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Doctors and patients are ping-pong balls to those in power
It’s 2015. Where am I? I have no idea anymore. The state of American medicine is less predictable and arguably more adversarial than ever before.
Quality of care and (when possible) good outcomes aren’t the benchmarks they used to be. In the modern era of pay for performance, we’re graded on things such as reducing stroke risk, blood sugar control, whether we use a meaningless computer system instead of one that works, and how many patients we can cram into a fixed time frame. Things that we can’t control, such as patients continuing to smoke or flat-out refusing to take their medications, are often considered to be our fault, even though we’ve clearly emphasized the importance of our advice.
Rate-a-doc” sites continue to proliferate. Any of us can be given a terrible review by a patient who is upset that we didn’t give them enough Percocet, didn’t like our office building, or never even met us and is upset that our kid made honor band and theirs didn’t. And we’re powerless to respond with the truth. Yet, a frightening number of people trying to choose a physician will base their decisions on such sites.
Most of us are going to get penalized by our government (you know, the one we support with our taxes) because we can’t afford to upgrade to an electronic health record program that does nothing to improve quality of care. Based on my experience with them, I’d have to say they make things worse. Instead of telling what’s going on with the patient and showing the physician’s reasoning in the case, they give you a list of check boxes for negatives and positives, and an unhelpful string of ICD codes. In my opinion, it simply continues the degradation of a patient from a person to a number.
My salary has gone down every year since 2007. My staff hasn’t had a raise in that time, either, and I’m grateful they’re still with me. All my other expenses have gone up. Besides the above-mentioned penalty, the year starts (as all do) with threatened large-scale cuts in Medicare (and, by extension, all insurance payments). Hopefully, they’ll get canceled quickly as they are every year, but you never know. It’s been easier for the last 15 years or so for the government to simply slap on an expensive bandage than to actually fix the problem, and so the overall cost of a real repair keeps going up. The shift in Congress this year likely won’t change anything as our patients, careers, and livelihoods are simply ping-pong balls to those in power, bounced back and forth to score political points against each other.
A year ago, I didn’t know I’d still be here when 2014 ended, but, battered, I am. Like other doctors, I’m trying to see more patients and find other ways of supporting my practice and family, but no one is increasing reimbursements to keep up with inflation or adding more hours to the day. I can’t predict how 2015 will play out any more than you can. But I hope it will be better. My wonderful staff deserves a raise, and my family needs me more than my office does.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
It’s 2015. Where am I? I have no idea anymore. The state of American medicine is less predictable and arguably more adversarial than ever before.
Quality of care and (when possible) good outcomes aren’t the benchmarks they used to be. In the modern era of pay for performance, we’re graded on things such as reducing stroke risk, blood sugar control, whether we use a meaningless computer system instead of one that works, and how many patients we can cram into a fixed time frame. Things that we can’t control, such as patients continuing to smoke or flat-out refusing to take their medications, are often considered to be our fault, even though we’ve clearly emphasized the importance of our advice.
Rate-a-doc” sites continue to proliferate. Any of us can be given a terrible review by a patient who is upset that we didn’t give them enough Percocet, didn’t like our office building, or never even met us and is upset that our kid made honor band and theirs didn’t. And we’re powerless to respond with the truth. Yet, a frightening number of people trying to choose a physician will base their decisions on such sites.
Most of us are going to get penalized by our government (you know, the one we support with our taxes) because we can’t afford to upgrade to an electronic health record program that does nothing to improve quality of care. Based on my experience with them, I’d have to say they make things worse. Instead of telling what’s going on with the patient and showing the physician’s reasoning in the case, they give you a list of check boxes for negatives and positives, and an unhelpful string of ICD codes. In my opinion, it simply continues the degradation of a patient from a person to a number.
My salary has gone down every year since 2007. My staff hasn’t had a raise in that time, either, and I’m grateful they’re still with me. All my other expenses have gone up. Besides the above-mentioned penalty, the year starts (as all do) with threatened large-scale cuts in Medicare (and, by extension, all insurance payments). Hopefully, they’ll get canceled quickly as they are every year, but you never know. It’s been easier for the last 15 years or so for the government to simply slap on an expensive bandage than to actually fix the problem, and so the overall cost of a real repair keeps going up. The shift in Congress this year likely won’t change anything as our patients, careers, and livelihoods are simply ping-pong balls to those in power, bounced back and forth to score political points against each other.
A year ago, I didn’t know I’d still be here when 2014 ended, but, battered, I am. Like other doctors, I’m trying to see more patients and find other ways of supporting my practice and family, but no one is increasing reimbursements to keep up with inflation or adding more hours to the day. I can’t predict how 2015 will play out any more than you can. But I hope it will be better. My wonderful staff deserves a raise, and my family needs me more than my office does.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
It’s 2015. Where am I? I have no idea anymore. The state of American medicine is less predictable and arguably more adversarial than ever before.
Quality of care and (when possible) good outcomes aren’t the benchmarks they used to be. In the modern era of pay for performance, we’re graded on things such as reducing stroke risk, blood sugar control, whether we use a meaningless computer system instead of one that works, and how many patients we can cram into a fixed time frame. Things that we can’t control, such as patients continuing to smoke or flat-out refusing to take their medications, are often considered to be our fault, even though we’ve clearly emphasized the importance of our advice.
Rate-a-doc” sites continue to proliferate. Any of us can be given a terrible review by a patient who is upset that we didn’t give them enough Percocet, didn’t like our office building, or never even met us and is upset that our kid made honor band and theirs didn’t. And we’re powerless to respond with the truth. Yet, a frightening number of people trying to choose a physician will base their decisions on such sites.
Most of us are going to get penalized by our government (you know, the one we support with our taxes) because we can’t afford to upgrade to an electronic health record program that does nothing to improve quality of care. Based on my experience with them, I’d have to say they make things worse. Instead of telling what’s going on with the patient and showing the physician’s reasoning in the case, they give you a list of check boxes for negatives and positives, and an unhelpful string of ICD codes. In my opinion, it simply continues the degradation of a patient from a person to a number.
My salary has gone down every year since 2007. My staff hasn’t had a raise in that time, either, and I’m grateful they’re still with me. All my other expenses have gone up. Besides the above-mentioned penalty, the year starts (as all do) with threatened large-scale cuts in Medicare (and, by extension, all insurance payments). Hopefully, they’ll get canceled quickly as they are every year, but you never know. It’s been easier for the last 15 years or so for the government to simply slap on an expensive bandage than to actually fix the problem, and so the overall cost of a real repair keeps going up. The shift in Congress this year likely won’t change anything as our patients, careers, and livelihoods are simply ping-pong balls to those in power, bounced back and forth to score political points against each other.
A year ago, I didn’t know I’d still be here when 2014 ended, but, battered, I am. Like other doctors, I’m trying to see more patients and find other ways of supporting my practice and family, but no one is increasing reimbursements to keep up with inflation or adding more hours to the day. I can’t predict how 2015 will play out any more than you can. But I hope it will be better. My wonderful staff deserves a raise, and my family needs me more than my office does.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Umbilical cord clamping
Embryogenesis is an incredible phenomenon. It begins with fertilization and implantation of the blastocyst into the uterine wall, followed by development of the extraembryonic membrane which gives rise to the placenta, which is, literally, the lifeblood of the fetus. Although physicians often focus on the health of the placenta during pregnancy, the umbilical cord is an equally important organ.
The umbilical cord acts as a conduit through which metabolic products and biproducts, such as nutrients, antibodies, iron, and blood, pass bidirectionally between a mother and her baby. Many problems can arise if the cord becomes altered. For example, true umbilical cord knot is associated with small-for-gestational-age fetuses, premature birth, neonatal intensive care unit admissions, and fetal death (Int. J. Gynaecol. Obstet. 2013;122:18-21). In addition, short or long cord length may lead to fetal heart rate anomalies and higher risk for birth asphyxia (J. Obstet. Gynaecol. India. 2012;62:520-5).
While the health of the umbilical cord during pregnancy closely correlates to successful outcomes, the cord’s functions conclude at birth. Physicians clamp the umbilical cord at parturition as a routine part of the delivery process. Many ob.gyns. may not even stop to think about cord clamping. To borrow the phrase from the old Nike slogan, they “just do it.”
However, exactly when physicians should clamp the umbilical cord remains a topic for debate. Should ob.gyns. clamp the cord immediately or shortly after birth? Proponents of immediate clamping might argue that waiting too long could cause an influx of placental* blood in the neonate, leading to risk for jaundice. Those on the side of delayed cord clamping might say that waiting to terminate the cord prevents the baby’s oxygen supply from being prematurely cut off. Also, how long should the delay last: One minute? Two minutes? More? Less?
Clearly, the issue of cord clamping requires discussion. Therefore, we have devoted the first Master Class of 2015 to this important topic. We have invited Dr. George A. Macones, the Mitchell and Elaine Yanow Professor and Chair, and director of the division of maternal-fetal medicine and ultrasound in the department of obstetrics and gynecology at Washington University, St. Louis, to explore the debate. As the recent vice chair for the Committee on Practice Bulletins – Obstetrics for the American College of Obstetricians and Gynecologists, Dr. Macones has a unique perspective on the arguments for and against immediate or delayed cord clamping, as well as significant experience as a practicing ob.gyn. and leader at a vibrant academic medical center.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].
Correction, 4/14/15: An earlier version of this article misstated the potential consequences of waiting too long to clamp the umbilical cord.
Embryogenesis is an incredible phenomenon. It begins with fertilization and implantation of the blastocyst into the uterine wall, followed by development of the extraembryonic membrane which gives rise to the placenta, which is, literally, the lifeblood of the fetus. Although physicians often focus on the health of the placenta during pregnancy, the umbilical cord is an equally important organ.
The umbilical cord acts as a conduit through which metabolic products and biproducts, such as nutrients, antibodies, iron, and blood, pass bidirectionally between a mother and her baby. Many problems can arise if the cord becomes altered. For example, true umbilical cord knot is associated with small-for-gestational-age fetuses, premature birth, neonatal intensive care unit admissions, and fetal death (Int. J. Gynaecol. Obstet. 2013;122:18-21). In addition, short or long cord length may lead to fetal heart rate anomalies and higher risk for birth asphyxia (J. Obstet. Gynaecol. India. 2012;62:520-5).
While the health of the umbilical cord during pregnancy closely correlates to successful outcomes, the cord’s functions conclude at birth. Physicians clamp the umbilical cord at parturition as a routine part of the delivery process. Many ob.gyns. may not even stop to think about cord clamping. To borrow the phrase from the old Nike slogan, they “just do it.”
However, exactly when physicians should clamp the umbilical cord remains a topic for debate. Should ob.gyns. clamp the cord immediately or shortly after birth? Proponents of immediate clamping might argue that waiting too long could cause an influx of placental* blood in the neonate, leading to risk for jaundice. Those on the side of delayed cord clamping might say that waiting to terminate the cord prevents the baby’s oxygen supply from being prematurely cut off. Also, how long should the delay last: One minute? Two minutes? More? Less?
Clearly, the issue of cord clamping requires discussion. Therefore, we have devoted the first Master Class of 2015 to this important topic. We have invited Dr. George A. Macones, the Mitchell and Elaine Yanow Professor and Chair, and director of the division of maternal-fetal medicine and ultrasound in the department of obstetrics and gynecology at Washington University, St. Louis, to explore the debate. As the recent vice chair for the Committee on Practice Bulletins – Obstetrics for the American College of Obstetricians and Gynecologists, Dr. Macones has a unique perspective on the arguments for and against immediate or delayed cord clamping, as well as significant experience as a practicing ob.gyn. and leader at a vibrant academic medical center.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].
Correction, 4/14/15: An earlier version of this article misstated the potential consequences of waiting too long to clamp the umbilical cord.
Embryogenesis is an incredible phenomenon. It begins with fertilization and implantation of the blastocyst into the uterine wall, followed by development of the extraembryonic membrane which gives rise to the placenta, which is, literally, the lifeblood of the fetus. Although physicians often focus on the health of the placenta during pregnancy, the umbilical cord is an equally important organ.
The umbilical cord acts as a conduit through which metabolic products and biproducts, such as nutrients, antibodies, iron, and blood, pass bidirectionally between a mother and her baby. Many problems can arise if the cord becomes altered. For example, true umbilical cord knot is associated with small-for-gestational-age fetuses, premature birth, neonatal intensive care unit admissions, and fetal death (Int. J. Gynaecol. Obstet. 2013;122:18-21). In addition, short or long cord length may lead to fetal heart rate anomalies and higher risk for birth asphyxia (J. Obstet. Gynaecol. India. 2012;62:520-5).
While the health of the umbilical cord during pregnancy closely correlates to successful outcomes, the cord’s functions conclude at birth. Physicians clamp the umbilical cord at parturition as a routine part of the delivery process. Many ob.gyns. may not even stop to think about cord clamping. To borrow the phrase from the old Nike slogan, they “just do it.”
However, exactly when physicians should clamp the umbilical cord remains a topic for debate. Should ob.gyns. clamp the cord immediately or shortly after birth? Proponents of immediate clamping might argue that waiting too long could cause an influx of placental* blood in the neonate, leading to risk for jaundice. Those on the side of delayed cord clamping might say that waiting to terminate the cord prevents the baby’s oxygen supply from being prematurely cut off. Also, how long should the delay last: One minute? Two minutes? More? Less?
Clearly, the issue of cord clamping requires discussion. Therefore, we have devoted the first Master Class of 2015 to this important topic. We have invited Dr. George A. Macones, the Mitchell and Elaine Yanow Professor and Chair, and director of the division of maternal-fetal medicine and ultrasound in the department of obstetrics and gynecology at Washington University, St. Louis, to explore the debate. As the recent vice chair for the Committee on Practice Bulletins – Obstetrics for the American College of Obstetricians and Gynecologists, Dr. Macones has a unique perspective on the arguments for and against immediate or delayed cord clamping, as well as significant experience as a practicing ob.gyn. and leader at a vibrant academic medical center.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].
Correction, 4/14/15: An earlier version of this article misstated the potential consequences of waiting too long to clamp the umbilical cord.
5 ways digital health technologies are patient advocacy tools
When technology is mentioned in the context of health care, it is often received as an impersonal, profit- or regulatory-driven interface between a provider and patient. If designed – hopefully with a clinician involved – with the purpose of actually solving a problem, digital technology will ultimately gain favor. Examples of such tools include links and apps which provide reference information. Epocrates and doximity on the provider side and WebMD on the consumer/patient side are prime examples. There are increasingly more digital tools for patients and caregivers to help them improve self-participation in their health care as well as to navigate the system. The challenge in the health care technology space is to make people (both providers and patients) aware of them, to facilitate use, and to incorporate relevant and actionable data seamlessly into the patient’s electronic record. Technology needs to be designed in a way in which it conforms to the clinical work flow between the patient and provider. I will give examples of available tools that can improve a patient’s daunting journey. I do not have any financial or other affiliation with any companies mentioned.
1. They can help prepare for the office visit.
I don’t know why, but patients have evolved a belief that they need to present a self-diagnosed condition at the office visit. They often feel guilty not providing the diagnosis. I believe firmly (and tell patients) that their responsibility is to know when something isn’t right and to call the provider. Notwithstanding this, I encourage patients to do online research into their symptoms. Tools found at FamilyDoctor.org, the Mayo Clinic Symptom Checker, or iTriage can help frame thoughts or prompt a discussion with a caregiver prior to a visit, which can then serve as a foundation for the office encounter.
