HIPAA. The e-mail address used by the physician was a personal e-mail account. HIPAA precludes physicians from discussing medical information through a means of communication that a non–health care provider might have access to. In an electronic age with multiple modes of communication, we have to be ever more careful to have a well thought out approach to the protection of patient privacy. It is easy to send a quick text message or e-mail to a patient, but it is important to understand that HIPAA applies even when a communication seems trivial or benign in nature.

In summary, society realizes that primary care physicians need to communicate at times other than at scheduled visits, and there is no longer an expectation that the physician will make house calls like the doctor in “The Addam’s Family” episode did 50 years ago. Society, and the courts, recognize that e-mail and text messaging are potentially useful forms of quick, convenient communication. We want to conclude with two important points. First, when using e-mails and texts to communicate with patients, use a secure HIPAA-compliant technology. Second, we need to be cautious that these convenient technologies do not creep into areas where they don’t belong, such as in making a diagnosis when doing so requires more interactive discussion and a physical exam. E-mail and text messaging are emerging as useful mediums for communication with patients, but as with any new technology, we need to be careful and thoughtful in their use.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Cannon is an attorney at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh.

“WHAT IS THE RISK THAT A PATIENT WILL HAVE AN OCCULT UTERINE CANCER AT MYOMECTOMY?”
ROBERT L. BARBIERI, MD (EXAMINING THE EVIDENCE; APRIL 2015)

More questions than answers?
The data presented by Wright and colleagues on the prevalence of underlying cancer in women who undergo myomectomy is disturbing and thought-provoking.

Are those in the 50-and-older age group who undergo myomectomy different from their same-aged peers with fibroids who do not undergo myomectomy? If so, why? If not, then with a 1 in 154 to 1 in 31 risk of occult malignancy, should not all women 50 years and older with fibroids undergo hysterectomy for this occult risk? This certainly has not been the standard of care for women 50 and older with asymptomatic fibroids. Thoughts?

In conclusion, it appears that power morcellation, or should I say the morcellation issue, has brought forth more questions than answers.
Richard L. Myers, MD
Jacksonville, Florida

Dr. Barbieri responds
I agree with Dr. Myers: Women aged 50 and older who have fibroids and undergo myomectomy must be clinically different than women of the same age who have fibroids but do not undergo myomectomy. It is likely that the women who undergo myomectomy have larger pelvic tumors or are more symptomatic than those who do not undergo myomectomy. I think this demonstrates that gynecologists are successfully identifying those women with a pelvic mass thought to be due to fibroids with the greatest risk of occult cancer and recommending that those women undergo surgery, while simultaneously recommending expectant management for those at lowest risk of an occult cancer.

“UPDATE ON MINIMALLY INVASIVE gynecologic SURGERY”
AMY L. GARCIA, MD (APRIL 2015)

Additional tips for in-office hysteroscopy
Thank you for the excellent coverage of hysteroscopy in the April issue. For me, patient trust is extremely important. Before I begin in-office hysteroscopy, I explain how the procedure is performed and answer all questions. I reassure the patient that, if it is too painful, I will stop and we will move to the operating room. I find music to be distracting to me as I am talking and constantly reassuring her.

In addition, I don’t perform the procedure when the patient is menstruating as it decreases visibility and I don’t want the intrauterine lidocaine to enter open vessels. It is helpful to perform this procedure shortly after menses and prior to ovulation to avoid instrumenting a pregnant uterus. Even if the menses is normal in timing and flow, a pregnancy test is still performed prior to the procedure. Doing it in this time period also can offer better visibility, as the endometrium is thinner.

I prescribe oral misoprostol the night before (400 mg, or 200 mg if she has undergone a cesarean delivery). The patient also is instructed to take ibuprofen 800 mg 1 hour prior to the procedure.

I continuously tell the patient what to expect. First, I perform a bimanual exam to determine the uterine position. Then local anesthesia placed on the anterior lip of the cervix prevents pain when placing the tenaculum. A paracervical block is performed and lidocaine jelly is placed in the cervix. Using an angiocatheter, I inject 4 mL of 2% lidocaine into the uterus and then wait 3 minutes.

It is important to only use the amount of fluid necessary to avoid overdistending the uterus. I take care to avoid touching the fundus, as this increases pain. I use a 4-mm 30˚ scope. I agree that the pain is dependent on physician expertise and procedure length.

