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A wish list for a better doctor visit
I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.
With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:
• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.
• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.
• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.
It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.
• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.
• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.
In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.
Dr. Chan practices rheumatology in Pawtucket, R.I.
I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.
With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:
• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.
• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.
• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.
It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.
• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.
• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.
In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.
Dr. Chan practices rheumatology in Pawtucket, R.I.
I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.
With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:
• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.
• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.
• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.
It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.
• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.
• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.
In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.
Dr. Chan practices rheumatology in Pawtucket, R.I.
Cash pay is an unworkable proposition for most patients
We hear a lot about the pros and cons of cash-pay medicine. I’ve written about it in the past. So far, I haven’t made the leap of faith it would require in my own practice.
But recently I developed a gradually worsening toothache. For a while I ignored it, hoping it would go away. Like most doctors, my first thought was “I don’t have time for this.” But, as it progressed, I knew I didn’t have a choice.
I didn’t have a dentist, either, and have never had dental insurance. Now what?
So I called a family friend who’s a dentist. His actual charge for the visit was around $200, but he kindly charged me only $50. I sent him a $100 gift card to thank him for his help, and I’m well aware most folks don’t have the benefit of knowing a dentist on nonprofessional terms.
Unfortunately, he found he couldn’t help me. I had an upper molar that was busily reabsorbing itself, and needed to come out.
So I went to an oral surgeon. The first visit (“limited exam and counseling”) was $95. Two days later, I went back to get the tooth yanked for good. That was $275. I paid both in full by credit card.
Do I think any of these charges were unreasonable? Absolutely not. The transaction is done; the tooth is out. His office doesn’t have to bill my insurance, hope to collect part of it, and then bill me for the rest. I don’t have to worry about being billed for something my insurance didn’t pay, or spend an hour (or more) on hold to ask questions of an insurance representative as to why my claim was denied. And I get to put the $520 down on my 2015 taxes as a medical deduction.
It’s pretty simple, isn’t it? The guy pulls my tooth, and I pay a fair amount for his service. This is the same business relationship I have with a grocery store, car mechanic, or office landlord.
So why doesn’t this catch on for most of medicine? It would be nice if it were that simple.
I’m fortunate to be able to afford the total of $520 I’ve spent on the tooth. Many people don’t have that luxury, and have to rely on insurance coverage; $520 is also a pittance, compared with what other things may run. Multiple MRIs? An electromyogram/nerve conduction velocity test? Multiple sclerosis drugs? Chemotherapy? Neurosurgery? A hospital stay? In that group, you’re talking about things that can range from $1,000 to $100,000 (or more) – a far cry from what I spent on my tooth, but still medically necessary for many.
Some will argue these medical costs should all be cash pay, too. If patients can’t afford multiple sclerosis drugs out of pocket ($50,000/year and up for some), then the market will force the drug companies to lower their prices to where people will buy them. That may be, but the price an average person can likely afford isn’t going to support what the company spent to bring the drug to market or pay for trials of the next generation of treatments. So in the long run, it hurts people more than it helps.
Now if I apply this to my practice, I’m sure there are many who could afford my cash rates if I dropped their plan, but since there are other neurologists taking insurance in the area, people will generally go to whoever is best for their wallet. And a copay is going to trump my cash price for most – not to mention the costs of tests that may be needed.
For an office visit, cash pay would likely work for most. It’s simple, quick, and straightforward. But it’s the high costs of modern medicine – advanced tests, hospital stays, and upper-line pharmaceuticals (some patients don’t have other options) – that make it an unworkable proposition for many.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
We hear a lot about the pros and cons of cash-pay medicine. I’ve written about it in the past. So far, I haven’t made the leap of faith it would require in my own practice.
But recently I developed a gradually worsening toothache. For a while I ignored it, hoping it would go away. Like most doctors, my first thought was “I don’t have time for this.” But, as it progressed, I knew I didn’t have a choice.
I didn’t have a dentist, either, and have never had dental insurance. Now what?
So I called a family friend who’s a dentist. His actual charge for the visit was around $200, but he kindly charged me only $50. I sent him a $100 gift card to thank him for his help, and I’m well aware most folks don’t have the benefit of knowing a dentist on nonprofessional terms.
Unfortunately, he found he couldn’t help me. I had an upper molar that was busily reabsorbing itself, and needed to come out.
So I went to an oral surgeon. The first visit (“limited exam and counseling”) was $95. Two days later, I went back to get the tooth yanked for good. That was $275. I paid both in full by credit card.
Do I think any of these charges were unreasonable? Absolutely not. The transaction is done; the tooth is out. His office doesn’t have to bill my insurance, hope to collect part of it, and then bill me for the rest. I don’t have to worry about being billed for something my insurance didn’t pay, or spend an hour (or more) on hold to ask questions of an insurance representative as to why my claim was denied. And I get to put the $520 down on my 2015 taxes as a medical deduction.
It’s pretty simple, isn’t it? The guy pulls my tooth, and I pay a fair amount for his service. This is the same business relationship I have with a grocery store, car mechanic, or office landlord.
So why doesn’t this catch on for most of medicine? It would be nice if it were that simple.
I’m fortunate to be able to afford the total of $520 I’ve spent on the tooth. Many people don’t have that luxury, and have to rely on insurance coverage; $520 is also a pittance, compared with what other things may run. Multiple MRIs? An electromyogram/nerve conduction velocity test? Multiple sclerosis drugs? Chemotherapy? Neurosurgery? A hospital stay? In that group, you’re talking about things that can range from $1,000 to $100,000 (or more) – a far cry from what I spent on my tooth, but still medically necessary for many.
Some will argue these medical costs should all be cash pay, too. If patients can’t afford multiple sclerosis drugs out of pocket ($50,000/year and up for some), then the market will force the drug companies to lower their prices to where people will buy them. That may be, but the price an average person can likely afford isn’t going to support what the company spent to bring the drug to market or pay for trials of the next generation of treatments. So in the long run, it hurts people more than it helps.
Now if I apply this to my practice, I’m sure there are many who could afford my cash rates if I dropped their plan, but since there are other neurologists taking insurance in the area, people will generally go to whoever is best for their wallet. And a copay is going to trump my cash price for most – not to mention the costs of tests that may be needed.
For an office visit, cash pay would likely work for most. It’s simple, quick, and straightforward. But it’s the high costs of modern medicine – advanced tests, hospital stays, and upper-line pharmaceuticals (some patients don’t have other options) – that make it an unworkable proposition for many.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
We hear a lot about the pros and cons of cash-pay medicine. I’ve written about it in the past. So far, I haven’t made the leap of faith it would require in my own practice.
But recently I developed a gradually worsening toothache. For a while I ignored it, hoping it would go away. Like most doctors, my first thought was “I don’t have time for this.” But, as it progressed, I knew I didn’t have a choice.
I didn’t have a dentist, either, and have never had dental insurance. Now what?
So I called a family friend who’s a dentist. His actual charge for the visit was around $200, but he kindly charged me only $50. I sent him a $100 gift card to thank him for his help, and I’m well aware most folks don’t have the benefit of knowing a dentist on nonprofessional terms.
Unfortunately, he found he couldn’t help me. I had an upper molar that was busily reabsorbing itself, and needed to come out.
So I went to an oral surgeon. The first visit (“limited exam and counseling”) was $95. Two days later, I went back to get the tooth yanked for good. That was $275. I paid both in full by credit card.
Do I think any of these charges were unreasonable? Absolutely not. The transaction is done; the tooth is out. His office doesn’t have to bill my insurance, hope to collect part of it, and then bill me for the rest. I don’t have to worry about being billed for something my insurance didn’t pay, or spend an hour (or more) on hold to ask questions of an insurance representative as to why my claim was denied. And I get to put the $520 down on my 2015 taxes as a medical deduction.
It’s pretty simple, isn’t it? The guy pulls my tooth, and I pay a fair amount for his service. This is the same business relationship I have with a grocery store, car mechanic, or office landlord.
So why doesn’t this catch on for most of medicine? It would be nice if it were that simple.
I’m fortunate to be able to afford the total of $520 I’ve spent on the tooth. Many people don’t have that luxury, and have to rely on insurance coverage; $520 is also a pittance, compared with what other things may run. Multiple MRIs? An electromyogram/nerve conduction velocity test? Multiple sclerosis drugs? Chemotherapy? Neurosurgery? A hospital stay? In that group, you’re talking about things that can range from $1,000 to $100,000 (or more) – a far cry from what I spent on my tooth, but still medically necessary for many.
Some will argue these medical costs should all be cash pay, too. If patients can’t afford multiple sclerosis drugs out of pocket ($50,000/year and up for some), then the market will force the drug companies to lower their prices to where people will buy them. That may be, but the price an average person can likely afford isn’t going to support what the company spent to bring the drug to market or pay for trials of the next generation of treatments. So in the long run, it hurts people more than it helps.