2. Patient education content.
The term “patient engagement” is used commonly today. It implies the active participation of the patient in health care and disease management. Many believe that patient engagement should be focused on medication adherence. While this is critical, it remains a reflection of a patient’s understanding of diagnosis; long-term treatment goals (which need be personalized per a discussion about them); and the components of the treatment itself, which include lifestyle changes and nontraditional pharmacologic therapies as well. Seeing disease through a patient’s eyes (empathy) is the key to good relationships that in turn promote engagement. Excellent digital patient education tools are now available for download and review by patients and caregivers. They explain diagnoses, tests, procedures, and medications. Some are proprietary and made by pharmaceutical and medical device companies, while others are produced by third-party companies that allow the provider to white label the product or even customize the content. One excellent example is Liberate Health. (Ed. note: This publication’s parent company has a relationship with Liberate Health.)
3. Social media.
This is where the patients and caregivers are. It follows then that social media is where providers should be. There are some excellent online patient communities that contain disease-specific groups. Examples are Smart Patients and Treatment Diaries. Social media is a big part of motivating patients and giving support to them and to caregivers. It allows for information exchange in a convenient, relaxing, and nonthreatening setting. While skeptics might question the validity of medical information and advice on these sites, I would say that encouraging patients to participate shows empathy. If a disclaimer is offered stating that this is not a substitute for a health care provider, it can be a significant source of support.
4. Connections to caregivers.
Caregivers are left out of many digital health tools. A good working definition of a caregiver is “an unpaid individual (a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks.” About 29% of the U.S. adult population (65.7 million) provides care to someone who is ill, disabled, or aged. Other statistics about caregivers are more impressive. Health and medical apps are promising tools that can be offered to patients. The rubber has yet to fully meet the road in this arena for a few reasons, many of which are tied to the reputation, usability, and priorities of present electronic health record vendors who represent the face of digital health technology to most physicians and other health care providers. However, there is little denial that they (and other mobile health tools) will play an important role in health care’s future. Both patients and caregivers have expressed what is desired in a mobile app. As aging at home becomes a necessary goal of health care from social, financial, and societal standpoints, caregivers will assume an even greater portion of care.
5. Provide for better continuity of care.
Lack of continuity of care leading to medical errors is not a new topic of discussion. This is relevant in both the inpatient and the outpatient setting. Mobile digital technologies can reduce errors by improving communication to both providers and patients as well as among providers themselves. Use of digital tablets at the bedside by patients can improve provider-patient communication and decrease errors. Handoff of patients among providers is another opportunity for mobile health tools to decrease errors. One such app is Smart Sign Out. Ultimately, any tool that decreases errors is a patient advocate tool.
While some physicians believe that patient advocacy is distinct from patient care, I submit that patient advocacy is something any good physician does every day with every patient, including conveying empathy, providing easy to understand explanations of conditions, and offering advice to be considered in a shared decision-making process. We all enter the field of medicine because we want to contribute to the well-being of others. Let’s not lose sight of that, and let’s look to available and emerging technologies to assist us in this mission.
Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.
When technology is mentioned in the context of health care, it is often received as an impersonal, profit- or regulatory-driven interface between a provider and patient. If designed – hopefully with a clinician involved – with the purpose of actually solving a problem, digital technology will ultimately gain favor. Examples of such tools include links and apps which provide reference information. Epocrates and doximity on the provider side and WebMD on the consumer/patient side are prime examples. There are increasingly more digital tools for patients and caregivers to help them improve self-participation in their health care as well as to navigate the system. The challenge in the health care technology space is to make people (both providers and patients) aware of them, to facilitate use, and to incorporate relevant and actionable data seamlessly into the patient’s electronic record. Technology needs to be designed in a way in which it conforms to the clinical work flow between the patient and provider. I will give examples of available tools that can improve a patient’s daunting journey. I do not have any financial or other affiliation with any companies mentioned.
1. They can help prepare for the office visit.
I don’t know why, but patients have evolved a belief that they need to present a self-diagnosed condition at the office visit. They often feel guilty not providing the diagnosis. I believe firmly (and tell patients) that their responsibility is to know when something isn’t right and to call the provider. Notwithstanding this, I encourage patients to do online research into their symptoms. Tools found at FamilyDoctor.org, the Mayo Clinic Symptom Checker, or iTriage can help frame thoughts or prompt a discussion with a caregiver prior to a visit, which can then serve as a foundation for the office encounter.
2. Patient education content.
The term “patient engagement” is used commonly today. It implies the active participation of the patient in health care and disease management. Many believe that patient engagement should be focused on medication adherence. While this is critical, it remains a reflection of a patient’s understanding of diagnosis; long-term treatment goals (which need be personalized per a discussion about them); and the components of the treatment itself, which include lifestyle changes and nontraditional pharmacologic therapies as well. Seeing disease through a patient’s eyes (empathy) is the key to good relationships that in turn promote engagement. Excellent digital patient education tools are now available for download and review by patients and caregivers. They explain diagnoses, tests, procedures, and medications. Some are proprietary and made by pharmaceutical and medical device companies, while others are produced by third-party companies that allow the provider to white label the product or even customize the content. One excellent example is Liberate Health. (Ed. note: This publication’s parent company has a relationship with Liberate Health.)
3. Social media.
This is where the patients and caregivers are. It follows then that social media is where providers should be. There are some excellent online patient communities that contain disease-specific groups. Examples are Smart Patients and Treatment Diaries. Social media is a big part of motivating patients and giving support to them and to caregivers. It allows for information exchange in a convenient, relaxing, and nonthreatening setting. While skeptics might question the validity of medical information and advice on these sites, I would say that encouraging patients to participate shows empathy. If a disclaimer is offered stating that this is not a substitute for a health care provider, it can be a significant source of support.
4. Connections to caregivers.
Caregivers are left out of many digital health tools. A good working definition of a caregiver is “an unpaid individual (a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks.” About 29% of the U.S. adult population (65.7 million) provides care to someone who is ill, disabled, or aged. Other statistics about caregivers are more impressive. Health and medical apps are promising tools that can be offered to patients. The rubber has yet to fully meet the road in this arena for a few reasons, many of which are tied to the reputation, usability, and priorities of present electronic health record vendors who represent the face of digital health technology to most physicians and other health care providers. However, there is little denial that they (and other mobile health tools) will play an important role in health care’s future. Both patients and caregivers have expressed what is desired in a mobile app. As aging at home becomes a necessary goal of health care from social, financial, and societal standpoints, caregivers will assume an even greater portion of care.
5. Provide for better continuity of care.
Lack of continuity of care leading to medical errors is not a new topic of discussion. This is relevant in both the inpatient and the outpatient setting. Mobile digital technologies can reduce errors by improving communication to both providers and patients as well as among providers themselves. Use of digital tablets at the bedside by patients can improve provider-patient communication and decrease errors. Handoff of patients among providers is another opportunity for mobile health tools to decrease errors. One such app is Smart Sign Out. Ultimately, any tool that decreases errors is a patient advocate tool.
While some physicians believe that patient advocacy is distinct from patient care, I submit that patient advocacy is something any good physician does every day with every patient, including conveying empathy, providing easy to understand explanations of conditions, and offering advice to be considered in a shared decision-making process. We all enter the field of medicine because we want to contribute to the well-being of others. Let’s not lose sight of that, and let’s look to available and emerging technologies to assist us in this mission.
Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.
When technology is mentioned in the context of health care, it is often received as an impersonal, profit- or regulatory-driven interface between a provider and patient. If designed – hopefully with a clinician involved – with the purpose of actually solving a problem, digital technology will ultimately gain favor. Examples of such tools include links and apps which provide reference information. Epocrates and doximity on the provider side and WebMD on the consumer/patient side are prime examples. There are increasingly more digital tools for patients and caregivers to help them improve self-participation in their health care as well as to navigate the system. The challenge in the health care technology space is to make people (both providers and patients) aware of them, to facilitate use, and to incorporate relevant and actionable data seamlessly into the patient’s electronic record. Technology needs to be designed in a way in which it conforms to the clinical work flow between the patient and provider. I will give examples of available tools that can improve a patient’s daunting journey. I do not have any financial or other affiliation with any companies mentioned.
1. They can help prepare for the office visit.
I don’t know why, but patients have evolved a belief that they need to present a self-diagnosed condition at the office visit. They often feel guilty not providing the diagnosis. I believe firmly (and tell patients) that their responsibility is to know when something isn’t right and to call the provider. Notwithstanding this, I encourage patients to do online research into their symptoms. Tools found at FamilyDoctor.org, the Mayo Clinic Symptom Checker, or iTriage can help frame thoughts or prompt a discussion with a caregiver prior to a visit, which can then serve as a foundation for the office encounter.
2. Patient education content.
The term “patient engagement” is used commonly today. It implies the active participation of the patient in health care and disease management. Many believe that patient engagement should be focused on medication adherence. While this is critical, it remains a reflection of a patient’s understanding of diagnosis; long-term treatment goals (which need be personalized per a discussion about them); and the components of the treatment itself, which include lifestyle changes and nontraditional pharmacologic therapies as well. Seeing disease through a patient’s eyes (empathy) is the key to good relationships that in turn promote engagement. Excellent digital patient education tools are now available for download and review by patients and caregivers. They explain diagnoses, tests, procedures, and medications. Some are proprietary and made by pharmaceutical and medical device companies, while others are produced by third-party companies that allow the provider to white label the product or even customize the content. One excellent example is Liberate Health. (Ed. note: This publication’s parent company has a relationship with Liberate Health.)
3. Social media.
This is where the patients and caregivers are. It follows then that social media is where providers should be. There are some excellent online patient communities that contain disease-specific groups. Examples are Smart Patients and Treatment Diaries. Social media is a big part of motivating patients and giving support to them and to caregivers. It allows for information exchange in a convenient, relaxing, and nonthreatening setting. While skeptics might question the validity of medical information and advice on these sites, I would say that encouraging patients to participate shows empathy. If a disclaimer is offered stating that this is not a substitute for a health care provider, it can be a significant source of support.
4. Connections to caregivers.
Caregivers are left out of many digital health tools. A good working definition of a caregiver is “an unpaid individual (a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks.” About 29% of the U.S. adult population (65.7 million) provides care to someone who is ill, disabled, or aged. Other statistics about caregivers are more impressive. Health and medical apps are promising tools that can be offered to patients. The rubber has yet to fully meet the road in this arena for a few reasons, many of which are tied to the reputation, usability, and priorities of present electronic health record vendors who represent the face of digital health technology to most physicians and other health care providers. However, there is little denial that they (and other mobile health tools) will play an important role in health care’s future. Both patients and caregivers have expressed what is desired in a mobile app. As aging at home becomes a necessary goal of health care from social, financial, and societal standpoints, caregivers will assume an even greater portion of care.
5. Provide for better continuity of care.
Lack of continuity of care leading to medical errors is not a new topic of discussion. This is relevant in both the inpatient and the outpatient setting. Mobile digital technologies can reduce errors by improving communication to both providers and patients as well as among providers themselves. Use of digital tablets at the bedside by patients can improve provider-patient communication and decrease errors. Handoff of patients among providers is another opportunity for mobile health tools to decrease errors. One such app is Smart Sign Out. Ultimately, any tool that decreases errors is a patient advocate tool.
While some physicians believe that patient advocacy is distinct from patient care, I submit that patient advocacy is something any good physician does every day with every patient, including conveying empathy, providing easy to understand explanations of conditions, and offering advice to be considered in a shared decision-making process. We all enter the field of medicine because we want to contribute to the well-being of others. Let’s not lose sight of that, and let’s look to available and emerging technologies to assist us in this mission.
Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.
Editorial: Urgent Care and the Urgent Need for Care
The proliferation of urgent care centers (UCCs) in many urban areas during the past few years is beginning to significantly affect the practice of emergency medicine in both anticipated and unanticipated ways. The demand for rapid care of minor but urgent medical problems along with the diminishing availability of primary care providers, continued hospital closings, and overcrowded EDs make efficient, conveniently-located UCCs that accept most forms of insurance an attractive and profitable way to deliver needed health care.
In some areas, UCCs located in close proximity to hospital-based EDs are relieving the burden to divert resources from the care of seriously ill and injured patients to those with relatively minor emergencies. In other areas, however, UCCs are competing with EDs for patients who are relatively easy to care for and are a source of income that mitigates the financial burden of providing costly and poorly reimbursed care for other patients.
Freed of the need to comply with federal and state regulatory requirements imposed on hospital-based EDs -- particularly the obligation to evaluate and stabilize everyone who comes to an ED for care -- UCCs can offer less expensive care that is attractive to patients and third party payers alike. Many health insurers are now encouraging their patients to utilize UCCs instead of EDs by listing on their insurance cards lower co-payments for UCC visits directly next to those for EDs.
Many, if not most, health care providers who staff and frequently own UCCs are residency-trained, board certified emergency physicians, which undoubtedly offers prospective patients reassurance that the care provided in a store-front UCC is of the highest quality. Alternatives to UCC and ED care, such as retail pharmacy walk-in “clinics” staffed by NPs or PA’s, do not offer their self-triaging patients the safety of stabilization or treatment by trained EPs prior to transfer to a nearby ED, should the patient’s condition turn out to be life threatening or more serious than initially thought.
None of the foregoing is necessarily bad for the specialty of emergency medicine. For those who worry about the “fragmentation” of EM into subspecialty areas such as pediatric emergency medicine and now urgent care, it is worth recalling Heraclitus’ observation that change is the only thing that is constant, and that the scope and practice of EM has been expanding, not shrinking, to now include the evaluation and possible admission of many more patients referred by PMDs (See the 2012 Rand report, “The Evolving Role of Emergency Departments in the United States”), and to the provision of observation services for patients who require short hospital stays. Nor is it bad that UCCs are providing another venue for EPs to practice emergency medicine outside of EDs, i.e. to be emergency physicians instead of “emergency room doctors”
But in some cases, UCCs are beginning to jeopardize the future financial viability of hospital EDs — a shaky situation to begin with, based on a poor national model of attributing all costs, but only a small percentage of revenues to the ED. Moreover, a truly worrisome unanticipated consequence of the rapid proliferation of independent UCCs is the drain on the number of emergency physicians available to staff EDs, including many young EPs who opt for UCC positions offering higher compensation and no night duty, upon completing their residencies.
Should these trends continue, the ability to adequately staff the nation’s EDs with well-trained emergency physicians will become a severe problem. Ironically, the survival of all of the alternative venues to EDs, including UCCs and pharmacy-based walk-in clinics, depends on having well-functioning EDs to refer seriously ill patients to. This impending EP shortage should be addressed now by adjusting compensation formulas for hospital-based EPs where necessary to compete successfully with those of UCCs, and by increasing the number of available emergency medicine residency positions.
The proliferation of urgent care centers (UCCs) in many urban areas during the past few years is beginning to significantly affect the practice of emergency medicine in both anticipated and unanticipated ways. The demand for rapid care of minor but urgent medical problems along with the diminishing availability of primary care providers, continued hospital closings, and overcrowded EDs make efficient, conveniently-located UCCs that accept most forms of insurance an attractive and profitable way to deliver needed health care.
In some areas, UCCs located in close proximity to hospital-based EDs are relieving the burden to divert resources from the care of seriously ill and injured patients to those with relatively minor emergencies. In other areas, however, UCCs are competing with EDs for patients who are relatively easy to care for and are a source of income that mitigates the financial burden of providing costly and poorly reimbursed care for other patients.
Freed of the need to comply with federal and state regulatory requirements imposed on hospital-based EDs -- particularly the obligation to evaluate and stabilize everyone who comes to an ED for care -- UCCs can offer less expensive care that is attractive to patients and third party payers alike. Many health insurers are now encouraging their patients to utilize UCCs instead of EDs by listing on their insurance cards lower co-payments for UCC visits directly next to those for EDs.
Many, if not most, health care providers who staff and frequently own UCCs are residency-trained, board certified emergency physicians, which undoubtedly offers prospective patients reassurance that the care provided in a store-front UCC is of the highest quality. Alternatives to UCC and ED care, such as retail pharmacy walk-in “clinics” staffed by NPs or PA’s, do not offer their self-triaging patients the safety of stabilization or treatment by trained EPs prior to transfer to a nearby ED, should the patient’s condition turn out to be life threatening or more serious than initially thought.
