Commentary

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

As of this writing, there is much speculation in the press regarding the Germanwings’ copilot’s mental illness, with the implications that taking antidepressants or being depressed should be sufficient reason for a pilot’s never being allowed to fly or get a license to fly.

There is evidence that the airline knew that the copilot, Andreas Lubitz, had a history of depression, and had “suicidal tendencies” in the past, but it is unclear whether that meant suicidal thoughts just crossed his mind or he was seriously contemplating a suicide plan.

(German prosecutors report that searches on suicide were conducted on his computer in the days before the crash, suggesting that he had been considering and likely planning suicide in the preceding days.) Being depressed alone though, without serious thoughts about suicide if he were thought to be well-controlled with antidepressants without excessive sedation, would not necessarily mean that he was unfit to fly. But there might be questions about the adequacy of monitoring his mental state by those able to assess such risks, though suicide cannot always be predicted, especially if patients hide such intent.

Preliminary reports indicate that Mr. Lubitz was seeing a psychotherapist and a physician in the time before the crash. We do not know what he told them. It is not clear whether he was seeing a psychiatrist. It also looks as if the airline was made aware of the copilot’s past psychiatric problems before hiring him. It does appear that he recently feared losing his job, and it is possible that that might have affected his actions.

Although someone currently suicidal or homicidal undoubtedly should not be allowed to fly, there is no evidence at this time that the pilot communicated to anybody his intent to fly a commercial plane with passengers into a mountain. No mental health professional can adequately assess the risk a patient poses without information from the patient or another reliable source.

Legitimate questions remain whether more could have been done to minimize the risk or whether there were warning signs that should have warranted further evaluation and risk assessment of the copilot. Questions also can arise about what kind of monitoring is needed of those with a history of mental illness working in high-risk jobs such as piloting planes. But currently, there is a serious risk in Germany and even in the United States now of an overreaction to this tragedy that can increase danger by discouraging those with mental illness from getting help.

It has been reported that Mr. Lubitz had a note in his home from his doctor excusing him from flying on the date he crashed the plane. It was not submitted to his employer and he flew anyway. We do not know what the basis for the letter was or what specifically he told his psychotherapist. But the incident nonetheless raises questions about a psychotherapist’s duty to protect in both Germany and the United States. It is important to know that the laws and responsibilities of psychotherapists and physicians in Germany are not the same as those in the United States. In addition, the laws governing the responsibilities of psychotherapists differ even in the United States from one state to another.

The Tarasoff case itself creating the duty to protect in the United States originated in California. The 1974 decision of the California Supreme Court created a duty to warn. But 2 years later in 1976, the duty was changed to a duty to protect potential victims with warning potential victims and notifying the police being solely ways to satisfy the duty to protect. The 1976 decision found potential liability if a psychotherapist knew or should have known that the patient was dangerous. Since the “should have known” language opened up liability for failure to have a crystal ball to accurately predict the future, laws were passed in California and in many other states limiting liability to situations in which a serious threat was made to an identifiable victim.

For some reason, despite the original Tarasoff duty in California being a duty to warn for only 2 years from 1974 to 1976, the Tarasoff duty often was still erroneously referred to as a duty to warn. The ambiguous immunity statute referred to a duty to warn and protect, and this phrase was interpreted to mean the warn part of the duty could be satisfied only by warning. As a result, legislation was passed clarifying that the duty is to protect in California and not to warn. Warning the victim and notifying the police does, however, confer immunity from liability.

Other states have duties to protect and even duties to warn. Some have permissive but not required duties to protect or warn. Some have no such duties at all. So there are tremendous variations in such duties across the country with some states having no such duty at all.

According to a March 30 article in the Washington Post, Germany, in part in reaction to its Nazi past and the Communist past in East Germany, tries especially hard to limit intrusion into personal privacy. Although doctors in Germany can violate confidentiality for protective reasons, they can face steep legal repercussions if the confidentiality violations are later thought unwarranted. “Violations of medical privacy can carry criminal sentences of up to five years in jail.” Of course we do not know what the copilot told his psychotherapist or physician, but it is possible that fear of such penalties could intimidate professionals from taking a risk of notifying authorities since they face no penalty for opting not to report such information.

In contrast, California now allows confidentiality violations for protective reasons even for dangers that do not meet the duty to protect. It does not want psychotherapists to fear liability for notifying authorities in order to protect the public. California civil code 56.10 (19) in referring to release of confidential medical information now reads that information may be disclosed “if the psychotherapist in good faith believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”

Although we do not know what the copilot told his psychotherapist, it is important to keep in mind that the psychotherapist’s duty very much depends on the country and jurisdiction. Some legal changes might be necessary, and there might well be better monitoring of those with a serious mental illness in highly sensitive positions, but it is important not to overreact in ways that increase the dangers by increasing the stigma of mental illness unjustifiably. Stigma can discourage those with mental disorders from getting the help they need and cause people to hide any evidence of illness. Furthermore, overly frantic efforts to protect the public could discourage needed treatment and end up putting the public at even greater risk.

Dr. Weinstock is health sciences clinical professor of psychiatry, David Geffen School of Medicine, University of California, Los Angeles. He also is immediate past president of the American Academy of Psychiatry and the Law, and has coauthored or edited several textbooks about ethical practices in forensic psychiatry.

Dr. Darby is a current resident in the UCLA Semel Institute for Neuroscience and Human Behavior psychiatry residency program and a graduate of the Perelman School of Medicine at the University of Pennsylvania. He received his bachelor of arts degree from Swarthmore College in Pennsylvania with a special major in psychobiology.

As of this writing, there is much speculation in the press regarding the Germanwings’ copilot’s mental illness, with the implications that taking antidepressants or being depressed should be sufficient reason for a pilot’s never being allowed to fly or get a license to fly.

There is evidence that the airline knew that the copilot, Andreas Lubitz, had a history of depression, and had “suicidal tendencies” in the past, but it is unclear whether that meant suicidal thoughts just crossed his mind or he was seriously contemplating a suicide plan.

(German prosecutors report that searches on suicide were conducted on his computer in the days before the crash, suggesting that he had been considering and likely planning suicide in the preceding days.) Being depressed alone though, without serious thoughts about suicide if he were thought to be well-controlled with antidepressants without excessive sedation, would not necessarily mean that he was unfit to fly. But there might be questions about the adequacy of monitoring his mental state by those able to assess such risks, though suicide cannot always be predicted, especially if patients hide such intent.

