Commentary

If you ask most folks why some of us are obese, they will answer that it’s because overweight people have eaten too much of the wrong foods and not exercised enough. If prompted, they might expand their response by saying that people who come from families with overweight members will usually have more trouble maintaining a healthy weight. It seems to me that just about covers our state-of-the-art understanding of obesity.

You can argue that there is always new information coming out from experiments on genetically altered mice. And, the recently appreciated relationship between sleep deprivation and being overweight sounds interesting. But it still boils down to the simple equation of too much energy in and too little burned.

In 2007, it was discovered that a variant of a gene known as FTO was closely linked to excess weight gain in humans. Individuals with one copy of the gene were on average 3.5 pounds heavier than were those without the gene. Those people with a double copy of the variant gene were 7 pounds heavier and 50% more likely to be obese than was the general population.

It looked like the FTO gene might be one of the answers beyond the simplicity of too much consumption and too little expenditure. But why would the gene suddenly become more prevalent over the last 5 or 6 decades that obesity has become epidemic in America? It seemed unlikely that this shift could occur in such a short time frame.

A recently published study in Proceedings of the National Academy of Sciences (PNAS 2014 [doi: 10.1073/pnas.1411893111]) suggests another more plausible explanation. Using data from the venerable and ongoing Framingham Heart Study, the researchers found that the FTO variant became a risk factor only after World War II. In other words, people with the FTO variant born prior to 1942 weren’t any more likely to be overweight than the rest of the population.

What has changed since the 1940s? Our diet has shifted toward more processed and fried foods. And, our lives and our jobs have become more sedentary. Television crept into our living rooms in the 1950s and into our bedrooms in the 1970s.

The FTO gene variant may have been advantageous to humans in lean times when the heavier of us were more likely to survive long periods of starvation. But now here in the land of fries and soft drinks, the gene has become hazardous to our health. We now look (and are) fat wearing the same genes that seemed to fit us so well a century ago.

We must have sympathy for those of us who have a gene that makes us more vulnerable when food is plentiful, and technology has made it easier to survive with very little energy expenditure. It is tempting to hope that someday scientists will find a way to alter the offending genes to help those cursed to carry them. But this kind of manipulation must be considered cautiously because a natural or man-made catastrophe on a global scale could once again make this gene advantageous.

We must face the fact that it is the environment in which we live – an environment that we have altered and can continue to alter – that is the primary driver of the obesity epidemic. One wonders whether we are experiencing other epidemics analogous to the FTO/obesity story.

Attention-deficit/hyperactivity disorder (ADHD) comes to mind. Some observers feel that a short attention span and impulsivity may have been advantageous when we were hunter-gatherers. The disadvantages of those traits were just a nuisance when having a formal education was merely optional for success. However, we have now trapped those who carry these traits in a one-size-fits-all educational system and sleep deprived them with a combination of electric lights and electronic distractions, to name just a few of the environmental changes that we have imposed.

Maybe it’s not the genes, but the environment that is the issue. The problem is that we haven’t found the genetic variant(s) that might allow us to answer these kinds of questions about ADHD.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

If you ask most folks why some of us are obese, they will answer that it’s because overweight people have eaten too much of the wrong foods and not exercised enough. If prompted, they might expand their response by saying that people who come from families with overweight members will usually have more trouble maintaining a healthy weight. It seems to me that just about covers our state-of-the-art understanding of obesity.

You can argue that there is always new information coming out from experiments on genetically altered mice. And, the recently appreciated relationship between sleep deprivation and being overweight sounds interesting. But it still boils down to the simple equation of too much energy in and too little burned.

In 2007, it was discovered that a variant of a gene known as FTO was closely linked to excess weight gain in humans. Individuals with one copy of the gene were on average 3.5 pounds heavier than were those without the gene. Those people with a double copy of the variant gene were 7 pounds heavier and 50% more likely to be obese than was the general population.

It looked like the FTO gene might be one of the answers beyond the simplicity of too much consumption and too little expenditure. But why would the gene suddenly become more prevalent over the last 5 or 6 decades that obesity has become epidemic in America? It seemed unlikely that this shift could occur in such a short time frame.

A recently published study in Proceedings of the National Academy of Sciences (PNAS 2014 [doi: 10.1073/pnas.1411893111]) suggests another more plausible explanation. Using data from the venerable and ongoing Framingham Heart Study, the researchers found that the FTO variant became a risk factor only after World War II. In other words, people with the FTO variant born prior to 1942 weren’t any more likely to be overweight than the rest of the population.

What has changed since the 1940s? Our diet has shifted toward more processed and fried foods. And, our lives and our jobs have become more sedentary. Television crept into our living rooms in the 1950s and into our bedrooms in the 1970s.

The FTO gene variant may have been advantageous to humans in lean times when the heavier of us were more likely to survive long periods of starvation. But now here in the land of fries and soft drinks, the gene has become hazardous to our health. We now look (and are) fat wearing the same genes that seemed to fit us so well a century ago.

We must have sympathy for those of us who have a gene that makes us more vulnerable when food is plentiful, and technology has made it easier to survive with very little energy expenditure. It is tempting to hope that someday scientists will find a way to alter the offending genes to help those cursed to carry them. But this kind of manipulation must be considered cautiously because a natural or man-made catastrophe on a global scale could once again make this gene advantageous.

We must face the fact that it is the environment in which we live – an environment that we have altered and can continue to alter – that is the primary driver of the obesity epidemic. One wonders whether we are experiencing other epidemics analogous to the FTO/obesity story.

Attention-deficit/hyperactivity disorder (ADHD) comes to mind. Some observers feel that a short attention span and impulsivity may have been advantageous when we were hunter-gatherers. The disadvantages of those traits were just a nuisance when having a formal education was merely optional for success. However, we have now trapped those who carry these traits in a one-size-fits-all educational system and sleep deprived them with a combination of electric lights and electronic distractions, to name just a few of the environmental changes that we have imposed.

Maybe it’s not the genes, but the environment that is the issue. The problem is that we haven’t found the genetic variant(s) that might allow us to answer these kinds of questions about ADHD.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

If you ask most folks why some of us are obese, they will answer that it’s because overweight people have eaten too much of the wrong foods and not exercised enough. If prompted, they might expand their response by saying that people who come from families with overweight members will usually have more trouble maintaining a healthy weight. It seems to me that just about covers our state-of-the-art understanding of obesity.

You can argue that there is always new information coming out from experiments on genetically altered mice. And, the recently appreciated relationship between sleep deprivation and being overweight sounds interesting. But it still boils down to the simple equation of too much energy in and too little burned.

In 2007, it was discovered that a variant of a gene known as FTO was closely linked to excess weight gain in humans. Individuals with one copy of the gene were on average 3.5 pounds heavier than were those without the gene. Those people with a double copy of the variant gene were 7 pounds heavier and 50% more likely to be obese than was the general population.

It looked like the FTO gene might be one of the answers beyond the simplicity of too much consumption and too little expenditure. But why would the gene suddenly become more prevalent over the last 5 or 6 decades that obesity has become epidemic in America? It seemed unlikely that this shift could occur in such a short time frame.

A recently published study in Proceedings of the National Academy of Sciences (PNAS 2014 [doi: 10.1073/pnas.1411893111]) suggests another more plausible explanation. Using data from the venerable and ongoing Framingham Heart Study, the researchers found that the FTO variant became a risk factor only after World War II. In other words, people with the FTO variant born prior to 1942 weren’t any more likely to be overweight than the rest of the population.

What has changed since the 1940s? Our diet has shifted toward more processed and fried foods. And, our lives and our jobs have become more sedentary. Television crept into our living rooms in the 1950s and into our bedrooms in the 1970s.

The FTO gene variant may have been advantageous to humans in lean times when the heavier of us were more likely to survive long periods of starvation. But now here in the land of fries and soft drinks, the gene has become hazardous to our health. We now look (and are) fat wearing the same genes that seemed to fit us so well a century ago.

We must have sympathy for those of us who have a gene that makes us more vulnerable when food is plentiful, and technology has made it easier to survive with very little energy expenditure. It is tempting to hope that someday scientists will find a way to alter the offending genes to help those cursed to carry them. But this kind of manipulation must be considered cautiously because a natural or man-made catastrophe on a global scale could once again make this gene advantageous.

We must face the fact that it is the environment in which we live – an environment that we have altered and can continue to alter – that is the primary driver of the obesity epidemic. One wonders whether we are experiencing other epidemics analogous to the FTO/obesity story.

Attention-deficit/hyperactivity disorder (ADHD) comes to mind. Some observers feel that a short attention span and impulsivity may have been advantageous when we were hunter-gatherers. The disadvantages of those traits were just a nuisance when having a formal education was merely optional for success. However, we have now trapped those who carry these traits in a one-size-fits-all educational system and sleep deprived them with a combination of electric lights and electronic distractions, to name just a few of the environmental changes that we have imposed.

Maybe it’s not the genes, but the environment that is the issue. The problem is that we haven’t found the genetic variant(s) that might allow us to answer these kinds of questions about ADHD.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson sits atop a massively complex health care system. With an annual budget of > $50 billion and 133,000 military and civilian health care providers, allied health professionals, and health administrators spread around the globe, the Military Health System (MHS) is exceedingly complex. Keeping the system running is challenging enough, but Woodson is focused on transforming it into a more nimble, efficient, proactive and cost-effective health care system.

Federal Practitioner recently talked with Dr. Woodson about the challenges of transforming the MHS. We also discussed the Defense Health Agency and how global health threats like Ebola fit in to the MHS mission. The following is condensed and edited, but the complete interview can be heard here: Jonathan Woodson on Military Health Readiness.

The Military Health System Mission

Assistant Secretary of Defense for Health Affairs Jonathan Woodson. The Department of Defense has a unique mission. So yes, we do deliver health care; but we deliver health care on a global basis. And in fact, we are the ones who are asked anytime there is a crisis to set up health care systems in austere places as a key enabler to those who would go in harm’s way and defend our nation.