None of the foregoing is necessarily bad for the specialty of emergency medicine. For those who worry about the “fragmentation” of EM into subspecialty areas such as pediatric emergency medicine and now urgent care, it is worth recalling Heraclitus’ observation that change is the only thing that is constant, and that the scope and practice of EM has been expanding, not shrinking, to now include the evaluation and possible admission of many more patients referred by PMDs (See the 2012 Rand report, “The Evolving Role of Emergency Departments in the United States”), and to the provision of observation services for patients who require short hospital stays. Nor is it bad that UCCs are providing another venue for EPs to practice emergency medicine outside of EDs, i.e. to be emergency physicians instead of “emergency room doctors”
But in some cases, UCCs are beginning to jeopardize the future financial viability of hospital EDs — a shaky situation to begin with, based on a poor national model of attributing all costs, but only a small percentage of revenues to the ED. Moreover, a truly worrisome unanticipated consequence of the rapid proliferation of independent UCCs is the drain on the number of emergency physicians available to staff EDs, including many young EPs who opt for UCC positions offering higher compensation and no night duty, upon completing their residencies.
Should these trends continue, the ability to adequately staff the nation’s EDs with well-trained emergency physicians will become a severe problem. Ironically, the survival of all of the alternative venues to EDs, including UCCs and pharmacy-based walk-in clinics, depends on having well-functioning EDs to refer seriously ill patients to. This impending EP shortage should be addressed now by adjusting compensation formulas for hospital-based EPs where necessary to compete successfully with those of UCCs, and by increasing the number of available emergency medicine residency positions.
The proliferation of urgent care centers (UCCs) in many urban areas during the past few years is beginning to significantly affect the practice of emergency medicine in both anticipated and unanticipated ways. The demand for rapid care of minor but urgent medical problems along with the diminishing availability of primary care providers, continued hospital closings, and overcrowded EDs make efficient, conveniently-located UCCs that accept most forms of insurance an attractive and profitable way to deliver needed health care.
In some areas, UCCs located in close proximity to hospital-based EDs are relieving the burden to divert resources from the care of seriously ill and injured patients to those with relatively minor emergencies. In other areas, however, UCCs are competing with EDs for patients who are relatively easy to care for and are a source of income that mitigates the financial burden of providing costly and poorly reimbursed care for other patients.
Freed of the need to comply with federal and state regulatory requirements imposed on hospital-based EDs -- particularly the obligation to evaluate and stabilize everyone who comes to an ED for care -- UCCs can offer less expensive care that is attractive to patients and third party payers alike. Many health insurers are now encouraging their patients to utilize UCCs instead of EDs by listing on their insurance cards lower co-payments for UCC visits directly next to those for EDs.
Many, if not most, health care providers who staff and frequently own UCCs are residency-trained, board certified emergency physicians, which undoubtedly offers prospective patients reassurance that the care provided in a store-front UCC is of the highest quality. Alternatives to UCC and ED care, such as retail pharmacy walk-in “clinics” staffed by NPs or PA’s, do not offer their self-triaging patients the safety of stabilization or treatment by trained EPs prior to transfer to a nearby ED, should the patient’s condition turn out to be life threatening or more serious than initially thought.
None of the foregoing is necessarily bad for the specialty of emergency medicine. For those who worry about the “fragmentation” of EM into subspecialty areas such as pediatric emergency medicine and now urgent care, it is worth recalling Heraclitus’ observation that change is the only thing that is constant, and that the scope and practice of EM has been expanding, not shrinking, to now include the evaluation and possible admission of many more patients referred by PMDs (See the 2012 Rand report, “The Evolving Role of Emergency Departments in the United States”), and to the provision of observation services for patients who require short hospital stays. Nor is it bad that UCCs are providing another venue for EPs to practice emergency medicine outside of EDs, i.e. to be emergency physicians instead of “emergency room doctors”
But in some cases, UCCs are beginning to jeopardize the future financial viability of hospital EDs — a shaky situation to begin with, based on a poor national model of attributing all costs, but only a small percentage of revenues to the ED. Moreover, a truly worrisome unanticipated consequence of the rapid proliferation of independent UCCs is the drain on the number of emergency physicians available to staff EDs, including many young EPs who opt for UCC positions offering higher compensation and no night duty, upon completing their residencies.
Should these trends continue, the ability to adequately staff the nation’s EDs with well-trained emergency physicians will become a severe problem. Ironically, the survival of all of the alternative venues to EDs, including UCCs and pharmacy-based walk-in clinics, depends on having well-functioning EDs to refer seriously ill patients to. This impending EP shortage should be addressed now by adjusting compensation formulas for hospital-based EPs where necessary to compete successfully with those of UCCs, and by increasing the number of available emergency medicine residency positions.
Short and sweet: Writing better consult notes in the era of the electronic medical record
After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.
In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.
This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.
Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.
WHY ARE CONSULT NOTES SO LONG?
The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.1 Physicians are under constant pressure from professional fee-coders to meet these requirements.
Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.
Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,13 including, in my experience, in consultations.
WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?
Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.
An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.14,15 The educational value of the consultation is especially important in teaching hospitals.
If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.
HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?
The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.
The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.
The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.
The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy4,14 and thereby contribute to cost-saving.
My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.
A CASE VIGNETTE
The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.
A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.
He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.
In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.
Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:
- Prerenal azotemia due to volume depletion
- Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
- Obstructive uropathy to be ruled out.
Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.
Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).
FINAL THOUGHTS
The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.
Accountable-care organizations are an important part of the Affordable Care Act,16 which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.17
Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.
- Department of Health and Human Services; Office of Inspector General. Consultations in Medicare: coding and reimbursement. http://oig.hhs.gov/oei/reports/oei-09-02-00030.pdf. Accessed November 24, 2014.
- Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. N Engl J Med 2008; 358:1656–1658.
- O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med 2010; 25:177–185.
- The Center for Public Integrity; Schulte F. Electronic medical records probed for over-billing. Critics question credibility of federal panel charged with investigating. www.publicintegrity.org/2013/02/14/12208/electronic-medical-records-probed-over-billing. Accessed November 24, 2014.
- Li B. Cracking the codes: do electronic medical records facilitate hospital revenue enhancement? www.kellogg.northwestern.edu/faculty/b-li/JMP.pdf. Accessed November 24, 2014.
- Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006; 295:2335–2336.
- Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform 2007; 76(suppl 1):S122–S128.
- Hanlon JT. The electronic medical record: diving into a shallow pool? Cleve Clin J Med 2010; 77:408–411.
- Fitzgerald FT. The emperor’s new clothes. Ann Intern Med 2012; 156:396–397.
- Bernat JL. Ethical and quality pitfalls in electronic health records. Neurology 2013; 80:1057–1061.
- Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med 2013; 41:382–388.
- Foote RS. The challenge to the medical record. JAMA Intern Med 2013; 173:1171–1172.
- Tamburello LM. The road to EMR noncompliance and fraud is paved with cut and paste. MD Advis 2013; 6:24–30.
- Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983; 143:1753–1755.
- Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med 2007; 167:271–275.
- Longworth DL. Accountable care organizations, the patient-centered medical home, and health care reform: what does it all mean? Cleve Clin J Med 2011; 78:571–582.
- Meyer H. Many accountable care organizations are now up and running, if not off to the races. Health Aff (Millwood) 2012; 31:2363–2367.
After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.
In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.
This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.
Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.
WHY ARE CONSULT NOTES SO LONG?
The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.1 Physicians are under constant pressure from professional fee-coders to meet these requirements.
Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.
Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,13 including, in my experience, in consultations.
WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?
Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.
An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.14,15 The educational value of the consultation is especially important in teaching hospitals.
If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.
HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?
The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.
The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.
The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.
The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy4,14 and thereby contribute to cost-saving.
My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.
A CASE VIGNETTE
The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.
A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.
He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.
In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.
Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:
- Prerenal azotemia due to volume depletion
- Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
- Obstructive uropathy to be ruled out.
Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.
Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).
FINAL THOUGHTS
The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.
Accountable-care organizations are an important part of the Affordable Care Act,16 which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.17
Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.
After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.
In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.
This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.
Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.
WHY ARE CONSULT NOTES SO LONG?
The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.1 Physicians are under constant pressure from professional fee-coders to meet these requirements.
Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.
Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,13 including, in my experience, in consultations.
WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?
Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.
An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.14,15 The educational value of the consultation is especially important in teaching hospitals.
If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.
HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?
The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.
The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.
The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.
The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy4,14 and thereby contribute to cost-saving.
My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.
A CASE VIGNETTE
The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.
A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.
He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.
In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.
Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:
- Prerenal azotemia due to volume depletion
- Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
- Obstructive uropathy to be ruled out.
Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.
Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).
FINAL THOUGHTS
The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.
Accountable-care organizations are an important part of the Affordable Care Act,16 which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.17
Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.
- Department of Health and Human Services; Office of Inspector General. Consultations in Medicare: coding and reimbursement. http://oig.hhs.gov/oei/reports/oei-09-02-00030.pdf. Accessed November 24, 2014.
- Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. N Engl J Med 2008; 358:1656–1658.
- O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med 2010; 25:177–185.
- The Center for Public Integrity; Schulte F. Electronic medical records probed for over-billing. Critics question credibility of federal panel charged with investigating. www.publicintegrity.org/2013/02/14/12208/electronic-medical-records-probed-over-billing. Accessed November 24, 2014.
- Li B. Cracking the codes: do electronic medical records facilitate hospital revenue enhancement? www.kellogg.northwestern.edu/faculty/b-li/JMP.pdf. Accessed November 24, 2014.
- Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006; 295:2335–2336.
- Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform 2007; 76(suppl 1):S122–S128.
- Hanlon JT. The electronic medical record: diving into a shallow pool? Cleve Clin J Med 2010; 77:408–411.
- Fitzgerald FT. The emperor’s new clothes. Ann Intern Med 2012; 156:396–397.
- Bernat JL. Ethical and quality pitfalls in electronic health records. Neurology 2013; 80:1057–1061.
- Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med 2013; 41:382–388.
- Foote RS. The challenge to the medical record. JAMA Intern Med 2013; 173:1171–1172.
- Tamburello LM. The road to EMR noncompliance and fraud is paved with cut and paste. MD Advis 2013; 6:24–30.
- Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983; 143:1753–1755.
- Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med 2007; 167:271–275.
- Longworth DL. Accountable care organizations, the patient-centered medical home, and health care reform: what does it all mean? Cleve Clin J Med 2011; 78:571–582.
- Meyer H. Many accountable care organizations are now up and running, if not off to the races. Health Aff (Millwood) 2012; 31:2363–2367.
- Department of Health and Human Services; Office of Inspector General. Consultations in Medicare: coding and reimbursement. http://oig.hhs.gov/oei/reports/oei-09-02-00030.pdf. Accessed November 24, 2014.
- Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. N Engl J Med 2008; 358:1656–1658.
- O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med 2010; 25:177–185.
- The Center for Public Integrity; Schulte F. Electronic medical records probed for over-billing. Critics question credibility of federal panel charged with investigating. www.publicintegrity.org/2013/02/14/12208/electronic-medical-records-probed-over-billing. Accessed November 24, 2014.
- Li B. Cracking the codes: do electronic medical records facilitate hospital revenue enhancement? www.kellogg.northwestern.edu/faculty/b-li/JMP.pdf. Accessed November 24, 2014.
- Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006; 295:2335–2336.
- Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform 2007; 76(suppl 1):S122–S128.
- Hanlon JT. The electronic medical record: diving into a shallow pool? Cleve Clin J Med 2010; 77:408–411.
- Fitzgerald FT. The emperor’s new clothes. Ann Intern Med 2012; 156:396–397.
- Bernat JL. Ethical and quality pitfalls in electronic health records. Neurology 2013; 80:1057–1061.
- Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med 2013; 41:382–388.
- Foote RS. The challenge to the medical record. JAMA Intern Med 2013; 173:1171–1172.
- Tamburello LM. The road to EMR noncompliance and fraud is paved with cut and paste. MD Advis 2013; 6:24–30.
- Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983; 143:1753–1755.
- Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med 2007; 167:271–275.
- Longworth DL. Accountable care organizations, the patient-centered medical home, and health care reform: what does it all mean? Cleve Clin J Med 2011; 78:571–582.
- Meyer H. Many accountable care organizations are now up and running, if not off to the races. Health Aff (Millwood) 2012; 31:2363–2367.
A disease that strikes close to home
Besides caring for these patients, many of us also have a parent, spouse, or a close relative with dementia. My 90-year-old mother has multi-infarct dementia from her diabetes and vascular disease, but is still able to live in an apartment with my 91-year-old father, with assistance from wonderful home aides. Despite her profound dementia, she can still play the piano and read music.
Menchola and Weiss are to be congratulated for their excellent, evidence-based review of the diagnosis, treatment, and prevention of Alzheimer’s disease (AD). (See "Addressing Alzheimer’s: A pragmatic approach.") They do not get caught up in unjustified enthusiasm for screening and drug treatment. Some of their important recommendations bear repeating here:
Do not routinely screen for AD. This may seem like heresy in these days of early detection and prevention. But for screening to be useful, there must be effective early interventions, and so far, early treatments for AD have been disappointing. Cholinesterase inhibitors and N-methyl-D-aspartate glutamate receptor blockers provide very small improvements in cognitive function and have significant adverse effects. Some behavioral interventions to delay onset of cognitive decline show promise—but are unproven.
Although routine screening is not recommended, “case finding” remains important. We need to be alert to signs and symptoms that suggest early dementia in our patients, and we need to evaluate these patients carefully or refer them for neurologic testing if the diagnosis is in doubt.
Use drugs sparingly, especially when treating behavioral problems. They have serious adverse effects, and behavioral interventions should always be used first. Encourage caregivers to seek out social support. My father attends an Alzheimer’s support group each month, and this has lifted some of the burden.
Address prognosis and end-of-life care, and avoid unnecessary and aggressive treatments that are likely to cause more harm than benefit. Hospice care is suitable and beneficial for those with late-stage Alzheimer’s, but feeding tubes are not.
With many new advances in research techniques, it is likely that investigators will develop better methods of diagnosis and treatment of AD. In the meantime, there is already much we can do to alleviate the suffering of these patients and support their caregivers. This knowledge will likely serve us at home, as well.
Besides caring for these patients, many of us also have a parent, spouse, or a close relative with dementia. My 90-year-old mother has multi-infarct dementia from her diabetes and vascular disease, but is still able to live in an apartment with my 91-year-old father, with assistance from wonderful home aides. Despite her profound dementia, she can still play the piano and read music.
Menchola and Weiss are to be congratulated for their excellent, evidence-based review of the diagnosis, treatment, and prevention of Alzheimer’s disease (AD). (See "Addressing Alzheimer’s: A pragmatic approach.") They do not get caught up in unjustified enthusiasm for screening and drug treatment. Some of their important recommendations bear repeating here:
Do not routinely screen for AD. This may seem like heresy in these days of early detection and prevention. But for screening to be useful, there must be effective early interventions, and so far, early treatments for AD have been disappointing. Cholinesterase inhibitors and N-methyl-D-aspartate glutamate receptor blockers provide very small improvements in cognitive function and have significant adverse effects. Some behavioral interventions to delay onset of cognitive decline show promise—but are unproven.
Although routine screening is not recommended, “case finding” remains important. We need to be alert to signs and symptoms that suggest early dementia in our patients, and we need to evaluate these patients carefully or refer them for neurologic testing if the diagnosis is in doubt.
Use drugs sparingly, especially when treating behavioral problems. They have serious adverse effects, and behavioral interventions should always be used first. Encourage caregivers to seek out social support. My father attends an Alzheimer’s support group each month, and this has lifted some of the burden.