Now if I apply this to my practice, I’m sure there are many who could afford my cash rates if I dropped their plan, but since there are other neurologists taking insurance in the area, people will generally go to whoever is best for their wallet. And a copay is going to trump my cash price for most – not to mention the costs of tests that may be needed.
For an office visit, cash pay would likely work for most. It’s simple, quick, and straightforward. But it’s the high costs of modern medicine – advanced tests, hospital stays, and upper-line pharmaceuticals (some patients don’t have other options) – that make it an unworkable proposition for many.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
The facts don’t speak for themselves
Whenever I meet families who oppose vaccination, my first response is to flood them with more evidence, reciting the pro-vaccine fact sheet that every doctor knows by heart. I can’t help myself. The evidence is so self-explanatory that it should put any question to rest.
But this approach may just exacerbate the problem. In fact, studies suggest that attacking parents’ beliefs can backfire, and that “attempts to increase concerns about communicable diseases or correct false claims about vaccines may be … counterproductive.” We can inform parents that vaccines prevent thousands of deaths and millions of cases of disease while saving billions in health care costs, but this will not change the mind of someone who does not trust the data.
One major problem is that doctors and parents sometimes speak different languages. As trainees, we are raised on nomograms, algorithms, and clinical trials. When a problem presents itself, we instinctively seek out a rational, data-driven response. This is how doctors are built, but studies suggest that vaccine-hesitant parents may be built differently, driven more by fears and negative emotions than by data. Their decisions seem to be based not on a misunderstanding of the facts, but rather a mistrust of the facts.
As pediatric trainees, this is the world we are inheriting. The more successful vaccines become at preventing disease, the harder it will become to convince parents of the serious risks of nonvaccination. It is a perpetual uphill battle.
To make the future better for our patients (and to contribute to our future sanity), we need to work past frustrations and focus on developing pragmatic solutions. There is surely no easy or perfect answer, and different parents may require different approaches, but the status quo is not working. To find the solutions, we need to develop a robust evidence base to guide our good intentions. Perhaps the answer will come from tailoring communication strategies, refocusing public outreach efforts, creating legal mandates, or maybe something completely different.
And if we are successful, maybe we can close the communications gap between vaccine-resisting parents and doctors.
Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at [email protected].
Whenever I meet families who oppose vaccination, my first response is to flood them with more evidence, reciting the pro-vaccine fact sheet that every doctor knows by heart. I can’t help myself. The evidence is so self-explanatory that it should put any question to rest.
But this approach may just exacerbate the problem. In fact, studies suggest that attacking parents’ beliefs can backfire, and that “attempts to increase concerns about communicable diseases or correct false claims about vaccines may be … counterproductive.” We can inform parents that vaccines prevent thousands of deaths and millions of cases of disease while saving billions in health care costs, but this will not change the mind of someone who does not trust the data.
One major problem is that doctors and parents sometimes speak different languages. As trainees, we are raised on nomograms, algorithms, and clinical trials. When a problem presents itself, we instinctively seek out a rational, data-driven response. This is how doctors are built, but studies suggest that vaccine-hesitant parents may be built differently, driven more by fears and negative emotions than by data. Their decisions seem to be based not on a misunderstanding of the facts, but rather a mistrust of the facts.
As pediatric trainees, this is the world we are inheriting. The more successful vaccines become at preventing disease, the harder it will become to convince parents of the serious risks of nonvaccination. It is a perpetual uphill battle.
To make the future better for our patients (and to contribute to our future sanity), we need to work past frustrations and focus on developing pragmatic solutions. There is surely no easy or perfect answer, and different parents may require different approaches, but the status quo is not working. To find the solutions, we need to develop a robust evidence base to guide our good intentions. Perhaps the answer will come from tailoring communication strategies, refocusing public outreach efforts, creating legal mandates, or maybe something completely different.
And if we are successful, maybe we can close the communications gap between vaccine-resisting parents and doctors.
Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at [email protected].
Whenever I meet families who oppose vaccination, my first response is to flood them with more evidence, reciting the pro-vaccine fact sheet that every doctor knows by heart. I can’t help myself. The evidence is so self-explanatory that it should put any question to rest.
But this approach may just exacerbate the problem. In fact, studies suggest that attacking parents’ beliefs can backfire, and that “attempts to increase concerns about communicable diseases or correct false claims about vaccines may be … counterproductive.” We can inform parents that vaccines prevent thousands of deaths and millions of cases of disease while saving billions in health care costs, but this will not change the mind of someone who does not trust the data.
One major problem is that doctors and parents sometimes speak different languages. As trainees, we are raised on nomograms, algorithms, and clinical trials. When a problem presents itself, we instinctively seek out a rational, data-driven response. This is how doctors are built, but studies suggest that vaccine-hesitant parents may be built differently, driven more by fears and negative emotions than by data. Their decisions seem to be based not on a misunderstanding of the facts, but rather a mistrust of the facts.
As pediatric trainees, this is the world we are inheriting. The more successful vaccines become at preventing disease, the harder it will become to convince parents of the serious risks of nonvaccination. It is a perpetual uphill battle.
To make the future better for our patients (and to contribute to our future sanity), we need to work past frustrations and focus on developing pragmatic solutions. There is surely no easy or perfect answer, and different parents may require different approaches, but the status quo is not working. To find the solutions, we need to develop a robust evidence base to guide our good intentions. Perhaps the answer will come from tailoring communication strategies, refocusing public outreach efforts, creating legal mandates, or maybe something completely different.
And if we are successful, maybe we can close the communications gap between vaccine-resisting parents and doctors.
Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at [email protected].
Duped
While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.
While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.
While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.
Surviving a meaningful use audit
Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.
First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:
Prepare, but don’t panic
The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.
It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...
Audits may come before or after payment
There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …
There is no such thing as TMI (too much information)
When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.
For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...
Don’t neglect the security risk analysis
This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.
This leads us to one final important piece of advice:
Make sure you follow up
It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.
First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:
Prepare, but don’t panic
The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.
It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...
Audits may come before or after payment
There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …
There is no such thing as TMI (too much information)
When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.
For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...
Don’t neglect the security risk analysis
This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.
This leads us to one final important piece of advice:
Make sure you follow up
It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.
First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:
Prepare, but don’t panic
The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.
It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...
Audits may come before or after payment
There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …
There is no such thing as TMI (too much information)
When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.
For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...
Don’t neglect the security risk analysis
This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.
This leads us to one final important piece of advice:
Make sure you follow up
It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Telemedicine and healing touch
The practice of medicine is a sacred event between a doctor and a patient – two individuals who have met each other in the flesh. This is the sentiment of many, and soon to be the law in the great state of Texas. It was also a popular topic of conversation at the American Telemedicine Association meeting in Los Angeles.
As a physician, I’m passionate about the profession of medicine, and as a soon-to-be MBA, I’m passionate about the practice of medicine. In this case, these ideals are pulling in opposite directions. I’m writing this dialectic as much to help me form my opinion as to help you with yours.
Should the practice of medicine be reserved only for those patients whom you have met in person? This is, after all, our history. All of us who practice medicine know the laying on of hands heals. It is a core human interaction that conveys care and concern, warmth and protection. It is the most powerful tool we have as clinicians to diagnose and heal. Touching patients can only be done in the flesh, and any interaction between a doctor and a patient that lacks this is, in one way, inferior. Not only does seeing a patient in person ensure that we won’t miss the obvious melanoma not visualized in the photo or video, but it also enables us to better connect this visit with every other visit and with the entirety of the patient’s record.
Having access to a patient’s medical record improves the quality and efficiency of care, a value conspicuously missing from one-off-dial-a-doc interactions from an online doctor who cares nothing of patient history or future.
Dr. Jack Resneck, a plenary presenter at ATA this year, told a cautionary tale of an acne patient who was treated online with an antibiotic that caused him to develop Stevens-Johnson syndrome, a life-threatening condition requiring extreme medicine and extraordinary costs. Clearly, digital medicine has shortcomings.
On the other hand, should we yield to the demands of our patients who want convenient care? Leaving work (or family) to endure traffic, to find a parking space, to sit in your waiting room, then your exam room, to have a chance to touch you once and see you for 10 minutes is not convenient. Given the option to receive care by the phone, online, or in person, patients increasingly are choosing the more convenient channels. And if you wrote a prescription for trimethoprim-sulfamethoxazole for an acne patient with no history of medication allergy and he developed Stevens-Johnson syndrome, would seeing him in person have helped? Perhaps, but probably not.
We are reluctant to call our patients “customers” for good reasons. I respect that, and I caution us to consider the truth that the trade of service for a fee is a business transaction. No matter how much patients love and respect us as doctors, if the price of our services grew exorbitantly high, or if it became impossible to see us, then they would abandon us. They would do so with remorse, yet they would do so.