That is a sober undertaking, and we undertake it with the full understanding that in today’s world, the American leadership and the American public expect us to not only deliver the standard of care, but really go above the standard of care and advance care anywhere in the world....If you look at the experience of the last 12 plus years of war, and you look at what has been accomplished in terms of combat casualty care, we have advanced that strategy for care.

At the beginning of the war, it was clear that we were operating from a traditional platform but a number of experts recognized that what we needed to develop was a system that could drive change based upon data. The Joint Trauma System was born, which analyzed the outcomes of just about every case that was treated. But more importantly, [it] mined the data and rapidly changed the strategies for care as we found optimal ways of delivering care.

This included everything from our strategy for evacuation and the development of critical care air medical transplant units that provided prompt evacuation from the battlefield and echelons of care so those service members would receive very sophisticated advanced care, to strategies for employing new drugs, new techniques, new training strategies for medics and bringing critical care skills closer to the point of injury. Across a wide swath of strategies for delivering care, the system has been constantly improved.

And now we see from the data that despite the fact that we’re taking care of more severely injured individuals, the fatality rates have dropped. An individual who makes it to a role 3 facility—whatever the injury severity—has a 98% chance of surviving.

This has culminated most recently in terms of this transfer of knowledge with us signing a partnership agreement with the American College of Surgeons, which will allow us to further interact with the civilian communities in terms of trying to define optimal ways for caring for injured patients. This will be good not only for us, but it will be good for the civilian communities as well.

Research and Sharing Advances

Dr. Woodson. We have outlined 6 strategic lines of effort to help modernize the military health system, and they include modernizing our management with an enterprise focus, defining our 21st century capabilities that are necessary to make us better, stronger, and more relevant for the future. [We are also] looking at the medical force structure, particularly since today we have to ensure that we understand and employ subspecialists in the right way.

In addition, we are looking at defining and investing in strategic partners. Our strategic partners are like the American College of Surgeons but represent a wide range of potential academic and research institutions that can collaborate with us to ensure that we achieve results in our research portfolio, particularly against the priorities that are very important to military medicine.

The other areas that we need to concentrate on is reforming TRICARE and defining our requirements and competencies in global health engagement. The issue is investing in and defining our strategic partners, which is what I think is going to make us extraordinarily strong, because realistically we need to approach this as the whole-of-society investment in our national defense. Our strategic partners, of course, include our other federal partners, such as the Veterans Administration.

Continuity of Care

Dr. Woodson. We are committed to serving the needs of servicemen and women who might be injured or become ill as a result of their service for decades to come. That is, we understand that they may, in fact, require care for decades. And as a result, we, of course, have several ways of ensuring that they do receive that care. We have a defined sort of insurance benefit called TRICARE; a vehicle that allows separating servicemen and women who qualify to receive care in the civilian sector.

But beyond that, we have strengthened our partnership and our collaboration with the Veterans Administration to break down barriers so that we can transition servicemen and women more effectively and easily. [For] things like transferring critical medical information, we’ve developed an integrative mental health strategy so that we have common evidence-based strategies for mental health care.

We’ve recently concluded an agreement to reform the way the 2 departments reimburse each other so that the whole issue of billing doesn’t become an encumbrance to delivery of care. We’ve agreed to a common credentialing system so that our providers can more easily serve in either system, which leads to more effective, efficient care and use of our human resources.

Across many lines—the ones I’ve mentioned, and many others—we are ensuring that we can care for the servicemen and women who might become ill or injured and require care going on into the decades to ensure that they have high-quality lives and they’re kept healthy.

The Global Response to Ebola

Dr. Woodson. We have subject matter experts that have worked in infectious diseases for some time. You know, the United States Army Institute of Infectious Diseases is a well-recognized, longstanding organization that has helped produce vaccines and strategies to care for infectious diseases and has contributed very substantially to the biosecurity not only of this nation, but of the world.

We’ve got really the indomitable spirit of the average serviceman and woman who, when given a complex job, know how to meet the mission. And so we have superb leaders, and we have become a key enabler.

When the U.S. shows up, then other countries rally. It provides a platform in which other countries can now commit to the effort. And that’s probably as important as anything else, because this needs to be a worldwide effort to stem this epidemic that is occurring in West Africa.

The Defense Health Agency

The Defense Health Agency has as its mission to put in effect common clinical and business processes to achieve those economies of scale and allow us to use our dollars and other resources more wisely. The Defense Health Agency was charged with initially standing up 10 shared services to include facilities planning, medical logistics, health information technology, managing the TRICARE health plan, pharmacy programs, the Public Health System, acquisitions, budget and resources, management systems, medical education and training, and medical research and development.

As such, we’ve achieved great results over the first year, saving about $248 million. But more importantly, we set the foundation for 21st century systems that will allow us to manage the Military Health System much more effectively, such as establishing a foundation for a common cost accounting system and the development of an enterprise performance management system.

The Military Health System added what we call the Quadruple Aim, which is providing better outcomes, better patient care experience, managing costs, and meeting our readiness mission. We have also established a solid strategic plan and framework in which to ensure that we will meet that end. We’ve had tremendous progress over the first year.

I just want to remind you and everyone of what a heavy lift this was. This is a major reorganization where thousands of people have been reassigned and reorganized to produce a more effective management system. This was no easy lift, but it has been tremendously successful to date.

You don’t necessarily flip the switch and everything is mature and working optimally overnight. The intent was to ensure that it was fully operational and capable by 1 October 2015. What we have seen to date is that it’s ahead of schedule, and that’s good news.

It represents major transformational change. Many people have to be moved. We had to build a new leadership team that, in fact, was heavily invested and contributed to by the uniformed services, the Army, Navy, and Air Force. So they’re deeply invested in the leadership and the governance of the Defense Health Agency.

The Military’s Health Care Challenges

Dr. Woodson. Our central guiding principle is the Quadruple Aim. And at the center, as I mentioned before, is this issue of readiness; and readiness is about ensuring that we have a healthy force to do the nation’s bidding in terms of defense. Not only do we have a healthy force, but we keep them healthy. So we commit to looking at environmental concerns wherever they are deployed. Of course, we provide force protection measures such as vaccines and medicines to prevent infectious diseases, such as malaria if they’re working in a part of the world where that’s endemic.

This is all part of the responsibilities of the military health system. But also, the second part of the readiness responsibility is ensuring that we have a ready medical force. A group of superbly trained providers from the embedded combat medic up to the super subspecialist neurosurgeon, nurses of all specialties and varieties, and other allied health professionals that can create a robust Military Health System and provide above the standard of care anywhere in the world where our sailors, marines, airmen, and soldiers may be operating.

We also have to deal with the issue of chronic problems, health problems that afflict our society. We have started initiatives to address obesity and fitness across a broad spectrum. As a strategy for the military health system, we’re moving from the system of health care, which is just providing treatment after an established disease has occurred, to one of health, which is looking at the whole paradigm of wellness and preventing disease from occurring. It is about reaching into that white space where people learn, work, and play to ensure that they can make healthy choices....We’re deeply invested in the health of the beneficiaries that we serve across a broad spectrum, and we’re deeply invested in the issue of prevention, not only the treatment of disease.

The issue that I would want everyone to understand is that health care and health care delivery in the 21st century is very complex. It’s about not only the actual technology, advances in medical science, but it’s also about addressing where medical science hits human systems and how do you make the system work so that you achieve the best outcomes? And in that mix are the issues of cost and ensuring that you have the ability to deliver that care wherever it’s needed. We’ve mapped out with the leadership of the Military Health System, the surgeons general, and all of their leaders a pathway forward that, in fact, will ensure that the Military Health System will be strong, better, and relevant going into the 21st century and will continue to be a key enabler for the national security, national defense, and the national military strategies.

As a designated Combat Support Agency, the Defense Health Agency is also responsible for meeting the medical needs of the combatant commanders. Central to this role is to ensure our service members are medically ready to perform their mission, and our military medical personnel are ready to perform their mission—“Medically Ready Force…Ready Medical Force.”

Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson sits atop a massively complex health care system. With an annual budget of > $50 billion and 133,000 military and civilian health care providers, allied health professionals, and health administrators spread around the globe, the Military Health System (MHS) is exceedingly complex. Keeping the system running is challenging enough, but Woodson is focused on transforming it into a more nimble, efficient, proactive and cost-effective health care system.

Federal Practitioner recently talked with Dr. Woodson about the challenges of transforming the MHS. We also discussed the Defense Health Agency and how global health threats like Ebola fit in to the MHS mission. The following is condensed and edited, but the complete interview can be heard here: Jonathan Woodson on Military Health Readiness.

The Military Health System Mission

Assistant Secretary of Defense for Health Affairs Jonathan Woodson. The Department of Defense has a unique mission. So yes, we do deliver health care; but we deliver health care on a global basis. And in fact, we are the ones who are asked anytime there is a crisis to set up health care systems in austere places as a key enabler to those who would go in harm’s way and defend our nation.

That is a sober undertaking, and we undertake it with the full understanding that in today’s world, the American leadership and the American public expect us to not only deliver the standard of care, but really go above the standard of care and advance care anywhere in the world....If you look at the experience of the last 12 plus years of war, and you look at what has been accomplished in terms of combat casualty care, we have advanced that strategy for care.

At the beginning of the war, it was clear that we were operating from a traditional platform but a number of experts recognized that what we needed to develop was a system that could drive change based upon data. The Joint Trauma System was born, which analyzed the outcomes of just about every case that was treated. But more importantly, [it] mined the data and rapidly changed the strategies for care as we found optimal ways of delivering care.

This included everything from our strategy for evacuation and the development of critical care air medical transplant units that provided prompt evacuation from the battlefield and echelons of care so those service members would receive very sophisticated advanced care, to strategies for employing new drugs, new techniques, new training strategies for medics and bringing critical care skills closer to the point of injury. Across a wide swath of strategies for delivering care, the system has been constantly improved.