Address prognosis and end-of-life care, and avoid unnecessary and aggressive treatments that are likely to cause more harm than benefit. Hospice care is suitable and beneficial for those with late-stage Alzheimer’s, but feeding tubes are not.
With many new advances in research techniques, it is likely that investigators will develop better methods of diagnosis and treatment of AD. In the meantime, there is already much we can do to alleviate the suffering of these patients and support their caregivers. This knowledge will likely serve us at home, as well.
Besides caring for these patients, many of us also have a parent, spouse, or a close relative with dementia. My 90-year-old mother has multi-infarct dementia from her diabetes and vascular disease, but is still able to live in an apartment with my 91-year-old father, with assistance from wonderful home aides. Despite her profound dementia, she can still play the piano and read music.
Menchola and Weiss are to be congratulated for their excellent, evidence-based review of the diagnosis, treatment, and prevention of Alzheimer’s disease (AD). (See "Addressing Alzheimer’s: A pragmatic approach.") They do not get caught up in unjustified enthusiasm for screening and drug treatment. Some of their important recommendations bear repeating here:
Do not routinely screen for AD. This may seem like heresy in these days of early detection and prevention. But for screening to be useful, there must be effective early interventions, and so far, early treatments for AD have been disappointing. Cholinesterase inhibitors and N-methyl-D-aspartate glutamate receptor blockers provide very small improvements in cognitive function and have significant adverse effects. Some behavioral interventions to delay onset of cognitive decline show promise—but are unproven.
Although routine screening is not recommended, “case finding” remains important. We need to be alert to signs and symptoms that suggest early dementia in our patients, and we need to evaluate these patients carefully or refer them for neurologic testing if the diagnosis is in doubt.
Use drugs sparingly, especially when treating behavioral problems. They have serious adverse effects, and behavioral interventions should always be used first. Encourage caregivers to seek out social support. My father attends an Alzheimer’s support group each month, and this has lifted some of the burden.
Address prognosis and end-of-life care, and avoid unnecessary and aggressive treatments that are likely to cause more harm than benefit. Hospice care is suitable and beneficial for those with late-stage Alzheimer’s, but feeding tubes are not.
With many new advances in research techniques, it is likely that investigators will develop better methods of diagnosis and treatment of AD. In the meantime, there is already much we can do to alleviate the suffering of these patients and support their caregivers. This knowledge will likely serve us at home, as well.
Use baby formula to check for bladder integrity
“FAREWELL TO INDIGO CARMINE”
ROBERT L. BARBIERI, MD (EDITORIAL; SEPTEMBER 2014)
Use baby formula to check for bladder integrity
There is an additional method that can be used to check for bladder injury that some of us “older” gynecologists have employed. Baby formula is packaged in sterile bottles. I have had the rare occasion to need to check for bladder integrity and have had the circulating nurse inject diluted formula through the indwelling urinary catheter. I have yet to encounter (or read about) an allergic response from this technique.
Martin E. Kanoff, DO
Sewell, New Jersey
I found Dr. Barbieri’s editorial on the indigo carmine shortage very appropriate and timely.
When intraoperatively testing a bladder repair or looking for a possible bladder injury, administration of phenazopyridine or instillation of dilute methylene blue as noted are reasonable approaches. Due to tissue staining, which can make repeat bladder assessment more difficult, I have found that instilling sterile formula, usually easily available on the obstetric unit, will allow detection of “leaks” and easily can be rinsed out of the pelvis with saline, allowing repeat instillation if necessary.
Also, if the bladder is distended with fluid when looking for defects, it pays to wait a few minutes before decompressing, as small leaks may gradually deflate the bladder and alert the surgeon to the need for further investigation.
William J. Mann, Jr, MD
Executive Medical Director
Olde Towne Medical and Dental Center
Clinical Professor, ObGyn
Virginia Commonwealth School of Medicine
Richmond, Virginia
What about using sterile milk?
Dr. Barbieri, what is your opinion and do you have any ideas on sourcing sterile milk for use in diagnostic cystoscopy and tubal patency in gynecology?
Donna G. Ivery, MD
Titusville, Florida
Is there a methylene blue shortage too?
I commonly perform chromotubation for my infertility patients and for tubal reversals. I have been substituting methylene blue for indigo carmine. Recently, I was told by my surgical center that methylene blue is on back order. Have you noticed the methylene blue shortage? Do you have suggestions for a replacement for my indications of chromotubation and tubal reversal surgeries?
Online I have seen mention of isosulfan blue being injected into lymphatic tissue to identify sentinel nodes—although it is more expensive. I will be searching now for a supplier of isosulfan blue. Sterile milk has been used to identify bladder fistulas. Can it be used for chromotubation?
Peter G. Van Deerlin, MD
South Jersey Fertility Center
Marlton, New Jersey
Can we brainstorm a solution to the shortage?
Dr. Barbieri, once again you have demonstrated your clear thinking and reasoned approach to what is a clinical problem.
I would add the following thought: Perhaps a group of physicians from major specialty/subspecialty organizations could meet with the present manufacturers and brainstorm for a solution. Self-interest is clearly the practical path and patient safety/customer satisfaction can come into play also.
Stephen S. Schuster, MD
Queens, New York
Another way to diagnose PROM
I read with interest the editorial covering the shortage of indigo carmine. In the section “Options to diagnose PROM … ”, you stated NONE as the option for diagnosing premature rupture of membranes (PROM) when standard clinical testing is equivocal.
A recent article in Journal of Perinatal Medicine suggests that placental alpha microglobulin-1 (PAMG-1) testing is as reliable as dye studies.1 This was a 140-patient prospective study and is certainly encouraging.
I don’t use PAMG-1 as a first-line agent for diagnosing rupture of membranes (ROM). Speculum examination with pooling of amniotic fluid, nitrozine testing, and microscopic examination for ferning confirm or rule out ROM in most cases. This article points toward avoiding the more invasive dye study. The data are timely in light of the indigo carmine shortage.
John R. Hannig, MD
Salem, Oregon
Reference
- Sosa CG, Herrera E, Restrepo JC, Strauss A, Alonso J. Comparison of placental alpha macroglobulin-1 in vaginal fluid with intra-amniotic injection of indigo carmine for the diagnosis of rupture of membranes. J Perinat Med. 2014;42(5):611–616.
Dr. Barbieri responds
I appreciate the great suggestion by Drs. Kanoff, Mann, and Ivery to use sterile baby formula to test bladder integrity. Sterile baby formula is usually available on an obstetric unit, and less available in a main operating room environment. One small caveat about the use of the word “sterile.” Baby formula is “sterile” using criteria for a commercial food product. Injectable agents typically need to be both sterile, using criteria for a pharmaceutical agent, and pyrogen free. These criteria are more stringent than for a food product. Some surgical nursing and pharmacy administrators may focus on this technical difference and resist the use of sterile baby formula to test bladder integrity.
First it was indigo carmine, now methylene blue is on back order. As Dr. Van Deerlin suspects, isosulfan blue is expensive. A 5-mL vial of isosulfan blue has a list price of $714. If no dye were available to test tubal patency, I would consider using saline or lactated Ringer’s solution. I would hesitate to use sterile baby formula because I would be concerned about peritoneal and tubal epithelial inflammation.
Dr. Schuster has a great suggestion to better coordinate the capabilities of manufacturers with the needs of clinicians and patients. We will forward your suggestion to the ACOG leadership.
I agree with Dr. Hannig’s suggestion that measurement of placental alpha macroglobulin-1 in vaginal fluid is an excellent option for replacing intra-amniotic injection of indigo carmine. Some obstetric units have not yet deployed this test because, in many centers, only a few cases per year needed this test. With the loss of access to indigo carmine, it is a good option to consider measurement of placental alpha macroglobulin-1 in vaginal fluid in cases where it is unclear if the membranes have ruptured.
“PREVENTING POSTOPERATIVE NEUROPATHIES: PATIENT POSITIONING FOR MINIMALLY INVASIVE PROCEDURES”
TIFFANY JACKSON, MD; BICH-VAN TRAN, MD; ARNOLD ADVINCULA, MD; KAREN WIERCINSKI, RN, BSN; JULIO LOPEZ (VIDEO; SEPTEMBER 2014)
May I share the video?
The video on patient positioning to prevent postoperative neuropathies is a great resource for physicians and nurses! May I share this video with our gynecologic operative room staff as a teaching tool?
Christinne D. Canela, MD
Roanoke, Virginia
The Editors respond
This, and all of the videos at obgmanagement.com are meant to be shared with your colleagues.
“TISSUE EXTRACTION DURING MINIMALLY INVASIVE GYN SURGERY. SECOND OF 2 PARTS: COUNSELING THE PATIENT”
(ROUNDTABLE; OCTOBER 2014)
May I morcellate your uterus please?
The laparoscopic approach to the fibroid uterus is currently a puzzle. After the FDA released a statement in April postulating that the use of power morcellation to remove uterine fibroids should be “discouraged,” a great controversy developed in the minimally invasive surgical community.
Subsequently in July, the Obstetrics and Gynecology Devices Advisory Panel of the FDA held a 2-day meeting to analyze risks, benefits, and the overall clinical role of laparoscopic power morcellation in gynecology. One recommendation was to include in the informed consent a disclosure of the risks of disseminating an occult uterine malignancy. I salute the efforts of the panel and agree on the necessity for a comprehensive consent process that discloses risks that could worsen the patient’s prognosis.
Soon after that FDA panel met in July, Ethicon, a division of Johnson and Johnson, made a business decision to initiate a worldwide withdrawal of the company’s morcellation devices.
Now, on November 24, the FDA issued an updated Safety Communication recommending that the use of power morcellators is contraindicated for removal of uterine tissue containing suspected fibroids in patients who are peri- or post-menopausal, or are candidates for en bloc tissue removal. They also said that laparoscopic power morcellators are contraindicated in gynecologic surgery in which the tissue to be morcellated is known or suspected to contain malignancy. The FDA is issuing a boxed warning, and recommends that surgeons thoroughly discuss the benefits and risks of all treatment to patients, including younger women who want to maintain their fertility or women not yet perimenopausal who wish to keep their uterus.
How will having a patient sign a consent form change the risk of unfortunate dispersion? How will it protect the surgeon from the subsequent liability? Who will be responsible for worsening the patient’s survival?
Month after month in the Medical Verdicts column, we see cases of unfortunate patients who suffer well-known surgical complications that are litigated, with different outcomes and compensations. I am certain that in most of these cases, the patients had signed at least a standard consent form that lists the most commonly known complications. Having a patient sign a consent form does not reduce the incidence of complications nor protect the physician from liability.
In my opinion, effort should be concentrated on finding a way to better preoperatively identify the patient at risk of occult uterine malignancy so that the surgical approach can be modified accordingly.
The controversy regarding morcellation is far from over. Perhaps the last tissue extractor remaining in the market should be used to morcellate the tort system and finally build a system that will protect patients and physicians.
Jose Carugno, MD
Miami, Florida
Dr. Iglesia responds
Dr. Carugno is correct. A “consent form” does not protect the surgeon from potential liability nor the patient from potential harm. Informed decision-making is a process wherein providers and patients discuss the diagnoses and conditions; the treatment options and alternatives ranging from expectant management, medical management or surgical intervention; and the potential risks and benefits of each of those options. Physicians should perform an adequate preoperative evaluation, and patients should be given the opportunity to ask questions with the understanding that no treatment is without risks (including the option for watchful waiting). Physicians should describe the steps that will be taken during the preoperative, intraoperative, and postoperative periods to mitigate those risks.
“TOTAL ABDOMINAL HYSTERECTOMY THE MAYO CLINIC WAY” JOHN B. GEBHART, MD, MS (SURGICAL TECHNIQUE; OCTOBER 2014)
We need to focus on improving vaginal hysterectomy
I found Dr. Gebhart’s article on abdominal hysterectomy technically very accurate and well written. It is with the greatest respect that I write to express my concern with the author’s response that because of the restriction of power morcellation devices, the rate of abdominal hysterectomy will increase.
Rather than focus on the improvement of the most common gynecologic surgical procedure, we should be focusing on improving techniques of vaginal hysterectomy, a route that unfortunately is under-taught in the United States.
I have been a practicing ObGyn for more than 20 years, and exclusively as a gynecologist for the last 4 years. I perform vaginal hysterectomies more than 90% of the time. My total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy rates remain less than 5%; laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy rates: 0%; and power morcellation rate: 0%.
In conclusion, why abdominal hysterectomy?
Robert C. Raymond, MD, MBA
Fort Payne, Alabama
Dr. Gebhart responds
Dr. Raymond, I thank you for your comments and question. I applaud your surgical skill set and approach to hysterectomy. My preferred route of hysterectomy for benign disease is the vaginal route. A few years ago we published an article in OBG Management on keys to success in vaginal hysterectomy.1 Indeed, the vaginal approach remains the least expensive and least morbid approach to hysterectomy, yet the least common. I continue to publish and lecture on the benefits of a vaginal approach and societies, such as the Society of Gynecologic Surgeons (SGS), remain committed to teaching and advocating this well-established, evidence-based yet underutilized approach.
Given the interest and controversy in the use of power morcellation after the FDA’s Safety Communication last April,2 it was felt that a good technical review of abdominal hysterectomy was cogent. If surgeons have a concern about using power morcellation or their institution has banned use of a power morcellator, then the abdominal route is the most likely alternative for removing the enlarged uterus intact. As you state, the abdominal approach remains the most common route of hysterectomy. My sense is that most providers faced with an enlarged uterus that cannot be removed via laparoscopic morcellation (for reasons stated previously) are likely to turn to abdominal hysterectomy. Hopefully, the article gives readers a chance to assess and develop their technical approach to abdominal hysterectomy.
References
- Occhino JA, Gebhart JB. The difficult vaginal hysterectomy: 5 keys to success. OBG Manag. 2010;22(11):32–47.
- US Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm. Published April 17, 2014. Accessed December 8, 2014.
Share your thoughts on these letters or on another article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“FAREWELL TO INDIGO CARMINE”
ROBERT L. BARBIERI, MD (EDITORIAL; SEPTEMBER 2014)
Use baby formula to check for bladder integrity
There is an additional method that can be used to check for bladder injury that some of us “older” gynecologists have employed. Baby formula is packaged in sterile bottles. I have had the rare occasion to need to check for bladder integrity and have had the circulating nurse inject diluted formula through the indwelling urinary catheter. I have yet to encounter (or read about) an allergic response from this technique.
Martin E. Kanoff, DO
Sewell, New Jersey
I found Dr. Barbieri’s editorial on the indigo carmine shortage very appropriate and timely.
When intraoperatively testing a bladder repair or looking for a possible bladder injury, administration of phenazopyridine or instillation of dilute methylene blue as noted are reasonable approaches. Due to tissue staining, which can make repeat bladder assessment more difficult, I have found that instilling sterile formula, usually easily available on the obstetric unit, will allow detection of “leaks” and easily can be rinsed out of the pelvis with saline, allowing repeat instillation if necessary.
Also, if the bladder is distended with fluid when looking for defects, it pays to wait a few minutes before decompressing, as small leaks may gradually deflate the bladder and alert the surgeon to the need for further investigation.
William J. Mann, Jr, MD
Executive Medical Director
Olde Towne Medical and Dental Center
Clinical Professor, ObGyn
Virginia Commonwealth School of Medicine
Richmond, Virginia
What about using sterile milk?
Dr. Barbieri, what is your opinion and do you have any ideas on sourcing sterile milk for use in diagnostic cystoscopy and tubal patency in gynecology?
Donna G. Ivery, MD
Titusville, Florida
Is there a methylene blue shortage too?
I commonly perform chromotubation for my infertility patients and for tubal reversals. I have been substituting methylene blue for indigo carmine. Recently, I was told by my surgical center that methylene blue is on back order. Have you noticed the methylene blue shortage? Do you have suggestions for a replacement for my indications of chromotubation and tubal reversal surgeries?
