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Law & Medicine: class-action lawsuits
Question: Choose the single best answer to complete the statement, “A class-action lawsuit ...”
A. Is a legal cause of action for a wrongful act perpetrated by a class of wrongdoers.
B. Requires prior certification by a judge before it can go forward.
C. Is appropriate where the claims of a few injured victims can be joined together against a common wrongdoer.
D. Fulfills twin criteria of numerosity and commonality.
E. Can only be filed where there are substantial monetary damages at issue.
Answer: B. A class-action lawsuit describes a legal cause of action where a representative plaintiff(s), known as the lead plaintiff, asserts claims on behalf of a large class of similarly injured members, who then give up their rights to pursue an individual lawsuit. Class-action suits are distinguished from the usual lawsuit, which characteristically affects only one or a few plaintiffs.
Four prerequisites govern an action before it can be deemed a class action: numerosity, commonality, typicality, and adequacy. These are words of art, with specific definitions.
Numerosity denotes a large class membership, usually exceeding 30-40, and sometimes numbering in the thousands, such that the usual joining together of a few injured plaintiffs is not practical. Commonality speaks to common questions of fact and law, typicality requires the claim(s) of the representative plaintiff to match that of the class members, and adequacy demands that the representation of the class members be adequate.
These rules, as well as other important technicalities governing class action, are enumerated in the Federal Rules of Civil Procedure under Rule 23.12Wal-Mart Stores, Inc. v. Dukes et al., where Wal-Mart was alleged to have violated Title VII of the Civil Rights Act of 1964 by having disparate wages and promotion reflecting gender discrimination.3 The plaintiffs sought an injunction against the alleged practice, as well as monetary damages. An earlier ruling of the U.S. Court of Appeals for the Ninth Circuit gave the green light to this sprawling nationwide class action.
It had started out with Betty Dukes and five other women employees, but grew to more than 1.5 million female Wal-Mart employees. However, on appeal, the U.S. Supreme Court reversed, holding that the certification of the plaintiff class was not consistent with Rule 23(a), as the prerequisite of commonality was not fulfilled. The Supreme Court also disallowed the claim for monetary relief, as it was not incidental or secondary to the injunction sought.
Class-action suits are commonly encountered in mass torts, where a product or accident causes injury to numerous individuals. Other situations include environmental pollution, securities fraud, and improper employment practices.
A favorite target is in the health care industry, where manufacturers of drugs and medical devices face allegations that defective products have been allowed to enter the market, causing harm to end users.
An example is the silicon breast implant litigation of the 1990s. The Food and Drug Administration had placed breast implants in the category of medical products and learned that the Dow Corning Corporation, which manufactured the silicon implants, had withheld safety information. The FDA severely restricted the use of these implants, which predictably led to widespread litigation with billions of dollars of judgment awards and settlements.45 and the FDA subsequently required the revision of the package insert of Lipitor and other statins to warn of this association. In 2013, a large Canadian study confirmed the increased incidence of new-onset diabetes in patients taking atorvastatin (hazard ratio, 1.22) or simvastatin.6
However, the outcome of the trial may turn on whether the clear health benefit of lowering serum cholesterol outweighs any purported safety concern.
A fast-growing trend is the filing of class-action suits against nursing homes for providing inadequate care. This is not unexpected, because large numbers of nursing home residents have a common concern over any breach of safety, hygiene, or other statutorily mandated standards of nursing home care. This important topic will be taken up in a subsequent column.
References
1. Available at www.classactionlitigation.com/rule23.html.
2. Mullenix LS. Ending class actions as we know them: rethinking the American class action. Emory Law J. 2014;64:399-449.
3. Wal-Mart Stores, Inc. v. Dukes et al.131 S. Ct. 2541 (2011).
4. Snyder JW. Silicon breast implants. Can emerging medical, legal and scientific concepts be reconciled? J. Leg. Med. 1997;18:133-220.
5. Sattar N, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010;375:735-42.
6. Carter AC, et al. Risk of incident diabetes among patients treated with statins: population based study. BMJ 2013;346:f2610.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: Choose the single best answer to complete the statement, “A class-action lawsuit ...”
A. Is a legal cause of action for a wrongful act perpetrated by a class of wrongdoers.
B. Requires prior certification by a judge before it can go forward.
C. Is appropriate where the claims of a few injured victims can be joined together against a common wrongdoer.
D. Fulfills twin criteria of numerosity and commonality.
E. Can only be filed where there are substantial monetary damages at issue.
Answer: B. A class-action lawsuit describes a legal cause of action where a representative plaintiff(s), known as the lead plaintiff, asserts claims on behalf of a large class of similarly injured members, who then give up their rights to pursue an individual lawsuit. Class-action suits are distinguished from the usual lawsuit, which characteristically affects only one or a few plaintiffs.
Four prerequisites govern an action before it can be deemed a class action: numerosity, commonality, typicality, and adequacy. These are words of art, with specific definitions.
Numerosity denotes a large class membership, usually exceeding 30-40, and sometimes numbering in the thousands, such that the usual joining together of a few injured plaintiffs is not practical. Commonality speaks to common questions of fact and law, typicality requires the claim(s) of the representative plaintiff to match that of the class members, and adequacy demands that the representation of the class members be adequate.
These rules, as well as other important technicalities governing class action, are enumerated in the Federal Rules of Civil Procedure under Rule 23.12Wal-Mart Stores, Inc. v. Dukes et al., where Wal-Mart was alleged to have violated Title VII of the Civil Rights Act of 1964 by having disparate wages and promotion reflecting gender discrimination.3 The plaintiffs sought an injunction against the alleged practice, as well as monetary damages. An earlier ruling of the U.S. Court of Appeals for the Ninth Circuit gave the green light to this sprawling nationwide class action.