Ideally, a person with a rash makes an appointment to see a dermatologist. In reality, patients turn to many services and products for this need. They choose primary care doctors, physician assistants, nurses, naturopaths, moisturizers, coconut oil, pharmacists, Dr. Oz, WebMD, customer care agents at WalMart, Google, and even God (see Book of Job). Our patients have many choices, and they choose us because we are the best value for their money. This could change.
I’m concerned that in a digital world where customers can book a trip to Italy, buy a house, and even get married without ever having to leave their phone, (yes, the last is legal in some states, but not in Texas), we risk irrelevance. By forcing our patients to use an inconvenient channel, we risk losing our one and only customer, our patient.
Dr. William Osler said, “In seeking the truth, we aim at the unattainable, and must be content with finding broken portions.” Telemedicine may not offer the warmth of our hand, but it does offer the service our modern patients desire. The question is not whether or not we practice medicine digitally, but rather how we will maintain the quality, trust and convenience that our patients ask of us.
Please discuss.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
The practice of medicine is a sacred event between a doctor and a patient – two individuals who have met each other in the flesh. This is the sentiment of many, and soon to be the law in the great state of Texas. It was also a popular topic of conversation at the American Telemedicine Association meeting in Los Angeles.
As a physician, I’m passionate about the profession of medicine, and as a soon-to-be MBA, I’m passionate about the practice of medicine. In this case, these ideals are pulling in opposite directions. I’m writing this dialectic as much to help me form my opinion as to help you with yours.
Should the practice of medicine be reserved only for those patients whom you have met in person? This is, after all, our history. All of us who practice medicine know the laying on of hands heals. It is a core human interaction that conveys care and concern, warmth and protection. It is the most powerful tool we have as clinicians to diagnose and heal. Touching patients can only be done in the flesh, and any interaction between a doctor and a patient that lacks this is, in one way, inferior. Not only does seeing a patient in person ensure that we won’t miss the obvious melanoma not visualized in the photo or video, but it also enables us to better connect this visit with every other visit and with the entirety of the patient’s record.
Having access to a patient’s medical record improves the quality and efficiency of care, a value conspicuously missing from one-off-dial-a-doc interactions from an online doctor who cares nothing of patient history or future.
Dr. Jack Resneck, a plenary presenter at ATA this year, told a cautionary tale of an acne patient who was treated online with an antibiotic that caused him to develop Stevens-Johnson syndrome, a life-threatening condition requiring extreme medicine and extraordinary costs. Clearly, digital medicine has shortcomings.
On the other hand, should we yield to the demands of our patients who want convenient care? Leaving work (or family) to endure traffic, to find a parking space, to sit in your waiting room, then your exam room, to have a chance to touch you once and see you for 10 minutes is not convenient. Given the option to receive care by the phone, online, or in person, patients increasingly are choosing the more convenient channels. And if you wrote a prescription for trimethoprim-sulfamethoxazole for an acne patient with no history of medication allergy and he developed Stevens-Johnson syndrome, would seeing him in person have helped? Perhaps, but probably not.
We are reluctant to call our patients “customers” for good reasons. I respect that, and I caution us to consider the truth that the trade of service for a fee is a business transaction. No matter how much patients love and respect us as doctors, if the price of our services grew exorbitantly high, or if it became impossible to see us, then they would abandon us. They would do so with remorse, yet they would do so.
Ideally, a person with a rash makes an appointment to see a dermatologist. In reality, patients turn to many services and products for this need. They choose primary care doctors, physician assistants, nurses, naturopaths, moisturizers, coconut oil, pharmacists, Dr. Oz, WebMD, customer care agents at WalMart, Google, and even God (see Book of Job). Our patients have many choices, and they choose us because we are the best value for their money. This could change.
I’m concerned that in a digital world where customers can book a trip to Italy, buy a house, and even get married without ever having to leave their phone, (yes, the last is legal in some states, but not in Texas), we risk irrelevance. By forcing our patients to use an inconvenient channel, we risk losing our one and only customer, our patient.
Dr. William Osler said, “In seeking the truth, we aim at the unattainable, and must be content with finding broken portions.” Telemedicine may not offer the warmth of our hand, but it does offer the service our modern patients desire. The question is not whether or not we practice medicine digitally, but rather how we will maintain the quality, trust and convenience that our patients ask of us.
Please discuss.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
The practice of medicine is a sacred event between a doctor and a patient – two individuals who have met each other in the flesh. This is the sentiment of many, and soon to be the law in the great state of Texas. It was also a popular topic of conversation at the American Telemedicine Association meeting in Los Angeles.
As a physician, I’m passionate about the profession of medicine, and as a soon-to-be MBA, I’m passionate about the practice of medicine. In this case, these ideals are pulling in opposite directions. I’m writing this dialectic as much to help me form my opinion as to help you with yours.
Should the practice of medicine be reserved only for those patients whom you have met in person? This is, after all, our history. All of us who practice medicine know the laying on of hands heals. It is a core human interaction that conveys care and concern, warmth and protection. It is the most powerful tool we have as clinicians to diagnose and heal. Touching patients can only be done in the flesh, and any interaction between a doctor and a patient that lacks this is, in one way, inferior. Not only does seeing a patient in person ensure that we won’t miss the obvious melanoma not visualized in the photo or video, but it also enables us to better connect this visit with every other visit and with the entirety of the patient’s record.
Having access to a patient’s medical record improves the quality and efficiency of care, a value conspicuously missing from one-off-dial-a-doc interactions from an online doctor who cares nothing of patient history or future.
Dr. Jack Resneck, a plenary presenter at ATA this year, told a cautionary tale of an acne patient who was treated online with an antibiotic that caused him to develop Stevens-Johnson syndrome, a life-threatening condition requiring extreme medicine and extraordinary costs. Clearly, digital medicine has shortcomings.
On the other hand, should we yield to the demands of our patients who want convenient care? Leaving work (or family) to endure traffic, to find a parking space, to sit in your waiting room, then your exam room, to have a chance to touch you once and see you for 10 minutes is not convenient. Given the option to receive care by the phone, online, or in person, patients increasingly are choosing the more convenient channels. And if you wrote a prescription for trimethoprim-sulfamethoxazole for an acne patient with no history of medication allergy and he developed Stevens-Johnson syndrome, would seeing him in person have helped? Perhaps, but probably not.
We are reluctant to call our patients “customers” for good reasons. I respect that, and I caution us to consider the truth that the trade of service for a fee is a business transaction. No matter how much patients love and respect us as doctors, if the price of our services grew exorbitantly high, or if it became impossible to see us, then they would abandon us. They would do so with remorse, yet they would do so.
Ideally, a person with a rash makes an appointment to see a dermatologist. In reality, patients turn to many services and products for this need. They choose primary care doctors, physician assistants, nurses, naturopaths, moisturizers, coconut oil, pharmacists, Dr. Oz, WebMD, customer care agents at WalMart, Google, and even God (see Book of Job). Our patients have many choices, and they choose us because we are the best value for their money. This could change.
I’m concerned that in a digital world where customers can book a trip to Italy, buy a house, and even get married without ever having to leave their phone, (yes, the last is legal in some states, but not in Texas), we risk irrelevance. By forcing our patients to use an inconvenient channel, we risk losing our one and only customer, our patient.
Dr. William Osler said, “In seeking the truth, we aim at the unattainable, and must be content with finding broken portions.” Telemedicine may not offer the warmth of our hand, but it does offer the service our modern patients desire. The question is not whether or not we practice medicine digitally, but rather how we will maintain the quality, trust and convenience that our patients ask of us.
Please discuss.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
Sunshine Act – another reminder
I’ve written about the Physician Payment Sunshine Act several times since it became law in 2013. My basic opinion – that it is a tempest in a teapot – has not changed. Nonetheless, now is the time to review the 2014 data reported under your name – and if necessary, initiate a dispute – before the information is posted publicly on June 30.
A quick review: The Sunshine Act, known officially as the “Open Payments Program,” requires all manufacturers of drugs, devices, and medical supplies covered by federal health care programs to report to the Centers for Medicare & Medicaid Services any financial interactions with physicians and teaching hospitals.
Reportable interactions include consulting, food, ownership or investment interest, direct compensation for speakers at education programs, and research. Compensation for clinical trials must be reported but is not made public until the product receives FDA approval, or until 4 years after the payment, whichever is earlier. Payments for trials involving a new indication for an approved drug are posted the following year.
Exemptions include CME activities funded by manufacturers and product samples for patient use. Medical students and residents are exempted entirely.
You are allowed to review your data and request corrections before information is posted publicly. You will have an additional 2 years to pursue corrections after the content goes live at the end of June, but any erroneous information will remain online until the next scheduled update, so you should find and fix errors as promptly as possible.
If you don’t see drug reps, accept sponsored lunches, or give sponsored talks, don’t assume that you won’t be on the website. Check anyway: You might be indirectly involved in a compensation that you were not aware of, or you might have been reported in error.
To review your data, register at the CMS Enterprise Portal (https://portal.cms.gov/wps/portal/unauthportal/home/) and request access to the Open Payments system.