Online I have seen mention of isosulfan blue being injected into lymphatic tissue to identify sentinel nodes—although it is more expensive. I will be searching now for a supplier of isosulfan blue. Sterile milk has been used to identify bladder fistulas. Can it be used for chromotubation?
Peter G. Van Deerlin, MD
South Jersey Fertility Center
Marlton, New Jersey
Can we brainstorm a solution to the shortage?
Dr. Barbieri, once again you have demonstrated your clear thinking and reasoned approach to what is a clinical problem.
I would add the following thought: Perhaps a group of physicians from major specialty/subspecialty organizations could meet with the present manufacturers and brainstorm for a solution. Self-interest is clearly the practical path and patient safety/customer satisfaction can come into play also.
Stephen S. Schuster, MD
Queens, New York
Another way to diagnose PROM
I read with interest the editorial covering the shortage of indigo carmine. In the section “Options to diagnose PROM … ”, you stated NONE as the option for diagnosing premature rupture of membranes (PROM) when standard clinical testing is equivocal.
A recent article in Journal of Perinatal Medicine suggests that placental alpha microglobulin-1 (PAMG-1) testing is as reliable as dye studies.1 This was a 140-patient prospective study and is certainly encouraging.
I don’t use PAMG-1 as a first-line agent for diagnosing rupture of membranes (ROM). Speculum examination with pooling of amniotic fluid, nitrozine testing, and microscopic examination for ferning confirm or rule out ROM in most cases. This article points toward avoiding the more invasive dye study. The data are timely in light of the indigo carmine shortage.
John R. Hannig, MD
Salem, Oregon
Reference
- Sosa CG, Herrera E, Restrepo JC, Strauss A, Alonso J. Comparison of placental alpha macroglobulin-1 in vaginal fluid with intra-amniotic injection of indigo carmine for the diagnosis of rupture of membranes. J Perinat Med. 2014;42(5):611–616.
Dr. Barbieri responds
I appreciate the great suggestion by Drs. Kanoff, Mann, and Ivery to use sterile baby formula to test bladder integrity. Sterile baby formula is usually available on an obstetric unit, and less available in a main operating room environment. One small caveat about the use of the word “sterile.” Baby formula is “sterile” using criteria for a commercial food product. Injectable agents typically need to be both sterile, using criteria for a pharmaceutical agent, and pyrogen free. These criteria are more stringent than for a food product. Some surgical nursing and pharmacy administrators may focus on this technical difference and resist the use of sterile baby formula to test bladder integrity.
First it was indigo carmine, now methylene blue is on back order. As Dr. Van Deerlin suspects, isosulfan blue is expensive. A 5-mL vial of isosulfan blue has a list price of $714. If no dye were available to test tubal patency, I would consider using saline or lactated Ringer’s solution. I would hesitate to use sterile baby formula because I would be concerned about peritoneal and tubal epithelial inflammation.
Dr. Schuster has a great suggestion to better coordinate the capabilities of manufacturers with the needs of clinicians and patients. We will forward your suggestion to the ACOG leadership.
I agree with Dr. Hannig’s suggestion that measurement of placental alpha macroglobulin-1 in vaginal fluid is an excellent option for replacing intra-amniotic injection of indigo carmine. Some obstetric units have not yet deployed this test because, in many centers, only a few cases per year needed this test. With the loss of access to indigo carmine, it is a good option to consider measurement of placental alpha macroglobulin-1 in vaginal fluid in cases where it is unclear if the membranes have ruptured.
“PREVENTING POSTOPERATIVE NEUROPATHIES: PATIENT POSITIONING FOR MINIMALLY INVASIVE PROCEDURES”
TIFFANY JACKSON, MD; BICH-VAN TRAN, MD; ARNOLD ADVINCULA, MD; KAREN WIERCINSKI, RN, BSN; JULIO LOPEZ (VIDEO; SEPTEMBER 2014)
May I share the video?
The video on patient positioning to prevent postoperative neuropathies is a great resource for physicians and nurses! May I share this video with our gynecologic operative room staff as a teaching tool?
Christinne D. Canela, MD
Roanoke, Virginia
The Editors respond
This, and all of the videos at obgmanagement.com are meant to be shared with your colleagues.
“TISSUE EXTRACTION DURING MINIMALLY INVASIVE GYN SURGERY. SECOND OF 2 PARTS: COUNSELING THE PATIENT”
(ROUNDTABLE; OCTOBER 2014)
May I morcellate your uterus please?
The laparoscopic approach to the fibroid uterus is currently a puzzle. After the FDA released a statement in April postulating that the use of power morcellation to remove uterine fibroids should be “discouraged,” a great controversy developed in the minimally invasive surgical community.
Subsequently in July, the Obstetrics and Gynecology Devices Advisory Panel of the FDA held a 2-day meeting to analyze risks, benefits, and the overall clinical role of laparoscopic power morcellation in gynecology. One recommendation was to include in the informed consent a disclosure of the risks of disseminating an occult uterine malignancy. I salute the efforts of the panel and agree on the necessity for a comprehensive consent process that discloses risks that could worsen the patient’s prognosis.
Soon after that FDA panel met in July, Ethicon, a division of Johnson and Johnson, made a business decision to initiate a worldwide withdrawal of the company’s morcellation devices.
Now, on November 24, the FDA issued an updated Safety Communication recommending that the use of power morcellators is contraindicated for removal of uterine tissue containing suspected fibroids in patients who are peri- or post-menopausal, or are candidates for en bloc tissue removal. They also said that laparoscopic power morcellators are contraindicated in gynecologic surgery in which the tissue to be morcellated is known or suspected to contain malignancy. The FDA is issuing a boxed warning, and recommends that surgeons thoroughly discuss the benefits and risks of all treatment to patients, including younger women who want to maintain their fertility or women not yet perimenopausal who wish to keep their uterus.
How will having a patient sign a consent form change the risk of unfortunate dispersion? How will it protect the surgeon from the subsequent liability? Who will be responsible for worsening the patient’s survival?
Month after month in the Medical Verdicts column, we see cases of unfortunate patients who suffer well-known surgical complications that are litigated, with different outcomes and compensations. I am certain that in most of these cases, the patients had signed at least a standard consent form that lists the most commonly known complications. Having a patient sign a consent form does not reduce the incidence of complications nor protect the physician from liability.
In my opinion, effort should be concentrated on finding a way to better preoperatively identify the patient at risk of occult uterine malignancy so that the surgical approach can be modified accordingly.
The controversy regarding morcellation is far from over. Perhaps the last tissue extractor remaining in the market should be used to morcellate the tort system and finally build a system that will protect patients and physicians.
Jose Carugno, MD
Miami, Florida
Dr. Iglesia responds
Dr. Carugno is correct. A “consent form” does not protect the surgeon from potential liability nor the patient from potential harm. Informed decision-making is a process wherein providers and patients discuss the diagnoses and conditions; the treatment options and alternatives ranging from expectant management, medical management or surgical intervention; and the potential risks and benefits of each of those options. Physicians should perform an adequate preoperative evaluation, and patients should be given the opportunity to ask questions with the understanding that no treatment is without risks (including the option for watchful waiting). Physicians should describe the steps that will be taken during the preoperative, intraoperative, and postoperative periods to mitigate those risks.
“TOTAL ABDOMINAL HYSTERECTOMY THE MAYO CLINIC WAY” JOHN B. GEBHART, MD, MS (SURGICAL TECHNIQUE; OCTOBER 2014)
We need to focus on improving vaginal hysterectomy
I found Dr. Gebhart’s article on abdominal hysterectomy technically very accurate and well written. It is with the greatest respect that I write to express my concern with the author’s response that because of the restriction of power morcellation devices, the rate of abdominal hysterectomy will increase.
Rather than focus on the improvement of the most common gynecologic surgical procedure, we should be focusing on improving techniques of vaginal hysterectomy, a route that unfortunately is under-taught in the United States.
I have been a practicing ObGyn for more than 20 years, and exclusively as a gynecologist for the last 4 years. I perform vaginal hysterectomies more than 90% of the time. My total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy rates remain less than 5%; laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy rates: 0%; and power morcellation rate: 0%.
In conclusion, why abdominal hysterectomy?
Robert C. Raymond, MD, MBA
Fort Payne, Alabama
Dr. Gebhart responds
Dr. Raymond, I thank you for your comments and question. I applaud your surgical skill set and approach to hysterectomy. My preferred route of hysterectomy for benign disease is the vaginal route. A few years ago we published an article in OBG Management on keys to success in vaginal hysterectomy.1 Indeed, the vaginal approach remains the least expensive and least morbid approach to hysterectomy, yet the least common. I continue to publish and lecture on the benefits of a vaginal approach and societies, such as the Society of Gynecologic Surgeons (SGS), remain committed to teaching and advocating this well-established, evidence-based yet underutilized approach.
Given the interest and controversy in the use of power morcellation after the FDA’s Safety Communication last April,2 it was felt that a good technical review of abdominal hysterectomy was cogent. If surgeons have a concern about using power morcellation or their institution has banned use of a power morcellator, then the abdominal route is the most likely alternative for removing the enlarged uterus intact. As you state, the abdominal approach remains the most common route of hysterectomy. My sense is that most providers faced with an enlarged uterus that cannot be removed via laparoscopic morcellation (for reasons stated previously) are likely to turn to abdominal hysterectomy. Hopefully, the article gives readers a chance to assess and develop their technical approach to abdominal hysterectomy.
References
- Occhino JA, Gebhart JB. The difficult vaginal hysterectomy: 5 keys to success. OBG Manag. 2010;22(11):32–47.
- US Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm. Published April 17, 2014. Accessed December 8, 2014.
Share your thoughts on these letters or on another article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“FAREWELL TO INDIGO CARMINE”
ROBERT L. BARBIERI, MD (EDITORIAL; SEPTEMBER 2014)
Use baby formula to check for bladder integrity
There is an additional method that can be used to check for bladder injury that some of us “older” gynecologists have employed. Baby formula is packaged in sterile bottles. I have had the rare occasion to need to check for bladder integrity and have had the circulating nurse inject diluted formula through the indwelling urinary catheter. I have yet to encounter (or read about) an allergic response from this technique.
Martin E. Kanoff, DO
Sewell, New Jersey
I found Dr. Barbieri’s editorial on the indigo carmine shortage very appropriate and timely.
When intraoperatively testing a bladder repair or looking for a possible bladder injury, administration of phenazopyridine or instillation of dilute methylene blue as noted are reasonable approaches. Due to tissue staining, which can make repeat bladder assessment more difficult, I have found that instilling sterile formula, usually easily available on the obstetric unit, will allow detection of “leaks” and easily can be rinsed out of the pelvis with saline, allowing repeat instillation if necessary.
Also, if the bladder is distended with fluid when looking for defects, it pays to wait a few minutes before decompressing, as small leaks may gradually deflate the bladder and alert the surgeon to the need for further investigation.
William J. Mann, Jr, MD
Executive Medical Director
Olde Towne Medical and Dental Center
Clinical Professor, ObGyn
Virginia Commonwealth School of Medicine
Richmond, Virginia
What about using sterile milk?
Dr. Barbieri, what is your opinion and do you have any ideas on sourcing sterile milk for use in diagnostic cystoscopy and tubal patency in gynecology?
Donna G. Ivery, MD
Titusville, Florida
Is there a methylene blue shortage too?
I commonly perform chromotubation for my infertility patients and for tubal reversals. I have been substituting methylene blue for indigo carmine. Recently, I was told by my surgical center that methylene blue is on back order. Have you noticed the methylene blue shortage? Do you have suggestions for a replacement for my indications of chromotubation and tubal reversal surgeries?
Online I have seen mention of isosulfan blue being injected into lymphatic tissue to identify sentinel nodes—although it is more expensive. I will be searching now for a supplier of isosulfan blue. Sterile milk has been used to identify bladder fistulas. Can it be used for chromotubation?
Peter G. Van Deerlin, MD
South Jersey Fertility Center
Marlton, New Jersey
Can we brainstorm a solution to the shortage?
Dr. Barbieri, once again you have demonstrated your clear thinking and reasoned approach to what is a clinical problem.
I would add the following thought: Perhaps a group of physicians from major specialty/subspecialty organizations could meet with the present manufacturers and brainstorm for a solution. Self-interest is clearly the practical path and patient safety/customer satisfaction can come into play also.
Stephen S. Schuster, MD
Queens, New York
Another way to diagnose PROM
I read with interest the editorial covering the shortage of indigo carmine. In the section “Options to diagnose PROM … ”, you stated NONE as the option for diagnosing premature rupture of membranes (PROM) when standard clinical testing is equivocal.
A recent article in Journal of Perinatal Medicine suggests that placental alpha microglobulin-1 (PAMG-1) testing is as reliable as dye studies.1 This was a 140-patient prospective study and is certainly encouraging.
I don’t use PAMG-1 as a first-line agent for diagnosing rupture of membranes (ROM). Speculum examination with pooling of amniotic fluid, nitrozine testing, and microscopic examination for ferning confirm or rule out ROM in most cases. This article points toward avoiding the more invasive dye study. The data are timely in light of the indigo carmine shortage.
John R. Hannig, MD
Salem, Oregon
Reference
- Sosa CG, Herrera E, Restrepo JC, Strauss A, Alonso J. Comparison of placental alpha macroglobulin-1 in vaginal fluid with intra-amniotic injection of indigo carmine for the diagnosis of rupture of membranes. J Perinat Med. 2014;42(5):611–616.
Dr. Barbieri responds
I appreciate the great suggestion by Drs. Kanoff, Mann, and Ivery to use sterile baby formula to test bladder integrity. Sterile baby formula is usually available on an obstetric unit, and less available in a main operating room environment. One small caveat about the use of the word “sterile.” Baby formula is “sterile” using criteria for a commercial food product. Injectable agents typically need to be both sterile, using criteria for a pharmaceutical agent, and pyrogen free. These criteria are more stringent than for a food product. Some surgical nursing and pharmacy administrators may focus on this technical difference and resist the use of sterile baby formula to test bladder integrity.
First it was indigo carmine, now methylene blue is on back order. As Dr. Van Deerlin suspects, isosulfan blue is expensive. A 5-mL vial of isosulfan blue has a list price of $714. If no dye were available to test tubal patency, I would consider using saline or lactated Ringer’s solution. I would hesitate to use sterile baby formula because I would be concerned about peritoneal and tubal epithelial inflammation.
Dr. Schuster has a great suggestion to better coordinate the capabilities of manufacturers with the needs of clinicians and patients. We will forward your suggestion to the ACOG leadership.
I agree with Dr. Hannig’s suggestion that measurement of placental alpha macroglobulin-1 in vaginal fluid is an excellent option for replacing intra-amniotic injection of indigo carmine. Some obstetric units have not yet deployed this test because, in many centers, only a few cases per year needed this test. With the loss of access to indigo carmine, it is a good option to consider measurement of placental alpha macroglobulin-1 in vaginal fluid in cases where it is unclear if the membranes have ruptured.
“PREVENTING POSTOPERATIVE NEUROPATHIES: PATIENT POSITIONING FOR MINIMALLY INVASIVE PROCEDURES”
TIFFANY JACKSON, MD; BICH-VAN TRAN, MD; ARNOLD ADVINCULA, MD; KAREN WIERCINSKI, RN, BSN; JULIO LOPEZ (VIDEO; SEPTEMBER 2014)
May I share the video?
The video on patient positioning to prevent postoperative neuropathies is a great resource for physicians and nurses! May I share this video with our gynecologic operative room staff as a teaching tool?
Christinne D. Canela, MD
Roanoke, Virginia
The Editors respond
This, and all of the videos at obgmanagement.com are meant to be shared with your colleagues.