It had started out with Betty Dukes and five other women employees, but grew to more than 1.5 million female Wal-Mart employees. However, on appeal, the U.S. Supreme Court reversed, holding that the certification of the plaintiff class was not consistent with Rule 23(a), as the prerequisite of commonality was not fulfilled. The Supreme Court also disallowed the claim for monetary relief, as it was not incidental or secondary to the injunction sought.
Class-action suits are commonly encountered in mass torts, where a product or accident causes injury to numerous individuals. Other situations include environmental pollution, securities fraud, and improper employment practices.
A favorite target is in the health care industry, where manufacturers of drugs and medical devices face allegations that defective products have been allowed to enter the market, causing harm to end users.
An example is the silicon breast implant litigation of the 1990s. The Food and Drug Administration had placed breast implants in the category of medical products and learned that the Dow Corning Corporation, which manufactured the silicon implants, had withheld safety information. The FDA severely restricted the use of these implants, which predictably led to widespread litigation with billions of dollars of judgment awards and settlements.45 and the FDA subsequently required the revision of the package insert of Lipitor and other statins to warn of this association. In 2013, a large Canadian study confirmed the increased incidence of new-onset diabetes in patients taking atorvastatin (hazard ratio, 1.22) or simvastatin.6
However, the outcome of the trial may turn on whether the clear health benefit of lowering serum cholesterol outweighs any purported safety concern.
A fast-growing trend is the filing of class-action suits against nursing homes for providing inadequate care. This is not unexpected, because large numbers of nursing home residents have a common concern over any breach of safety, hygiene, or other statutorily mandated standards of nursing home care. This important topic will be taken up in a subsequent column.
References
1. Available at www.classactionlitigation.com/rule23.html.
2. Mullenix LS. Ending class actions as we know them: rethinking the American class action. Emory Law J. 2014;64:399-449.
3. Wal-Mart Stores, Inc. v. Dukes et al.131 S. Ct. 2541 (2011).
4. Snyder JW. Silicon breast implants. Can emerging medical, legal and scientific concepts be reconciled? J. Leg. Med. 1997;18:133-220.
5. Sattar N, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010;375:735-42.
6. Carter AC, et al. Risk of incident diabetes among patients treated with statins: population based study. BMJ 2013;346:f2610.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: Choose the single best answer to complete the statement, “A class-action lawsuit ...”
A. Is a legal cause of action for a wrongful act perpetrated by a class of wrongdoers.
B. Requires prior certification by a judge before it can go forward.
C. Is appropriate where the claims of a few injured victims can be joined together against a common wrongdoer.
D. Fulfills twin criteria of numerosity and commonality.
E. Can only be filed where there are substantial monetary damages at issue.
Answer: B. A class-action lawsuit describes a legal cause of action where a representative plaintiff(s), known as the lead plaintiff, asserts claims on behalf of a large class of similarly injured members, who then give up their rights to pursue an individual lawsuit. Class-action suits are distinguished from the usual lawsuit, which characteristically affects only one or a few plaintiffs.
Four prerequisites govern an action before it can be deemed a class action: numerosity, commonality, typicality, and adequacy. These are words of art, with specific definitions.
Numerosity denotes a large class membership, usually exceeding 30-40, and sometimes numbering in the thousands, such that the usual joining together of a few injured plaintiffs is not practical. Commonality speaks to common questions of fact and law, typicality requires the claim(s) of the representative plaintiff to match that of the class members, and adequacy demands that the representation of the class members be adequate.
These rules, as well as other important technicalities governing class action, are enumerated in the Federal Rules of Civil Procedure under Rule 23.12Wal-Mart Stores, Inc. v. Dukes et al., where Wal-Mart was alleged to have violated Title VII of the Civil Rights Act of 1964 by having disparate wages and promotion reflecting gender discrimination.3 The plaintiffs sought an injunction against the alleged practice, as well as monetary damages. An earlier ruling of the U.S. Court of Appeals for the Ninth Circuit gave the green light to this sprawling nationwide class action.
It had started out with Betty Dukes and five other women employees, but grew to more than 1.5 million female Wal-Mart employees. However, on appeal, the U.S. Supreme Court reversed, holding that the certification of the plaintiff class was not consistent with Rule 23(a), as the prerequisite of commonality was not fulfilled. The Supreme Court also disallowed the claim for monetary relief, as it was not incidental or secondary to the injunction sought.
Class-action suits are commonly encountered in mass torts, where a product or accident causes injury to numerous individuals. Other situations include environmental pollution, securities fraud, and improper employment practices.
A favorite target is in the health care industry, where manufacturers of drugs and medical devices face allegations that defective products have been allowed to enter the market, causing harm to end users.
An example is the silicon breast implant litigation of the 1990s. The Food and Drug Administration had placed breast implants in the category of medical products and learned that the Dow Corning Corporation, which manufactured the silicon implants, had withheld safety information. The FDA severely restricted the use of these implants, which predictably led to widespread litigation with billions of dollars of judgment awards and settlements.45 and the FDA subsequently required the revision of the package insert of Lipitor and other statins to warn of this association. In 2013, a large Canadian study confirmed the increased incidence of new-onset diabetes in patients taking atorvastatin (hazard ratio, 1.22) or simvastatin.6
However, the outcome of the trial may turn on whether the clear health benefit of lowering serum cholesterol outweighs any purported safety concern.
A fast-growing trend is the filing of class-action suits against nursing homes for providing inadequate care. This is not unexpected, because large numbers of nursing home residents have a common concern over any breach of safety, hygiene, or other statutorily mandated standards of nursing home care. This important topic will be taken up in a subsequent column.
References
1. Available at www.classactionlitigation.com/rule23.html.
2. Mullenix LS. Ending class actions as we know them: rethinking the American class action. Emory Law J. 2014;64:399-449.