If the cavity is clean, I perform a thorough endometrial biopsy that causes minimal pain because of the intrauterine lidocaine. I recently started doing in-office diagnostic hysteroscopy again. When I did it years ago without intrauterine lidocaine, it was unacceptably painful. I have performed 25 cases, all of which were successful, including on postmenopausal patients. All of the patients reported being highly satisfied and glad to have had the procedure performed in the office.
Ray Wertheim, MD
Fairfax, Virginia

Would you approve this candidate for uterus transplantation?

“UTERUS TRANSPLANTATION: MEDICAL BREAKTHROUGH OR SURGICAL FOLLY?”
ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2015)

Instant Poll
Dr. Barbieri presented 3 cases to readers in his recent editorial on uterus transplantation and asked, “Would you approve or disapprove of transplantation of the uterus in these cases?”

1. 23-year-old Army sergeant (G0) injured by improvised explosive device. To save her life, military surgeons removed her uterus, which had been lacerated in the explosion. She requested uterus transplantation to pursue a pregnancy. The Department of Defense has approved her request.
2. 30-year-old woman (G0) with congenital absence of the uterus who is a devout member of a religious community in which the tenets of faith prohibit gestational carriers. Rather than pursue adoption, she is seeking a uterus transplantation to pursue a pregnancy.
3. 35-year-old woman (G1P1) who had her uterus removed to treat cervical cancer. She has been disease-free for 3 years. She would like a uterus transplant to pursue a pregnancy.

READERS WEIGH IN:
Concentrate on saving lives
We should be concentrating our resources on saving lives rather than on satisfying the wishes of some very genuine people.

Where will it end? Let us not compare uterine transplant with kidney, heart, and lung transplants.
Ram A. Singh, MD
Oklahoma City, Oklahoma

No to 35-year-old patient
Assuming, as stated, that the women are healthy and psychosocially approved, to which I would add, they are fully informed on the preparation, medications, procedure, postoperative recovery, and potential complications,I would approve the first 2 cases and disapprove of the last. My reasoning for denying a uterus transplant to the 35-year-old woman is that, after she goes through the process of screening and evaluation, she will be an “elderly gravida,” which in itself has risks. I would also be concerned that all the family members fully understand the potential risks of her undertaking.
Helen T. Jackson, MD
Brookline, Massachusetts

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.

“WHAT IS THE RISK THAT A PATIENT WILL HAVE AN OCCULT UTERINE CANCER AT MYOMECTOMY?”
ROBERT L. BARBIERI, MD (EXAMINING THE EVIDENCE; APRIL 2015)

More questions than answers?
The data presented by Wright and colleagues on the prevalence of underlying cancer in women who undergo myomectomy is disturbing and thought-provoking.

Are those in the 50-and-older age group who undergo myomectomy different from their same-aged peers with fibroids who do not undergo myomectomy? If so, why? If not, then with a 1 in 154 to 1 in 31 risk of occult malignancy, should not all women 50 years and older with fibroids undergo hysterectomy for this occult risk? This certainly has not been the standard of care for women 50 and older with asymptomatic fibroids. Thoughts?

In conclusion, it appears that power morcellation, or should I say the morcellation issue, has brought forth more questions than answers.
Richard L. Myers, MD
Jacksonville, Florida

Dr. Barbieri responds
I agree with Dr. Myers: Women aged 50 and older who have fibroids and undergo myomectomy must be clinically different than women of the same age who have fibroids but do not undergo myomectomy. It is likely that the women who undergo myomectomy have larger pelvic tumors or are more symptomatic than those who do not undergo myomectomy. I think this demonstrates that gynecologists are successfully identifying those women with a pelvic mass thought to be due to fibroids with the greatest risk of occult cancer and recommending that those women undergo surgery, while simultaneously recommending expectant management for those at lowest risk of an occult cancer.

“UPDATE ON MINIMALLY INVASIVE gynecologic SURGERY”
AMY L. GARCIA, MD (APRIL 2015)

Additional tips for in-office hysteroscopy
Thank you for the excellent coverage of hysteroscopy in the April issue. For me, patient trust is extremely important. Before I begin in-office hysteroscopy, I explain how the procedure is performed and answer all questions. I reassure the patient that, if it is too painful, I will stop and we will move to the operating room. I find music to be distracting to me as I am talking and constantly reassuring her.