Preliminary reports indicate that Mr. Lubitz was seeing a psychotherapist and a physician in the time before the crash. We do not know what he told them. It is not clear whether he was seeing a psychiatrist. It also looks as if the airline was made aware of the copilot’s past psychiatric problems before hiring him. It does appear that he recently feared losing his job, and it is possible that that might have affected his actions.

Although someone currently suicidal or homicidal undoubtedly should not be allowed to fly, there is no evidence at this time that the pilot communicated to anybody his intent to fly a commercial plane with passengers into a mountain. No mental health professional can adequately assess the risk a patient poses without information from the patient or another reliable source.

Legitimate questions remain whether more could have been done to minimize the risk or whether there were warning signs that should have warranted further evaluation and risk assessment of the copilot. Questions also can arise about what kind of monitoring is needed of those with a history of mental illness working in high-risk jobs such as piloting planes. But currently, there is a serious risk in Germany and even in the United States now of an overreaction to this tragedy that can increase danger by discouraging those with mental illness from getting help.

It has been reported that Mr. Lubitz had a note in his home from his doctor excusing him from flying on the date he crashed the plane. It was not submitted to his employer and he flew anyway. We do not know what the basis for the letter was or what specifically he told his psychotherapist. But the incident nonetheless raises questions about a psychotherapist’s duty to protect in both Germany and the United States. It is important to know that the laws and responsibilities of psychotherapists and physicians in Germany are not the same as those in the United States. In addition, the laws governing the responsibilities of psychotherapists differ even in the United States from one state to another.

The Tarasoff case itself creating the duty to protect in the United States originated in California. The 1974 decision of the California Supreme Court created a duty to warn. But 2 years later in 1976, the duty was changed to a duty to protect potential victims with warning potential victims and notifying the police being solely ways to satisfy the duty to protect. The 1976 decision found potential liability if a psychotherapist knew or should have known that the patient was dangerous. Since the “should have known” language opened up liability for failure to have a crystal ball to accurately predict the future, laws were passed in California and in many other states limiting liability to situations in which a serious threat was made to an identifiable victim.

For some reason, despite the original Tarasoff duty in California being a duty to warn for only 2 years from 1974 to 1976, the Tarasoff duty often was still erroneously referred to as a duty to warn. The ambiguous immunity statute referred to a duty to warn and protect, and this phrase was interpreted to mean the warn part of the duty could be satisfied only by warning. As a result, legislation was passed clarifying that the duty is to protect in California and not to warn. Warning the victim and notifying the police does, however, confer immunity from liability.

Other states have duties to protect and even duties to warn. Some have permissive but not required duties to protect or warn. Some have no such duties at all. So there are tremendous variations in such duties across the country with some states having no such duty at all.

According to a March 30 article in the Washington Post, Germany, in part in reaction to its Nazi past and the Communist past in East Germany, tries especially hard to limit intrusion into personal privacy. Although doctors in Germany can violate confidentiality for protective reasons, they can face steep legal repercussions if the confidentiality violations are later thought unwarranted. “Violations of medical privacy can carry criminal sentences of up to five years in jail.” Of course we do not know what the copilot told his psychotherapist or physician, but it is possible that fear of such penalties could intimidate professionals from taking a risk of notifying authorities since they face no penalty for opting not to report such information.

In contrast, California now allows confidentiality violations for protective reasons even for dangers that do not meet the duty to protect. It does not want psychotherapists to fear liability for notifying authorities in order to protect the public. California civil code 56.10 (19) in referring to release of confidential medical information now reads that information may be disclosed “if the psychotherapist in good faith believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”

Although we do not know what the copilot told his psychotherapist, it is important to keep in mind that the psychotherapist’s duty very much depends on the country and jurisdiction. Some legal changes might be necessary, and there might well be better monitoring of those with a serious mental illness in highly sensitive positions, but it is important not to overreact in ways that increase the dangers by increasing the stigma of mental illness unjustifiably. Stigma can discourage those with mental disorders from getting the help they need and cause people to hide any evidence of illness. Furthermore, overly frantic efforts to protect the public could discourage needed treatment and end up putting the public at even greater risk.

Dr. Weinstock is health sciences clinical professor of psychiatry, David Geffen School of Medicine, University of California, Los Angeles. He also is immediate past president of the American Academy of Psychiatry and the Law, and has coauthored or edited several textbooks about ethical practices in forensic psychiatry.

Dr. Darby is a current resident in the UCLA Semel Institute for Neuroscience and Human Behavior psychiatry residency program and a graduate of the Perelman School of Medicine at the University of Pennsylvania. He received his bachelor of arts degree from Swarthmore College in Pennsylvania with a special major in psychobiology.

As of this writing, there is much speculation in the press regarding the Germanwings’ copilot’s mental illness, with the implications that taking antidepressants or being depressed should be sufficient reason for a pilot’s never being allowed to fly or get a license to fly.

There is evidence that the airline knew that the copilot, Andreas Lubitz, had a history of depression, and had “suicidal tendencies” in the past, but it is unclear whether that meant suicidal thoughts just crossed his mind or he was seriously contemplating a suicide plan.

(German prosecutors report that searches on suicide were conducted on his computer in the days before the crash, suggesting that he had been considering and likely planning suicide in the preceding days.) Being depressed alone though, without serious thoughts about suicide if he were thought to be well-controlled with antidepressants without excessive sedation, would not necessarily mean that he was unfit to fly. But there might be questions about the adequacy of monitoring his mental state by those able to assess such risks, though suicide cannot always be predicted, especially if patients hide such intent.

Preliminary reports indicate that Mr. Lubitz was seeing a psychotherapist and a physician in the time before the crash. We do not know what he told them. It is not clear whether he was seeing a psychiatrist. It also looks as if the airline was made aware of the copilot’s past psychiatric problems before hiring him. It does appear that he recently feared losing his job, and it is possible that that might have affected his actions.

Although someone currently suicidal or homicidal undoubtedly should not be allowed to fly, there is no evidence at this time that the pilot communicated to anybody his intent to fly a commercial plane with passengers into a mountain. No mental health professional can adequately assess the risk a patient poses without information from the patient or another reliable source.