3. Wal-Mart Stores, Inc. v. Dukes et al.131 S. Ct. 2541 (2011).
4. Snyder JW. Silicon breast implants. Can emerging medical, legal and scientific concepts be reconciled? J. Leg. Med. 1997;18:133-220.
5. Sattar N, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010;375:735-42.
6. Carter AC, et al. Risk of incident diabetes among patients treated with statins: population based study. BMJ 2013;346:f2610.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
CBT is worthwhile—but are we making 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!
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.
1. Rutten JM, Korterink JJ, Venmans LM, et al. Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics. 2015;135:522-535.
2. Spoelstra SL, Schueller M, Hilton M, et al. Interventions combining motivational interviewing and cognitive behaviour to promote medication adherence: a literature review. J Clin Nurs. 2014. [Epub ahead of print].
3. Irwin MR, Olmstead R, Breen EC, et al. Cognitive behavioral therapy and tai chi reverse cellular and genomic markers of inflammation in late life insomnia: a randomized controlled trial. Biol Psychiatry. 2015. [Epub ahead of print].
4. Pennant ME, Loucas CE, Whittington C, et al; Expert Advisory Group. Computerised therapies for anxiety and depression in children and young people: A systematic review and meta-analysis. Behav Res Ther. 2015;67:1-18.
5. McCombie A, Gearry R, Andrews J, et al. Computerised cognitive behavioural therapy for psychological distress in patients with physical illnesses: a systematic review. J Clin Psychol Med Settings. 2015;22:20-44.
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!
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!
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.
1. Rutten JM, Korterink JJ, Venmans LM, et al. Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics. 2015;135:522-535.
2. Spoelstra SL, Schueller M, Hilton M, et al. Interventions combining motivational interviewing and cognitive behaviour to promote medication adherence: a literature review. J Clin Nurs. 2014. [Epub ahead of print].
3. Irwin MR, Olmstead R, Breen EC, et al. Cognitive behavioral therapy and tai chi reverse cellular and genomic markers of inflammation in late life insomnia: a randomized controlled trial. Biol Psychiatry. 2015. [Epub ahead of print].
4. Pennant ME, Loucas CE, Whittington C, et al; Expert Advisory Group. Computerised therapies for anxiety and depression in children and young people: A systematic review and meta-analysis. Behav Res Ther. 2015;67:1-18.
5. McCombie A, Gearry R, Andrews J, et al. Computerised cognitive behavioural therapy for psychological distress in patients with physical illnesses: a systematic review. J Clin Psychol Med Settings. 2015;22:20-44.
1. Rutten JM, Korterink JJ, Venmans LM, et al. Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review. Pediatrics. 2015;135:522-535.
2. Spoelstra SL, Schueller M, Hilton M, et al. Interventions combining motivational interviewing and cognitive behaviour to promote medication adherence: a literature review. J Clin Nurs. 2014. [Epub ahead of print].
3. Irwin MR, Olmstead R, Breen EC, et al. Cognitive behavioral therapy and tai chi reverse cellular and genomic markers of inflammation in late life insomnia: a randomized controlled trial. Biol Psychiatry. 2015. [Epub ahead of print].
4. Pennant ME, Loucas CE, Whittington C, et al; Expert Advisory Group. Computerised therapies for anxiety and depression in children and young people: A systematic review and meta-analysis. Behav Res Ther. 2015;67:1-18.
5. McCombie A, Gearry R, Andrews J, et al. Computerised cognitive behavioural therapy for psychological distress in patients with physical illnesses: a systematic review. J Clin Psychol Med Settings. 2015;22:20-44.
Is oral vitamin B12 therapy effective?
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].
Editorial: Anger Management
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.
Supreme Court: Docs cannot sue over low Medicaid payments
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).
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.”
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).
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.”
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).
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.”
Breast cancer survivors should try glycerin-containing products
“UPDATE ON SEXUAL DYSFUNCTION”
BARBARA S. LEVY, MD (SEPTEMBER 2014)
Breast cancer survivors should try glycerin-containing products
Dr. Levy’s well-written article on dyspareunia said everything I would tell a patient, until I had breast cancer and started estrogen antagonist therapy. Not only does the vagina lose elasticity but there is a similar sensation to spilling a strong acid on your skin in chemistry lab!
The silicone products Dr. Levy suggests may not be enough. Online support groups suggest a glycerin-containing product called “Probe Personal Lubricant.” If women find it too slippery to handle, they can mix it with an unscented petroleum gel product, such as “Albolene” [Albolene Moisturizing Cleanser] or “Aquaphor” [Aquaphor Healing Ointment]. I cannot tell you how many marriages this has saved for my patients and our local breast cancer survivors.
Joan Eggert, MD, MPH
St. George, Utah
Dr. Levy responds
I thank Dr. Eggert for sharing her personal experience and offering readers excellent practical advice. There is no substitute for listening to our patients and modifying recommendations based on their input and feedback. This is an important part of continuous quality improvement and experiential learning. I truly appreciate the suggestion from someone far more expert than I.
I do want to express a concern about using a petroleum jelly or mineral oil–based product as a lubricant with condoms. Albolene and Aquaphor dissolve latex and increase the chance of rupture. I do not recommend their use when a woman is using a condom for birth control or prevention of sexually transmitted disease.
Clarification requested
In the February issue of OBG Management, you quoted me as saying that the recent FDA analysis of power morcellation was inadequate. Actually, what I said was that the “FDA did an inadequate and irresponsible analysis and it has been a disservice to women.” I didn’t mince words when I spoke and I am appalled by the FDA’s lack of rigor in this important matter.
William H. Parker, MD
Santa Monica, California
The editors respond
We thank Dr. Parker for expressing his concern to us. Although the full title of Dr. Parker’s Web exclusive audio was included online, it was truncated in print due to space and may have not conveyed his full meaning to print readers. Dr. Parker’s voice, and how it is portrayed within the journal’s pages and online, is very important to us.