The question remains as to what effect the law might be having on research, continuing education, or physicians’ relationships with the pharmaceutical industry. The short answer is that no one knows. The first data posting this past September came and went with little fanfare, and no repercussions directly attributable to the program have been reported as of this writing.
Sunshine laws have been in effect for several years in six states: California, Colorado, Massachusetts, Minnesota, Vermont, and West Virginia, plus the District of Columbia. (Maine repealed its law in 2011.) Observers disagree on their impact. Studies in Maine and West Virginia showed no significant public reaction or changes in prescribing patterns, according to a 2012 article in the Archives of Internal Medicine (now JAMA Internal Medicine).
Reactions from the public are equally inscrutable. Do citizens think less of doctors who accept the occasional industry-sponsored lunch for their employees? Do they think more of doctors who speak at meetings, or conduct industry-sponsored clinical research? There are no objective data. Anecdotally, I haven’t heard a peep – positive, negative, or indifferent – from any of my patients, nor have any other physicians that I’ve asked.
As of now, I stand by my initial prediction that attorneys, activists, and the occasional reporter will data-mine the information for various purposes, but few patients will bother to visit. Of course, that doesn’t mean you should ignore it as well. As always, I suggest you review the accuracy of anything posted about you, in any form or context, on any venue. This year’s data (reflecting all 2014 reports) have been available for review since April 6. You can initiate a dispute at any time over the next 2 years, before or after public release on June 30, but the sooner the better. Corrections are made each time CMS updates the system.
Maintaining accurate financial records has always been important, but it will be even more important now to support your disputes. CMS won’t simply take your word for it. A free app is available to help you track payments and other reportable industry interactions; search for “Open Payments” at your favorite app store.
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.
I’ve written about the Physician Payment Sunshine Act several times since it became law in 2013. My basic opinion – that it is a tempest in a teapot – has not changed. Nonetheless, now is the time to review the 2014 data reported under your name – and if necessary, initiate a dispute – before the information is posted publicly on June 30.
A quick review: The Sunshine Act, known officially as the “Open Payments Program,” requires all manufacturers of drugs, devices, and medical supplies covered by federal health care programs to report to the Centers for Medicare & Medicaid Services any financial interactions with physicians and teaching hospitals.
Reportable interactions include consulting, food, ownership or investment interest, direct compensation for speakers at education programs, and research. Compensation for clinical trials must be reported but is not made public until the product receives FDA approval, or until 4 years after the payment, whichever is earlier. Payments for trials involving a new indication for an approved drug are posted the following year.
Exemptions include CME activities funded by manufacturers and product samples for patient use. Medical students and residents are exempted entirely.
You are allowed to review your data and request corrections before information is posted publicly. You will have an additional 2 years to pursue corrections after the content goes live at the end of June, but any erroneous information will remain online until the next scheduled update, so you should find and fix errors as promptly as possible.
If you don’t see drug reps, accept sponsored lunches, or give sponsored talks, don’t assume that you won’t be on the website. Check anyway: You might be indirectly involved in a compensation that you were not aware of, or you might have been reported in error.
To review your data, register at the CMS Enterprise Portal (https://portal.cms.gov/wps/portal/unauthportal/home/) and request access to the Open Payments system.
The question remains as to what effect the law might be having on research, continuing education, or physicians’ relationships with the pharmaceutical industry. The short answer is that no one knows. The first data posting this past September came and went with little fanfare, and no repercussions directly attributable to the program have been reported as of this writing.
Sunshine laws have been in effect for several years in six states: California, Colorado, Massachusetts, Minnesota, Vermont, and West Virginia, plus the District of Columbia. (Maine repealed its law in 2011.) Observers disagree on their impact. Studies in Maine and West Virginia showed no significant public reaction or changes in prescribing patterns, according to a 2012 article in the Archives of Internal Medicine (now JAMA Internal Medicine).
Reactions from the public are equally inscrutable. Do citizens think less of doctors who accept the occasional industry-sponsored lunch for their employees? Do they think more of doctors who speak at meetings, or conduct industry-sponsored clinical research? There are no objective data. Anecdotally, I haven’t heard a peep – positive, negative, or indifferent – from any of my patients, nor have any other physicians that I’ve asked.
As of now, I stand by my initial prediction that attorneys, activists, and the occasional reporter will data-mine the information for various purposes, but few patients will bother to visit. Of course, that doesn’t mean you should ignore it as well. As always, I suggest you review the accuracy of anything posted about you, in any form or context, on any venue. This year’s data (reflecting all 2014 reports) have been available for review since April 6. You can initiate a dispute at any time over the next 2 years, before or after public release on June 30, but the sooner the better. Corrections are made each time CMS updates the system.
Maintaining accurate financial records has always been important, but it will be even more important now to support your disputes. CMS won’t simply take your word for it. A free app is available to help you track payments and other reportable industry interactions; search for “Open Payments” at your favorite app store.
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.
I’ve written about the Physician Payment Sunshine Act several times since it became law in 2013. My basic opinion – that it is a tempest in a teapot – has not changed. Nonetheless, now is the time to review the 2014 data reported under your name – and if necessary, initiate a dispute – before the information is posted publicly on June 30.
A quick review: The Sunshine Act, known officially as the “Open Payments Program,” requires all manufacturers of drugs, devices, and medical supplies covered by federal health care programs to report to the Centers for Medicare & Medicaid Services any financial interactions with physicians and teaching hospitals.
Reportable interactions include consulting, food, ownership or investment interest, direct compensation for speakers at education programs, and research. Compensation for clinical trials must be reported but is not made public until the product receives FDA approval, or until 4 years after the payment, whichever is earlier. Payments for trials involving a new indication for an approved drug are posted the following year.
Exemptions include CME activities funded by manufacturers and product samples for patient use. Medical students and residents are exempted entirely.
You are allowed to review your data and request corrections before information is posted publicly. You will have an additional 2 years to pursue corrections after the content goes live at the end of June, but any erroneous information will remain online until the next scheduled update, so you should find and fix errors as promptly as possible.
If you don’t see drug reps, accept sponsored lunches, or give sponsored talks, don’t assume that you won’t be on the website. Check anyway: You might be indirectly involved in a compensation that you were not aware of, or you might have been reported in error.
To review your data, register at the CMS Enterprise Portal (https://portal.cms.gov/wps/portal/unauthportal/home/) and request access to the Open Payments system.
The question remains as to what effect the law might be having on research, continuing education, or physicians’ relationships with the pharmaceutical industry. The short answer is that no one knows. The first data posting this past September came and went with little fanfare, and no repercussions directly attributable to the program have been reported as of this writing.
Sunshine laws have been in effect for several years in six states: California, Colorado, Massachusetts, Minnesota, Vermont, and West Virginia, plus the District of Columbia. (Maine repealed its law in 2011.) Observers disagree on their impact. Studies in Maine and West Virginia showed no significant public reaction or changes in prescribing patterns, according to a 2012 article in the Archives of Internal Medicine (now JAMA Internal Medicine).
Reactions from the public are equally inscrutable. Do citizens think less of doctors who accept the occasional industry-sponsored lunch for their employees? Do they think more of doctors who speak at meetings, or conduct industry-sponsored clinical research? There are no objective data. Anecdotally, I haven’t heard a peep – positive, negative, or indifferent – from any of my patients, nor have any other physicians that I’ve asked.
As of now, I stand by my initial prediction that attorneys, activists, and the occasional reporter will data-mine the information for various purposes, but few patients will bother to visit. Of course, that doesn’t mean you should ignore it as well. As always, I suggest you review the accuracy of anything posted about you, in any form or context, on any venue. This year’s data (reflecting all 2014 reports) have been available for review since April 6. You can initiate a dispute at any time over the next 2 years, before or after public release on June 30, but the sooner the better. Corrections are made each time CMS updates the system.
Maintaining accurate financial records has always been important, but it will be even more important now to support your disputes. CMS won’t simply take your word for it. A free app is available to help you track payments and other reportable industry interactions; search for “Open Payments” at your favorite app store.
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.
Take Your Statins, for Heaven’s Sake
It’s an extremely common scenario. A patient’s screening tests return, showing a significant elevation of the calculated low-density lipoprotein cholesterol (LDL-C), known to the lay public as bad cholesterol. To a physician like myself, someone who prides himself on a modest bit of expertise in lipids, it’s an absolute no-brainer. The patient should be placed on statin therapy pronto to reduce the major risks of heart attack, stroke, and other vascular misfortunes that are clearly associated with an elevated LDL-C level.
The tremendous ability of statins to reduce cardiovascular risk is among the best-demonstrated therapeutic effects of any class of medication in any branch of medical practice. The first major trial to show definitive benefits with the use of statins was the Scandinavian Simvastatin Survival Study, which came out in 1994 and showed a 30% relative reduction in cardiovascular events in a high-risk secondary prevention population, meaning that the subjects already had documented vascular disease before entering the trial.