Legitimate questions remain whether more could have been done to minimize the risk or whether there were warning signs that should have warranted further evaluation and risk assessment of the copilot. Questions also can arise about what kind of monitoring is needed of those with a history of mental illness working in high-risk jobs such as piloting planes. But currently, there is a serious risk in Germany and even in the United States now of an overreaction to this tragedy that can increase danger by discouraging those with mental illness from getting help.

It has been reported that Mr. Lubitz had a note in his home from his doctor excusing him from flying on the date he crashed the plane. It was not submitted to his employer and he flew anyway. We do not know what the basis for the letter was or what specifically he told his psychotherapist. But the incident nonetheless raises questions about a psychotherapist’s duty to protect in both Germany and the United States. It is important to know that the laws and responsibilities of psychotherapists and physicians in Germany are not the same as those in the United States. In addition, the laws governing the responsibilities of psychotherapists differ even in the United States from one state to another.

The Tarasoff case itself creating the duty to protect in the United States originated in California. The 1974 decision of the California Supreme Court created a duty to warn. But 2 years later in 1976, the duty was changed to a duty to protect potential victims with warning potential victims and notifying the police being solely ways to satisfy the duty to protect. The 1976 decision found potential liability if a psychotherapist knew or should have known that the patient was dangerous. Since the “should have known” language opened up liability for failure to have a crystal ball to accurately predict the future, laws were passed in California and in many other states limiting liability to situations in which a serious threat was made to an identifiable victim.

For some reason, despite the original Tarasoff duty in California being a duty to warn for only 2 years from 1974 to 1976, the Tarasoff duty often was still erroneously referred to as a duty to warn. The ambiguous immunity statute referred to a duty to warn and protect, and this phrase was interpreted to mean the warn part of the duty could be satisfied only by warning. As a result, legislation was passed clarifying that the duty is to protect in California and not to warn. Warning the victim and notifying the police does, however, confer immunity from liability.

Other states have duties to protect and even duties to warn. Some have permissive but not required duties to protect or warn. Some have no such duties at all. So there are tremendous variations in such duties across the country with some states having no such duty at all.

According to a March 30 article in the Washington Post, Germany, in part in reaction to its Nazi past and the Communist past in East Germany, tries especially hard to limit intrusion into personal privacy. Although doctors in Germany can violate confidentiality for protective reasons, they can face steep legal repercussions if the confidentiality violations are later thought unwarranted. “Violations of medical privacy can carry criminal sentences of up to five years in jail.” Of course we do not know what the copilot told his psychotherapist or physician, but it is possible that fear of such penalties could intimidate professionals from taking a risk of notifying authorities since they face no penalty for opting not to report such information.

In contrast, California now allows confidentiality violations for protective reasons even for dangers that do not meet the duty to protect. It does not want psychotherapists to fear liability for notifying authorities in order to protect the public. California civil code 56.10 (19) in referring to release of confidential medical information now reads that information may be disclosed “if the psychotherapist in good faith believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”

Although we do not know what the copilot told his psychotherapist, it is important to keep in mind that the psychotherapist’s duty very much depends on the country and jurisdiction. Some legal changes might be necessary, and there might well be better monitoring of those with a serious mental illness in highly sensitive positions, but it is important not to overreact in ways that increase the dangers by increasing the stigma of mental illness unjustifiably. Stigma can discourage those with mental disorders from getting the help they need and cause people to hide any evidence of illness. Furthermore, overly frantic efforts to protect the public could discourage needed treatment and end up putting the public at even greater risk.

Dr. Weinstock is health sciences clinical professor of psychiatry, David Geffen School of Medicine, University of California, Los Angeles. He also is immediate past president of the American Academy of Psychiatry and the Law, and has coauthored or edited several textbooks about ethical practices in forensic psychiatry.

Dr. Darby is a current resident in the UCLA Semel Institute for Neuroscience and Human Behavior psychiatry residency program and a graduate of the Perelman School of Medicine at the University of Pennsylvania. He received his bachelor of arts degree from Swarthmore College in Pennsylvania with a special major in psychobiology.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

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.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

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.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

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.

Even though I was a psychology major, psychotherapy has always been a bit of a mystery to me. Is it truly effective in relieving patients’ distress? Which methods work?

As a practitioner who tries to recommend evidence-based treatments, I have often wondered what kinds of psychotherapy have evidence of effectiveness from randomized trials.

Cognitive behavioral therapy (CBT) is certainly one of them. A vast amount of research supports its effectiveness for a variety of conditions. A recent PubMed search for “cognitive behavioral therapy” yielded 34,507 original references and 5027 systematic reviews!

CBT is effective not only for anxiety and trauma-related distress, but also for somatic complaints such as headache and irritable bowel disease.

In this issue, Vinci et al provide an excellent summary with guidance for family physicians about using CBT to treat anxiety and trauma-related psychological distress. (See "When to recommend cognitive behavioral therapy.") This review’s case study is especially interesting because the patient initially presented with abdominal symptoms—not with psychological distress.

The long list of conditions for which CBT has been studied and found effective is quite impressive. In addition to effectively treating psychological conditions, CBT works for various somatic complaints as well, including headache, chronic pain syndromes, insomnia, irritable bowel disease, and nonspecific abdominal pain in children.¹ Research has shown that it also is effective for improving medication compliance.² For some conditions, CBT might work by reducing inflammation.³

Although usually delivered by a health care practitioner trained in its use, CBT may also be delivered electronically via computer programs and the Internet. Randomized trials of “computerized” CBT have found positive treatment effects for anxiety and depression.⁴ Computerized CBT helps reduce psychological distress in patients with physical illness.⁵ Some insurers now offer online CBT as a covered benefit.

I am convinced that CBT has something to offer many of our patients who have conditions that we find difficult to treat. It’s time we made better use of it.

Even though I was a psychology major, psychotherapy has always been a bit of a mystery to me. Is it truly effective in relieving patients’ distress? Which methods work?

As a practitioner who tries to recommend evidence-based treatments, I have often wondered what kinds of psychotherapy have evidence of effectiveness from randomized trials.

Cognitive behavioral therapy (CBT) is certainly one of them. A vast amount of research supports its effectiveness for a variety of conditions. A recent PubMed search for “cognitive behavioral therapy” yielded 34,507 original references and 5027 systematic reviews!

CBT is effective not only for anxiety and trauma-related distress, but also for somatic complaints such as headache and irritable bowel disease.