ANSWERING YOUR CODING QUESTIONS
A reader recently requested assistance for a specific coding challenge. We’ve asked our reimbursement specialist, Melanie Witt, RN, CPC, COBGC, MA, to provide her insight.
What billing code for patients with inconclusive viability?
Dr. Barbieri’s editorial on suspected nonviable pregnancy (“Stop using the hCG discriminatory zone of 1,500 to 2,000 mIU/mL to guide intervention during early pregnancy,” January 2015) and other recent articles help guide our trainees to not “pull the trigger,” so to speak, so quickly on early pregnancies with uncertain viability. It confirms our teaching to be patient and let the pregnancy develop, or not, especially when patients are stable.
I find billing for these encounters to be difficult, however. What do you recommend as the billing code for patients with inconclusive viability—V23.87? Is there anything other than a V-code?
Rana Snipe Berry, MD
Indianapolis, Indiana
Ms. Witt responds
Currently there is only one ICD-9-CM code that describes uncertain fetal viability: V23.87 (Pregnancy with inconclusive fetal viability). This code represents the supervision of a high-risk pregnancy for this reason, and it helps to explain additional testing that may be required. Unlike other “V” codes that many payers ignore, the V codes for pregnancy care, whether for routine supervision, high-risk supervision, or antenatal screening, are accepted by payers as reasons for care.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“UPDATE ON SEXUAL DYSFUNCTION”
BARBARA S. LEVY, MD (SEPTEMBER 2014)
Breast cancer survivors should try glycerin-containing products
Dr. Levy’s well-written article on dyspareunia said everything I would tell a patient, until I had breast cancer and started estrogen antagonist therapy. Not only does the vagina lose elasticity but there is a similar sensation to spilling a strong acid on your skin in chemistry lab!
The silicone products Dr. Levy suggests may not be enough. Online support groups suggest a glycerin-containing product called “Probe Personal Lubricant.” If women find it too slippery to handle, they can mix it with an unscented petroleum gel product, such as “Albolene” [Albolene Moisturizing Cleanser] or “Aquaphor” [Aquaphor Healing Ointment]. I cannot tell you how many marriages this has saved for my patients and our local breast cancer survivors.
Joan Eggert, MD, MPH
St. George, Utah
Dr. Levy responds
I thank Dr. Eggert for sharing her personal experience and offering readers excellent practical advice. There is no substitute for listening to our patients and modifying recommendations based on their input and feedback. This is an important part of continuous quality improvement and experiential learning. I truly appreciate the suggestion from someone far more expert than I.
I do want to express a concern about using a petroleum jelly or mineral oil–based product as a lubricant with condoms. Albolene and Aquaphor dissolve latex and increase the chance of rupture. I do not recommend their use when a woman is using a condom for birth control or prevention of sexually transmitted disease.
Clarification requested
In the February issue of OBG Management, you quoted me as saying that the recent FDA analysis of power morcellation was inadequate. Actually, what I said was that the “FDA did an inadequate and irresponsible analysis and it has been a disservice to women.” I didn’t mince words when I spoke and I am appalled by the FDA’s lack of rigor in this important matter.
William H. Parker, MD
Santa Monica, California
The editors respond
We thank Dr. Parker for expressing his concern to us. Although the full title of Dr. Parker’s Web exclusive audio was included online, it was truncated in print due to space and may have not conveyed his full meaning to print readers. Dr. Parker’s voice, and how it is portrayed within the journal’s pages and online, is very important to us.
ANSWERING YOUR CODING QUESTIONS
A reader recently requested assistance for a specific coding challenge. We’ve asked our reimbursement specialist, Melanie Witt, RN, CPC, COBGC, MA, to provide her insight.
What billing code for patients with inconclusive viability?
Dr. Barbieri’s editorial on suspected nonviable pregnancy (“Stop using the hCG discriminatory zone of 1,500 to 2,000 mIU/mL to guide intervention during early pregnancy,” January 2015) and other recent articles help guide our trainees to not “pull the trigger,” so to speak, so quickly on early pregnancies with uncertain viability. It confirms our teaching to be patient and let the pregnancy develop, or not, especially when patients are stable.
I find billing for these encounters to be difficult, however. What do you recommend as the billing code for patients with inconclusive viability—V23.87? Is there anything other than a V-code?
Rana Snipe Berry, MD
Indianapolis, Indiana
Ms. Witt responds
Currently there is only one ICD-9-CM code that describes uncertain fetal viability: V23.87 (Pregnancy with inconclusive fetal viability). This code represents the supervision of a high-risk pregnancy for this reason, and it helps to explain additional testing that may be required. Unlike other “V” codes that many payers ignore, the V codes for pregnancy care, whether for routine supervision, high-risk supervision, or antenatal screening, are accepted by payers as reasons for care.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“UPDATE ON SEXUAL DYSFUNCTION”
BARBARA S. LEVY, MD (SEPTEMBER 2014)
Breast cancer survivors should try glycerin-containing products
Dr. Levy’s well-written article on dyspareunia said everything I would tell a patient, until I had breast cancer and started estrogen antagonist therapy. Not only does the vagina lose elasticity but there is a similar sensation to spilling a strong acid on your skin in chemistry lab!
The silicone products Dr. Levy suggests may not be enough. Online support groups suggest a glycerin-containing product called “Probe Personal Lubricant.” If women find it too slippery to handle, they can mix it with an unscented petroleum gel product, such as “Albolene” [Albolene Moisturizing Cleanser] or “Aquaphor” [Aquaphor Healing Ointment]. I cannot tell you how many marriages this has saved for my patients and our local breast cancer survivors.