In addition, I don’t perform the procedure when the patient is menstruating as it decreases visibility and I don’t want the intrauterine lidocaine to enter open vessels. It is helpful to perform this procedure shortly after menses and prior to ovulation to avoid instrumenting a pregnant uterus. Even if the menses is normal in timing and flow, a pregnancy test is still performed prior to the procedure. Doing it in this time period also can offer better visibility, as the endometrium is thinner.

I prescribe oral misoprostol the night before (400 mg, or 200 mg if she has undergone a cesarean delivery). The patient also is instructed to take ibuprofen 800 mg 1 hour prior to the procedure.

I continuously tell the patient what to expect. First, I perform a bimanual exam to determine the uterine position. Then local anesthesia placed on the anterior lip of the cervix prevents pain when placing the tenaculum. A paracervical block is performed and lidocaine jelly is placed in the cervix. Using an angiocatheter, I inject 4 mL of 2% lidocaine into the uterus and then wait 3 minutes.

It is important to only use the amount of fluid necessary to avoid overdistending the uterus. I take care to avoid touching the fundus, as this increases pain. I use a 4-mm 30˚ scope. I agree that the pain is dependent on physician expertise and procedure length.

If the cavity is clean, I perform a thorough endometrial biopsy that causes minimal pain because of the intrauterine lidocaine. I recently started doing in-office diagnostic hysteroscopy again. When I did it years ago without intrauterine lidocaine, it was unacceptably painful. I have performed 25 cases, all of which were successful, including on postmenopausal patients. All of the patients reported being highly satisfied and glad to have had the procedure performed in the office.
Ray Wertheim, MD
Fairfax, Virginia

Would you approve this candidate for uterus transplantation?

“UTERUS TRANSPLANTATION: MEDICAL BREAKTHROUGH OR SURGICAL FOLLY?”
ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2015)

Instant Poll
Dr. Barbieri presented 3 cases to readers in his recent editorial on uterus transplantation and asked, “Would you approve or disapprove of transplantation of the uterus in these cases?”

1. 23-year-old Army sergeant (G0) injured by improvised explosive device. To save her life, military surgeons removed her uterus, which had been lacerated in the explosion. She requested uterus transplantation to pursue a pregnancy. The Department of Defense has approved her request.
2. 30-year-old woman (G0) with congenital absence of the uterus who is a devout member of a religious community in which the tenets of faith prohibit gestational carriers. Rather than pursue adoption, she is seeking a uterus transplantation to pursue a pregnancy.
3. 35-year-old woman (G1P1) who had her uterus removed to treat cervical cancer. She has been disease-free for 3 years. She would like a uterus transplant to pursue a pregnancy.

READERS WEIGH IN:
Concentrate on saving lives
We should be concentrating our resources on saving lives rather than on satisfying the wishes of some very genuine people.

Where will it end? Let us not compare uterine transplant with kidney, heart, and lung transplants.
Ram A. Singh, MD
Oklahoma City, Oklahoma

No to 35-year-old patient
Assuming, as stated, that the women are healthy and psychosocially approved, to which I would add, they are fully informed on the preparation, medications, procedure, postoperative recovery, and potential complications,I would approve the first 2 cases and disapprove of the last. My reasoning for denying a uterus transplant to the 35-year-old woman is that, after she goes through the process of screening and evaluation, she will be an “elderly gravida,” which in itself has risks. I would also be concerned that all the family members fully understand the potential risks of her undertaking.
Helen T. Jackson, MD
Brookline, Massachusetts

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.

“WHAT IS THE RISK THAT A PATIENT WILL HAVE AN OCCULT UTERINE CANCER AT MYOMECTOMY?”
ROBERT L. BARBIERI, MD (EXAMINING THE EVIDENCE; APRIL 2015)

More questions than answers?
The data presented by Wright and colleagues on the prevalence of underlying cancer in women who undergo myomectomy is disturbing and thought-provoking.

Are those in the 50-and-older age group who undergo myomectomy different from their same-aged peers with fibroids who do not undergo myomectomy? If so, why? If not, then with a 1 in 154 to 1 in 31 risk of occult malignancy, should not all women 50 years and older with fibroids undergo hysterectomy for this occult risk? This certainly has not been the standard of care for women 50 and older with asymptomatic fibroids. Thoughts?