In this issue, Vinci et al provide an excellent summary with guidance for family physicians about using CBT to treat anxiety and trauma-related psychological distress. (See "When to recommend cognitive behavioral therapy.") This review’s case study is especially interesting because the patient initially presented with abdominal symptoms—not with psychological distress.

The long list of conditions for which CBT has been studied and found effective is quite impressive. In addition to effectively treating psychological conditions, CBT works for various somatic complaints as well, including headache, chronic pain syndromes, insomnia, irritable bowel disease, and nonspecific abdominal pain in children.¹ Research has shown that it also is effective for improving medication compliance.² For some conditions, CBT might work by reducing inflammation.³

Although usually delivered by a health care practitioner trained in its use, CBT may also be delivered electronically via computer programs and the Internet. Randomized trials of “computerized” CBT have found positive treatment effects for anxiety and depression.⁴ Computerized CBT helps reduce psychological distress in patients with physical illness.⁵ Some insurers now offer online CBT as a covered benefit.

I am convinced that CBT has something to offer many of our patients who have conditions that we find difficult to treat. It’s time we made better use of it.

Even though I was a psychology major, psychotherapy has always been a bit of a mystery to me. Is it truly effective in relieving patients’ distress? Which methods work?

As a practitioner who tries to recommend evidence-based treatments, I have often wondered what kinds of psychotherapy have evidence of effectiveness from randomized trials.

Cognitive behavioral therapy (CBT) is certainly one of them. A vast amount of research supports its effectiveness for a variety of conditions. A recent PubMed search for “cognitive behavioral therapy” yielded 34,507 original references and 5027 systematic reviews!

CBT is effective not only for anxiety and trauma-related distress, but also for somatic complaints such as headache and irritable bowel disease.

In this issue, Vinci et al provide an excellent summary with guidance for family physicians about using CBT to treat anxiety and trauma-related psychological distress. (See "When to recommend cognitive behavioral therapy.") This review’s case study is especially interesting because the patient initially presented with abdominal symptoms—not with psychological distress.

The long list of conditions for which CBT has been studied and found effective is quite impressive. In addition to effectively treating psychological conditions, CBT works for various somatic complaints as well, including headache, chronic pain syndromes, insomnia, irritable bowel disease, and nonspecific abdominal pain in children.¹ Research has shown that it also is effective for improving medication compliance.² For some conditions, CBT might work by reducing inflammation.³

Although usually delivered by a health care practitioner trained in its use, CBT may also be delivered electronically via computer programs and the Internet. Randomized trials of “computerized” CBT have found positive treatment effects for anxiety and depression.⁴ Computerized CBT helps reduce psychological distress in patients with physical illness.⁵ Some insurers now offer online CBT as a covered benefit.

I am convinced that CBT has something to offer many of our patients who have conditions that we find difficult to treat. It’s time we made better use of it.

An 88-year-old Scandinavian man is seen for weakness and fatigue. Physical examination reveals a normal mental status and evidence of bilateral lower-extremity neuropathy. His hematocrit is 24%, with a hemoglobin of 8 g/dL and a mean corpuscular value of 118 fL. The serum cobalamin level is 64 pg/mL (normal >200 pg/mL), and the plasma methylmalonic acid level is high. A diagnosis of pernicious anemia is made.

What do you recommend for treatment?

A) Intramuscular hydroxycobalamin 1,000-mcg load daily for 1 week, then 1,000 mcg monthly.

B) Intramuscular hydroxycobalamin 1,000 mcg monthly.

C) Vitamin B₁₂ 1,000 mcg orally.

Myth: Replacement of vitamin B12 deficiency because of pernicious anemia must not be done orally.

For decades, it has been taught that vitamin B₁₂ deficiency in patients with pernicious anemia is due to poor B₁₂ absorption caused by a lack of intrinsic factor, and that replacement must be given intramuscularly.

This belief was presented in the following statement of the USP Anti-Anemia Preparations Advisory Board: “In the management of a disease for which parenteral therapy with vitamin B₁₂ is a completely adequate and wholly reliable form of therapy, it is unwise to employ a type of treatment which is, at best, unpredictably effective” (JAMA 1959;171:2092-4).

This belief is still being propagated, as this quote from an article published recently attests: “Pernicious anemia is caused by inadequate secretion of gastric intrinsic factor necessary for vitamin B₁₂ absorption and thus cannot be treated with oral vitamin B₁₂ supplements; rather, vitamin B₁₂ must be administered parenterally” (Autoimmun. Rev. 2014;13:565-8).

Studies dating back to the 1950s showed that B₁₂ could be absorbed orally in patients with pernicious anemia, and that two mechanisms of absorption of B₁₂ exist: one involving intrinsic factor and one that does not (J. Clin. Invest. 1957;36:1551-7; N. Engl. J. Med. 1959;260:361-7). The earliest studies of vitamin B₁₂ used low doses of vitamin B₁₂, and some of the studies also used oral intrinsic factor. These studies failed to show adequate vitamin B₁₂ absorption.

In the early 1960s, several studies showed that oral replacement with vitamin B₁₂ could lead to correction of anemia (Acta Med. Scand. 1968;184:247-58; Arch. Intern. Med. 1960;106:280-92; Ann. Intern. Med. 1963;58:810-17). When doses of cyanocobalamin 300 mcg or greater were used, normalization of serum B₁₂ levels was readily achievable. In one study, 64 patients receiving 500 mcg or 1,000 mcg of B₁₂ orally daily for pernicious anemia all had normal serum B₁₂ levels, normalization of hemoglobin levels, and no neurologic complications at follow-up through 5 years.

In a dose-finding trial in elderly patients with B₁₂ deficiency, doses of 500 mcg or more were needed to normalize mild vitamin B₁₂ deficiency (Arch. Intern. Med. 2005;165:1167-72) Using very high doses of daily oral vitamin B₁₂ (1,000-2,000 mcg) leads to blood levels of vitamin B₁₂ as high or higher than are achieved with monthly intramuscular administration of vitamin B₁₂ (Acta Med. Scand. 1978;204:81-4; Blood 1998;92:1191-8; Cochrane Database Syst. Rev. 2005;3:CD004655).