Joan Eggert, MD, MPH
St. George, Utah
Dr. Levy responds
I thank Dr. Eggert for sharing her personal experience and offering readers excellent practical advice. There is no substitute for listening to our patients and modifying recommendations based on their input and feedback. This is an important part of continuous quality improvement and experiential learning. I truly appreciate the suggestion from someone far more expert than I.
I do want to express a concern about using a petroleum jelly or mineral oil–based product as a lubricant with condoms. Albolene and Aquaphor dissolve latex and increase the chance of rupture. I do not recommend their use when a woman is using a condom for birth control or prevention of sexually transmitted disease.
Clarification requested
In the February issue of OBG Management, you quoted me as saying that the recent FDA analysis of power morcellation was inadequate. Actually, what I said was that the “FDA did an inadequate and irresponsible analysis and it has been a disservice to women.” I didn’t mince words when I spoke and I am appalled by the FDA’s lack of rigor in this important matter.
William H. Parker, MD
Santa Monica, California
The editors respond
We thank Dr. Parker for expressing his concern to us. Although the full title of Dr. Parker’s Web exclusive audio was included online, it was truncated in print due to space and may have not conveyed his full meaning to print readers. Dr. Parker’s voice, and how it is portrayed within the journal’s pages and online, is very important to us.
ANSWERING YOUR CODING QUESTIONS
A reader recently requested assistance for a specific coding challenge. We’ve asked our reimbursement specialist, Melanie Witt, RN, CPC, COBGC, MA, to provide her insight.
What billing code for patients with inconclusive viability?
Dr. Barbieri’s editorial on suspected nonviable pregnancy (“Stop using the hCG discriminatory zone of 1,500 to 2,000 mIU/mL to guide intervention during early pregnancy,” January 2015) and other recent articles help guide our trainees to not “pull the trigger,” so to speak, so quickly on early pregnancies with uncertain viability. It confirms our teaching to be patient and let the pregnancy develop, or not, especially when patients are stable.
I find billing for these encounters to be difficult, however. What do you recommend as the billing code for patients with inconclusive viability—V23.87? Is there anything other than a V-code?
Rana Snipe Berry, MD
Indianapolis, Indiana
Ms. Witt responds
Currently there is only one ICD-9-CM code that describes uncertain fetal viability: V23.87 (Pregnancy with inconclusive fetal viability). This code represents the supervision of a high-risk pregnancy for this reason, and it helps to explain additional testing that may be required. Unlike other “V” codes that many payers ignore, the V codes for pregnancy care, whether for routine supervision, high-risk supervision, or antenatal screening, are accepted by payers as reasons for care.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Consent to treat minors: a major complexity
The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.
When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.
The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.
Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.
A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.
Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.
Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.
Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.
Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.
Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).
Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.
The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.
The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.
When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.
The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.
Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.
A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.
Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.
Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.
Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.
Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.
Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).
Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.
The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.
The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.
When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.
The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.
Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org. Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.
A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care (Int. J. Gynaecol. Obstet. 1998;63:295-300). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.
Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included (Med. Clin. North Am, 1990; 74:1097-112). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion (Arch. Pediatr. Adolesc. Med. 2003;157:361-5). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.
Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.
Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.
Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.
Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception (Pediatrics 2007;119:627-30).
Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.
The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code to view similar columns or go to pediatricnews.com.
The ABIM sends a follow-up letter
A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.
While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.
Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”
They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.
Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?
Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.
Dr. Chan practices rheumatology in Pawtucket, R.I.
A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.
While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.
Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”
They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.
Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?
Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.
Dr. Chan practices rheumatology in Pawtucket, R.I.
A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.
While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.
Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”
They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.
Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?
Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.
Dr. Chan practices rheumatology in Pawtucket, R.I.
Cardiologists honor a fallen colleague
It’s extremely unusual for a cardiologist or cardiac surgeon to die in the line of duty, but that tragedy occurred last January in Boston when the enraged son of a patient mortally shot Dr. Michael J. Davidson while he was on the job as director of endovascular cardiac surgery at Brigham and Women’s Hospital in Boston.
Dr. Davidson had been an active coinvestigator in the PARTNER study since it began in 2007 to make the first direct comparison of a transcatheter aortic valve replacement (TAVR) system against aortic-valve replacement with conventional heart surgery.
Because of Dr. Davidson’s long and active involvement with the PARTNER trial, his colleagues decided to dedicate the study’s 5-year follow-up findings to him, making the announcement during the first public release of the 5-year results in mid-March at the annual meeting of the American College of Cardiology.
“On behalf of the PARTNER team, we would like to dedicate this study – the 5-year outcomes – to Mike Davidson,” said Dr. Michael J. Mack as he finished his podium presentation of the report.
Preceding Dr. Mack’s talk, the session began with brief remarks about Dr. Davidson from Dr. Martin B. Leon, coleader of the PARTNER trial, and then the airing of a 6-minute video featuring several of Dr. Davidson’s colleagues recalling his unique career and accomplishments.
Notable in their comments was the outline they provided of the unusual training and career path Dr. Davidson forged for himself, based on his remarkably prescient realization a decade or more ago that the future of cardiology and cardiac surgery lay in fusing the two into a hybrid discipline.
Dr. Davidson’s colleagues cited the training he undertook to become both a fully qualified cardiac surgeon and a skilled interventional cardiologist, turning himself into an embodiment of the “heart team.” Several in the video called him “visionary” for recognizing this fusion as an important step toward the future of treating heart disease.
The poignancy of the moment did not stop there.
After the video ended and before Dr. Mack delivered the session’s first talk, ACC president Dr. Patrick T. O’Gara presented a posthumous distinguished-service award from the ACC to Dr. Davidson – with Dr. O’Gara handing the award to the fallen surgeon’s parents, including his father, Dr. Robert M. Davidson, a long-time ACC fellow and former clinical chief of cardiology at Cedars-Sinai Medical Center in Los Angeles.