In conclusion, it appears that power morcellation, or should I say the morcellation issue, has brought forth more questions than answers.
Richard L. Myers, MD
Jacksonville, Florida

Dr. Barbieri responds
I agree with Dr. Myers: Women aged 50 and older who have fibroids and undergo myomectomy must be clinically different than women of the same age who have fibroids but do not undergo myomectomy. It is likely that the women who undergo myomectomy have larger pelvic tumors or are more symptomatic than those who do not undergo myomectomy. I think this demonstrates that gynecologists are successfully identifying those women with a pelvic mass thought to be due to fibroids with the greatest risk of occult cancer and recommending that those women undergo surgery, while simultaneously recommending expectant management for those at lowest risk of an occult cancer.

“UPDATE ON MINIMALLY INVASIVE gynecologic SURGERY”
AMY L. GARCIA, MD (APRIL 2015)

Additional tips for in-office hysteroscopy
Thank you for the excellent coverage of hysteroscopy in the April issue. For me, patient trust is extremely important. Before I begin in-office hysteroscopy, I explain how the procedure is performed and answer all questions. I reassure the patient that, if it is too painful, I will stop and we will move to the operating room. I find music to be distracting to me as I am talking and constantly reassuring her.

In addition, I don’t perform the procedure when the patient is menstruating as it decreases visibility and I don’t want the intrauterine lidocaine to enter open vessels. It is helpful to perform this procedure shortly after menses and prior to ovulation to avoid instrumenting a pregnant uterus. Even if the menses is normal in timing and flow, a pregnancy test is still performed prior to the procedure. Doing it in this time period also can offer better visibility, as the endometrium is thinner.

I prescribe oral misoprostol the night before (400 mg, or 200 mg if she has undergone a cesarean delivery). The patient also is instructed to take ibuprofen 800 mg 1 hour prior to the procedure.

I continuously tell the patient what to expect. First, I perform a bimanual exam to determine the uterine position. Then local anesthesia placed on the anterior lip of the cervix prevents pain when placing the tenaculum. A paracervical block is performed and lidocaine jelly is placed in the cervix. Using an angiocatheter, I inject 4 mL of 2% lidocaine into the uterus and then wait 3 minutes.

It is important to only use the amount of fluid necessary to avoid overdistending the uterus. I take care to avoid touching the fundus, as this increases pain. I use a 4-mm 30˚ scope. I agree that the pain is dependent on physician expertise and procedure length.

If the cavity is clean, I perform a thorough endometrial biopsy that causes minimal pain because of the intrauterine lidocaine. I recently started doing in-office diagnostic hysteroscopy again. When I did it years ago without intrauterine lidocaine, it was unacceptably painful. I have performed 25 cases, all of which were successful, including on postmenopausal patients. All of the patients reported being highly satisfied and glad to have had the procedure performed in the office.
Ray Wertheim, MD
Fairfax, Virginia

Would you approve this candidate for uterus transplantation?

“UTERUS TRANSPLANTATION: MEDICAL BREAKTHROUGH OR SURGICAL FOLLY?”
ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2015)

Instant Poll
Dr. Barbieri presented 3 cases to readers in his recent editorial on uterus transplantation and asked, “Would you approve or disapprove of transplantation of the uterus in these cases?”

1. 23-year-old Army sergeant (G0) injured by improvised explosive device. To save her life, military surgeons removed her uterus, which had been lacerated in the explosion. She requested uterus transplantation to pursue a pregnancy. The Department of Defense has approved her request.
2. 30-year-old woman (G0) with congenital absence of the uterus who is a devout member of a religious community in which the tenets of faith prohibit gestational carriers. Rather than pursue adoption, she is seeking a uterus transplantation to pursue a pregnancy.
3. 35-year-old woman (G1P1) who had her uterus removed to treat cervical cancer. She has been disease-free for 3 years. She would like a uterus transplant to pursue a pregnancy.

READERS WEIGH IN:
Concentrate on saving lives
We should be concentrating our resources on saving lives rather than on satisfying the wishes of some very genuine people.

Where will it end? Let us not compare uterine transplant with kidney, heart, and lung transplants.
Ram A. Singh, MD
Oklahoma City, Oklahoma

No to 35-year-old patient
Assuming, as stated, that the women are healthy and psychosocially approved, to which I would add, they are fully informed on the preparation, medications, procedure, postoperative recovery, and potential complications,I would approve the first 2 cases and disapprove of the last. My reasoning for denying a uterus transplant to the 35-year-old woman is that, after she goes through the process of screening and evaluation, she will be an “elderly gravida,” which in itself has risks. I would also be concerned that all the family members fully understand the potential risks of her undertaking.
Helen T. Jackson, MD
Brookline, Massachusetts

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.