And now we see from the data that despite the fact that we’re taking care of more severely injured individuals, the fatality rates have dropped. An individual who makes it to a role 3 facility—whatever the injury severity—has a 98% chance of surviving.

This has culminated most recently in terms of this transfer of knowledge with us signing a partnership agreement with the American College of Surgeons, which will allow us to further interact with the civilian communities in terms of trying to define optimal ways for caring for injured patients. This will be good not only for us, but it will be good for the civilian communities as well.

Research and Sharing Advances

Dr. Woodson. We have outlined 6 strategic lines of effort to help modernize the military health system, and they include modernizing our management with an enterprise focus, defining our 21st century capabilities that are necessary to make us better, stronger, and more relevant for the future. [We are also] looking at the medical force structure, particularly since today we have to ensure that we understand and employ subspecialists in the right way.

In addition, we are looking at defining and investing in strategic partners. Our strategic partners are like the American College of Surgeons but represent a wide range of potential academic and research institutions that can collaborate with us to ensure that we achieve results in our research portfolio, particularly against the priorities that are very important to military medicine.

The other areas that we need to concentrate on is reforming TRICARE and defining our requirements and competencies in global health engagement. The issue is investing in and defining our strategic partners, which is what I think is going to make us extraordinarily strong, because realistically we need to approach this as the whole-of-society investment in our national defense. Our strategic partners, of course, include our other federal partners, such as the Veterans Administration.

Continuity of Care

Dr. Woodson. We are committed to serving the needs of servicemen and women who might be injured or become ill as a result of their service for decades to come. That is, we understand that they may, in fact, require care for decades. And as a result, we, of course, have several ways of ensuring that they do receive that care. We have a defined sort of insurance benefit called TRICARE; a vehicle that allows separating servicemen and women who qualify to receive care in the civilian sector.

But beyond that, we have strengthened our partnership and our collaboration with the Veterans Administration to break down barriers so that we can transition servicemen and women more effectively and easily. [For] things like transferring critical medical information, we’ve developed an integrative mental health strategy so that we have common evidence-based strategies for mental health care.

We’ve recently concluded an agreement to reform the way the 2 departments reimburse each other so that the whole issue of billing doesn’t become an encumbrance to delivery of care. We’ve agreed to a common credentialing system so that our providers can more easily serve in either system, which leads to more effective, efficient care and use of our human resources.

Across many lines—the ones I’ve mentioned, and many others—we are ensuring that we can care for the servicemen and women who might become ill or injured and require care going on into the decades to ensure that they have high-quality lives and they’re kept healthy.

The Global Response to Ebola

Dr. Woodson. We have subject matter experts that have worked in infectious diseases for some time. You know, the United States Army Institute of Infectious Diseases is a well-recognized, longstanding organization that has helped produce vaccines and strategies to care for infectious diseases and has contributed very substantially to the biosecurity not only of this nation, but of the world.

We’ve got really the indomitable spirit of the average serviceman and woman who, when given a complex job, know how to meet the mission. And so we have superb leaders, and we have become a key enabler.

When the U.S. shows up, then other countries rally. It provides a platform in which other countries can now commit to the effort. And that’s probably as important as anything else, because this needs to be a worldwide effort to stem this epidemic that is occurring in West Africa.

The Defense Health Agency

The Defense Health Agency has as its mission to put in effect common clinical and business processes to achieve those economies of scale and allow us to use our dollars and other resources more wisely. The Defense Health Agency was charged with initially standing up 10 shared services to include facilities planning, medical logistics, health information technology, managing the TRICARE health plan, pharmacy programs, the Public Health System, acquisitions, budget and resources, management systems, medical education and training, and medical research and development.

As such, we’ve achieved great results over the first year, saving about $248 million. But more importantly, we set the foundation for 21st century systems that will allow us to manage the Military Health System much more effectively, such as establishing a foundation for a common cost accounting system and the development of an enterprise performance management system.

The Military Health System added what we call the Quadruple Aim, which is providing better outcomes, better patient care experience, managing costs, and meeting our readiness mission. We have also established a solid strategic plan and framework in which to ensure that we will meet that end. We’ve had tremendous progress over the first year.

I just want to remind you and everyone of what a heavy lift this was. This is a major reorganization where thousands of people have been reassigned and reorganized to produce a more effective management system. This was no easy lift, but it has been tremendously successful to date.

You don’t necessarily flip the switch and everything is mature and working optimally overnight. The intent was to ensure that it was fully operational and capable by 1 October 2015. What we have seen to date is that it’s ahead of schedule, and that’s good news.

It represents major transformational change. Many people have to be moved. We had to build a new leadership team that, in fact, was heavily invested and contributed to by the uniformed services, the Army, Navy, and Air Force. So they’re deeply invested in the leadership and the governance of the Defense Health Agency.

The Military’s Health Care Challenges

Dr. Woodson. Our central guiding principle is the Quadruple Aim. And at the center, as I mentioned before, is this issue of readiness; and readiness is about ensuring that we have a healthy force to do the nation’s bidding in terms of defense. Not only do we have a healthy force, but we keep them healthy. So we commit to looking at environmental concerns wherever they are deployed. Of course, we provide force protection measures such as vaccines and medicines to prevent infectious diseases, such as malaria if they’re working in a part of the world where that’s endemic.

This is all part of the responsibilities of the military health system. But also, the second part of the readiness responsibility is ensuring that we have a ready medical force. A group of superbly trained providers from the embedded combat medic up to the super subspecialist neurosurgeon, nurses of all specialties and varieties, and other allied health professionals that can create a robust Military Health System and provide above the standard of care anywhere in the world where our sailors, marines, airmen, and soldiers may be operating.

We also have to deal with the issue of chronic problems, health problems that afflict our society. We have started initiatives to address obesity and fitness across a broad spectrum. As a strategy for the military health system, we’re moving from the system of health care, which is just providing treatment after an established disease has occurred, to one of health, which is looking at the whole paradigm of wellness and preventing disease from occurring. It is about reaching into that white space where people learn, work, and play to ensure that they can make healthy choices....We’re deeply invested in the health of the beneficiaries that we serve across a broad spectrum, and we’re deeply invested in the issue of prevention, not only the treatment of disease.

The issue that I would want everyone to understand is that health care and health care delivery in the 21st century is very complex. It’s about not only the actual technology, advances in medical science, but it’s also about addressing where medical science hits human systems and how do you make the system work so that you achieve the best outcomes? And in that mix are the issues of cost and ensuring that you have the ability to deliver that care wherever it’s needed. We’ve mapped out with the leadership of the Military Health System, the surgeons general, and all of their leaders a pathway forward that, in fact, will ensure that the Military Health System will be strong, better, and relevant going into the 21st century and will continue to be a key enabler for the national security, national defense, and the national military strategies.

As a designated Combat Support Agency, the Defense Health Agency is also responsible for meeting the medical needs of the combatant commanders. Central to this role is to ensure our service members are medically ready to perform their mission, and our military medical personnel are ready to perform their mission—“Medically Ready Force…Ready Medical Force.”

Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson sits atop a massively complex health care system. With an annual budget of > $50 billion and 133,000 military and civilian health care providers, allied health professionals, and health administrators spread around the globe, the Military Health System (MHS) is exceedingly complex. Keeping the system running is challenging enough, but Woodson is focused on transforming it into a more nimble, efficient, proactive and cost-effective health care system.

Federal Practitioner recently talked with Dr. Woodson about the challenges of transforming the MHS. We also discussed the Defense Health Agency and how global health threats like Ebola fit in to the MHS mission. The following is condensed and edited, but the complete interview can be heard here: Jonathan Woodson on Military Health Readiness.

The Military Health System Mission

Assistant Secretary of Defense for Health Affairs Jonathan Woodson. The Department of Defense has a unique mission. So yes, we do deliver health care; but we deliver health care on a global basis. And in fact, we are the ones who are asked anytime there is a crisis to set up health care systems in austere places as a key enabler to those who would go in harm’s way and defend our nation.

That is a sober undertaking, and we undertake it with the full understanding that in today’s world, the American leadership and the American public expect us to not only deliver the standard of care, but really go above the standard of care and advance care anywhere in the world....If you look at the experience of the last 12 plus years of war, and you look at what has been accomplished in terms of combat casualty care, we have advanced that strategy for care.

At the beginning of the war, it was clear that we were operating from a traditional platform but a number of experts recognized that what we needed to develop was a system that could drive change based upon data. The Joint Trauma System was born, which analyzed the outcomes of just about every case that was treated. But more importantly, [it] mined the data and rapidly changed the strategies for care as we found optimal ways of delivering care.

This included everything from our strategy for evacuation and the development of critical care air medical transplant units that provided prompt evacuation from the battlefield and echelons of care so those service members would receive very sophisticated advanced care, to strategies for employing new drugs, new techniques, new training strategies for medics and bringing critical care skills closer to the point of injury. Across a wide swath of strategies for delivering care, the system has been constantly improved.

And now we see from the data that despite the fact that we’re taking care of more severely injured individuals, the fatality rates have dropped. An individual who makes it to a role 3 facility—whatever the injury severity—has a 98% chance of surviving.

This has culminated most recently in terms of this transfer of knowledge with us signing a partnership agreement with the American College of Surgeons, which will allow us to further interact with the civilian communities in terms of trying to define optimal ways for caring for injured patients. This will be good not only for us, but it will be good for the civilian communities as well.

Research and Sharing Advances

Dr. Woodson. We have outlined 6 strategic lines of effort to help modernize the military health system, and they include modernizing our management with an enterprise focus, defining our 21st century capabilities that are necessary to make us better, stronger, and more relevant for the future. [We are also] looking at the medical force structure, particularly since today we have to ensure that we understand and employ subspecialists in the right way.