Following the award, Dr. Athena Poppas, chair of the meeting’s program committee and cochair for the latebreaker session on heart valve replacement, stressed that the entire session was dedicated to honor Dr. Michael Davidson.
Perhaps most moving of all were the small white buttons that Dr. O’Gara, Dr. Davidson’s parents, and others wore on their lapels during the session, featuring a blue heart and the initials MJD. It combined for an affecting tribute to someone who had played a central role in transforming heart-valve replacement and then was murdered for doing this work.
On Twitter @mitchelzoler
It’s extremely unusual for a cardiologist or cardiac surgeon to die in the line of duty, but that tragedy occurred last January in Boston when the enraged son of a patient mortally shot Dr. Michael J. Davidson while he was on the job as director of endovascular cardiac surgery at Brigham and Women’s Hospital in Boston.
Dr. Davidson had been an active coinvestigator in the PARTNER study since it began in 2007 to make the first direct comparison of a transcatheter aortic valve replacement (TAVR) system against aortic-valve replacement with conventional heart surgery.
Because of Dr. Davidson’s long and active involvement with the PARTNER trial, his colleagues decided to dedicate the study’s 5-year follow-up findings to him, making the announcement during the first public release of the 5-year results in mid-March at the annual meeting of the American College of Cardiology.
“On behalf of the PARTNER team, we would like to dedicate this study – the 5-year outcomes – to Mike Davidson,” said Dr. Michael J. Mack as he finished his podium presentation of the report.
Preceding Dr. Mack’s talk, the session began with brief remarks about Dr. Davidson from Dr. Martin B. Leon, coleader of the PARTNER trial, and then the airing of a 6-minute video featuring several of Dr. Davidson’s colleagues recalling his unique career and accomplishments.
Notable in their comments was the outline they provided of the unusual training and career path Dr. Davidson forged for himself, based on his remarkably prescient realization a decade or more ago that the future of cardiology and cardiac surgery lay in fusing the two into a hybrid discipline.
Dr. Davidson’s colleagues cited the training he undertook to become both a fully qualified cardiac surgeon and a skilled interventional cardiologist, turning himself into an embodiment of the “heart team.” Several in the video called him “visionary” for recognizing this fusion as an important step toward the future of treating heart disease.
The poignancy of the moment did not stop there.
After the video ended and before Dr. Mack delivered the session’s first talk, ACC president Dr. Patrick T. O’Gara presented a posthumous distinguished-service award from the ACC to Dr. Davidson – with Dr. O’Gara handing the award to the fallen surgeon’s parents, including his father, Dr. Robert M. Davidson, a long-time ACC fellow and former clinical chief of cardiology at Cedars-Sinai Medical Center in Los Angeles.
Following the award, Dr. Athena Poppas, chair of the meeting’s program committee and cochair for the latebreaker session on heart valve replacement, stressed that the entire session was dedicated to honor Dr. Michael Davidson.
Perhaps most moving of all were the small white buttons that Dr. O’Gara, Dr. Davidson’s parents, and others wore on their lapels during the session, featuring a blue heart and the initials MJD. It combined for an affecting tribute to someone who had played a central role in transforming heart-valve replacement and then was murdered for doing this work.
On Twitter @mitchelzoler
It’s extremely unusual for a cardiologist or cardiac surgeon to die in the line of duty, but that tragedy occurred last January in Boston when the enraged son of a patient mortally shot Dr. Michael J. Davidson while he was on the job as director of endovascular cardiac surgery at Brigham and Women’s Hospital in Boston.
Dr. Davidson had been an active coinvestigator in the PARTNER study since it began in 2007 to make the first direct comparison of a transcatheter aortic valve replacement (TAVR) system against aortic-valve replacement with conventional heart surgery.
Because of Dr. Davidson’s long and active involvement with the PARTNER trial, his colleagues decided to dedicate the study’s 5-year follow-up findings to him, making the announcement during the first public release of the 5-year results in mid-March at the annual meeting of the American College of Cardiology.
“On behalf of the PARTNER team, we would like to dedicate this study – the 5-year outcomes – to Mike Davidson,” said Dr. Michael J. Mack as he finished his podium presentation of the report.
Preceding Dr. Mack’s talk, the session began with brief remarks about Dr. Davidson from Dr. Martin B. Leon, coleader of the PARTNER trial, and then the airing of a 6-minute video featuring several of Dr. Davidson’s colleagues recalling his unique career and accomplishments.
Notable in their comments was the outline they provided of the unusual training and career path Dr. Davidson forged for himself, based on his remarkably prescient realization a decade or more ago that the future of cardiology and cardiac surgery lay in fusing the two into a hybrid discipline.
Dr. Davidson’s colleagues cited the training he undertook to become both a fully qualified cardiac surgeon and a skilled interventional cardiologist, turning himself into an embodiment of the “heart team.” Several in the video called him “visionary” for recognizing this fusion as an important step toward the future of treating heart disease.
The poignancy of the moment did not stop there.
After the video ended and before Dr. Mack delivered the session’s first talk, ACC president Dr. Patrick T. O’Gara presented a posthumous distinguished-service award from the ACC to Dr. Davidson – with Dr. O’Gara handing the award to the fallen surgeon’s parents, including his father, Dr. Robert M. Davidson, a long-time ACC fellow and former clinical chief of cardiology at Cedars-Sinai Medical Center in Los Angeles.
Following the award, Dr. Athena Poppas, chair of the meeting’s program committee and cochair for the latebreaker session on heart valve replacement, stressed that the entire session was dedicated to honor Dr. Michael Davidson.
Perhaps most moving of all were the small white buttons that Dr. O’Gara, Dr. Davidson’s parents, and others wore on their lapels during the session, featuring a blue heart and the initials MJD. It combined for an affecting tribute to someone who had played a central role in transforming heart-valve replacement and then was murdered for doing this work.