Related: Did Niacin Get a Bum Rap?
Similar results were reported soon after in primary prevention populations in the WOSCOPS study in the United Kingdom (UK), and from the AFCAPS/TexCAPS studies in the U.S. Then the large UK-based Heart Protection Study showed that statins reduce cardiovascular risk regardless of the initial LDL-C level. Some experts suspected that many of the protective effects of statins were due not only to the LDL-C reduction per se, but also the so-called pleiotropic benefits, which included vasodilation, antithrombotic effects, and improved function of the endothelial cells that line the walls of blood vessels.
A number of additional studies have since markedly expanded the role of statins. The CARDS study showed that patients with diabetes had fewer events on statins. The ASCOT study suggested that statins reduce risk in patients with hypertension. And the SPARCL study revealed fewer recurrent events in patients on statins who had experienced a stroke or transient ischemic attack. Perhaps an even greater advance came with the JUPITER study, which showed that patients with elevated C-reactive protein levels—a marker of systemic inflammation—had fewer cardiovascular events when treated with statins than with placebo.
As you can imagine, there are plenty of times when I reach for my prescription pad (actually, my mouse) with the intention of ordering a statin to reduce a patient’s cardiovascular risk. But unfortunately, many times the patient catches me up short by objecting to such a plan. I can’t tell you how many times a patient responds by asking rather pointedly about the adverse effects (AEs) of statins. Now, I’ll readily admit that a small number of patients ask about AEs with any medication, but I would submit that the question comes up far more commonly with statins than it does with almost any other class of medication. Why?
I firmly believe that a huge driver of my patients’ irrational suspicions of statins is the drivel that is found on countless unreliable and unscientific websites. Antistatin nonsense is readily available, and many patients have thoroughly marinated themselves in a toxic slurry of misinformation and medical fantasy. Most of these sites emphasize known statin AEs, such as myalgias and myopathies, liver damage, and rhabdomyolysis, but then grossly exaggerate the severity and frequency. Other sites hammer on the modest number of patients who are nudged from prediabetes to full-fledged diabetes by the statins or rant about medically unsubstantiated AEs of statins, such as worsened mentation and depression.
Related: Are Statins Safe to Use in Pregnancy? (Clinical Edge)
That’s all bad enough, but what’s even worse is when patients attack the very medical foundation for prescribing statins, claiming that their online “research” causes them to doubt the reported association between LDL-C levels and cardiovascular risk. They also hint darkly at a vast medical-industrial conspiracy to inflate the true importance of LDL-C, thus allowing for more sales of the highly questionable statins and increased drug company profits. No patient has directly accused me of personally benefitting financially by overprescribing statins, but some have certainly hinted at it.
Another large group of patients declines to take the proffered statins by insisting that they would much rather pursue diet and exercise to bring down their high levels of LDL-C. They are invariably surprised when I tell them that even the most aggressive approaches are unlikely to reduce LDL-C by more than a negligible amount. I suspect that they think that their tired old doctor has bought into a reflexive pills-cure-all mentality and does not appreciate the wondrous benefits of a holistic approach.
The most annoying patients tell me they will instead take red yeast rice to bring down their LDL-C, because they prefer a “natural” remedy to some monstrous artificial chemical produced in a pharmaceutical company laboratory. When I try to tell them that red yeast rice contains a varying but unknown amount of a natural inhibitor of hMG-coA reductase, the same enzyme targeted with precisely dosed statins, they gape at me with unhidden disgust for completely missing the point: The naturally occurring remedy is inherently superior, precisely because it is naturally occurring!
Of course, I have to remind myself that a good number of patients simply do not want to take statins because it is a reminder of their vulnerability, status as a cardiac patient, or as a potential future victim of a heart attack or stroke. Some patients find that concept so upsetting that they would rather ignore it altogether.
Reluctantly, I admit that statins are not perfect drugs. But I would still submit that they’re the closest things we have to wonder drugs today. Yes, a fair number of patients do develop myalgias, but these are often mild and transient and can be managed. Very infrequently, patients may manifest some degree of hepatotoxicity, and very rarely rhabdomyolysis can rear its ugly head. Statins can sometimes nudge prediabetes into diabetes, just as thiazide diuretics and beta-blockers will sometimes do. However, on balance, the risk-benefit analysis of taking statins in both primary and secondary prevention settings is very much in favor of taking the drugs.
So my message to my patients (and to your patients as well) is a very simple one. Take advantage of the phenomenal life-saving benefits of these near-wonder drugs, ignore the unscientific online nonsense authored by individuals practicing medicine without a license, and do what your tired but well-meaning doctor urges: take your statins, for Heaven’s sake!
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
It’s an extremely common scenario. A patient’s screening tests return, showing a significant elevation of the calculated low-density lipoprotein cholesterol (LDL-C), known to the lay public as bad cholesterol. To a physician like myself, someone who prides himself on a modest bit of expertise in lipids, it’s an absolute no-brainer. The patient should be placed on statin therapy pronto to reduce the major risks of heart attack, stroke, and other vascular misfortunes that are clearly associated with an elevated LDL-C level.
The tremendous ability of statins to reduce cardiovascular risk is among the best-demonstrated therapeutic effects of any class of medication in any branch of medical practice. The first major trial to show definitive benefits with the use of statins was the Scandinavian Simvastatin Survival Study, which came out in 1994 and showed a 30% relative reduction in cardiovascular events in a high-risk secondary prevention population, meaning that the subjects already had documented vascular disease before entering the trial.
Related: Did Niacin Get a Bum Rap?
Similar results were reported soon after in primary prevention populations in the WOSCOPS study in the United Kingdom (UK), and from the AFCAPS/TexCAPS studies in the U.S. Then the large UK-based Heart Protection Study showed that statins reduce cardiovascular risk regardless of the initial LDL-C level. Some experts suspected that many of the protective effects of statins were due not only to the LDL-C reduction per se, but also the so-called pleiotropic benefits, which included vasodilation, antithrombotic effects, and improved function of the endothelial cells that line the walls of blood vessels.
A number of additional studies have since markedly expanded the role of statins. The CARDS study showed that patients with diabetes had fewer events on statins. The ASCOT study suggested that statins reduce risk in patients with hypertension. And the SPARCL study revealed fewer recurrent events in patients on statins who had experienced a stroke or transient ischemic attack. Perhaps an even greater advance came with the JUPITER study, which showed that patients with elevated C-reactive protein levels—a marker of systemic inflammation—had fewer cardiovascular events when treated with statins than with placebo.
As you can imagine, there are plenty of times when I reach for my prescription pad (actually, my mouse) with the intention of ordering a statin to reduce a patient’s cardiovascular risk. But unfortunately, many times the patient catches me up short by objecting to such a plan. I can’t tell you how many times a patient responds by asking rather pointedly about the adverse effects (AEs) of statins. Now, I’ll readily admit that a small number of patients ask about AEs with any medication, but I would submit that the question comes up far more commonly with statins than it does with almost any other class of medication. Why?
I firmly believe that a huge driver of my patients’ irrational suspicions of statins is the drivel that is found on countless unreliable and unscientific websites. Antistatin nonsense is readily available, and many patients have thoroughly marinated themselves in a toxic slurry of misinformation and medical fantasy. Most of these sites emphasize known statin AEs, such as myalgias and myopathies, liver damage, and rhabdomyolysis, but then grossly exaggerate the severity and frequency. Other sites hammer on the modest number of patients who are nudged from prediabetes to full-fledged diabetes by the statins or rant about medically unsubstantiated AEs of statins, such as worsened mentation and depression.
Related: Are Statins Safe to Use in Pregnancy? (Clinical Edge)
That’s all bad enough, but what’s even worse is when patients attack the very medical foundation for prescribing statins, claiming that their online “research” causes them to doubt the reported association between LDL-C levels and cardiovascular risk. They also hint darkly at a vast medical-industrial conspiracy to inflate the true importance of LDL-C, thus allowing for more sales of the highly questionable statins and increased drug company profits. No patient has directly accused me of personally benefitting financially by overprescribing statins, but some have certainly hinted at it.
Another large group of patients declines to take the proffered statins by insisting that they would much rather pursue diet and exercise to bring down their high levels of LDL-C. They are invariably surprised when I tell them that even the most aggressive approaches are unlikely to reduce LDL-C by more than a negligible amount. I suspect that they think that their tired old doctor has bought into a reflexive pills-cure-all mentality and does not appreciate the wondrous benefits of a holistic approach.
The most annoying patients tell me they will instead take red yeast rice to bring down their LDL-C, because they prefer a “natural” remedy to some monstrous artificial chemical produced in a pharmaceutical company laboratory. When I try to tell them that red yeast rice contains a varying but unknown amount of a natural inhibitor of hMG-coA reductase, the same enzyme targeted with precisely dosed statins, they gape at me with unhidden disgust for completely missing the point: The naturally occurring remedy is inherently superior, precisely because it is naturally occurring!