The cost of vitamin B₁₂ replacement is comparable orally and parenterally. The cost of 100 tablets of 1,000 mcg of vitamin B₁₂ is about $5-$10. Ten doses of B₁₂ for injection (1,000 mcg) is about $15, but charges for administration either by clinic personnel or a visiting nurse dramatically increase the monthly cost. If patients are able to give themselves the B₁₂ injection, the additional cost is the cost of the monthly syringe, needle, and alcohol wipes.

Given the evidence and the costs, why is oral vitamin B₁₂ not widely used for replacement?

Most physicians do not believe that vitamin B₁₂ can be replaced orally. In a survey of internists, 94% were not aware of an available, effective oral therapy for B₁₂ replacement (JAMA 1991;265:94-5). In the same survey, 88% of the internists stated that an oral replacement form of B₁₂ would be useful in their practice. These data are more than 20 years old, but physician knowledge in this area is slow to develop. When I lecture on the topic of medical myths and poll the audience about B₁₂ replacement, 60%-80% still recommend intramuscular replacement instead of oral replacement.

This myth combines several features seen in medical myths.

First, it makes some sense from a pathophysiologic standpoint, as intrinsic factor is needed to absorb the small amounts of vitamin B₁₂ in our usual diets. It is easy to understand why one would think that without intrinsic factor, vitamin B₁₂ couldn’t be absorbed and would require intramuscular replacement.

In addition, the studies that refuted the myth were published at a time when high-dose oral vitamin B₁₂ was not available in the United States, so oral replacement did not become standard practice.

Finally, the earliest studies on oral vitamin B₁₂ replacement using low doses of vitamin B₁₂ were failures, which gave evidence to the thinking that the only way vitamin B₁₂ could be replaced would be via parenteral administration.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

An 88-year-old Scandinavian man is seen for weakness and fatigue. Physical examination reveals a normal mental status and evidence of bilateral lower-extremity neuropathy. His hematocrit is 24%, with a hemoglobin of 8 g/dL and a mean corpuscular value of 118 fL. The serum cobalamin level is 64 pg/mL (normal >200 pg/mL), and the plasma methylmalonic acid level is high. A diagnosis of pernicious anemia is made.

What do you recommend for treatment?

A) Intramuscular hydroxycobalamin 1,000-mcg load daily for 1 week, then 1,000 mcg monthly.

B) Intramuscular hydroxycobalamin 1,000 mcg monthly.

C) Vitamin B₁₂ 1,000 mcg orally.

Myth: Replacement of vitamin B12 deficiency because of pernicious anemia must not be done orally.

For decades, it has been taught that vitamin B₁₂ deficiency in patients with pernicious anemia is due to poor B₁₂ absorption caused by a lack of intrinsic factor, and that replacement must be given intramuscularly.

This belief was presented in the following statement of the USP Anti-Anemia Preparations Advisory Board: “In the management of a disease for which parenteral therapy with vitamin B₁₂ is a completely adequate and wholly reliable form of therapy, it is unwise to employ a type of treatment which is, at best, unpredictably effective” (JAMA 1959;171:2092-4).

This belief is still being propagated, as this quote from an article published recently attests: “Pernicious anemia is caused by inadequate secretion of gastric intrinsic factor necessary for vitamin B₁₂ absorption and thus cannot be treated with oral vitamin B₁₂ supplements; rather, vitamin B₁₂ must be administered parenterally” (Autoimmun. Rev. 2014;13:565-8).

Studies dating back to the 1950s showed that B₁₂ could be absorbed orally in patients with pernicious anemia, and that two mechanisms of absorption of B₁₂ exist: one involving intrinsic factor and one that does not (J. Clin. Invest. 1957;36:1551-7; N. Engl. J. Med. 1959;260:361-7). The earliest studies of vitamin B₁₂ used low doses of vitamin B₁₂, and some of the studies also used oral intrinsic factor. These studies failed to show adequate vitamin B₁₂ absorption.

In the early 1960s, several studies showed that oral replacement with vitamin B₁₂ could lead to correction of anemia (Acta Med. Scand. 1968;184:247-58; Arch. Intern. Med. 1960;106:280-92; Ann. Intern. Med. 1963;58:810-17). When doses of cyanocobalamin 300 mcg or greater were used, normalization of serum B₁₂ levels was readily achievable. In one study, 64 patients receiving 500 mcg or 1,000 mcg of B₁₂ orally daily for pernicious anemia all had normal serum B₁₂ levels, normalization of hemoglobin levels, and no neurologic complications at follow-up through 5 years.

In a dose-finding trial in elderly patients with B₁₂ deficiency, doses of 500 mcg or more were needed to normalize mild vitamin B₁₂ deficiency (Arch. Intern. Med. 2005;165:1167-72) Using very high doses of daily oral vitamin B₁₂ (1,000-2,000 mcg) leads to blood levels of vitamin B₁₂ as high or higher than are achieved with monthly intramuscular administration of vitamin B₁₂ (Acta Med. Scand. 1978;204:81-4; Blood 1998;92:1191-8; Cochrane Database Syst. Rev. 2005;3:CD004655).

The cost of vitamin B₁₂ replacement is comparable orally and parenterally. The cost of 100 tablets of 1,000 mcg of vitamin B₁₂ is about $5-$10. Ten doses of B₁₂ for injection (1,000 mcg) is about $15, but charges for administration either by clinic personnel or a visiting nurse dramatically increase the monthly cost. If patients are able to give themselves the B₁₂ injection, the additional cost is the cost of the monthly syringe, needle, and alcohol wipes.

Given the evidence and the costs, why is oral vitamin B₁₂ not widely used for replacement?

Most physicians do not believe that vitamin B₁₂ can be replaced orally. In a survey of internists, 94% were not aware of an available, effective oral therapy for B₁₂ replacement (JAMA 1991;265:94-5). In the same survey, 88% of the internists stated that an oral replacement form of B₁₂ would be useful in their practice. These data are more than 20 years old, but physician knowledge in this area is slow to develop. When I lecture on the topic of medical myths and poll the audience about B₁₂ replacement, 60%-80% still recommend intramuscular replacement instead of oral replacement.

This myth combines several features seen in medical myths.

First, it makes some sense from a pathophysiologic standpoint, as intrinsic factor is needed to absorb the small amounts of vitamin B₁₂ in our usual diets. It is easy to understand why one would think that without intrinsic factor, vitamin B₁₂ couldn’t be absorbed and would require intramuscular replacement.