In addition, we are looking at defining and investing in strategic partners. Our strategic partners are like the American College of Surgeons but represent a wide range of potential academic and research institutions that can collaborate with us to ensure that we achieve results in our research portfolio, particularly against the priorities that are very important to military medicine.

The other areas that we need to concentrate on is reforming TRICARE and defining our requirements and competencies in global health engagement. The issue is investing in and defining our strategic partners, which is what I think is going to make us extraordinarily strong, because realistically we need to approach this as the whole-of-society investment in our national defense. Our strategic partners, of course, include our other federal partners, such as the Veterans Administration.

Continuity of Care

Dr. Woodson. We are committed to serving the needs of servicemen and women who might be injured or become ill as a result of their service for decades to come. That is, we understand that they may, in fact, require care for decades. And as a result, we, of course, have several ways of ensuring that they do receive that care. We have a defined sort of insurance benefit called TRICARE; a vehicle that allows separating servicemen and women who qualify to receive care in the civilian sector.

But beyond that, we have strengthened our partnership and our collaboration with the Veterans Administration to break down barriers so that we can transition servicemen and women more effectively and easily. [For] things like transferring critical medical information, we’ve developed an integrative mental health strategy so that we have common evidence-based strategies for mental health care.

We’ve recently concluded an agreement to reform the way the 2 departments reimburse each other so that the whole issue of billing doesn’t become an encumbrance to delivery of care. We’ve agreed to a common credentialing system so that our providers can more easily serve in either system, which leads to more effective, efficient care and use of our human resources.

Across many lines—the ones I’ve mentioned, and many others—we are ensuring that we can care for the servicemen and women who might become ill or injured and require care going on into the decades to ensure that they have high-quality lives and they’re kept healthy.

The Global Response to Ebola

Dr. Woodson. We have subject matter experts that have worked in infectious diseases for some time. You know, the United States Army Institute of Infectious Diseases is a well-recognized, longstanding organization that has helped produce vaccines and strategies to care for infectious diseases and has contributed very substantially to the biosecurity not only of this nation, but of the world.

We’ve got really the indomitable spirit of the average serviceman and woman who, when given a complex job, know how to meet the mission. And so we have superb leaders, and we have become a key enabler.

When the U.S. shows up, then other countries rally. It provides a platform in which other countries can now commit to the effort. And that’s probably as important as anything else, because this needs to be a worldwide effort to stem this epidemic that is occurring in West Africa.

The Defense Health Agency

The Defense Health Agency has as its mission to put in effect common clinical and business processes to achieve those economies of scale and allow us to use our dollars and other resources more wisely. The Defense Health Agency was charged with initially standing up 10 shared services to include facilities planning, medical logistics, health information technology, managing the TRICARE health plan, pharmacy programs, the Public Health System, acquisitions, budget and resources, management systems, medical education and training, and medical research and development.

As such, we’ve achieved great results over the first year, saving about $248 million. But more importantly, we set the foundation for 21st century systems that will allow us to manage the Military Health System much more effectively, such as establishing a foundation for a common cost accounting system and the development of an enterprise performance management system.

The Military Health System added what we call the Quadruple Aim, which is providing better outcomes, better patient care experience, managing costs, and meeting our readiness mission. We have also established a solid strategic plan and framework in which to ensure that we will meet that end. We’ve had tremendous progress over the first year.

I just want to remind you and everyone of what a heavy lift this was. This is a major reorganization where thousands of people have been reassigned and reorganized to produce a more effective management system. This was no easy lift, but it has been tremendously successful to date.

You don’t necessarily flip the switch and everything is mature and working optimally overnight. The intent was to ensure that it was fully operational and capable by 1 October 2015. What we have seen to date is that it’s ahead of schedule, and that’s good news.

It represents major transformational change. Many people have to be moved. We had to build a new leadership team that, in fact, was heavily invested and contributed to by the uniformed services, the Army, Navy, and Air Force. So they’re deeply invested in the leadership and the governance of the Defense Health Agency.

The Military’s Health Care Challenges

Dr. Woodson. Our central guiding principle is the Quadruple Aim. And at the center, as I mentioned before, is this issue of readiness; and readiness is about ensuring that we have a healthy force to do the nation’s bidding in terms of defense. Not only do we have a healthy force, but we keep them healthy. So we commit to looking at environmental concerns wherever they are deployed. Of course, we provide force protection measures such as vaccines and medicines to prevent infectious diseases, such as malaria if they’re working in a part of the world where that’s endemic.

This is all part of the responsibilities of the military health system. But also, the second part of the readiness responsibility is ensuring that we have a ready medical force. A group of superbly trained providers from the embedded combat medic up to the super subspecialist neurosurgeon, nurses of all specialties and varieties, and other allied health professionals that can create a robust Military Health System and provide above the standard of care anywhere in the world where our sailors, marines, airmen, and soldiers may be operating.

We also have to deal with the issue of chronic problems, health problems that afflict our society. We have started initiatives to address obesity and fitness across a broad spectrum. As a strategy for the military health system, we’re moving from the system of health care, which is just providing treatment after an established disease has occurred, to one of health, which is looking at the whole paradigm of wellness and preventing disease from occurring. It is about reaching into that white space where people learn, work, and play to ensure that they can make healthy choices....We’re deeply invested in the health of the beneficiaries that we serve across a broad spectrum, and we’re deeply invested in the issue of prevention, not only the treatment of disease.

The issue that I would want everyone to understand is that health care and health care delivery in the 21st century is very complex. It’s about not only the actual technology, advances in medical science, but it’s also about addressing where medical science hits human systems and how do you make the system work so that you achieve the best outcomes? And in that mix are the issues of cost and ensuring that you have the ability to deliver that care wherever it’s needed. We’ve mapped out with the leadership of the Military Health System, the surgeons general, and all of their leaders a pathway forward that, in fact, will ensure that the Military Health System will be strong, better, and relevant going into the 21st century and will continue to be a key enabler for the national security, national defense, and the national military strategies.

As a designated Combat Support Agency, the Defense Health Agency is also responsible for meeting the medical needs of the combatant commanders. Central to this role is to ensure our service members are medically ready to perform their mission, and our military medical personnel are ready to perform their mission—“Medically Ready Force…Ready Medical Force.”

Now and then I have met someone who seems to have grown up, without therapy, into a relatively balanced, contented person, little encumbered by internal conflicts. As a psychoanalyst and psychiatrist, I continue to wonder how to account for this.

Growing up has so many difficulties and challenges that successfully traversing them all on one’s own seems a daunting task. Where is the child’s guide to developing a sense of personal autonomy while also enjoying relationships with others? How does the child of 3 or 13 figure out how to deal with envy, sexual feelings, and vengeful and destructive wishes? How can the child figure out that her stomachache represents anxiety about going to school, or further, that her worry about school may serve to distract her from more serious concerns about events and fantasies at home?

There is a reason why so many movies about or for children (such as E.T. the Extra-Terrestrial) depict adults as uncomprehending of children’s worlds: There is a certain truth to it. Even the most intuitive and empathic parents can never fully grasp the inner world of a child, even though they were children once themselves. Nonetheless, their efforts are important, and parents routinely help children learn to understand, accept, and regulate their feelings and wishes. But there are always shameful and guilty feelings that children prefer their parents not know, and always feelings and fantasies that parents can’t imagine.

A 4-year-old girl may brazenly tell her mother that she plans to marry Daddy but hide how much she would love to destroy her younger brother – or vice versa. No matter how her mother responds, the little girl still is significantly on her own as she tries to figure out fantasy and reality. With little knowledge or experience, children are called upon to deal with their own imperious wishes, their own self-criticisms, their changing bodies, and parents’ and teachers’ demands, not to mention the existence of gravity, hunger, sickness, sadness, friends’ rejections, baseball strikeouts, and so on. Parents can help and can hurt, but there is always a lot that is beyond their control.

Given their inevitable reliance on their own limited resources, children pass through phases of various fears, quirks, beliefs, rituals, and ways of relating to the world. These adaptations ebb and flow, change, become dormant, and reappear. We all carry at least some of this baggage, some of this crazy-as-it-is-I’m-dealing-with-it-the-best-that-I-can, into adulthood, and we typically want to leave the contents of the baggage unexamined. It’s so hard to see one’s own blind spots and amazing how tenaciously most of us want to hold onto them.

There’s an aphorism that says, “If you think education is expensive, try ignorance.” This is how I feel about psychoanalytic therapy. In my office, I see people all the time who have married so as to avoid deep involvement and then divorce because there wasn’t enough involvement; or who, unconsciously, are trying so hard to marry or to avoid marrying one of their parents, that they can’t make a relationship work with a partner; or who keep playing out, while trying not to, guilty and shameful revenges for childhood traumas great and small. Often they say to me, “I should have come to see you 20 years ago,” and I don’t disagree.

Why didn’t they? Most often it is because the uncomfortable feelings that people tend to have about their emotional struggles are carried forward from childhood into the present. People talk about the stigma of seeking help for emotional problems, but the most important, and overlooked, “stigma” is typically one’s own internal hesitations and self-deprecations. The statement “I need some help, and I’m going to get it” is seldom met with disrespect, but the shame of wanting or needing help with one’s mind is so great that few people are comfortable saying it.

When I was in college, I was as ashamed and scared of needing therapy as anyone else, but there were things troubling me that I couldn’t master. A little bit of psychotherapy at that time helped me recognize how little I understood about myself and my feelings toward my family – a very helpful start. More psychotherapy when I was a medical student helped more. Having a full psychoanalysis as I pursued training as a psychoanalyst provided a tremendously gratifying sense of finally really unraveling the tightest, most hidden emotional knots. How fortunate that I didn’t feel obliged to pretend that I was so grown up as to deprive myself of essential help from others.

Freud suggested it was desirable for people to be able to love and to work, and some might add, to play. These might sound like simple matters – love, work, and play – but they require emotional balance and flexibility, as well as realistic perceptions of oneself and others. Since there is so much of the past in the present, even invisibly, the emotional obstacles to unencumbered work, love, and play are many. Some people do indeed accomplish these seemingly simple but actually very ambitious aims on their own, but it is so much easier when one has help to clarify one’s misperceptions.