Of course, I have to remind myself that a good number of patients simply do not want to take statins because it is a reminder of their vulnerability, status as a cardiac patient, or as a potential future victim of a heart attack or stroke. Some patients find that concept so upsetting that they would rather ignore it altogether.
Reluctantly, I admit that statins are not perfect drugs. But I would still submit that they’re the closest things we have to wonder drugs today. Yes, a fair number of patients do develop myalgias, but these are often mild and transient and can be managed. Very infrequently, patients may manifest some degree of hepatotoxicity, and very rarely rhabdomyolysis can rear its ugly head. Statins can sometimes nudge prediabetes into diabetes, just as thiazide diuretics and beta-blockers will sometimes do. However, on balance, the risk-benefit analysis of taking statins in both primary and secondary prevention settings is very much in favor of taking the drugs.
So my message to my patients (and to your patients as well) is a very simple one. Take advantage of the phenomenal life-saving benefits of these near-wonder drugs, ignore the unscientific online nonsense authored by individuals practicing medicine without a license, and do what your tired but well-meaning doctor urges: take your statins, for Heaven’s sake!
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
It’s an extremely common scenario. A patient’s screening tests return, showing a significant elevation of the calculated low-density lipoprotein cholesterol (LDL-C), known to the lay public as bad cholesterol. To a physician like myself, someone who prides himself on a modest bit of expertise in lipids, it’s an absolute no-brainer. The patient should be placed on statin therapy pronto to reduce the major risks of heart attack, stroke, and other vascular misfortunes that are clearly associated with an elevated LDL-C level.
The tremendous ability of statins to reduce cardiovascular risk is among the best-demonstrated therapeutic effects of any class of medication in any branch of medical practice. The first major trial to show definitive benefits with the use of statins was the Scandinavian Simvastatin Survival Study, which came out in 1994 and showed a 30% relative reduction in cardiovascular events in a high-risk secondary prevention population, meaning that the subjects already had documented vascular disease before entering the trial.
Related: Did Niacin Get a Bum Rap?
Similar results were reported soon after in primary prevention populations in the WOSCOPS study in the United Kingdom (UK), and from the AFCAPS/TexCAPS studies in the U.S. Then the large UK-based Heart Protection Study showed that statins reduce cardiovascular risk regardless of the initial LDL-C level. Some experts suspected that many of the protective effects of statins were due not only to the LDL-C reduction per se, but also the so-called pleiotropic benefits, which included vasodilation, antithrombotic effects, and improved function of the endothelial cells that line the walls of blood vessels.
A number of additional studies have since markedly expanded the role of statins. The CARDS study showed that patients with diabetes had fewer events on statins. The ASCOT study suggested that statins reduce risk in patients with hypertension. And the SPARCL study revealed fewer recurrent events in patients on statins who had experienced a stroke or transient ischemic attack. Perhaps an even greater advance came with the JUPITER study, which showed that patients with elevated C-reactive protein levels—a marker of systemic inflammation—had fewer cardiovascular events when treated with statins than with placebo.
As you can imagine, there are plenty of times when I reach for my prescription pad (actually, my mouse) with the intention of ordering a statin to reduce a patient’s cardiovascular risk. But unfortunately, many times the patient catches me up short by objecting to such a plan. I can’t tell you how many times a patient responds by asking rather pointedly about the adverse effects (AEs) of statins. Now, I’ll readily admit that a small number of patients ask about AEs with any medication, but I would submit that the question comes up far more commonly with statins than it does with almost any other class of medication. Why?
I firmly believe that a huge driver of my patients’ irrational suspicions of statins is the drivel that is found on countless unreliable and unscientific websites. Antistatin nonsense is readily available, and many patients have thoroughly marinated themselves in a toxic slurry of misinformation and medical fantasy. Most of these sites emphasize known statin AEs, such as myalgias and myopathies, liver damage, and rhabdomyolysis, but then grossly exaggerate the severity and frequency. Other sites hammer on the modest number of patients who are nudged from prediabetes to full-fledged diabetes by the statins or rant about medically unsubstantiated AEs of statins, such as worsened mentation and depression.
Related: Are Statins Safe to Use in Pregnancy? (Clinical Edge)
That’s all bad enough, but what’s even worse is when patients attack the very medical foundation for prescribing statins, claiming that their online “research” causes them to doubt the reported association between LDL-C levels and cardiovascular risk. They also hint darkly at a vast medical-industrial conspiracy to inflate the true importance of LDL-C, thus allowing for more sales of the highly questionable statins and increased drug company profits. No patient has directly accused me of personally benefitting financially by overprescribing statins, but some have certainly hinted at it.
Another large group of patients declines to take the proffered statins by insisting that they would much rather pursue diet and exercise to bring down their high levels of LDL-C. They are invariably surprised when I tell them that even the most aggressive approaches are unlikely to reduce LDL-C by more than a negligible amount. I suspect that they think that their tired old doctor has bought into a reflexive pills-cure-all mentality and does not appreciate the wondrous benefits of a holistic approach.
The most annoying patients tell me they will instead take red yeast rice to bring down their LDL-C, because they prefer a “natural” remedy to some monstrous artificial chemical produced in a pharmaceutical company laboratory. When I try to tell them that red yeast rice contains a varying but unknown amount of a natural inhibitor of hMG-coA reductase, the same enzyme targeted with precisely dosed statins, they gape at me with unhidden disgust for completely missing the point: The naturally occurring remedy is inherently superior, precisely because it is naturally occurring!
Of course, I have to remind myself that a good number of patients simply do not want to take statins because it is a reminder of their vulnerability, status as a cardiac patient, or as a potential future victim of a heart attack or stroke. Some patients find that concept so upsetting that they would rather ignore it altogether.
Reluctantly, I admit that statins are not perfect drugs. But I would still submit that they’re the closest things we have to wonder drugs today. Yes, a fair number of patients do develop myalgias, but these are often mild and transient and can be managed. Very infrequently, patients may manifest some degree of hepatotoxicity, and very rarely rhabdomyolysis can rear its ugly head. Statins can sometimes nudge prediabetes into diabetes, just as thiazide diuretics and beta-blockers will sometimes do. However, on balance, the risk-benefit analysis of taking statins in both primary and secondary prevention settings is very much in favor of taking the drugs.
So my message to my patients (and to your patients as well) is a very simple one. Take advantage of the phenomenal life-saving benefits of these near-wonder drugs, ignore the unscientific online nonsense authored by individuals practicing medicine without a license, and do what your tired but well-meaning doctor urges: take your statins, for Heaven’s sake!
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
No Man Is an Island in the Public Health Service
Below is an edited and condensed version of the Federal Practitioner interview with Jeffrey W. Sherman, DO, chief medical officer of the Department of Homeland Security’s Transportation Security Administration. Dr. Sherman recently received the Outstanding Service Medal from PHS. To hear the complete interview, visit: http://www.fedprac.com/multimedia/multimedia-library.html.
The Transportation Security Administration
Jeffrey W. Sherman, DO. I’m primarily responsible for providing expert opinion to the senior leadership of the Transportation Security Administration (TSA) as it relates to occupational health, preventive medicine, and other medical topics. The position of chief medical officer at the TSA has been on the books for quite a while. However, it hasn’t been filled on a permanent basis until the time that I came over from the Office of Health Affairs…. For the most part, the marching orders that I was given from the senior leadership was to take a fairly neutral look at the agency’s ability to manage the health and wellness of its workforce and find both positive areas and areas for improvement where the TSA could impact the welfare of the TSA population.
Related: Committed to Showing Results at the VA
Programs that we were able to identify that were already in existence and working really well for the TSA were in abundance. However, there were a number of programs that I found would probably enhance the TSA’ s ability to manage its workforce better and to provide a more comfortable, safe workplace. The main one was an ability to measure the transportation security officers’ medical capability and aptitude over a period of time, so more or less to manage them periodically and allow us to review the requirements and assessments for that particular workforce from an occupational health standpoint.
Having a Career in the PHS
Dr. Sherman. My previous work with the PHS included being a director for a number of different medical programs in other government agencies, including Immigration and Customs Enforcement (ICE), where I was acting director of the Division of Immigration Health Services for a period of time. I moved on to be the senior medical advisor to the principal legal advisor at ICE; and again, working with the attorneys on various medical issues allowed me to build greater confidence in my ability to manage the interface between what’s appropriate legally from the medical standpoint and what’s appropriate from the clinical practice of medicine in occupational health. So that was very vital and important.
Just prior to coming to the TSA, I was the medical director for a number of programs for the U.S. Marshals Services. Working alongside law enforcement in their unique roles and managing programs that are variously clinical and nonclinical gives good insight as to how to come into a large organization such as the TSA, with more than 48,000 transportation security officers, and put in place programs in a preexisting organization. To retrofit programs into an organization of that size requires some tact and ability. So all that time previously spent has allowed me to gain those skills.