In addition, the studies that refuted the myth were published at a time when high-dose oral vitamin B₁₂ was not available in the United States, so oral replacement did not become standard practice.

Finally, the earliest studies on oral vitamin B₁₂ replacement using low doses of vitamin B₁₂ were failures, which gave evidence to the thinking that the only way vitamin B₁₂ could be replaced would be via parenteral administration.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

An 88-year-old Scandinavian man is seen for weakness and fatigue. Physical examination reveals a normal mental status and evidence of bilateral lower-extremity neuropathy. His hematocrit is 24%, with a hemoglobin of 8 g/dL and a mean corpuscular value of 118 fL. The serum cobalamin level is 64 pg/mL (normal >200 pg/mL), and the plasma methylmalonic acid level is high. A diagnosis of pernicious anemia is made.

What do you recommend for treatment?

A) Intramuscular hydroxycobalamin 1,000-mcg load daily for 1 week, then 1,000 mcg monthly.

B) Intramuscular hydroxycobalamin 1,000 mcg monthly.

C) Vitamin B₁₂ 1,000 mcg orally.

Myth: Replacement of vitamin B12 deficiency because of pernicious anemia must not be done orally.

For decades, it has been taught that vitamin B₁₂ deficiency in patients with pernicious anemia is due to poor B₁₂ absorption caused by a lack of intrinsic factor, and that replacement must be given intramuscularly.

This belief was presented in the following statement of the USP Anti-Anemia Preparations Advisory Board: “In the management of a disease for which parenteral therapy with vitamin B₁₂ is a completely adequate and wholly reliable form of therapy, it is unwise to employ a type of treatment which is, at best, unpredictably effective” (JAMA 1959;171:2092-4).

This belief is still being propagated, as this quote from an article published recently attests: “Pernicious anemia is caused by inadequate secretion of gastric intrinsic factor necessary for vitamin B₁₂ absorption and thus cannot be treated with oral vitamin B₁₂ supplements; rather, vitamin B₁₂ must be administered parenterally” (Autoimmun. Rev. 2014;13:565-8).

Studies dating back to the 1950s showed that B₁₂ could be absorbed orally in patients with pernicious anemia, and that two mechanisms of absorption of B₁₂ exist: one involving intrinsic factor and one that does not (J. Clin. Invest. 1957;36:1551-7; N. Engl. J. Med. 1959;260:361-7). The earliest studies of vitamin B₁₂ used low doses of vitamin B₁₂, and some of the studies also used oral intrinsic factor. These studies failed to show adequate vitamin B₁₂ absorption.

In the early 1960s, several studies showed that oral replacement with vitamin B₁₂ could lead to correction of anemia (Acta Med. Scand. 1968;184:247-58; Arch. Intern. Med. 1960;106:280-92; Ann. Intern. Med. 1963;58:810-17). When doses of cyanocobalamin 300 mcg or greater were used, normalization of serum B₁₂ levels was readily achievable. In one study, 64 patients receiving 500 mcg or 1,000 mcg of B₁₂ orally daily for pernicious anemia all had normal serum B₁₂ levels, normalization of hemoglobin levels, and no neurologic complications at follow-up through 5 years.

In a dose-finding trial in elderly patients with B₁₂ deficiency, doses of 500 mcg or more were needed to normalize mild vitamin B₁₂ deficiency (Arch. Intern. Med. 2005;165:1167-72) Using very high doses of daily oral vitamin B₁₂ (1,000-2,000 mcg) leads to blood levels of vitamin B₁₂ as high or higher than are achieved with monthly intramuscular administration of vitamin B₁₂ (Acta Med. Scand. 1978;204:81-4; Blood 1998;92:1191-8; Cochrane Database Syst. Rev. 2005;3:CD004655).

The cost of vitamin B₁₂ replacement is comparable orally and parenterally. The cost of 100 tablets of 1,000 mcg of vitamin B₁₂ is about $5-$10. Ten doses of B₁₂ for injection (1,000 mcg) is about $15, but charges for administration either by clinic personnel or a visiting nurse dramatically increase the monthly cost. If patients are able to give themselves the B₁₂ injection, the additional cost is the cost of the monthly syringe, needle, and alcohol wipes.

Given the evidence and the costs, why is oral vitamin B₁₂ not widely used for replacement?

Most physicians do not believe that vitamin B₁₂ can be replaced orally. In a survey of internists, 94% were not aware of an available, effective oral therapy for B₁₂ replacement (JAMA 1991;265:94-5). In the same survey, 88% of the internists stated that an oral replacement form of B₁₂ would be useful in their practice. These data are more than 20 years old, but physician knowledge in this area is slow to develop. When I lecture on the topic of medical myths and poll the audience about B₁₂ replacement, 60%-80% still recommend intramuscular replacement instead of oral replacement.

This myth combines several features seen in medical myths.

First, it makes some sense from a pathophysiologic standpoint, as intrinsic factor is needed to absorb the small amounts of vitamin B₁₂ in our usual diets. It is easy to understand why one would think that without intrinsic factor, vitamin B₁₂ couldn’t be absorbed and would require intramuscular replacement.

In addition, the studies that refuted the myth were published at a time when high-dose oral vitamin B₁₂ was not available in the United States, so oral replacement did not become standard practice.

Finally, the earliest studies on oral vitamin B₁₂ replacement using low doses of vitamin B₁₂ were failures, which gave evidence to the thinking that the only way vitamin B₁₂ could be replaced would be via parenteral administration.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

Angry ED patients, or family members, are angry for a variety of reasons.  Some arrive angry, but many more become angry waiting to be seen by an EP, waiting for lab results or a consult, waiting for an inpatient bed, or waiting to be discharged. Persistent pain, hunger, overcrowded ED conditions, and harried staff are ingredients for potential explosions among even those patients who do not arrive intoxicated, hypoxic, febrile, delirious, demented, or psychotic.

In a 1998 perspective on aggression and violence directed toward physicians, (J Gen Intern Med. 1998;13[8]:556-561), Morrison et al, noted that health-care patients were responsible for almost half of the nonfatal workplace violence, and that among doctors, psychiatrists and emergency physicians were believed to be at the highest risk of aggression and violence.  In a more recent observational study of ED staff and patient interactions, accompanied by staff interviews and questionnaires, (Emerg Med Int. 2012. doi:10.1155/2012/603215) Cheshin et al found that length of stay (averaging about 3 hours in the study) was the most common reason for angry patient outbursts characterized by hostile stares, shouts, and pounding on the counter.