It can be difficult at any age to grow up and take the next developmental step forward. And developmental missteps are resolved much more readily, and usually more completely, with therapy than without. Yet so many of us seem to prefer to try to grow up the hard way, stumbling and struggling alone through our own personal obstacle courses. There are other options.

Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.

Now and then I have met someone who seems to have grown up, without therapy, into a relatively balanced, contented person, little encumbered by internal conflicts. As a psychoanalyst and psychiatrist, I continue to wonder how to account for this.

Growing up has so many difficulties and challenges that successfully traversing them all on one’s own seems a daunting task. Where is the child’s guide to developing a sense of personal autonomy while also enjoying relationships with others? How does the child of 3 or 13 figure out how to deal with envy, sexual feelings, and vengeful and destructive wishes? How can the child figure out that her stomachache represents anxiety about going to school, or further, that her worry about school may serve to distract her from more serious concerns about events and fantasies at home?

There is a reason why so many movies about or for children (such as E.T. the Extra-Terrestrial) depict adults as uncomprehending of children’s worlds: There is a certain truth to it. Even the most intuitive and empathic parents can never fully grasp the inner world of a child, even though they were children once themselves. Nonetheless, their efforts are important, and parents routinely help children learn to understand, accept, and regulate their feelings and wishes. But there are always shameful and guilty feelings that children prefer their parents not know, and always feelings and fantasies that parents can’t imagine.

A 4-year-old girl may brazenly tell her mother that she plans to marry Daddy but hide how much she would love to destroy her younger brother – or vice versa. No matter how her mother responds, the little girl still is significantly on her own as she tries to figure out fantasy and reality. With little knowledge or experience, children are called upon to deal with their own imperious wishes, their own self-criticisms, their changing bodies, and parents’ and teachers’ demands, not to mention the existence of gravity, hunger, sickness, sadness, friends’ rejections, baseball strikeouts, and so on. Parents can help and can hurt, but there is always a lot that is beyond their control.

Given their inevitable reliance on their own limited resources, children pass through phases of various fears, quirks, beliefs, rituals, and ways of relating to the world. These adaptations ebb and flow, change, become dormant, and reappear. We all carry at least some of this baggage, some of this crazy-as-it-is-I’m-dealing-with-it-the-best-that-I-can, into adulthood, and we typically want to leave the contents of the baggage unexamined. It’s so hard to see one’s own blind spots and amazing how tenaciously most of us want to hold onto them.

There’s an aphorism that says, “If you think education is expensive, try ignorance.” This is how I feel about psychoanalytic therapy. In my office, I see people all the time who have married so as to avoid deep involvement and then divorce because there wasn’t enough involvement; or who, unconsciously, are trying so hard to marry or to avoid marrying one of their parents, that they can’t make a relationship work with a partner; or who keep playing out, while trying not to, guilty and shameful revenges for childhood traumas great and small. Often they say to me, “I should have come to see you 20 years ago,” and I don’t disagree.

Why didn’t they? Most often it is because the uncomfortable feelings that people tend to have about their emotional struggles are carried forward from childhood into the present. People talk about the stigma of seeking help for emotional problems, but the most important, and overlooked, “stigma” is typically one’s own internal hesitations and self-deprecations. The statement “I need some help, and I’m going to get it” is seldom met with disrespect, but the shame of wanting or needing help with one’s mind is so great that few people are comfortable saying it.

When I was in college, I was as ashamed and scared of needing therapy as anyone else, but there were things troubling me that I couldn’t master. A little bit of psychotherapy at that time helped me recognize how little I understood about myself and my feelings toward my family – a very helpful start. More psychotherapy when I was a medical student helped more. Having a full psychoanalysis as I pursued training as a psychoanalyst provided a tremendously gratifying sense of finally really unraveling the tightest, most hidden emotional knots. How fortunate that I didn’t feel obliged to pretend that I was so grown up as to deprive myself of essential help from others.

Freud suggested it was desirable for people to be able to love and to work, and some might add, to play. These might sound like simple matters – love, work, and play – but they require emotional balance and flexibility, as well as realistic perceptions of oneself and others. Since there is so much of the past in the present, even invisibly, the emotional obstacles to unencumbered work, love, and play are many. Some people do indeed accomplish these seemingly simple but actually very ambitious aims on their own, but it is so much easier when one has help to clarify one’s misperceptions.

It can be difficult at any age to grow up and take the next developmental step forward. And developmental missteps are resolved much more readily, and usually more completely, with therapy than without. Yet so many of us seem to prefer to try to grow up the hard way, stumbling and struggling alone through our own personal obstacle courses. There are other options.

Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.

Now and then I have met someone who seems to have grown up, without therapy, into a relatively balanced, contented person, little encumbered by internal conflicts. As a psychoanalyst and psychiatrist, I continue to wonder how to account for this.

Growing up has so many difficulties and challenges that successfully traversing them all on one’s own seems a daunting task. Where is the child’s guide to developing a sense of personal autonomy while also enjoying relationships with others? How does the child of 3 or 13 figure out how to deal with envy, sexual feelings, and vengeful and destructive wishes? How can the child figure out that her stomachache represents anxiety about going to school, or further, that her worry about school may serve to distract her from more serious concerns about events and fantasies at home?

There is a reason why so many movies about or for children (such as E.T. the Extra-Terrestrial) depict adults as uncomprehending of children’s worlds: There is a certain truth to it. Even the most intuitive and empathic parents can never fully grasp the inner world of a child, even though they were children once themselves. Nonetheless, their efforts are important, and parents routinely help children learn to understand, accept, and regulate their feelings and wishes. But there are always shameful and guilty feelings that children prefer their parents not know, and always feelings and fantasies that parents can’t imagine.

A 4-year-old girl may brazenly tell her mother that she plans to marry Daddy but hide how much she would love to destroy her younger brother – or vice versa. No matter how her mother responds, the little girl still is significantly on her own as she tries to figure out fantasy and reality. With little knowledge or experience, children are called upon to deal with their own imperious wishes, their own self-criticisms, their changing bodies, and parents’ and teachers’ demands, not to mention the existence of gravity, hunger, sickness, sadness, friends’ rejections, baseball strikeouts, and so on. Parents can help and can hurt, but there is always a lot that is beyond their control.

Given their inevitable reliance on their own limited resources, children pass through phases of various fears, quirks, beliefs, rituals, and ways of relating to the world. These adaptations ebb and flow, change, become dormant, and reappear. We all carry at least some of this baggage, some of this crazy-as-it-is-I’m-dealing-with-it-the-best-that-I-can, into adulthood, and we typically want to leave the contents of the baggage unexamined. It’s so hard to see one’s own blind spots and amazing how tenaciously most of us want to hold onto them.

There’s an aphorism that says, “If you think education is expensive, try ignorance.” This is how I feel about psychoanalytic therapy. In my office, I see people all the time who have married so as to avoid deep involvement and then divorce because there wasn’t enough involvement; or who, unconsciously, are trying so hard to marry or to avoid marrying one of their parents, that they can’t make a relationship work with a partner; or who keep playing out, while trying not to, guilty and shameful revenges for childhood traumas great and small. Often they say to me, “I should have come to see you 20 years ago,” and I don’t disagree.

Why didn’t they? Most often it is because the uncomfortable feelings that people tend to have about their emotional struggles are carried forward from childhood into the present. People talk about the stigma of seeking help for emotional problems, but the most important, and overlooked, “stigma” is typically one’s own internal hesitations and self-deprecations. The statement “I need some help, and I’m going to get it” is seldom met with disrespect, but the shame of wanting or needing help with one’s mind is so great that few people are comfortable saying it.

When I was in college, I was as ashamed and scared of needing therapy as anyone else, but there were things troubling me that I couldn’t master. A little bit of psychotherapy at that time helped me recognize how little I understood about myself and my feelings toward my family – a very helpful start. More psychotherapy when I was a medical student helped more. Having a full psychoanalysis as I pursued training as a psychoanalyst provided a tremendously gratifying sense of finally really unraveling the tightest, most hidden emotional knots. How fortunate that I didn’t feel obliged to pretend that I was so grown up as to deprive myself of essential help from others.

Freud suggested it was desirable for people to be able to love and to work, and some might add, to play. These might sound like simple matters – love, work, and play – but they require emotional balance and flexibility, as well as realistic perceptions of oneself and others. Since there is so much of the past in the present, even invisibly, the emotional obstacles to unencumbered work, love, and play are many. Some people do indeed accomplish these seemingly simple but actually very ambitious aims on their own, but it is so much easier when one has help to clarify one’s misperceptions.

It can be difficult at any age to grow up and take the next developmental step forward. And developmental missteps are resolved much more readily, and usually more completely, with therapy than without. Yet so many of us seem to prefer to try to grow up the hard way, stumbling and struggling alone through our own personal obstacle courses. There are other options.

Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.

This month, I’m going to wade headfirst into a dangerous and controversial area of medicine: Whether or not hormone replacement therapy (HRT) might be a reasonable, long-term option for postmenopausal women. Many of you are probably wondering whether I’ve completely lost it, because you’re thinking that this issue has already been definitively, irrevocably settled by the landmark Women’s Health Initiative (WHI) trial. I’ll admit upfront that I can’t give you any definitive answers, but I’m hoping that I may be able to persuade you that things are not nearly as cut-and-dried as you may have been led to believe.

As a self-styled (and overly opinionated) cardiovascular endocrinologist, I’m especially interested in the question of whether or not postmenopausal HRT might actually have a beneficial role in retarding the progression of atherosclerotic cardiovascular disease in older women. This, after all, is a pretty relevant question, because the numero uno cause of death in American women today is cardiovascular disease, notwithstanding the huge amount of attention and money that the breast cancer lobby has been able to attract.