Joining the PHS
Dr. Sherman. We are a group of dedicated professionals; we have a very close connection and a close network of collegial interactions. I was the Professional Advisory Committee (PAC) chair for the Physicians PAC for a year and vice chair before that. Meeting all the individuals and working with them on various cross-agency public health and professional projects has absolutely brought a lot of their wealth into what I do here at the TSA specifically. No man is an island; and certainly, in the PHS, you never feel that way…
Related: Pharmacist Management of Adult Asthma at an Indian Health Service Facility
I was in private practice in rural upstate New York in 2005 when Hurricane Katrina and Hurricane Rita came ashore, and I was part of the National Health Service Corps at that time. Part of my response as a National Health Service Corps Scholar was to join colleagues—some of whom were PHS officers—down in the recovery area in Louisiana; that is where I met my first uniformed Commissioned Corps officer, 2 of them, in fact. I worked with them for several weeks and was so incredibly impressed with the work of the PHS that while I was there, I applied for my commission. So I was hit pretty hard and pretty heavy, and I haven’t looked back…
It’s, of course, very satisfying to hear your uniformed service spoken highly of in a public forum and especially by elected officials such as the president. I mean it’s difficult not to smile when you hear that. I will say, as one of the 7 uniformed services of the U.S., we do take a lot of knuckling under from our sister services that are more well known. But frankly, at the end of the day, we work beside them regardless of the notoriety or note that we get from them or from anyone else.
I’ve served alongside the Navy on the USNS Mercy, and I’ve been out with Air Force and Coast Guard on their vessels as well. So I’m very comfortable, and I think most of the PHS officers are comfortable working with our sister uniformed services. It is nice to hear the recognition.
The PHS Outstanding Service Medal
Dr. Sherman. It’s a real honor and a privilege to have received that medal…. There are things you do in your professional career that you do not do for notoriety; you do it because it’s the right thing to do, and you know it’s in the greater service to your profession.
In this case, our profession is also a uniformed service. And so for the uniformed service itself to take note and to give recognition for what I would do anyway and the manner in which I do it, it’s again, very satisfying; and it’s very humbling.
Mentoring Junior Officers
Dr. Sherman. The PHS has a very robust program of mentoring junior officers; and I think one of the things that has been most satisfying in my time in uniform, outside of the obvious professional things, has really been mentoring junior officers on their way up through the ranks and as they find their pathway forward in a career as a Commissioned Corps officer. And if I can say one thing to any new officer coming into the organization, it’s make sure that you reach out to your senior officers, and make sure you learn from both their successes and their errors so that by the time you finish your career, you can look back and say you’ve done everything you’ve wanted to.
I still maintain relationships with [my] mentors. I don’t think you’re ever too old or ever too experienced to have a mentor. There’s always something you can learn from another individual. So you know, you never stop learning, and you never stop appreciating the people who you’re working beside who come before you and who are coming behind you. And please don’t ask me to state names, because there are too many.
Below is an edited and condensed version of the Federal Practitioner interview with Jeffrey W. Sherman, DO, chief medical officer of the Department of Homeland Security’s Transportation Security Administration. Dr. Sherman recently received the Outstanding Service Medal from PHS. To hear the complete interview, visit: http://www.fedprac.com/multimedia/multimedia-library.html.
The Transportation Security Administration
Jeffrey W. Sherman, DO. I’m primarily responsible for providing expert opinion to the senior leadership of the Transportation Security Administration (TSA) as it relates to occupational health, preventive medicine, and other medical topics. The position of chief medical officer at the TSA has been on the books for quite a while. However, it hasn’t been filled on a permanent basis until the time that I came over from the Office of Health Affairs…. For the most part, the marching orders that I was given from the senior leadership was to take a fairly neutral look at the agency’s ability to manage the health and wellness of its workforce and find both positive areas and areas for improvement where the TSA could impact the welfare of the TSA population.
Related: Committed to Showing Results at the VA
Programs that we were able to identify that were already in existence and working really well for the TSA were in abundance. However, there were a number of programs that I found would probably enhance the TSA’ s ability to manage its workforce better and to provide a more comfortable, safe workplace. The main one was an ability to measure the transportation security officers’ medical capability and aptitude over a period of time, so more or less to manage them periodically and allow us to review the requirements and assessments for that particular workforce from an occupational health standpoint.
Having a Career in the PHS
Dr. Sherman. My previous work with the PHS included being a director for a number of different medical programs in other government agencies, including Immigration and Customs Enforcement (ICE), where I was acting director of the Division of Immigration Health Services for a period of time. I moved on to be the senior medical advisor to the principal legal advisor at ICE; and again, working with the attorneys on various medical issues allowed me to build greater confidence in my ability to manage the interface between what’s appropriate legally from the medical standpoint and what’s appropriate from the clinical practice of medicine in occupational health. So that was very vital and important.
Just prior to coming to the TSA, I was the medical director for a number of programs for the U.S. Marshals Services. Working alongside law enforcement in their unique roles and managing programs that are variously clinical and nonclinical gives good insight as to how to come into a large organization such as the TSA, with more than 48,000 transportation security officers, and put in place programs in a preexisting organization. To retrofit programs into an organization of that size requires some tact and ability. So all that time previously spent has allowed me to gain those skills.
Joining the PHS
Dr. Sherman. We are a group of dedicated professionals; we have a very close connection and a close network of collegial interactions. I was the Professional Advisory Committee (PAC) chair for the Physicians PAC for a year and vice chair before that. Meeting all the individuals and working with them on various cross-agency public health and professional projects has absolutely brought a lot of their wealth into what I do here at the TSA specifically. No man is an island; and certainly, in the PHS, you never feel that way…
Related: Pharmacist Management of Adult Asthma at an Indian Health Service Facility
I was in private practice in rural upstate New York in 2005 when Hurricane Katrina and Hurricane Rita came ashore, and I was part of the National Health Service Corps at that time. Part of my response as a National Health Service Corps Scholar was to join colleagues—some of whom were PHS officers—down in the recovery area in Louisiana; that is where I met my first uniformed Commissioned Corps officer, 2 of them, in fact. I worked with them for several weeks and was so incredibly impressed with the work of the PHS that while I was there, I applied for my commission. So I was hit pretty hard and pretty heavy, and I haven’t looked back…
It’s, of course, very satisfying to hear your uniformed service spoken highly of in a public forum and especially by elected officials such as the president. I mean it’s difficult not to smile when you hear that. I will say, as one of the 7 uniformed services of the U.S., we do take a lot of knuckling under from our sister services that are more well known. But frankly, at the end of the day, we work beside them regardless of the notoriety or note that we get from them or from anyone else.
I’ve served alongside the Navy on the USNS Mercy, and I’ve been out with Air Force and Coast Guard on their vessels as well. So I’m very comfortable, and I think most of the PHS officers are comfortable working with our sister uniformed services. It is nice to hear the recognition.
The PHS Outstanding Service Medal
Dr. Sherman. It’s a real honor and a privilege to have received that medal…. There are things you do in your professional career that you do not do for notoriety; you do it because it’s the right thing to do, and you know it’s in the greater service to your profession.
In this case, our profession is also a uniformed service. And so for the uniformed service itself to take note and to give recognition for what I would do anyway and the manner in which I do it, it’s again, very satisfying; and it’s very humbling.
Mentoring Junior Officers
Dr. Sherman. The PHS has a very robust program of mentoring junior officers; and I think one of the things that has been most satisfying in my time in uniform, outside of the obvious professional things, has really been mentoring junior officers on their way up through the ranks and as they find their pathway forward in a career as a Commissioned Corps officer. And if I can say one thing to any new officer coming into the organization, it’s make sure that you reach out to your senior officers, and make sure you learn from both their successes and their errors so that by the time you finish your career, you can look back and say you’ve done everything you’ve wanted to.
I still maintain relationships with [my] mentors. I don’t think you’re ever too old or ever too experienced to have a mentor. There’s always something you can learn from another individual. So you know, you never stop learning, and you never stop appreciating the people who you’re working beside who come before you and who are coming behind you. And please don’t ask me to state names, because there are too many.
Below is an edited and condensed version of the Federal Practitioner interview with Jeffrey W. Sherman, DO, chief medical officer of the Department of Homeland Security’s Transportation Security Administration. Dr. Sherman recently received the Outstanding Service Medal from PHS. To hear the complete interview, visit: http://www.fedprac.com/multimedia/multimedia-library.html.
The Transportation Security Administration
Jeffrey W. Sherman, DO. I’m primarily responsible for providing expert opinion to the senior leadership of the Transportation Security Administration (TSA) as it relates to occupational health, preventive medicine, and other medical topics. The position of chief medical officer at the TSA has been on the books for quite a while. However, it hasn’t been filled on a permanent basis until the time that I came over from the Office of Health Affairs…. For the most part, the marching orders that I was given from the senior leadership was to take a fairly neutral look at the agency’s ability to manage the health and wellness of its workforce and find both positive areas and areas for improvement where the TSA could impact the welfare of the TSA population.