A new and potentially dangerous form of anger expression are the unmonitored consumer-rating blogs on social media that are increasingly being used by angry patients to rail against EDs, EPs, and ED nurses. The blogs frequently include the names of specific physicians and nurses blamed for unsatisfactory care, often naming individuals who have little or nothing to do with the complaints expressed.

But patients aren’t the only ones who may be angry at EDs or EPs. Physicians from other specialties sometimes become angry when they are not consulted about one of their patients in the ED, or when they disagree about an EP’s treatment or disposition plan.    

Emergency physicians in turn can become frustrated or angry by the number of phone calls often required to reach another physician, or when they end up speaking with a covering physician who knows very little about a patient, or when no physician who knows the patient is available when needed. Emergency physicians can also become angry when another physician doesn’t agree with the EP’s management decisions, or makes what are considered to be unreasonable demands, or afterwards unfairly blames the EP for a bad result.

Emergency physicians are also angered by lawyers who drag them into malpractice suits that may have little to do with the ED care a patient received, or by law enforcement officials who  demand that they obtain specimens from uncooperative prisoners. In some areas of the country, EPs have become very angry with other EPs who operate urgent care centers or free-standing EDs that compete with their own hospital-based ED for patients.

Some of the anger that other physicians harbor toward EPs and EDs, and the anger that some EPs have toward fellow EPs has been expressed in the nastiest of tones in recent medical tabloid “commentaries” or editorials, and in the blogs that follow.

The keys to managing to all of this anger are anticipation followed by prevention whenever possible, mitigation when prevention fails, and calling for appropriate help early on before an incident escalates further. For EPs, it is most important not to allow an angry incident to affect other patient interactions during a shift, and to channel their own angry energy into activities that benefit patients.  But organized emergency medicine must also act immediately to address the potential dangers to EPs caused by irresponsible blogs on social media.

Angry ED patients, or family members, are angry for a variety of reasons.  Some arrive angry, but many more become angry waiting to be seen by an EP, waiting for lab results or a consult, waiting for an inpatient bed, or waiting to be discharged. Persistent pain, hunger, overcrowded ED conditions, and harried staff are ingredients for potential explosions among even those patients who do not arrive intoxicated, hypoxic, febrile, delirious, demented, or psychotic.

In a 1998 perspective on aggression and violence directed toward physicians, (J Gen Intern Med. 1998;13[8]:556-561), Morrison et al, noted that health-care patients were responsible for almost half of the nonfatal workplace violence, and that among doctors, psychiatrists and emergency physicians were believed to be at the highest risk of aggression and violence.  In a more recent observational study of ED staff and patient interactions, accompanied by staff interviews and questionnaires, (Emerg Med Int. 2012. doi:10.1155/2012/603215) Cheshin et al found that length of stay (averaging about 3 hours in the study) was the most common reason for angry patient outbursts characterized by hostile stares, shouts, and pounding on the counter.

A new and potentially dangerous form of anger expression are the unmonitored consumer-rating blogs on social media that are increasingly being used by angry patients to rail against EDs, EPs, and ED nurses. The blogs frequently include the names of specific physicians and nurses blamed for unsatisfactory care, often naming individuals who have little or nothing to do with the complaints expressed.

But patients aren’t the only ones who may be angry at EDs or EPs. Physicians from other specialties sometimes become angry when they are not consulted about one of their patients in the ED, or when they disagree about an EP’s treatment or disposition plan.    

Emergency physicians in turn can become frustrated or angry by the number of phone calls often required to reach another physician, or when they end up speaking with a covering physician who knows very little about a patient, or when no physician who knows the patient is available when needed. Emergency physicians can also become angry when another physician doesn’t agree with the EP’s management decisions, or makes what are considered to be unreasonable demands, or afterwards unfairly blames the EP for a bad result.

Emergency physicians are also angered by lawyers who drag them into malpractice suits that may have little to do with the ED care a patient received, or by law enforcement officials who  demand that they obtain specimens from uncooperative prisoners. In some areas of the country, EPs have become very angry with other EPs who operate urgent care centers or free-standing EDs that compete with their own hospital-based ED for patients.

Some of the anger that other physicians harbor toward EPs and EDs, and the anger that some EPs have toward fellow EPs has been expressed in the nastiest of tones in recent medical tabloid “commentaries” or editorials, and in the blogs that follow.

The keys to managing to all of this anger are anticipation followed by prevention whenever possible, mitigation when prevention fails, and calling for appropriate help early on before an incident escalates further. For EPs, it is most important not to allow an angry incident to affect other patient interactions during a shift, and to channel their own angry energy into activities that benefit patients.  But organized emergency medicine must also act immediately to address the potential dangers to EPs caused by irresponsible blogs on social media.

Angry ED patients, or family members, are angry for a variety of reasons.  Some arrive angry, but many more become angry waiting to be seen by an EP, waiting for lab results or a consult, waiting for an inpatient bed, or waiting to be discharged. Persistent pain, hunger, overcrowded ED conditions, and harried staff are ingredients for potential explosions among even those patients who do not arrive intoxicated, hypoxic, febrile, delirious, demented, or psychotic.

In a 1998 perspective on aggression and violence directed toward physicians, (J Gen Intern Med. 1998;13[8]:556-561), Morrison et al, noted that health-care patients were responsible for almost half of the nonfatal workplace violence, and that among doctors, psychiatrists and emergency physicians were believed to be at the highest risk of aggression and violence.  In a more recent observational study of ED staff and patient interactions, accompanied by staff interviews and questionnaires, (Emerg Med Int. 2012. doi:10.1155/2012/603215) Cheshin et al found that length of stay (averaging about 3 hours in the study) was the most common reason for angry patient outbursts characterized by hostile stares, shouts, and pounding on the counter.

A new and potentially dangerous form of anger expression are the unmonitored consumer-rating blogs on social media that are increasingly being used by angry patients to rail against EDs, EPs, and ED nurses. The blogs frequently include the names of specific physicians and nurses blamed for unsatisfactory care, often naming individuals who have little or nothing to do with the complaints expressed.

But patients aren’t the only ones who may be angry at EDs or EPs. Physicians from other specialties sometimes become angry when they are not consulted about one of their patients in the ED, or when they disagree about an EP’s treatment or disposition plan.    