“TISSUE EXTRACTION DURING MINIMALLY INVASIVE GYN SURGERY. SECOND OF 2 PARTS: COUNSELING THE PATIENT”
(ROUNDTABLE; OCTOBER 2014)
May I morcellate your uterus please?
The laparoscopic approach to the fibroid uterus is currently a puzzle. After the FDA released a statement in April postulating that the use of power morcellation to remove uterine fibroids should be “discouraged,” a great controversy developed in the minimally invasive surgical community.
Subsequently in July, the Obstetrics and Gynecology Devices Advisory Panel of the FDA held a 2-day meeting to analyze risks, benefits, and the overall clinical role of laparoscopic power morcellation in gynecology. One recommendation was to include in the informed consent a disclosure of the risks of disseminating an occult uterine malignancy. I salute the efforts of the panel and agree on the necessity for a comprehensive consent process that discloses risks that could worsen the patient’s prognosis.
Soon after that FDA panel met in July, Ethicon, a division of Johnson and Johnson, made a business decision to initiate a worldwide withdrawal of the company’s morcellation devices.
Now, on November 24, the FDA issued an updated Safety Communication recommending that the use of power morcellators is contraindicated for removal of uterine tissue containing suspected fibroids in patients who are peri- or post-menopausal, or are candidates for en bloc tissue removal. They also said that laparoscopic power morcellators are contraindicated in gynecologic surgery in which the tissue to be morcellated is known or suspected to contain malignancy. The FDA is issuing a boxed warning, and recommends that surgeons thoroughly discuss the benefits and risks of all treatment to patients, including younger women who want to maintain their fertility or women not yet perimenopausal who wish to keep their uterus.
How will having a patient sign a consent form change the risk of unfortunate dispersion? How will it protect the surgeon from the subsequent liability? Who will be responsible for worsening the patient’s survival?
Month after month in the Medical Verdicts column, we see cases of unfortunate patients who suffer well-known surgical complications that are litigated, with different outcomes and compensations. I am certain that in most of these cases, the patients had signed at least a standard consent form that lists the most commonly known complications. Having a patient sign a consent form does not reduce the incidence of complications nor protect the physician from liability.
In my opinion, effort should be concentrated on finding a way to better preoperatively identify the patient at risk of occult uterine malignancy so that the surgical approach can be modified accordingly.
The controversy regarding morcellation is far from over. Perhaps the last tissue extractor remaining in the market should be used to morcellate the tort system and finally build a system that will protect patients and physicians.
Jose Carugno, MD
Miami, Florida
Dr. Iglesia responds
Dr. Carugno is correct. A “consent form” does not protect the surgeon from potential liability nor the patient from potential harm. Informed decision-making is a process wherein providers and patients discuss the diagnoses and conditions; the treatment options and alternatives ranging from expectant management, medical management or surgical intervention; and the potential risks and benefits of each of those options. Physicians should perform an adequate preoperative evaluation, and patients should be given the opportunity to ask questions with the understanding that no treatment is without risks (including the option for watchful waiting). Physicians should describe the steps that will be taken during the preoperative, intraoperative, and postoperative periods to mitigate those risks.
“TOTAL ABDOMINAL HYSTERECTOMY THE MAYO CLINIC WAY” JOHN B. GEBHART, MD, MS (SURGICAL TECHNIQUE; OCTOBER 2014)
We need to focus on improving vaginal hysterectomy
I found Dr. Gebhart’s article on abdominal hysterectomy technically very accurate and well written. It is with the greatest respect that I write to express my concern with the author’s response that because of the restriction of power morcellation devices, the rate of abdominal hysterectomy will increase.
Rather than focus on the improvement of the most common gynecologic surgical procedure, we should be focusing on improving techniques of vaginal hysterectomy, a route that unfortunately is under-taught in the United States.
I have been a practicing ObGyn for more than 20 years, and exclusively as a gynecologist for the last 4 years. I perform vaginal hysterectomies more than 90% of the time. My total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy rates remain less than 5%; laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy rates: 0%; and power morcellation rate: 0%.
In conclusion, why abdominal hysterectomy?
Robert C. Raymond, MD, MBA
Fort Payne, Alabama
Dr. Gebhart responds
Dr. Raymond, I thank you for your comments and question. I applaud your surgical skill set and approach to hysterectomy. My preferred route of hysterectomy for benign disease is the vaginal route. A few years ago we published an article in OBG Management on keys to success in vaginal hysterectomy.1 Indeed, the vaginal approach remains the least expensive and least morbid approach to hysterectomy, yet the least common. I continue to publish and lecture on the benefits of a vaginal approach and societies, such as the Society of Gynecologic Surgeons (SGS), remain committed to teaching and advocating this well-established, evidence-based yet underutilized approach.
Given the interest and controversy in the use of power morcellation after the FDA’s Safety Communication last April,2 it was felt that a good technical review of abdominal hysterectomy was cogent. If surgeons have a concern about using power morcellation or their institution has banned use of a power morcellator, then the abdominal route is the most likely alternative for removing the enlarged uterus intact. As you state, the abdominal approach remains the most common route of hysterectomy. My sense is that most providers faced with an enlarged uterus that cannot be removed via laparoscopic morcellation (for reasons stated previously) are likely to turn to abdominal hysterectomy. Hopefully, the article gives readers a chance to assess and develop their technical approach to abdominal hysterectomy.
References
- Occhino JA, Gebhart JB. The difficult vaginal hysterectomy: 5 keys to success. OBG Manag. 2010;22(11):32–47.
- US Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm. Published April 17, 2014. Accessed December 8, 2014.
Share your thoughts on these letters or on another article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Featured letters:
– Use baby formula to check for bladder integrity
– What about using sterile milk?
– Is there a methylene blue shortage too?
– Can we brainstorm a solution to the shortage?
– Another way to diagnose PROM
– May I share the video?
– May I morcellate your uterus please?
– We need to focus on improving vaginal hysterectomy
Protecting adolescents from radicalization, recruitment
Why do young people go to war zones – especially if their parents brought them to the United States for a new start? To stop adolescents from being lured to places such as Syria, Iraq, or Somalia, we need answers to that question.
One answer we hear from Somali Americans is, “We are the generation that was supposed to fix Somalia.” They were not presented with good options for doing so in a peaceful way, however, and this has made it relatively easy for terrorist organizations to exploit their passion. In 2007 and 2008, at least 17 Somali American adolescent boys and young men living in Minneapolis–St. Paul secretly left their homes and flew to Somalia to join militant extremist training camps run by Al Shabaab (Dynamics of Asymmetric Conflict 2009;2:181-200).
To better understand why this happened and how it can be prevented, we conducted a research study of Somali Americans funded by the U.S. Department of Homeland Security. We interviewed 57 people in Minneapolis–St. Paul who were either Somali American males aged 16-30 years, Somali American parents or adult family members, or service providers who worked within that community.
Multiple risks found
What we found is that no single risk factor explains violent radicalization. Instead, a combination of multiple risks at the individual, family, community, and societal levels are implicated.
To explain how to address these risks, we built a model called Diminishing Opportunities for Violent Extremism, or DOVE. This model shows that building community resilience to violent extremism depends on sustaining and strengthening (or in some cases initiating) protective resources through collaborations between family and youth, community, and government.
According to the DOVE model, these protective resources should focus on three risk levels:
• Diminishing youth’s unaccountable times and unobserved spaces (the times when adolescents and young adults are not answerable to parents or other adults and are in spaces where they are out of the sight of adults).
• Diminishing the perceived social legitimacy of violent extremism (perceptions of the appropriateness and necessity of violent extremist ideology and actions).
• Diminishing contact with recruiters or associates (adolescents and young adults interacting directly with either recruiters or companions who facilitate their increased involvement in violent extremism).
The U.S. government, state and local law enforcement, and local communities have been trying to organize prevention activities to address these and other risks. In Pres. Barack Obama’s Sept. 24, 2014, address to the United Nations, he stated: “There is no military solution to the problem of misguided individuals seeking to join terrorist organizations.” He supported a strategy called countering violent extremism, or CVE. This strategy is concerned with preventing violent ideologies from taking hold of people in the first place, and intervening and dissuading people from crossing the line toward actual violence.
The DOVE model supports the basic claim of CVE that government can’t do it alone, and it is going to require changes in communities. Meaningful preventive responses to radicalization must originate from within communities. One promising example is the Safe Spaces Initiative, a community-led preventive intervention developed by the Muslim Public Affairs Council. Safe Spaces leaves it up to communities to intervene with young people who might be getting involved with radicalization but have not yet entered into criminal space. It calls for communities to form Critical Inquiry Teams that include the participation of mental health professionals.
Role of mental health professionals
Incorporating mental health into CVE holds significant potential for enhancing both intervention and prevention capabilities with adolescents and young adults. In the United Kingdom, a national strategy called Prevent includes Channel, a multiagency program aimed at providing support to people at risk of being drawn into radicalization. One key component of Channel is for mental health professionals to be involved in assessment and support, but in order for mental health, law enforcement, and communities to be able to work together on radicalization and recruitment in the United States, we are going to have to invest in developing, implementing, and evaluating new collaborative models.
The threat of recruitment and radicalization has heightened significantly with the rise of ISIS (Islamic State of Iraq and Syria). ISIS uses propaganda videos and social media messages to appeal to a range of audiences, including would-be violent avengers, humanitarians, immigrants and refugees, and converts – males and females. Hundreds of U.S. foreign fighters reportedly have gone to ISIS. U.S. law enforcement agencies are concerned that more Americans will join ISIS, and that those foreign fighters who have joined and traveled abroad might pose security threats here at home.
To compete with ISIS to prevent more young people from going to Syria and Iraq, implementing CVE programs and policies is a national priority. This could be an opportunity for psychiatry and other mental health professionals to contribute to national and local response strategies.
One new initiative is a project recently begun by our team that is funded by the Science and Technology Directorate of the Homeland Security Dept. as part of a broader research portfolio on CVE conducted by the START Consortium, which aims to better understand how to integrate mental health professionals into countering violent extremism. This project presents an opportunity for psychiatrists and other mental health professionals to contribute to national and local response strategies to radicalization and recruitment.
Dr. Weine is professor of psychiatry at the University of Illinois at Chicago. He will address the issue of radicalization and recruitment to violence among Muslim-American teens at the upcoming joint meeting between the American Society for Adolescent Psychiatry (ASAP) and the Internal Society for Adolescent Psychiatry March 26-29 in New York. The meeting, which is themed “The Art and Science of Adolescent Psychiatry and Psychotherapy,” also will include resumption of ASAP’s Certification Examination in Adolescent Psychiatry.
Why do young people go to war zones – especially if their parents brought them to the United States for a new start? To stop adolescents from being lured to places such as Syria, Iraq, or Somalia, we need answers to that question.
One answer we hear from Somali Americans is, “We are the generation that was supposed to fix Somalia.” They were not presented with good options for doing so in a peaceful way, however, and this has made it relatively easy for terrorist organizations to exploit their passion. In 2007 and 2008, at least 17 Somali American adolescent boys and young men living in Minneapolis–St. Paul secretly left their homes and flew to Somalia to join militant extremist training camps run by Al Shabaab (Dynamics of Asymmetric Conflict 2009;2:181-200).
To better understand why this happened and how it can be prevented, we conducted a research study of Somali Americans funded by the U.S. Department of Homeland Security. We interviewed 57 people in Minneapolis–St. Paul who were either Somali American males aged 16-30 years, Somali American parents or adult family members, or service providers who worked within that community.
Multiple risks found
What we found is that no single risk factor explains violent radicalization. Instead, a combination of multiple risks at the individual, family, community, and societal levels are implicated.
To explain how to address these risks, we built a model called Diminishing Opportunities for Violent Extremism, or DOVE. This model shows that building community resilience to violent extremism depends on sustaining and strengthening (or in some cases initiating) protective resources through collaborations between family and youth, community, and government.
According to the DOVE model, these protective resources should focus on three risk levels:
• Diminishing youth’s unaccountable times and unobserved spaces (the times when adolescents and young adults are not answerable to parents or other adults and are in spaces where they are out of the sight of adults).
• Diminishing the perceived social legitimacy of violent extremism (perceptions of the appropriateness and necessity of violent extremist ideology and actions).
• Diminishing contact with recruiters or associates (adolescents and young adults interacting directly with either recruiters or companions who facilitate their increased involvement in violent extremism).
The U.S. government, state and local law enforcement, and local communities have been trying to organize prevention activities to address these and other risks. In Pres. Barack Obama’s Sept. 24, 2014, address to the United Nations, he stated: “There is no military solution to the problem of misguided individuals seeking to join terrorist organizations.” He supported a strategy called countering violent extremism, or CVE. This strategy is concerned with preventing violent ideologies from taking hold of people in the first place, and intervening and dissuading people from crossing the line toward actual violence.
The DOVE model supports the basic claim of CVE that government can’t do it alone, and it is going to require changes in communities. Meaningful preventive responses to radicalization must originate from within communities. One promising example is the Safe Spaces Initiative, a community-led preventive intervention developed by the Muslim Public Affairs Council. Safe Spaces leaves it up to communities to intervene with young people who might be getting involved with radicalization but have not yet entered into criminal space. It calls for communities to form Critical Inquiry Teams that include the participation of mental health professionals.
Role of mental health professionals
Incorporating mental health into CVE holds significant potential for enhancing both intervention and prevention capabilities with adolescents and young adults. In the United Kingdom, a national strategy called Prevent includes Channel, a multiagency program aimed at providing support to people at risk of being drawn into radicalization. One key component of Channel is for mental health professionals to be involved in assessment and support, but in order for mental health, law enforcement, and communities to be able to work together on radicalization and recruitment in the United States, we are going to have to invest in developing, implementing, and evaluating new collaborative models.
The threat of recruitment and radicalization has heightened significantly with the rise of ISIS (Islamic State of Iraq and Syria). ISIS uses propaganda videos and social media messages to appeal to a range of audiences, including would-be violent avengers, humanitarians, immigrants and refugees, and converts – males and females. Hundreds of U.S. foreign fighters reportedly have gone to ISIS. U.S. law enforcement agencies are concerned that more Americans will join ISIS, and that those foreign fighters who have joined and traveled abroad might pose security threats here at home.
To compete with ISIS to prevent more young people from going to Syria and Iraq, implementing CVE programs and policies is a national priority. This could be an opportunity for psychiatry and other mental health professionals to contribute to national and local response strategies.
One new initiative is a project recently begun by our team that is funded by the Science and Technology Directorate of the Homeland Security Dept. as part of a broader research portfolio on CVE conducted by the START Consortium, which aims to better understand how to integrate mental health professionals into countering violent extremism. This project presents an opportunity for psychiatrists and other mental health professionals to contribute to national and local response strategies to radicalization and recruitment.
Dr. Weine is professor of psychiatry at the University of Illinois at Chicago. He will address the issue of radicalization and recruitment to violence among Muslim-American teens at the upcoming joint meeting between the American Society for Adolescent Psychiatry (ASAP) and the Internal Society for Adolescent Psychiatry March 26-29 in New York. The meeting, which is themed “The Art and Science of Adolescent Psychiatry and Psychotherapy,” also will include resumption of ASAP’s Certification Examination in Adolescent Psychiatry.
Why do young people go to war zones – especially if their parents brought them to the United States for a new start? To stop adolescents from being lured to places such as Syria, Iraq, or Somalia, we need answers to that question.
One answer we hear from Somali Americans is, “We are the generation that was supposed to fix Somalia.” They were not presented with good options for doing so in a peaceful way, however, and this has made it relatively easy for terrorist organizations to exploit their passion. In 2007 and 2008, at least 17 Somali American adolescent boys and young men living in Minneapolis–St. Paul secretly left their homes and flew to Somalia to join militant extremist training camps run by Al Shabaab (Dynamics of Asymmetric Conflict 2009;2:181-200).