Related: Committed to Showing Results at the VA
Programs that we were able to identify that were already in existence and working really well for the TSA were in abundance. However, there were a number of programs that I found would probably enhance the TSA’ s ability to manage its workforce better and to provide a more comfortable, safe workplace. The main one was an ability to measure the transportation security officers’ medical capability and aptitude over a period of time, so more or less to manage them periodically and allow us to review the requirements and assessments for that particular workforce from an occupational health standpoint.
Having a Career in the PHS
Dr. Sherman. My previous work with the PHS included being a director for a number of different medical programs in other government agencies, including Immigration and Customs Enforcement (ICE), where I was acting director of the Division of Immigration Health Services for a period of time. I moved on to be the senior medical advisor to the principal legal advisor at ICE; and again, working with the attorneys on various medical issues allowed me to build greater confidence in my ability to manage the interface between what’s appropriate legally from the medical standpoint and what’s appropriate from the clinical practice of medicine in occupational health. So that was very vital and important.
Just prior to coming to the TSA, I was the medical director for a number of programs for the U.S. Marshals Services. Working alongside law enforcement in their unique roles and managing programs that are variously clinical and nonclinical gives good insight as to how to come into a large organization such as the TSA, with more than 48,000 transportation security officers, and put in place programs in a preexisting organization. To retrofit programs into an organization of that size requires some tact and ability. So all that time previously spent has allowed me to gain those skills.
Joining the PHS
Dr. Sherman. We are a group of dedicated professionals; we have a very close connection and a close network of collegial interactions. I was the Professional Advisory Committee (PAC) chair for the Physicians PAC for a year and vice chair before that. Meeting all the individuals and working with them on various cross-agency public health and professional projects has absolutely brought a lot of their wealth into what I do here at the TSA specifically. No man is an island; and certainly, in the PHS, you never feel that way…
Related: Pharmacist Management of Adult Asthma at an Indian Health Service Facility
I was in private practice in rural upstate New York in 2005 when Hurricane Katrina and Hurricane Rita came ashore, and I was part of the National Health Service Corps at that time. Part of my response as a National Health Service Corps Scholar was to join colleagues—some of whom were PHS officers—down in the recovery area in Louisiana; that is where I met my first uniformed Commissioned Corps officer, 2 of them, in fact. I worked with them for several weeks and was so incredibly impressed with the work of the PHS that while I was there, I applied for my commission. So I was hit pretty hard and pretty heavy, and I haven’t looked back…
It’s, of course, very satisfying to hear your uniformed service spoken highly of in a public forum and especially by elected officials such as the president. I mean it’s difficult not to smile when you hear that. I will say, as one of the 7 uniformed services of the U.S., we do take a lot of knuckling under from our sister services that are more well known. But frankly, at the end of the day, we work beside them regardless of the notoriety or note that we get from them or from anyone else.
I’ve served alongside the Navy on the USNS Mercy, and I’ve been out with Air Force and Coast Guard on their vessels as well. So I’m very comfortable, and I think most of the PHS officers are comfortable working with our sister uniformed services. It is nice to hear the recognition.
The PHS Outstanding Service Medal
Dr. Sherman. It’s a real honor and a privilege to have received that medal…. There are things you do in your professional career that you do not do for notoriety; you do it because it’s the right thing to do, and you know it’s in the greater service to your profession.
In this case, our profession is also a uniformed service. And so for the uniformed service itself to take note and to give recognition for what I would do anyway and the manner in which I do it, it’s again, very satisfying; and it’s very humbling.
Mentoring Junior Officers
Dr. Sherman. The PHS has a very robust program of mentoring junior officers; and I think one of the things that has been most satisfying in my time in uniform, outside of the obvious professional things, has really been mentoring junior officers on their way up through the ranks and as they find their pathway forward in a career as a Commissioned Corps officer. And if I can say one thing to any new officer coming into the organization, it’s make sure that you reach out to your senior officers, and make sure you learn from both their successes and their errors so that by the time you finish your career, you can look back and say you’ve done everything you’ve wanted to.
I still maintain relationships with [my] mentors. I don’t think you’re ever too old or ever too experienced to have a mentor. There’s always something you can learn from another individual. So you know, you never stop learning, and you never stop appreciating the people who you’re working beside who come before you and who are coming behind you. And please don’t ask me to state names, because there are too many.
Be true to yourself
How often have nonphysicians told you that they could never work the hours you do?
Most people think physicians are a unique breed, and in some respects, we are. But in important ways we are just like everyone else. When we work long hours under stressful conditions and go without adequate sleep or nourishment, we cannot function at peak performance. Just like everyone else, we can become irritable, grumpy, and cynical when our basic needs are not met. We are human too, and we are at higher risk than most people for burnout, depression, and even suicide.
An article in the Journal of Hospital Medicine in 2014 noted that slightly over 50% of hospitalists were affected by burnout. We scored high on the emotional exhaustion subscale, and 40.3% of us had symptoms of depression, with a surprising 9.2% rate of recent suicidality. Hospital medicine definitely has its advantages over many other fields of medicine, but as this study demonstrates, there is still much to be desired in our “work-life balance.”
Each practice has its own perks and negatives, and what will enhance the lives of hospitalists in one group may make intolerable the lives of members of another group. For instance, it is no surprise that 12-hour shifts with 7-on, 7-off block scheduling can be exhausting. If you have a family, this schedule leaves plenty of fun time on the weeks you are off, but you may still be missing 50% of your family’s life if you leave for work before your kids wake up and return after they go to bed.
Whatever your concerns and stressors may be, rest assured, you are not alone, and if enough of the members of your group have similar issues, you may be successful addressing them with your director or hospital administrator. Retaining good hospitalists is vital to the financial success of many hospitals, and being flexible enough to truly meet their reasonable needs can literally make or break a hospitalist team.
How often have nonphysicians told you that they could never work the hours you do?
Most people think physicians are a unique breed, and in some respects, we are. But in important ways we are just like everyone else. When we work long hours under stressful conditions and go without adequate sleep or nourishment, we cannot function at peak performance. Just like everyone else, we can become irritable, grumpy, and cynical when our basic needs are not met. We are human too, and we are at higher risk than most people for burnout, depression, and even suicide.
An article in the Journal of Hospital Medicine in 2014 noted that slightly over 50% of hospitalists were affected by burnout. We scored high on the emotional exhaustion subscale, and 40.3% of us had symptoms of depression, with a surprising 9.2% rate of recent suicidality. Hospital medicine definitely has its advantages over many other fields of medicine, but as this study demonstrates, there is still much to be desired in our “work-life balance.”
Each practice has its own perks and negatives, and what will enhance the lives of hospitalists in one group may make intolerable the lives of members of another group. For instance, it is no surprise that 12-hour shifts with 7-on, 7-off block scheduling can be exhausting. If you have a family, this schedule leaves plenty of fun time on the weeks you are off, but you may still be missing 50% of your family’s life if you leave for work before your kids wake up and return after they go to bed.
Whatever your concerns and stressors may be, rest assured, you are not alone, and if enough of the members of your group have similar issues, you may be successful addressing them with your director or hospital administrator. Retaining good hospitalists is vital to the financial success of many hospitals, and being flexible enough to truly meet their reasonable needs can literally make or break a hospitalist team.
How often have nonphysicians told you that they could never work the hours you do?
Most people think physicians are a unique breed, and in some respects, we are. But in important ways we are just like everyone else. When we work long hours under stressful conditions and go without adequate sleep or nourishment, we cannot function at peak performance. Just like everyone else, we can become irritable, grumpy, and cynical when our basic needs are not met. We are human too, and we are at higher risk than most people for burnout, depression, and even suicide.
An article in the Journal of Hospital Medicine in 2014 noted that slightly over 50% of hospitalists were affected by burnout. We scored high on the emotional exhaustion subscale, and 40.3% of us had symptoms of depression, with a surprising 9.2% rate of recent suicidality. Hospital medicine definitely has its advantages over many other fields of medicine, but as this study demonstrates, there is still much to be desired in our “work-life balance.”
Each practice has its own perks and negatives, and what will enhance the lives of hospitalists in one group may make intolerable the lives of members of another group. For instance, it is no surprise that 12-hour shifts with 7-on, 7-off block scheduling can be exhausting. If you have a family, this schedule leaves plenty of fun time on the weeks you are off, but you may still be missing 50% of your family’s life if you leave for work before your kids wake up and return after they go to bed.
Whatever your concerns and stressors may be, rest assured, you are not alone, and if enough of the members of your group have similar issues, you may be successful addressing them with your director or hospital administrator. Retaining good hospitalists is vital to the financial success of many hospitals, and being flexible enough to truly meet their reasonable needs can literally make or break a hospitalist team.