Let’s go back a few decades and review the standard medical practices of the 1990s, before the estrogen waters became very, very muddied. Postmenopausal estrogens were routinely prescribed in that blessedly naive era, both to treat disconcerting symptoms such as hot flushes and mood fluctuations, and also for their purported benefits to reduce the progression of cardiovascular disease. After all, a large number of observational studies, upward of 30, had all demonstrated rather convincingly that there is a very strong correlation between the use of postmenopausal HRT and a lower incidence of adverse cardiovascular events.

This made very good sense, because estrogens are very potent vasodilators, and they also increase high-density lipoprotein (Lp) cholesterol levels quite smartly (and reduce Lp(a) levels to boot). But the fundamental problem here is that these were strictly observational studies with the inherent selection biases that are part and parcel of such studies. It seems probable in retrospect that the women who were taking postmenopausal estrogens were a rather select group of health-conscious patients who were less likely to develop heart disease than were those women not on estrogens, simply because the former group was living a much healthier lifestyle with better diet, more exercise, and better medical care.

Then along came the era of controlled randomized trials in this area. The Heart and Estrogen/progestin Replacement Study (HERS) trial in the late 1990s was the first to begin to shake our faith in the value of postmenopausal HRT. This trial seemed to show that women had an increased incidence of heart attacks and other thrombotic events in the first few years after initiating HRT, compared with their counterparts who were randomized to placebo therapy. But those who looked closely at the data noted that this apparent negative effect waned dramatically in the fourth and fifth years of the study, suggesting that perhaps there was an unfortunate early effect to promote thrombotic events by revving up the coagulation machinery, but which was then followed by a counter-balancing beneficial effect of estrogens on the rate of progression of cardiovascular disease over time.

But the HERS trial was completely overshadowed several years later by WHI, a huge NIH-funded trial that aimed to provide final answers as to whether or not postmenopausal women should take HRT. The WHI was actually 2 separate studies, one of combined estrogen/progestin replacement therapy, and one of estrogen therapy alone in women who previously had a hysterectomy and, hence, had no need of the cancer protection that progestins offer in women with intact uteruses.

The combined therapy study included nearly 16,000 postmenopausal women with an average age of 63 years. Those randomized to active therapy received conjugated estrogens in a dose of 0.625 mg, along with medroxyprogesterone acetate 2.5 mg, for the planned study duration of 5 years. But the combined study was terminated early because of a modestly increased occurrence of breast cancer in the treated group. Most relevant here is that the early reports of the WHI results suggested a hazard ratio for coronary heart disease (nonfatal myocardial infarction or death due to coronary artery disease) in the treated cohort of 1.24 (24% more events than in the placebo group), a number that is not very impressive at all in the grand scheme of things.

Subsequently, more detailed analyses of the data suggested that any increase in cardiovascular risk was confined to the older (aged ≥ late 60s) women of the combined-therapy cohort.

The estrogen-only wing of the WHI continued for a while longer. Its results were not very concerning at all when it came to cardiovascular events. The hazard ratio for cardiovascular events in the treatment group was only 0.95, hardly a concerning number, since it actually hinted ever so gently at a beneficial effect of HRT on cardiovascular events. And there was a stronger suggestion of such a possible cardioprotective effect in the subset of younger women enrolled in the estrogen-only trial, those aged 50 to 59 years when they entered the study. Might it be that estrogens are actually beneficial in slowing the rapid acceleration in atherosclerosis that occurs in the early postmenopausal years, particularly in the absence of progestins, if only one can avoid the exceptionally bad luck of an early estrogen-induced thrombotic event?

Those questions are still largely unanswered, but a very interesting trial published recently aimed to reopen the question of the true effects of HRT on cardiovascular outcomes in postmenopausal women. The findings of the Kronos Early Estrogen Prevention Study (KEEPS) came out recently.¹ The lead author and lead investigator Dr. S. Mitchell Harman is a close friend of mine who served recently as my Chief of Endocrinology at the Phoenix VA and then became my interim successor as Chief of Medicine when I moved to the Greater Los Angeles VAMC because of my wife’s Sjogren’s-driven need for a more humid climate.

The KEEPS trial was a 4-year, randomized, double-blind, placebo-controlled trial in 727 women aged 45 to 54 years who were all newly menopausal, so that the effects of HRT could be assessed right after the onset of menopause. The KEEPS investigators hoped to demonstrate a favorable effect on cardiovascular outcomes with the administration of HRT so early on, but the trial was unfortunately too small to come up with those results. However, the trial went for its full planned duration, because there were absolutely no harmful effects seen with either oral conjugated estrogen therapy or with transdermal estrogen therapy, each of which was given together with oral progesterone.

There was a trend toward a slower increase in coronary artery calcium (CAC) scores in the minority of women who had elevated scores to begin with. But overall there was no difference in the rate of progression of either CAC scores or of carotid
intima-media thickness as measured by ultrasound; the latter is a standard research measure used to detect subtle differences in the rate of progression of cardiovascular disease. A pessimist would observe quite correctly that estrogens did not show a protective effect on cardiovascular outcomes, apart from the hint of a slower rate of progression of CAC scores in those with elevated levels at the onset. But an optimist would say that these results demonstrate the cardiovascular safety of early postmenopausal HRT, since there was no signal at all of a harmful effect.

So where does this leave us now? Unfortunately, we are completely bereft of definitive answers, and we are unlikely to get meaningful new data anytime soon, as there is currently zero enthusiasm at the NIH for devoting scarce resources to a re-examination of these same issues.

The bottom line is that we can agree that cardiovascular worries need to be put into proper perspective and that they have been overblown, at least in the lay press. I further believe that younger postmenopausal women who have solid indications for such therapy, be they hot flushes or advanced osteoporosis, should not be denied the benefits of HRT because of cardiovascular concerns.

I would be willing to consider long-term open-ended therapy in at least some of these patients. And let’s also not forget that estrogens clearly reduce the incidence of colon cancer and may well reduce the prevalence of the much-dreaded Alzheimer disease that awaits many older women.

I’ll be the first to acknowledge that this editorial is ending with not a bang, but a whimper. But that’s about the best I can come up with given the extremely severe limitations of the data available to us. I’ll consider this editorial a success if it encourages you to at least keep an open mind on the issue of the cardiovascular effects of estrogens and to accept my premise that we still lack so much of the data we truly need to reach definitive conclusions.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

This month, I’m going to wade headfirst into a dangerous and controversial area of medicine: Whether or not hormone replacement therapy (HRT) might be a reasonable, long-term option for postmenopausal women. Many of you are probably wondering whether I’ve completely lost it, because you’re thinking that this issue has already been definitively, irrevocably settled by the landmark Women’s Health Initiative (WHI) trial. I’ll admit upfront that I can’t give you any definitive answers, but I’m hoping that I may be able to persuade you that things are not nearly as cut-and-dried as you may have been led to believe.

As a self-styled (and overly opinionated) cardiovascular endocrinologist, I’m especially interested in the question of whether or not postmenopausal HRT might actually have a beneficial role in retarding the progression of atherosclerotic cardiovascular disease in older women. This, after all, is a pretty relevant question, because the numero uno cause of death in American women today is cardiovascular disease, notwithstanding the huge amount of attention and money that the breast cancer lobby has been able to attract.

Let’s go back a few decades and review the standard medical practices of the 1990s, before the estrogen waters became very, very muddied. Postmenopausal estrogens were routinely prescribed in that blessedly naive era, both to treat disconcerting symptoms such as hot flushes and mood fluctuations, and also for their purported benefits to reduce the progression of cardiovascular disease. After all, a large number of observational studies, upward of 30, had all demonstrated rather convincingly that there is a very strong correlation between the use of postmenopausal HRT and a lower incidence of adverse cardiovascular events.

This made very good sense, because estrogens are very potent vasodilators, and they also increase high-density lipoprotein (Lp) cholesterol levels quite smartly (and reduce Lp(a) levels to boot). But the fundamental problem here is that these were strictly observational studies with the inherent selection biases that are part and parcel of such studies. It seems probable in retrospect that the women who were taking postmenopausal estrogens were a rather select group of health-conscious patients who were less likely to develop heart disease than were those women not on estrogens, simply because the former group was living a much healthier lifestyle with better diet, more exercise, and better medical care.

Then along came the era of controlled randomized trials in this area. The Heart and Estrogen/progestin Replacement Study (HERS) trial in the late 1990s was the first to begin to shake our faith in the value of postmenopausal HRT. This trial seemed to show that women had an increased incidence of heart attacks and other thrombotic events in the first few years after initiating HRT, compared with their counterparts who were randomized to placebo therapy. But those who looked closely at the data noted that this apparent negative effect waned dramatically in the fourth and fifth years of the study, suggesting that perhaps there was an unfortunate early effect to promote thrombotic events by revving up the coagulation machinery, but which was then followed by a counter-balancing beneficial effect of estrogens on the rate of progression of cardiovascular disease over time.

But the HERS trial was completely overshadowed several years later by WHI, a huge NIH-funded trial that aimed to provide final answers as to whether or not postmenopausal women should take HRT. The WHI was actually 2 separate studies, one of combined estrogen/progestin replacement therapy, and one of estrogen therapy alone in women who previously had a hysterectomy and, hence, had no need of the cancer protection that progestins offer in women with intact uteruses.

The combined therapy study included nearly 16,000 postmenopausal women with an average age of 63 years. Those randomized to active therapy received conjugated estrogens in a dose of 0.625 mg, along with medroxyprogesterone acetate 2.5 mg, for the planned study duration of 5 years. But the combined study was terminated early because of a modestly increased occurrence of breast cancer in the treated group. Most relevant here is that the early reports of the WHI results suggested a hazard ratio for coronary heart disease (nonfatal myocardial infarction or death due to coronary artery disease) in the treated cohort of 1.24 (24% more events than in the placebo group), a number that is not very impressive at all in the grand scheme of things.