To better understand why this happened and how it can be prevented, we conducted a research study of Somali Americans funded by the U.S. Department of Homeland Security. We interviewed 57 people in Minneapolis–St. Paul who were either Somali American males aged 16-30 years, Somali American parents or adult family members, or service providers who worked within that community.
Multiple risks found
What we found is that no single risk factor explains violent radicalization. Instead, a combination of multiple risks at the individual, family, community, and societal levels are implicated.
To explain how to address these risks, we built a model called Diminishing Opportunities for Violent Extremism, or DOVE. This model shows that building community resilience to violent extremism depends on sustaining and strengthening (or in some cases initiating) protective resources through collaborations between family and youth, community, and government.
According to the DOVE model, these protective resources should focus on three risk levels:
• Diminishing youth’s unaccountable times and unobserved spaces (the times when adolescents and young adults are not answerable to parents or other adults and are in spaces where they are out of the sight of adults).
• Diminishing the perceived social legitimacy of violent extremism (perceptions of the appropriateness and necessity of violent extremist ideology and actions).
• Diminishing contact with recruiters or associates (adolescents and young adults interacting directly with either recruiters or companions who facilitate their increased involvement in violent extremism).
The U.S. government, state and local law enforcement, and local communities have been trying to organize prevention activities to address these and other risks. In Pres. Barack Obama’s Sept. 24, 2014, address to the United Nations, he stated: “There is no military solution to the problem of misguided individuals seeking to join terrorist organizations.” He supported a strategy called countering violent extremism, or CVE. This strategy is concerned with preventing violent ideologies from taking hold of people in the first place, and intervening and dissuading people from crossing the line toward actual violence.
The DOVE model supports the basic claim of CVE that government can’t do it alone, and it is going to require changes in communities. Meaningful preventive responses to radicalization must originate from within communities. One promising example is the Safe Spaces Initiative, a community-led preventive intervention developed by the Muslim Public Affairs Council. Safe Spaces leaves it up to communities to intervene with young people who might be getting involved with radicalization but have not yet entered into criminal space. It calls for communities to form Critical Inquiry Teams that include the participation of mental health professionals.
Role of mental health professionals
Incorporating mental health into CVE holds significant potential for enhancing both intervention and prevention capabilities with adolescents and young adults. In the United Kingdom, a national strategy called Prevent includes Channel, a multiagency program aimed at providing support to people at risk of being drawn into radicalization. One key component of Channel is for mental health professionals to be involved in assessment and support, but in order for mental health, law enforcement, and communities to be able to work together on radicalization and recruitment in the United States, we are going to have to invest in developing, implementing, and evaluating new collaborative models.
The threat of recruitment and radicalization has heightened significantly with the rise of ISIS (Islamic State of Iraq and Syria). ISIS uses propaganda videos and social media messages to appeal to a range of audiences, including would-be violent avengers, humanitarians, immigrants and refugees, and converts – males and females. Hundreds of U.S. foreign fighters reportedly have gone to ISIS. U.S. law enforcement agencies are concerned that more Americans will join ISIS, and that those foreign fighters who have joined and traveled abroad might pose security threats here at home.
To compete with ISIS to prevent more young people from going to Syria and Iraq, implementing CVE programs and policies is a national priority. This could be an opportunity for psychiatry and other mental health professionals to contribute to national and local response strategies.
One new initiative is a project recently begun by our team that is funded by the Science and Technology Directorate of the Homeland Security Dept. as part of a broader research portfolio on CVE conducted by the START Consortium, which aims to better understand how to integrate mental health professionals into countering violent extremism. This project presents an opportunity for psychiatrists and other mental health professionals to contribute to national and local response strategies to radicalization and recruitment.
Dr. Weine is professor of psychiatry at the University of Illinois at Chicago. He will address the issue of radicalization and recruitment to violence among Muslim-American teens at the upcoming joint meeting between the American Society for Adolescent Psychiatry (ASAP) and the Internal Society for Adolescent Psychiatry March 26-29 in New York. The meeting, which is themed “The Art and Science of Adolescent Psychiatry and Psychotherapy,” also will include resumption of ASAP’s Certification Examination in Adolescent Psychiatry.
When cardiologists attend meetings, do patients benefit?
Can the high-intensity care given acutely ill, high-risk U.S. patients with cardiac disease actually harm them?
Results from an unusual analysis of cardiology-meeting times seem to suggest that sobering possibility. Patient outcomes improved when thousands of high-level, American cardiologists left their practices for a few days each year to attend either of the two major U.S. heart disease meetings.
Researchers led by Dr. Anupam B. Jena of Harvard University, Boston, used Medicare data to examine mortality rates among patients hospitalized for cardiac arrest, heart failure, or acute myocardial infarction during 2002-2011. They focused on patients admitted during the annual meetings of the American College of Cardiology (usually in March) or the American Heart Association (during November).
As controls in their case-control analyses, they used data from patients admitted on similar days of the week during the 3 weeks immediately before or after these two meetings. This gave them roughly 11,000 total patients with cardiac arrest, nearly 134,000 with heart failure, and about 60,000 with acute MI – about 14% of patients in each disease category admitted during a meeting and the other 86% (controls) admitted when there was no meeting.
The results showed some statistically significant differences indicating that patients did better during the meetings, presumably when many cardiologists were away from their hospitals. These associations only occurred at teaching hospitals and among patients at high risk for inpatient mortality. The investigators saw no statistically significant differences, after adjustment, in mortality during meetings among patients treated at nonteaching hospitals or among patients with a low risk for inpatient mortality.
In analyses that adjusted for baseline differences in risk factors, the 30-day mortality rate for patients admitted to teaching hospitals with cardiac arrest was 69% during control dates and 59% during the meetings. Thirty-day mortality for patients admitted with heart failure was 25% during control dates and 18% during the meetings, researchers reported in an article published online on Dec. 22 (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2014.6781]).
Although 30-day mortality among patients admitted with an acute MI did not differ significantly at teaching hospitals between patients who presented during a major meeting and those who did not, the results showed that these similar mortality rates were achieved despite a statistically significant difference in the rate of percutaneous coronary interventions (PCI) that patients received: During the major meetings, 21% of the acute MI patients underwent PCI, but when a meeting was not in progress, the PCI rate jumped to 28% of all acute MI patients.
“One explanation for these findings is that the intensity of care provided during meeting dates is lower, and that for high-risk patients with cardiovascular disease, the harms of this care may unexpectedly outweigh the benefits,” Dr. Jena concluded.
It’s a remarkable and surprising finding, but can it be taken seriously? At least one expert said yes, at least seriously enough to warrant further study and consideration.
An editor’s note published with the new report suggested a plausible explanation for the findings is that “more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” In her note, Dr. Rita F. Redberg, a cardiologist at the University of California, San Francisco, and editor of JAMA Internal Medicine, concluded, “It is reassuring that patient outcomes do not suffer while many cardiologists are away. More important, this analysis may help us to understand how we could lower mortality throughout the year.”
It will be interesting to see if anyone takes up the challenge to further explore this relationship and tries to find ways to apply throughout the year the protective effect of having fewer teaching-hospital cardiologists around. If a drug had this beneficial effect on mortality, the pharmaceutical industry would be all over it.
On Twitter @mitchelzoler
Can the high-intensity care given acutely ill, high-risk U.S. patients with cardiac disease actually harm them?
Results from an unusual analysis of cardiology-meeting times seem to suggest that sobering possibility. Patient outcomes improved when thousands of high-level, American cardiologists left their practices for a few days each year to attend either of the two major U.S. heart disease meetings.
Researchers led by Dr. Anupam B. Jena of Harvard University, Boston, used Medicare data to examine mortality rates among patients hospitalized for cardiac arrest, heart failure, or acute myocardial infarction during 2002-2011. They focused on patients admitted during the annual meetings of the American College of Cardiology (usually in March) or the American Heart Association (during November).
As controls in their case-control analyses, they used data from patients admitted on similar days of the week during the 3 weeks immediately before or after these two meetings. This gave them roughly 11,000 total patients with cardiac arrest, nearly 134,000 with heart failure, and about 60,000 with acute MI – about 14% of patients in each disease category admitted during a meeting and the other 86% (controls) admitted when there was no meeting.
The results showed some statistically significant differences indicating that patients did better during the meetings, presumably when many cardiologists were away from their hospitals. These associations only occurred at teaching hospitals and among patients at high risk for inpatient mortality. The investigators saw no statistically significant differences, after adjustment, in mortality during meetings among patients treated at nonteaching hospitals or among patients with a low risk for inpatient mortality.
In analyses that adjusted for baseline differences in risk factors, the 30-day mortality rate for patients admitted to teaching hospitals with cardiac arrest was 69% during control dates and 59% during the meetings. Thirty-day mortality for patients admitted with heart failure was 25% during control dates and 18% during the meetings, researchers reported in an article published online on Dec. 22 (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2014.6781]).
Although 30-day mortality among patients admitted with an acute MI did not differ significantly at teaching hospitals between patients who presented during a major meeting and those who did not, the results showed that these similar mortality rates were achieved despite a statistically significant difference in the rate of percutaneous coronary interventions (PCI) that patients received: During the major meetings, 21% of the acute MI patients underwent PCI, but when a meeting was not in progress, the PCI rate jumped to 28% of all acute MI patients.
“One explanation for these findings is that the intensity of care provided during meeting dates is lower, and that for high-risk patients with cardiovascular disease, the harms of this care may unexpectedly outweigh the benefits,” Dr. Jena concluded.
It’s a remarkable and surprising finding, but can it be taken seriously? At least one expert said yes, at least seriously enough to warrant further study and consideration.
An editor’s note published with the new report suggested a plausible explanation for the findings is that “more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” In her note, Dr. Rita F. Redberg, a cardiologist at the University of California, San Francisco, and editor of JAMA Internal Medicine, concluded, “It is reassuring that patient outcomes do not suffer while many cardiologists are away. More important, this analysis may help us to understand how we could lower mortality throughout the year.”
It will be interesting to see if anyone takes up the challenge to further explore this relationship and tries to find ways to apply throughout the year the protective effect of having fewer teaching-hospital cardiologists around. If a drug had this beneficial effect on mortality, the pharmaceutical industry would be all over it.
On Twitter @mitchelzoler
Can the high-intensity care given acutely ill, high-risk U.S. patients with cardiac disease actually harm them?
Results from an unusual analysis of cardiology-meeting times seem to suggest that sobering possibility. Patient outcomes improved when thousands of high-level, American cardiologists left their practices for a few days each year to attend either of the two major U.S. heart disease meetings.
Researchers led by Dr. Anupam B. Jena of Harvard University, Boston, used Medicare data to examine mortality rates among patients hospitalized for cardiac arrest, heart failure, or acute myocardial infarction during 2002-2011. They focused on patients admitted during the annual meetings of the American College of Cardiology (usually in March) or the American Heart Association (during November).
As controls in their case-control analyses, they used data from patients admitted on similar days of the week during the 3 weeks immediately before or after these two meetings. This gave them roughly 11,000 total patients with cardiac arrest, nearly 134,000 with heart failure, and about 60,000 with acute MI – about 14% of patients in each disease category admitted during a meeting and the other 86% (controls) admitted when there was no meeting.
The results showed some statistically significant differences indicating that patients did better during the meetings, presumably when many cardiologists were away from their hospitals. These associations only occurred at teaching hospitals and among patients at high risk for inpatient mortality. The investigators saw no statistically significant differences, after adjustment, in mortality during meetings among patients treated at nonteaching hospitals or among patients with a low risk for inpatient mortality.
In analyses that adjusted for baseline differences in risk factors, the 30-day mortality rate for patients admitted to teaching hospitals with cardiac arrest was 69% during control dates and 59% during the meetings. Thirty-day mortality for patients admitted with heart failure was 25% during control dates and 18% during the meetings, researchers reported in an article published online on Dec. 22 (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2014.6781]).
Although 30-day mortality among patients admitted with an acute MI did not differ significantly at teaching hospitals between patients who presented during a major meeting and those who did not, the results showed that these similar mortality rates were achieved despite a statistically significant difference in the rate of percutaneous coronary interventions (PCI) that patients received: During the major meetings, 21% of the acute MI patients underwent PCI, but when a meeting was not in progress, the PCI rate jumped to 28% of all acute MI patients.
“One explanation for these findings is that the intensity of care provided during meeting dates is lower, and that for high-risk patients with cardiovascular disease, the harms of this care may unexpectedly outweigh the benefits,” Dr. Jena concluded.
It’s a remarkable and surprising finding, but can it be taken seriously? At least one expert said yes, at least seriously enough to warrant further study and consideration.
An editor’s note published with the new report suggested a plausible explanation for the findings is that “more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” In her note, Dr. Rita F. Redberg, a cardiologist at the University of California, San Francisco, and editor of JAMA Internal Medicine, concluded, “It is reassuring that patient outcomes do not suffer while many cardiologists are away. More important, this analysis may help us to understand how we could lower mortality throughout the year.”
It will be interesting to see if anyone takes up the challenge to further explore this relationship and tries to find ways to apply throughout the year the protective effect of having fewer teaching-hospital cardiologists around. If a drug had this beneficial effect on mortality, the pharmaceutical industry would be all over it.
On Twitter @mitchelzoler
Why Travel Health Belongs in Primary Care
Chelsea had been stationed with the Peace Corps in Ghana and decided to take her 7-year-old daughter, Amber, with her on a return trip to visit friends she had made there. They planned to spend three weeks in the African nation.
Since Amber was home-schooled, Chelsea had not felt it necessary to follow the CDC guidelines for routine childhood immunizations. Once they planned to travel abroad, however, she made appointments with their primary care provider (PCP) to update Amber’s immunizations and with the travel clinic—where I practice—for yellow fever vaccines (required for entry to Ghana) for both of them.
Chelsea explained their travel plans to the PCP, adding that she intended to get the yellow fever vaccine at another clinic. The PCP administered Amber’s varicella and MMR vaccines.
Aware that it takes 10 days for yellow fever vaccine to be effective, Chelsea scheduled their appointments with me at the travel clinic for two weeks prior to their departure—which was also one week after their visit to the PCP. Did I mention they had nonrefundable tickets?
Chelsea became very upset when I told her I could not give Amber her yellow fever vaccine. I explained the live virus vaccine rule, which states that live virus vaccines must be given either on the same day or 28 days apart.1 If they are not given 28 days apart, the second vaccine—in this case, Amber’s yellow fever immunization—is not considered effective.
Chelsea and Amber were not able to travel to Ghana as planned, because her PCP did not know enough about the administration of yellow fever vaccine. As a result, Chelsea lost $5,000 in airline tickets and cancellation fees. She insisted that her PCP pay her expenses, and her PCP did. But how easily could this have happened in your practice?
Continue for pretravel immunizations >>
It’s been only 100 years since the first commercial airline service began. Today, the travel industry is the largest service industry in the world; 1 billion people traveled internationally in 2013.2 We travel for pleasure, business, education, adventure, adoption, and humanitarian reasons (not to mention visiting friends and family). It is now possible to travel around the world in less than 36 hours.2
Study results vary, but many report that 50% or more of all international travelers will become sick or injured because of their travel.3 Travel health now plays a larger role in public health as travelers bring home more than just souvenirs. Measles outbreaks are at a 30-year high, with many cases attributed to importation by international travelers.4 Many microbes—including SARS, novel influenza strains, and Ebola—are able to spread more easily because of advances in international travel.
The field of travel health grew from the recognition that many of the conditions being treated in infectious disease clinics could have been prevented by pretravel interventions. To address these issues, travel health—a new multidisciplinary specialty—was created, and in 1985 the International Society for Travel Medicine was formed. As a result, the practice of travel health has been concentrated in specialist-led clinics, often in the infectious disease departments of hospitals.