Emergency physicians in turn can become frustrated or angry by the number of phone calls often required to reach another physician, or when they end up speaking with a covering physician who knows very little about a patient, or when no physician who knows the patient is available when needed. Emergency physicians can also become angry when another physician doesn’t agree with the EP’s management decisions, or makes what are considered to be unreasonable demands, or afterwards unfairly blames the EP for a bad result.

Emergency physicians are also angered by lawyers who drag them into malpractice suits that may have little to do with the ED care a patient received, or by law enforcement officials who  demand that they obtain specimens from uncooperative prisoners. In some areas of the country, EPs have become very angry with other EPs who operate urgent care centers or free-standing EDs that compete with their own hospital-based ED for patients.

Some of the anger that other physicians harbor toward EPs and EDs, and the anger that some EPs have toward fellow EPs has been expressed in the nastiest of tones in recent medical tabloid “commentaries” or editorials, and in the blogs that follow.

The keys to managing to all of this anger are anticipation followed by prevention whenever possible, mitigation when prevention fails, and calling for appropriate help early on before an incident escalates further. For EPs, it is most important not to allow an angry incident to affect other patient interactions during a shift, and to channel their own angry energy into activities that benefit patients.  But organized emergency medicine must also act immediately to address the potential dangers to EPs caused by irresponsible blogs on social media.

Physicians cannot sue state governments over low Medicaid payments, the U.S. Supreme Court ruled.

In a 5-4 decision, the high court overturned a decision by the 9th Circuit Court of Appeals that said physicians and other providers could sue to hold states accountable to the equal access provisions of the Medicaid Act (states accepting federal Medicaid funding are required to set pay rates at levels sufficient to ensure access to care).

©trekandshoot/thinkstockphotos.com

In the case, Armstrong v. Exceptional Child Centers Inc., justices were determining whether the Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – gives providers the right to sue. The case originates from a 2009 lawsuit by Exceptional Child Center Inc., of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director of the Idaho Department of Health and Welfare.

In the majority opinion, Justice Antonin Scalia noted that physicians who believe Medicaid rates are inadequate have an administrative remedy by petitioning the Centers for Medicare & Medicaid Services, a remedy that “shows that the Medicaid Act precludes private enforcement ... in the courts.” He added that the plaintiffs must first seek relief through CMS first before instigating legal action.

In the dissenting opinion, Justice Sonia Sotomayor noted that seeking administrative relief could lead to reduced federal funding to a state for violating the Medicaid Act’s rate requirements, adding that “HHS is often reluctant to initiate compliance actions because a ‘state’s noncompliance creates a damned-if-you-do, damned-if-you-don’t scenario where withholding of state funds will lead to depriving the poor of essential medical assistance.’ ”

Justice Scalia dismissed that logic. “The dissent’s complaint that the sanction available to the [HHS] Secretary (the cut-off of funding) is too massive to be a realistic source of relief seems to us mistaken. We doubt that the Secretary’s notice to a state that its compensation scheme is inadequate will be ignored.”

[email protected]

Physicians cannot sue state governments over low Medicaid payments, the U.S. Supreme Court ruled.

In a 5-4 decision, the high court overturned a decision by the 9th Circuit Court of Appeals that said physicians and other providers could sue to hold states accountable to the equal access provisions of the Medicaid Act (states accepting federal Medicaid funding are required to set pay rates at levels sufficient to ensure access to care).

©trekandshoot/thinkstockphotos.com

In the case, Armstrong v. Exceptional Child Centers Inc., justices were determining whether the Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – gives providers the right to sue. The case originates from a 2009 lawsuit by Exceptional Child Center Inc., of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director of the Idaho Department of Health and Welfare.

In the majority opinion, Justice Antonin Scalia noted that physicians who believe Medicaid rates are inadequate have an administrative remedy by petitioning the Centers for Medicare & Medicaid Services, a remedy that “shows that the Medicaid Act precludes private enforcement ... in the courts.” He added that the plaintiffs must first seek relief through CMS first before instigating legal action.

In the dissenting opinion, Justice Sonia Sotomayor noted that seeking administrative relief could lead to reduced federal funding to a state for violating the Medicaid Act’s rate requirements, adding that “HHS is often reluctant to initiate compliance actions because a ‘state’s noncompliance creates a damned-if-you-do, damned-if-you-don’t scenario where withholding of state funds will lead to depriving the poor of essential medical assistance.’ ”

Justice Scalia dismissed that logic. “The dissent’s complaint that the sanction available to the [HHS] Secretary (the cut-off of funding) is too massive to be a realistic source of relief seems to us mistaken. We doubt that the Secretary’s notice to a state that its compensation scheme is inadequate will be ignored.”

[email protected]

Physicians cannot sue state governments over low Medicaid payments, the U.S. Supreme Court ruled.

In a 5-4 decision, the high court overturned a decision by the 9th Circuit Court of Appeals that said physicians and other providers could sue to hold states accountable to the equal access provisions of the Medicaid Act (states accepting federal Medicaid funding are required to set pay rates at levels sufficient to ensure access to care).

©trekandshoot/thinkstockphotos.com

In the case, Armstrong v. Exceptional Child Centers Inc., justices were determining whether the Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – gives providers the right to sue. The case originates from a 2009 lawsuit by Exceptional Child Center Inc., of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director of the Idaho Department of Health and Welfare.

In the majority opinion, Justice Antonin Scalia noted that physicians who believe Medicaid rates are inadequate have an administrative remedy by petitioning the Centers for Medicare & Medicaid Services, a remedy that “shows that the Medicaid Act precludes private enforcement ... in the courts.” He added that the plaintiffs must first seek relief through CMS first before instigating legal action.

In the dissenting opinion, Justice Sonia Sotomayor noted that seeking administrative relief could lead to reduced federal funding to a state for violating the Medicaid Act’s rate requirements, adding that “HHS is often reluctant to initiate compliance actions because a ‘state’s noncompliance creates a damned-if-you-do, damned-if-you-don’t scenario where withholding of state funds will lead to depriving the poor of essential medical assistance.’ ”

Justice Scalia dismissed that logic. “The dissent’s complaint that the sanction available to the [HHS] Secretary (the cut-off of funding) is too massive to be a realistic source of relief seems to us mistaken. We doubt that the Secretary’s notice to a state that its compensation scheme is inadequate will be ignored.”

[email protected]