Subsequently, more detailed analyses of the data suggested that any increase in cardiovascular risk was confined to the older (aged ≥ late 60s) women of the combined-therapy cohort.

The estrogen-only wing of the WHI continued for a while longer. Its results were not very concerning at all when it came to cardiovascular events. The hazard ratio for cardiovascular events in the treatment group was only 0.95, hardly a concerning number, since it actually hinted ever so gently at a beneficial effect of HRT on cardiovascular events. And there was a stronger suggestion of such a possible cardioprotective effect in the subset of younger women enrolled in the estrogen-only trial, those aged 50 to 59 years when they entered the study. Might it be that estrogens are actually beneficial in slowing the rapid acceleration in atherosclerosis that occurs in the early postmenopausal years, particularly in the absence of progestins, if only one can avoid the exceptionally bad luck of an early estrogen-induced thrombotic event?

Those questions are still largely unanswered, but a very interesting trial published recently aimed to reopen the question of the true effects of HRT on cardiovascular outcomes in postmenopausal women. The findings of the Kronos Early Estrogen Prevention Study (KEEPS) came out recently.¹ The lead author and lead investigator Dr. S. Mitchell Harman is a close friend of mine who served recently as my Chief of Endocrinology at the Phoenix VA and then became my interim successor as Chief of Medicine when I moved to the Greater Los Angeles VAMC because of my wife’s Sjogren’s-driven need for a more humid climate.

The KEEPS trial was a 4-year, randomized, double-blind, placebo-controlled trial in 727 women aged 45 to 54 years who were all newly menopausal, so that the effects of HRT could be assessed right after the onset of menopause. The KEEPS investigators hoped to demonstrate a favorable effect on cardiovascular outcomes with the administration of HRT so early on, but the trial was unfortunately too small to come up with those results. However, the trial went for its full planned duration, because there were absolutely no harmful effects seen with either oral conjugated estrogen therapy or with transdermal estrogen therapy, each of which was given together with oral progesterone.

There was a trend toward a slower increase in coronary artery calcium (CAC) scores in the minority of women who had elevated scores to begin with. But overall there was no difference in the rate of progression of either CAC scores or of carotid
intima-media thickness as measured by ultrasound; the latter is a standard research measure used to detect subtle differences in the rate of progression of cardiovascular disease. A pessimist would observe quite correctly that estrogens did not show a protective effect on cardiovascular outcomes, apart from the hint of a slower rate of progression of CAC scores in those with elevated levels at the onset. But an optimist would say that these results demonstrate the cardiovascular safety of early postmenopausal HRT, since there was no signal at all of a harmful effect.

So where does this leave us now? Unfortunately, we are completely bereft of definitive answers, and we are unlikely to get meaningful new data anytime soon, as there is currently zero enthusiasm at the NIH for devoting scarce resources to a re-examination of these same issues.

The bottom line is that we can agree that cardiovascular worries need to be put into proper perspective and that they have been overblown, at least in the lay press. I further believe that younger postmenopausal women who have solid indications for such therapy, be they hot flushes or advanced osteoporosis, should not be denied the benefits of HRT because of cardiovascular concerns.

I would be willing to consider long-term open-ended therapy in at least some of these patients. And let’s also not forget that estrogens clearly reduce the incidence of colon cancer and may well reduce the prevalence of the much-dreaded Alzheimer disease that awaits many older women.

I’ll be the first to acknowledge that this editorial is ending with not a bang, but a whimper. But that’s about the best I can come up with given the extremely severe limitations of the data available to us. I’ll consider this editorial a success if it encourages you to at least keep an open mind on the issue of the cardiovascular effects of estrogens and to accept my premise that we still lack so much of the data we truly need to reach definitive conclusions.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

This month, I’m going to wade headfirst into a dangerous and controversial area of medicine: Whether or not hormone replacement therapy (HRT) might be a reasonable, long-term option for postmenopausal women. Many of you are probably wondering whether I’ve completely lost it, because you’re thinking that this issue has already been definitively, irrevocably settled by the landmark Women’s Health Initiative (WHI) trial. I’ll admit upfront that I can’t give you any definitive answers, but I’m hoping that I may be able to persuade you that things are not nearly as cut-and-dried as you may have been led to believe.

As a self-styled (and overly opinionated) cardiovascular endocrinologist, I’m especially interested in the question of whether or not postmenopausal HRT might actually have a beneficial role in retarding the progression of atherosclerotic cardiovascular disease in older women. This, after all, is a pretty relevant question, because the numero uno cause of death in American women today is cardiovascular disease, notwithstanding the huge amount of attention and money that the breast cancer lobby has been able to attract.

Let’s go back a few decades and review the standard medical practices of the 1990s, before the estrogen waters became very, very muddied. Postmenopausal estrogens were routinely prescribed in that blessedly naive era, both to treat disconcerting symptoms such as hot flushes and mood fluctuations, and also for their purported benefits to reduce the progression of cardiovascular disease. After all, a large number of observational studies, upward of 30, had all demonstrated rather convincingly that there is a very strong correlation between the use of postmenopausal HRT and a lower incidence of adverse cardiovascular events.

This made very good sense, because estrogens are very potent vasodilators, and they also increase high-density lipoprotein (Lp) cholesterol levels quite smartly (and reduce Lp(a) levels to boot). But the fundamental problem here is that these were strictly observational studies with the inherent selection biases that are part and parcel of such studies. It seems probable in retrospect that the women who were taking postmenopausal estrogens were a rather select group of health-conscious patients who were less likely to develop heart disease than were those women not on estrogens, simply because the former group was living a much healthier lifestyle with better diet, more exercise, and better medical care.

Then along came the era of controlled randomized trials in this area. The Heart and Estrogen/progestin Replacement Study (HERS) trial in the late 1990s was the first to begin to shake our faith in the value of postmenopausal HRT. This trial seemed to show that women had an increased incidence of heart attacks and other thrombotic events in the first few years after initiating HRT, compared with their counterparts who were randomized to placebo therapy. But those who looked closely at the data noted that this apparent negative effect waned dramatically in the fourth and fifth years of the study, suggesting that perhaps there was an unfortunate early effect to promote thrombotic events by revving up the coagulation machinery, but which was then followed by a counter-balancing beneficial effect of estrogens on the rate of progression of cardiovascular disease over time.

But the HERS trial was completely overshadowed several years later by WHI, a huge NIH-funded trial that aimed to provide final answers as to whether or not postmenopausal women should take HRT. The WHI was actually 2 separate studies, one of combined estrogen/progestin replacement therapy, and one of estrogen therapy alone in women who previously had a hysterectomy and, hence, had no need of the cancer protection that progestins offer in women with intact uteruses.

The combined therapy study included nearly 16,000 postmenopausal women with an average age of 63 years. Those randomized to active therapy received conjugated estrogens in a dose of 0.625 mg, along with medroxyprogesterone acetate 2.5 mg, for the planned study duration of 5 years. But the combined study was terminated early because of a modestly increased occurrence of breast cancer in the treated group. Most relevant here is that the early reports of the WHI results suggested a hazard ratio for coronary heart disease (nonfatal myocardial infarction or death due to coronary artery disease) in the treated cohort of 1.24 (24% more events than in the placebo group), a number that is not very impressive at all in the grand scheme of things.

Subsequently, more detailed analyses of the data suggested that any increase in cardiovascular risk was confined to the older (aged ≥ late 60s) women of the combined-therapy cohort.

The estrogen-only wing of the WHI continued for a while longer. Its results were not very concerning at all when it came to cardiovascular events. The hazard ratio for cardiovascular events in the treatment group was only 0.95, hardly a concerning number, since it actually hinted ever so gently at a beneficial effect of HRT on cardiovascular events. And there was a stronger suggestion of such a possible cardioprotective effect in the subset of younger women enrolled in the estrogen-only trial, those aged 50 to 59 years when they entered the study. Might it be that estrogens are actually beneficial in slowing the rapid acceleration in atherosclerosis that occurs in the early postmenopausal years, particularly in the absence of progestins, if only one can avoid the exceptionally bad luck of an early estrogen-induced thrombotic event?

Those questions are still largely unanswered, but a very interesting trial published recently aimed to reopen the question of the true effects of HRT on cardiovascular outcomes in postmenopausal women. The findings of the Kronos Early Estrogen Prevention Study (KEEPS) came out recently.¹ The lead author and lead investigator Dr. S. Mitchell Harman is a close friend of mine who served recently as my Chief of Endocrinology at the Phoenix VA and then became my interim successor as Chief of Medicine when I moved to the Greater Los Angeles VAMC because of my wife’s Sjogren’s-driven need for a more humid climate.

The KEEPS trial was a 4-year, randomized, double-blind, placebo-controlled trial in 727 women aged 45 to 54 years who were all newly menopausal, so that the effects of HRT could be assessed right after the onset of menopause. The KEEPS investigators hoped to demonstrate a favorable effect on cardiovascular outcomes with the administration of HRT so early on, but the trial was unfortunately too small to come up with those results. However, the trial went for its full planned duration, because there were absolutely no harmful effects seen with either oral conjugated estrogen therapy or with transdermal estrogen therapy, each of which was given together with oral progesterone.

There was a trend toward a slower increase in coronary artery calcium (CAC) scores in the minority of women who had elevated scores to begin with. But overall there was no difference in the rate of progression of either CAC scores or of carotid
intima-media thickness as measured by ultrasound; the latter is a standard research measure used to detect subtle differences in the rate of progression of cardiovascular disease. A pessimist would observe quite correctly that estrogens did not show a protective effect on cardiovascular outcomes, apart from the hint of a slower rate of progression of CAC scores in those with elevated levels at the onset. But an optimist would say that these results demonstrate the cardiovascular safety of early postmenopausal HRT, since there was no signal at all of a harmful effect.

So where does this leave us now? Unfortunately, we are completely bereft of definitive answers, and we are unlikely to get meaningful new data anytime soon, as there is currently zero enthusiasm at the NIH for devoting scarce resources to a re-examination of these same issues.