Research indicates that most international travelers do not seek any pretravel health advice.5 When they do, they consult their PCP more often than a travel clinic. Yet most PCPs are woefully undereducated in travel health. Patients such as Chelsea think it is less expensive to consult a PCP first to catch up on routine immunizations before going to a travel clinic for required vaccines. But it makes more sense to consult a travel clinic expert first.
The travel health specialist, who could be an NP, PA, registered pharmacist, RN, or MD, can devise a travel immunization plan that can be coordinated with a PCP to save costs. Many travel clinics don’t accept insurance because most payers do not cover travel health services or immunizations. This includes most private third-party insurers, Medicaid, and Medicare.
But what if Chelsea’s PCP could have provided her travel health needs? It is possible for PCPs to gain knowledge and expertise about travel health, even if they don’t choose to provide every travel immunization.
For example, yellow fever vaccine can only be provided at a certified yellow fever center. Certification requirements are determined at the state level and therefore vary by state. It is possible for PCPs to become certified to administer yellow fever vaccine, if they so choose.
But since not all international travelers require yellow fever vaccine, a PCP could still meet the needs of the majority of patients traveling internationally without taking that step. PCPs can provide vaccination against hepatitis A, typhoid, adult polio, meningococcal disease, Japanese encephalitis, and rabies (preexposure)—not to mention what I consider the most important travel vaccine, influenza. PCPs can counsel patients about food and water safety and insect precautions and provide strategies for self-treatment of traveler’s diarrhea and malaria chemoprophylaxis.
Patients go to a travel clinic because they recognize that they are exposing themselves to risk and want to mitigate that risk. In a primary care office, the PCP has an opportunity to identify patients who don’t know they are at risk and intervene.
Since I also work in a primary care setting, I look for opportunities to identify patients who may be traveling and evaluate their immunization status in that broader context. When I see patients who were born in other countries, I ask if they plan to travel back home. When patients ask for extra prescription refills because they are traveling, I ask where they are going. As part of wellness visits, I ask if my patient has any plans to travel outside the United States in the next year as I assess their vaccine needs. None of these interventions takes much time.
The foundations of travel health include immunization, patient education on food- and waterborne diseases, insect-borne diseases, and safety. PCPs are experts at patient education, risk identification and management, and immunizations.
So ask your patients if they are planning to travel. Make sure everyone’s routine immunizations are current at every visit. Provide every patient with a personal immunization record to take with them when they visit any other provider and when they travel.
More information on travel health is available from the CDC (www.cdc.gov/travel), the International Society of Travel Medicine (www.istm.org), and the American Travel Health Nurses Association (www.athna.org). By availing yourself of these resources, you will protect the health of your community and keep your traveling patients well, wherever they go.
REFERENCES
1. CDC. General recommendations on immunization. www.cdc.gov/vaccines/pubs/pink book/downloads/genrec.pdf. Accessed December 15, 2014.
2. World Tourism Organization. UNWTO Tourism Highlights: 2014 Edition. http://dtxtq4w60xqpw.cloudfront.net/sites/all/file/pdf/unwto_highlights14_en.pdf. Accessed December 15, 2014.
3. Freedman DO. Travel epidemiology. In: Brunette GW, ed. CDC Health Information for International Travel. Atlanta, GA: CDC; 2014:8-11. wwwnc.cdc.gov/travel/yellowbook/2014/chapter-1-introduction/travel-epidemiology. Accessed December 15, 2014.
4. Measles—United States, January 1–August 24, 2013. MMWR Morbid Mortal Wkly Rep. 2013;62(36):741-743.
5. LaRoque RC, Rao SR, Tribris A, et al. Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport. J Travel Med. 2010;17(6):387-391.
Chelsea had been stationed with the Peace Corps in Ghana and decided to take her 7-year-old daughter, Amber, with her on a return trip to visit friends she had made there. They planned to spend three weeks in the African nation.
Since Amber was home-schooled, Chelsea had not felt it necessary to follow the CDC guidelines for routine childhood immunizations. Once they planned to travel abroad, however, she made appointments with their primary care provider (PCP) to update Amber’s immunizations and with the travel clinic—where I practice—for yellow fever vaccines (required for entry to Ghana) for both of them.
Chelsea explained their travel plans to the PCP, adding that she intended to get the yellow fever vaccine at another clinic. The PCP administered Amber’s varicella and MMR vaccines.
Aware that it takes 10 days for yellow fever vaccine to be effective, Chelsea scheduled their appointments with me at the travel clinic for two weeks prior to their departure—which was also one week after their visit to the PCP. Did I mention they had nonrefundable tickets?
Chelsea became very upset when I told her I could not give Amber her yellow fever vaccine. I explained the live virus vaccine rule, which states that live virus vaccines must be given either on the same day or 28 days apart.1 If they are not given 28 days apart, the second vaccine—in this case, Amber’s yellow fever immunization—is not considered effective.
Chelsea and Amber were not able to travel to Ghana as planned, because her PCP did not know enough about the administration of yellow fever vaccine. As a result, Chelsea lost $5,000 in airline tickets and cancellation fees. She insisted that her PCP pay her expenses, and her PCP did. But how easily could this have happened in your practice?
Continue for pretravel immunizations >>
It’s been only 100 years since the first commercial airline service began. Today, the travel industry is the largest service industry in the world; 1 billion people traveled internationally in 2013.2 We travel for pleasure, business, education, adventure, adoption, and humanitarian reasons (not to mention visiting friends and family). It is now possible to travel around the world in less than 36 hours.2
Study results vary, but many report that 50% or more of all international travelers will become sick or injured because of their travel.3 Travel health now plays a larger role in public health as travelers bring home more than just souvenirs. Measles outbreaks are at a 30-year high, with many cases attributed to importation by international travelers.4 Many microbes—including SARS, novel influenza strains, and Ebola—are able to spread more easily because of advances in international travel.
The field of travel health grew from the recognition that many of the conditions being treated in infectious disease clinics could have been prevented by pretravel interventions. To address these issues, travel health—a new multidisciplinary specialty—was created, and in 1985 the International Society for Travel Medicine was formed. As a result, the practice of travel health has been concentrated in specialist-led clinics, often in the infectious disease departments of hospitals.
Research indicates that most international travelers do not seek any pretravel health advice.5 When they do, they consult their PCP more often than a travel clinic. Yet most PCPs are woefully undereducated in travel health. Patients such as Chelsea think it is less expensive to consult a PCP first to catch up on routine immunizations before going to a travel clinic for required vaccines. But it makes more sense to consult a travel clinic expert first.
The travel health specialist, who could be an NP, PA, registered pharmacist, RN, or MD, can devise a travel immunization plan that can be coordinated with a PCP to save costs. Many travel clinics don’t accept insurance because most payers do not cover travel health services or immunizations. This includes most private third-party insurers, Medicaid, and Medicare.
But what if Chelsea’s PCP could have provided her travel health needs? It is possible for PCPs to gain knowledge and expertise about travel health, even if they don’t choose to provide every travel immunization.
For example, yellow fever vaccine can only be provided at a certified yellow fever center. Certification requirements are determined at the state level and therefore vary by state. It is possible for PCPs to become certified to administer yellow fever vaccine, if they so choose.
But since not all international travelers require yellow fever vaccine, a PCP could still meet the needs of the majority of patients traveling internationally without taking that step. PCPs can provide vaccination against hepatitis A, typhoid, adult polio, meningococcal disease, Japanese encephalitis, and rabies (preexposure)—not to mention what I consider the most important travel vaccine, influenza. PCPs can counsel patients about food and water safety and insect precautions and provide strategies for self-treatment of traveler’s diarrhea and malaria chemoprophylaxis.
Patients go to a travel clinic because they recognize that they are exposing themselves to risk and want to mitigate that risk. In a primary care office, the PCP has an opportunity to identify patients who don’t know they are at risk and intervene.
Since I also work in a primary care setting, I look for opportunities to identify patients who may be traveling and evaluate their immunization status in that broader context. When I see patients who were born in other countries, I ask if they plan to travel back home. When patients ask for extra prescription refills because they are traveling, I ask where they are going. As part of wellness visits, I ask if my patient has any plans to travel outside the United States in the next year as I assess their vaccine needs. None of these interventions takes much time.
The foundations of travel health include immunization, patient education on food- and waterborne diseases, insect-borne diseases, and safety. PCPs are experts at patient education, risk identification and management, and immunizations.
So ask your patients if they are planning to travel. Make sure everyone’s routine immunizations are current at every visit. Provide every patient with a personal immunization record to take with them when they visit any other provider and when they travel.
More information on travel health is available from the CDC (www.cdc.gov/travel), the International Society of Travel Medicine (www.istm.org), and the American Travel Health Nurses Association (www.athna.org). By availing yourself of these resources, you will protect the health of your community and keep your traveling patients well, wherever they go.
REFERENCES
1. CDC. General recommendations on immunization. www.cdc.gov/vaccines/pubs/pink book/downloads/genrec.pdf. Accessed December 15, 2014.
2. World Tourism Organization. UNWTO Tourism Highlights: 2014 Edition. http://dtxtq4w60xqpw.cloudfront.net/sites/all/file/pdf/unwto_highlights14_en.pdf. Accessed December 15, 2014.
3. Freedman DO. Travel epidemiology. In: Brunette GW, ed. CDC Health Information for International Travel. Atlanta, GA: CDC; 2014:8-11. wwwnc.cdc.gov/travel/yellowbook/2014/chapter-1-introduction/travel-epidemiology. Accessed December 15, 2014.
4. Measles—United States, January 1–August 24, 2013. MMWR Morbid Mortal Wkly Rep. 2013;62(36):741-743.
5. LaRoque RC, Rao SR, Tribris A, et al. Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport. J Travel Med. 2010;17(6):387-391.
Chelsea had been stationed with the Peace Corps in Ghana and decided to take her 7-year-old daughter, Amber, with her on a return trip to visit friends she had made there. They planned to spend three weeks in the African nation.
Since Amber was home-schooled, Chelsea had not felt it necessary to follow the CDC guidelines for routine childhood immunizations. Once they planned to travel abroad, however, she made appointments with their primary care provider (PCP) to update Amber’s immunizations and with the travel clinic—where I practice—for yellow fever vaccines (required for entry to Ghana) for both of them.
Chelsea explained their travel plans to the PCP, adding that she intended to get the yellow fever vaccine at another clinic. The PCP administered Amber’s varicella and MMR vaccines.
Aware that it takes 10 days for yellow fever vaccine to be effective, Chelsea scheduled their appointments with me at the travel clinic for two weeks prior to their departure—which was also one week after their visit to the PCP. Did I mention they had nonrefundable tickets?
Chelsea became very upset when I told her I could not give Amber her yellow fever vaccine. I explained the live virus vaccine rule, which states that live virus vaccines must be given either on the same day or 28 days apart.1 If they are not given 28 days apart, the second vaccine—in this case, Amber’s yellow fever immunization—is not considered effective.
Chelsea and Amber were not able to travel to Ghana as planned, because her PCP did not know enough about the administration of yellow fever vaccine. As a result, Chelsea lost $5,000 in airline tickets and cancellation fees. She insisted that her PCP pay her expenses, and her PCP did. But how easily could this have happened in your practice?
Continue for pretravel immunizations >>
It’s been only 100 years since the first commercial airline service began. Today, the travel industry is the largest service industry in the world; 1 billion people traveled internationally in 2013.2 We travel for pleasure, business, education, adventure, adoption, and humanitarian reasons (not to mention visiting friends and family). It is now possible to travel around the world in less than 36 hours.2
Study results vary, but many report that 50% or more of all international travelers will become sick or injured because of their travel.3 Travel health now plays a larger role in public health as travelers bring home more than just souvenirs. Measles outbreaks are at a 30-year high, with many cases attributed to importation by international travelers.4 Many microbes—including SARS, novel influenza strains, and Ebola—are able to spread more easily because of advances in international travel.
The field of travel health grew from the recognition that many of the conditions being treated in infectious disease clinics could have been prevented by pretravel interventions. To address these issues, travel health—a new multidisciplinary specialty—was created, and in 1985 the International Society for Travel Medicine was formed. As a result, the practice of travel health has been concentrated in specialist-led clinics, often in the infectious disease departments of hospitals.
Research indicates that most international travelers do not seek any pretravel health advice.5 When they do, they consult their PCP more often than a travel clinic. Yet most PCPs are woefully undereducated in travel health. Patients such as Chelsea think it is less expensive to consult a PCP first to catch up on routine immunizations before going to a travel clinic for required vaccines. But it makes more sense to consult a travel clinic expert first.
The travel health specialist, who could be an NP, PA, registered pharmacist, RN, or MD, can devise a travel immunization plan that can be coordinated with a PCP to save costs. Many travel clinics don’t accept insurance because most payers do not cover travel health services or immunizations. This includes most private third-party insurers, Medicaid, and Medicare.
But what if Chelsea’s PCP could have provided her travel health needs? It is possible for PCPs to gain knowledge and expertise about travel health, even if they don’t choose to provide every travel immunization.
For example, yellow fever vaccine can only be provided at a certified yellow fever center. Certification requirements are determined at the state level and therefore vary by state. It is possible for PCPs to become certified to administer yellow fever vaccine, if they so choose.
But since not all international travelers require yellow fever vaccine, a PCP could still meet the needs of the majority of patients traveling internationally without taking that step. PCPs can provide vaccination against hepatitis A, typhoid, adult polio, meningococcal disease, Japanese encephalitis, and rabies (preexposure)—not to mention what I consider the most important travel vaccine, influenza. PCPs can counsel patients about food and water safety and insect precautions and provide strategies for self-treatment of traveler’s diarrhea and malaria chemoprophylaxis.
Patients go to a travel clinic because they recognize that they are exposing themselves to risk and want to mitigate that risk. In a primary care office, the PCP has an opportunity to identify patients who don’t know they are at risk and intervene.
Since I also work in a primary care setting, I look for opportunities to identify patients who may be traveling and evaluate their immunization status in that broader context. When I see patients who were born in other countries, I ask if they plan to travel back home. When patients ask for extra prescription refills because they are traveling, I ask where they are going. As part of wellness visits, I ask if my patient has any plans to travel outside the United States in the next year as I assess their vaccine needs. None of these interventions takes much time.
The foundations of travel health include immunization, patient education on food- and waterborne diseases, insect-borne diseases, and safety. PCPs are experts at patient education, risk identification and management, and immunizations.
So ask your patients if they are planning to travel. Make sure everyone’s routine immunizations are current at every visit. Provide every patient with a personal immunization record to take with them when they visit any other provider and when they travel.
More information on travel health is available from the CDC (www.cdc.gov/travel), the International Society of Travel Medicine (www.istm.org), and the American Travel Health Nurses Association (www.athna.org). By availing yourself of these resources, you will protect the health of your community and keep your traveling patients well, wherever they go.
REFERENCES
1. CDC. General recommendations on immunization. www.cdc.gov/vaccines/pubs/pink book/downloads/genrec.pdf. Accessed December 15, 2014.
2. World Tourism Organization. UNWTO Tourism Highlights: 2014 Edition. http://dtxtq4w60xqpw.cloudfront.net/sites/all/file/pdf/unwto_highlights14_en.pdf. Accessed December 15, 2014.
3. Freedman DO. Travel epidemiology. In: Brunette GW, ed. CDC Health Information for International Travel. Atlanta, GA: CDC; 2014:8-11. wwwnc.cdc.gov/travel/yellowbook/2014/chapter-1-introduction/travel-epidemiology. Accessed December 15, 2014.
4. Measles—United States, January 1–August 24, 2013. MMWR Morbid Mortal Wkly Rep. 2013;62(36):741-743.
5. LaRoque RC, Rao SR, Tribris A, et al. Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport. J Travel Med. 2010;17(6):387-391.