On Twitter @mitchelzoler
Was mental illness a factor in the Germanwings crash?
Earlier this week, an airplane headed from Barcelona to Dusseldorf crashed into the French Alps, leaving 150 people dead. The black box recorder indicated that the copilot was left alone in the cockpit, the pilot was locked out and attempted to gain re-entry, and the flight was reprogrammed to cruise at an altitude of 100 feet, causing the plane to crash after an 8-minute descent. The evidence indicates a deliberate action on the part of the 27-year-old co-pilot, Andreas Lubitz.
With nothing to point to terrorism at this point, the investigation will include the question of whether or not the copilot suffered from a mental illness as a way of explaining his unexplainable actions. In short, was this a combination mass murder/suicide? Was there any way to predict that such an atrocity might happen? Are there measures that can be taken to ensure that it doesn’t happen again?
In the United States, treatment with any psychotropic medication has been a reason to ground a pilot permanently. In April 2010, the Federal Aviation Administration’s rules changed such that a pilot could fly if he’d been treated for mild to moderate depression with a selective serotonin reuptake inhibitor after 12 months. At that time, the FAA announced a 6-month amnesty period where a pilot could come forward about a diagnosis of depression that he had not previously felt comfortable disclosing. Presumably, other countries also have rules that ground pilots for mental illness.
So far, some reports in the media indicate that the copilot was not obviously suffering from a psychiatric disorder; all those who have been interviewed for these reports have expressed shock that Lubitz might have deliberately crashed the plane.
There also has been speculation in the media that a break in the copilot’s training 6 years ago was due to depression, and the mother of a school mate reportedly said that Lubitz had been treated for depression. Finally, investigators found a doctor’s note excusing Lubitz from work. At this point, the Wall Street Journal is reporting that he was being treated for depression. Apparently, he had shredded the note and flew on Tuesday, despite the written work excuse.
Still, all discussion of the copilot’s mental state is purely speculation. The media is noted for sensationalist reporting – and in efforts to get information out quickly, the details are often confused or simply wrong, sometimes to a remarkable extent. We don’t know if the work excuse was written by a psychiatrist or another type of physician; we don’t know if it was for a psychiatric condition, cancer, or simply strep throat.
What we’ve been told is that a copilot who was cleared to fly did so despite a work excuse from a physician, he did not disclose this condition to his employer, and he crashed a plane killing 150 people.
We might assume that the pilot suffered from some type of psychic distress – whether he met criteria for a mental disorder or not, it’s not normal to kill 150 people. If the pilot did have a history of depression and was being treated at the time of this week’s flight, then we may be left with a very unsatisfactory answer.
The anti-psychiatry activists will say that psychotropic medications caused Lubitz to crash the plane. Psychiatrists will be left with no great answer with such a scenario and will be left to say that whatever treatment he was receiving, it wasn’t enough. Certainly, the physician who told Lubitz to take off from work was right: He didn’t belong in a cockpit that day. Presumably, that physician would have done more had he been aware that the patient was about to commit a mass murder.
If the copilot does have a history of depression, but his current work excuse was for an unrelated condition, we might wonder if an untreated recurrence of depression played some role in his actions. One might speculate that the copilot could have been afraid to seek care at this time, perhaps because of a fear that he would lose his vocation.
Still, major depression can hardly explain such an act, and it is unfortunate that the press has already begun to run headlines linking this man’s alleged psychiatric diagnosis to a catastrophic mass murder. Somehow, “mental illness” gets used as an endpoint explanation for why such things happen; and short of a severe psychotic delusional system, it’s a very unsatisfying answer for an unprecedented act of violence.
The facts will unfold and perhaps we’ll learn a little more. We’ll find out what condition the copilot was being treated for and whether there were other stresses going on in his personal life. But people get depressed, take antidepressants, and deal with stress all the time.
It’s possible, if not likely, that we’ll never understand why this copilot decided to end the lives of so many people along with his own.
Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: The Johns Hopkins University, 2011).
Earlier this week, an airplane headed from Barcelona to Dusseldorf crashed into the French Alps, leaving 150 people dead. The black box recorder indicated that the copilot was left alone in the cockpit, the pilot was locked out and attempted to gain re-entry, and the flight was reprogrammed to cruise at an altitude of 100 feet, causing the plane to crash after an 8-minute descent. The evidence indicates a deliberate action on the part of the 27-year-old co-pilot, Andreas Lubitz.
With nothing to point to terrorism at this point, the investigation will include the question of whether or not the copilot suffered from a mental illness as a way of explaining his unexplainable actions. In short, was this a combination mass murder/suicide? Was there any way to predict that such an atrocity might happen? Are there measures that can be taken to ensure that it doesn’t happen again?
In the United States, treatment with any psychotropic medication has been a reason to ground a pilot permanently. In April 2010, the Federal Aviation Administration’s rules changed such that a pilot could fly if he’d been treated for mild to moderate depression with a selective serotonin reuptake inhibitor after 12 months. At that time, the FAA announced a 6-month amnesty period where a pilot could come forward about a diagnosis of depression that he had not previously felt comfortable disclosing. Presumably, other countries also have rules that ground pilots for mental illness.
So far, some reports in the media indicate that the copilot was not obviously suffering from a psychiatric disorder; all those who have been interviewed for these reports have expressed shock that Lubitz might have deliberately crashed the plane.
There also has been speculation in the media that a break in the copilot’s training 6 years ago was due to depression, and the mother of a school mate reportedly said that Lubitz had been treated for depression. Finally, investigators found a doctor’s note excusing Lubitz from work. At this point, the Wall Street Journal is reporting that he was being treated for depression. Apparently, he had shredded the note and flew on Tuesday, despite the written work excuse.