The bottom line is that we can agree that cardiovascular worries need to be put into proper perspective and that they have been overblown, at least in the lay press. I further believe that younger postmenopausal women who have solid indications for such therapy, be they hot flushes or advanced osteoporosis, should not be denied the benefits of HRT because of cardiovascular concerns.

I would be willing to consider long-term open-ended therapy in at least some of these patients. And let’s also not forget that estrogens clearly reduce the incidence of colon cancer and may well reduce the prevalence of the much-dreaded Alzheimer disease that awaits many older women.

I’ll be the first to acknowledge that this editorial is ending with not a bang, but a whimper. But that’s about the best I can come up with given the extremely severe limitations of the data available to us. I’ll consider this editorial a success if it encourages you to at least keep an open mind on the issue of the cardiovascular effects of estrogens and to accept my premise that we still lack so much of the data we truly need to reach definitive conclusions.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

It is becoming increasingly obvious that we physicians are doing a pretty shabby job of listening to our patients. In a recent op-ed piece in the New York Times I read that a recent study (Doc, Shut Up and Listen by Nirmal Joshi, Jan. 4, 2015) found that on average doctors waited only 18 seconds before interrupting the patient. It is not unusual for me to hear complaints from friends about physicians they have visited who didn’t seem to be interested in what they had to say. In fact, it has happened to me.

The problem of physicians not listening isn’t just about patient dissatisfaction. The failure to hear what the patient said, or could have said if given the chance, can result in delayed or missed diagnoses and the ordering of costly and unnecessary diagnostic studies.

So, if physicians aren’t listening what are we doing during encounters with our patients? Many of us, and soon most of us, have our noses in computer screens looking through bloated and poorly organized electronic medical records or mouse clicking through templates to create the illusion of meaningful use. But, for the moment let’s stop beating that tired and dysfunctional horse of EHR’s and look deeper into what else could be interfering with listening.

The knee-jerk response that is most often offered is that we just don’t have enough time to listen. How often is that really the case? I wonder if we physicians had 40 minutes for an office visit instead of 20 minutes, how many of us would do a significantly better job of functional listening? I have always suspected that the notion that longer visits are automatically more effective at getting to the heart of the patient’s problem and moving toward a solution is a myth.

Listening is a skill. If you hand me a Rubik’s Cube and ask me to solve it, you could give me 15 minutes or give me an hour ­­ it won’t make any difference because I have no experience with Rubik’s Cubes. Learning how to ask questions that have a high likelihood of getting at what is really troubling the patient and then listening to their responses is a skill. A few master physicians are born with that ability and some doctors will never get it. However, it is a skill that most of us can be taught if medical schools and house officer training program knew how to teach it.

In the Times op-ed piece, Nirmal Joshi, the chief medical officer of Pinnacle Health Systems, Harrisburg, Penn., describes a physician training program in Harrisburg, in which the doctors participated in mock patient interviews in which the patient-actors provided feedback. The physicians also were provided with physician-coaches in real life clinical encounters. The result was a 40% increase in patient satisfaction. Other studies have shown that increased satisfaction correlates with improved outcomes.

You could argue that incorporating these listening skills are going gobble up more time. It probably would, more so on the steep slope of the learning curve. There will always be patients who ramble on and are hard to redirect even by the most skillful history taker. However, with practice I think physicians will find that listening with care will often not take as much time than they fear. It will certainly make the encounters more satisfying.

But, let’s look at that issue of how we are spending our time again. How often are office visits driven by the physician’s agenda and not by the patient’s? How much time do we spend lecturing and badgering patients in an attempt to follow advice that we think is important but they obviously haven’t? That wasted time could have been better invested in listening for the answer of why they haven’t complied in the past.

Finally, is the issue of caring. Unfortunately, this may mean a significant shift in attitude for some of us. If we genuinely care what the patient thinks is important, finding the time to listen won’t be that difficult.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to view similar articles or go to pediatricnews.com.

It is becoming increasingly obvious that we physicians are doing a pretty shabby job of listening to our patients. In a recent op-ed piece in the New York Times I read that a recent study (Doc, Shut Up and Listen by Nirmal Joshi, Jan. 4, 2015) found that on average doctors waited only 18 seconds before interrupting the patient. It is not unusual for me to hear complaints from friends about physicians they have visited who didn’t seem to be interested in what they had to say. In fact, it has happened to me.

The problem of physicians not listening isn’t just about patient dissatisfaction. The failure to hear what the patient said, or could have said if given the chance, can result in delayed or missed diagnoses and the ordering of costly and unnecessary diagnostic studies.

So, if physicians aren’t listening what are we doing during encounters with our patients? Many of us, and soon most of us, have our noses in computer screens looking through bloated and poorly organized electronic medical records or mouse clicking through templates to create the illusion of meaningful use. But, for the moment let’s stop beating that tired and dysfunctional horse of EHR’s and look deeper into what else could be interfering with listening.

The knee-jerk response that is most often offered is that we just don’t have enough time to listen. How often is that really the case? I wonder if we physicians had 40 minutes for an office visit instead of 20 minutes, how many of us would do a significantly better job of functional listening? I have always suspected that the notion that longer visits are automatically more effective at getting to the heart of the patient’s problem and moving toward a solution is a myth.

Listening is a skill. If you hand me a Rubik’s Cube and ask me to solve it, you could give me 15 minutes or give me an hour ­­ it won’t make any difference because I have no experience with Rubik’s Cubes. Learning how to ask questions that have a high likelihood of getting at what is really troubling the patient and then listening to their responses is a skill. A few master physicians are born with that ability and some doctors will never get it. However, it is a skill that most of us can be taught if medical schools and house officer training program knew how to teach it.

In the Times op-ed piece, Nirmal Joshi, the chief medical officer of Pinnacle Health Systems, Harrisburg, Penn., describes a physician training program in Harrisburg, in which the doctors participated in mock patient interviews in which the patient-actors provided feedback. The physicians also were provided with physician-coaches in real life clinical encounters. The result was a 40% increase in patient satisfaction. Other studies have shown that increased satisfaction correlates with improved outcomes.

You could argue that incorporating these listening skills are going gobble up more time. It probably would, more so on the steep slope of the learning curve. There will always be patients who ramble on and are hard to redirect even by the most skillful history taker. However, with practice I think physicians will find that listening with care will often not take as much time than they fear. It will certainly make the encounters more satisfying.

But, let’s look at that issue of how we are spending our time again. How often are office visits driven by the physician’s agenda and not by the patient’s? How much time do we spend lecturing and badgering patients in an attempt to follow advice that we think is important but they obviously haven’t? That wasted time could have been better invested in listening for the answer of why they haven’t complied in the past.

Finally, is the issue of caring. Unfortunately, this may mean a significant shift in attitude for some of us. If we genuinely care what the patient thinks is important, finding the time to listen won’t be that difficult.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to view similar articles or go to pediatricnews.com.

It is becoming increasingly obvious that we physicians are doing a pretty shabby job of listening to our patients. In a recent op-ed piece in the New York Times I read that a recent study (Doc, Shut Up and Listen by Nirmal Joshi, Jan. 4, 2015) found that on average doctors waited only 18 seconds before interrupting the patient. It is not unusual for me to hear complaints from friends about physicians they have visited who didn’t seem to be interested in what they had to say. In fact, it has happened to me.

The problem of physicians not listening isn’t just about patient dissatisfaction. The failure to hear what the patient said, or could have said if given the chance, can result in delayed or missed diagnoses and the ordering of costly and unnecessary diagnostic studies.

So, if physicians aren’t listening what are we doing during encounters with our patients? Many of us, and soon most of us, have our noses in computer screens looking through bloated and poorly organized electronic medical records or mouse clicking through templates to create the illusion of meaningful use. But, for the moment let’s stop beating that tired and dysfunctional horse of EHR’s and look deeper into what else could be interfering with listening.

The knee-jerk response that is most often offered is that we just don’t have enough time to listen. How often is that really the case? I wonder if we physicians had 40 minutes for an office visit instead of 20 minutes, how many of us would do a significantly better job of functional listening? I have always suspected that the notion that longer visits are automatically more effective at getting to the heart of the patient’s problem and moving toward a solution is a myth.

Listening is a skill. If you hand me a Rubik’s Cube and ask me to solve it, you could give me 15 minutes or give me an hour ­­ it won’t make any difference because I have no experience with Rubik’s Cubes. Learning how to ask questions that have a high likelihood of getting at what is really troubling the patient and then listening to their responses is a skill. A few master physicians are born with that ability and some doctors will never get it. However, it is a skill that most of us can be taught if medical schools and house officer training program knew how to teach it.

In the Times op-ed piece, Nirmal Joshi, the chief medical officer of Pinnacle Health Systems, Harrisburg, Penn., describes a physician training program in Harrisburg, in which the doctors participated in mock patient interviews in which the patient-actors provided feedback. The physicians also were provided with physician-coaches in real life clinical encounters. The result was a 40% increase in patient satisfaction. Other studies have shown that increased satisfaction correlates with improved outcomes.

You could argue that incorporating these listening skills are going gobble up more time. It probably would, more so on the steep slope of the learning curve. There will always be patients who ramble on and are hard to redirect even by the most skillful history taker. However, with practice I think physicians will find that listening with care will often not take as much time than they fear. It will certainly make the encounters more satisfying.

But, let’s look at that issue of how we are spending our time again. How often are office visits driven by the physician’s agenda and not by the patient’s? How much time do we spend lecturing and badgering patients in an attempt to follow advice that we think is important but they obviously haven’t? That wasted time could have been better invested in listening for the answer of why they haven’t complied in the past.

Finally, is the issue of caring. Unfortunately, this may mean a significant shift in attitude for some of us. If we genuinely care what the patient thinks is important, finding the time to listen won’t be that difficult.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to view similar articles or go to pediatricnews.com.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.