Still, all discussion of the copilot’s mental state is purely speculation. The media is noted for sensationalist reporting – and in efforts to get information out quickly, the details are often confused or simply wrong, sometimes to a remarkable extent. We don’t know if the work excuse was written by a psychiatrist or another type of physician; we don’t know if it was for a psychiatric condition, cancer, or simply strep throat.
What we’ve been told is that a copilot who was cleared to fly did so despite a work excuse from a physician, he did not disclose this condition to his employer, and he crashed a plane killing 150 people.
We might assume that the pilot suffered from some type of psychic distress – whether he met criteria for a mental disorder or not, it’s not normal to kill 150 people. If the pilot did have a history of depression and was being treated at the time of this week’s flight, then we may be left with a very unsatisfactory answer.
The anti-psychiatry activists will say that psychotropic medications caused Lubitz to crash the plane. Psychiatrists will be left with no great answer with such a scenario and will be left to say that whatever treatment he was receiving, it wasn’t enough. Certainly, the physician who told Lubitz to take off from work was right: He didn’t belong in a cockpit that day. Presumably, that physician would have done more had he been aware that the patient was about to commit a mass murder.
If the copilot does have a history of depression, but his current work excuse was for an unrelated condition, we might wonder if an untreated recurrence of depression played some role in his actions. One might speculate that the copilot could have been afraid to seek care at this time, perhaps because of a fear that he would lose his vocation.
Still, major depression can hardly explain such an act, and it is unfortunate that the press has already begun to run headlines linking this man’s alleged psychiatric diagnosis to a catastrophic mass murder. Somehow, “mental illness” gets used as an endpoint explanation for why such things happen; and short of a severe psychotic delusional system, it’s a very unsatisfying answer for an unprecedented act of violence.
The facts will unfold and perhaps we’ll learn a little more. We’ll find out what condition the copilot was being treated for and whether there were other stresses going on in his personal life. But people get depressed, take antidepressants, and deal with stress all the time.
It’s possible, if not likely, that we’ll never understand why this copilot decided to end the lives of so many people along with his own.
Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: The Johns Hopkins University, 2011).
Earlier this week, an airplane headed from Barcelona to Dusseldorf crashed into the French Alps, leaving 150 people dead. The black box recorder indicated that the copilot was left alone in the cockpit, the pilot was locked out and attempted to gain re-entry, and the flight was reprogrammed to cruise at an altitude of 100 feet, causing the plane to crash after an 8-minute descent. The evidence indicates a deliberate action on the part of the 27-year-old co-pilot, Andreas Lubitz.
With nothing to point to terrorism at this point, the investigation will include the question of whether or not the copilot suffered from a mental illness as a way of explaining his unexplainable actions. In short, was this a combination mass murder/suicide? Was there any way to predict that such an atrocity might happen? Are there measures that can be taken to ensure that it doesn’t happen again?
In the United States, treatment with any psychotropic medication has been a reason to ground a pilot permanently. In April 2010, the Federal Aviation Administration’s rules changed such that a pilot could fly if he’d been treated for mild to moderate depression with a selective serotonin reuptake inhibitor after 12 months. At that time, the FAA announced a 6-month amnesty period where a pilot could come forward about a diagnosis of depression that he had not previously felt comfortable disclosing. Presumably, other countries also have rules that ground pilots for mental illness.
So far, some reports in the media indicate that the copilot was not obviously suffering from a psychiatric disorder; all those who have been interviewed for these reports have expressed shock that Lubitz might have deliberately crashed the plane.
There also has been speculation in the media that a break in the copilot’s training 6 years ago was due to depression, and the mother of a school mate reportedly said that Lubitz had been treated for depression. Finally, investigators found a doctor’s note excusing Lubitz from work. At this point, the Wall Street Journal is reporting that he was being treated for depression. Apparently, he had shredded the note and flew on Tuesday, despite the written work excuse.
Still, all discussion of the copilot’s mental state is purely speculation. The media is noted for sensationalist reporting – and in efforts to get information out quickly, the details are often confused or simply wrong, sometimes to a remarkable extent. We don’t know if the work excuse was written by a psychiatrist or another type of physician; we don’t know if it was for a psychiatric condition, cancer, or simply strep throat.
What we’ve been told is that a copilot who was cleared to fly did so despite a work excuse from a physician, he did not disclose this condition to his employer, and he crashed a plane killing 150 people.
We might assume that the pilot suffered from some type of psychic distress – whether he met criteria for a mental disorder or not, it’s not normal to kill 150 people. If the pilot did have a history of depression and was being treated at the time of this week’s flight, then we may be left with a very unsatisfactory answer.
The anti-psychiatry activists will say that psychotropic medications caused Lubitz to crash the plane. Psychiatrists will be left with no great answer with such a scenario and will be left to say that whatever treatment he was receiving, it wasn’t enough. Certainly, the physician who told Lubitz to take off from work was right: He didn’t belong in a cockpit that day. Presumably, that physician would have done more had he been aware that the patient was about to commit a mass murder.
If the copilot does have a history of depression, but his current work excuse was for an unrelated condition, we might wonder if an untreated recurrence of depression played some role in his actions. One might speculate that the copilot could have been afraid to seek care at this time, perhaps because of a fear that he would lose his vocation.
Still, major depression can hardly explain such an act, and it is unfortunate that the press has already begun to run headlines linking this man’s alleged psychiatric diagnosis to a catastrophic mass murder. Somehow, “mental illness” gets used as an endpoint explanation for why such things happen; and short of a severe psychotic delusional system, it’s a very unsatisfying answer for an unprecedented act of violence.
The facts will unfold and perhaps we’ll learn a little more. We’ll find out what condition the copilot was being treated for and whether there were other stresses going on in his personal life. But people get depressed, take antidepressants, and deal with stress all the time.
It’s possible, if not likely, that we’ll never understand why this copilot decided to end the lives of so many people along with his own.
Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: The Johns Hopkins University, 2011).
