Commentary

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

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

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

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

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

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

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

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

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

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

Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.

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

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

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

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

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

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

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

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

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

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

Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.

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

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

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

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

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

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

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

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

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

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

Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

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

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

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

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

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

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

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

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

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

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

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

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

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

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

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

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

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

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

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

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

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

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

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

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

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

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

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

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

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

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

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

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

Fifty years! It might not have been easy to imagine that a journal that is not supported by a medical group or society and is supplied free of charge to its audience could survive for half a century. But here we are, thanks to the continued interest of our readers and the hundreds of clinicians and scientists who have committed to the task of composing articles to educate their fellow physicians in the field of dermatology.

In the first issue of Cutis^® (Figure), Chief Editor Eugene F. Traub, MD, outlined what were, and still are, the goals of the journal: to provide articles “dealing with common dermatoses or those rarer diseases of great interest to all practitioners.”¹ Dr. Traub chose John T. McCarthy, MD, to conduct the day-to-day business of the journal as the Assistant Chief Editor. Dr. McCarthy then became Editor of Cutis in 1983 following Dr. Traub’s retirement and led the journal until his death in 2000. Dr. McCarthy loved his job and the journal, serving for an amazing 35 years, and could rightly be called “the father of Cutis.” In his 25th anniversary editorial entitled “Thank You,” he emphasized both the struggles and successes he experienced during his leadership and concluded by thanking the readers of Cutis for their support.² During this time, his great friend and colleague Joseph W. Burnett, MD, served as Senior Associate Editor.

The evolution of Cutis® over the last 50 years, with the cover of the first issue (top) and the current issue (bottom).

In 2001, along with my colleagues Jeffrey M. Weinberg, MD, and Nanette B. Silverberg, MD, I was honored to join the staff of Cutis as the new Editor-in-Chief. On that occasion, we laid out what we hoped would be some changes in the journal’s structure, aesthetics, and content, but we also stated our intention to maintain what we considered to be the most important aspect of the journal: “to publish ORIGINAL and PRACTICAL articles.”³ We have continued to emphasize the publication of articles that describe the “clinical presentation, diagnosis, histopathology, therapy, and management of the more common entities.”³

Medicine and the specialty of dermatology have changed in our 13 years at the helm of Cutis. With the changes brought by the digital revolution, the ways physicians, both young and old, can access information have been broadened. Our editorial staff has expanded our reach with online exclusives that comprise the digital component of the journal (http://www.cutis.com). Our digital archive dates back to 2000. We have greatly increased our outreach to our young colleagues in training with a Resident Resources section on our Web site, and we also have expanded our online presence with our popular Photo Challenge as well as audio and video commentaries.

Because our specialty has become more and more complex, Cutis will be taking a new route in 2015, focusing solely on practicing dermatologists, dermatopathologists, dermatologic surgeons, dermatology nurse practitioners and physician assistants, and our resident colleagues. Loyal readers from other areas of medicine will still have full online access to the journal.

At this juncture, we look forward to a reinvigoration of our efforts and another 50 years! We wish to thank all of our Editorial Board members  for their continued dedication and support. Finally, my colleagues and I would like to thank all of the behind-the-scenes professionals that make the publication of this journal possible, with special thanks to the tireless efforts of our Senior Vice President/Group Publisher Sharon Finch and our Group Editor Melissa Steiger Sears. I would be remiss if I did not also thank our advertisers in the pharmaceutical industry; without their support publication would not be possible. And finally, in the words of Dr. McCarthy, “Most important of all is you, the reader.”²

Fifty years! It might not have been easy to imagine that a journal that is not supported by a medical group or society and is supplied free of charge to its audience could survive for half a century. But here we are, thanks to the continued interest of our readers and the hundreds of clinicians and scientists who have committed to the task of composing articles to educate their fellow physicians in the field of dermatology.

In the first issue of Cutis^® (Figure), Chief Editor Eugene F. Traub, MD, outlined what were, and still are, the goals of the journal: to provide articles “dealing with common dermatoses or those rarer diseases of great interest to all practitioners.”¹ Dr. Traub chose John T. McCarthy, MD, to conduct the day-to-day business of the journal as the Assistant Chief Editor. Dr. McCarthy then became Editor of Cutis in 1983 following Dr. Traub’s retirement and led the journal until his death in 2000. Dr. McCarthy loved his job and the journal, serving for an amazing 35 years, and could rightly be called “the father of Cutis.” In his 25th anniversary editorial entitled “Thank You,” he emphasized both the struggles and successes he experienced during his leadership and concluded by thanking the readers of Cutis for their support.² During this time, his great friend and colleague Joseph W. Burnett, MD, served as Senior Associate Editor.

The evolution of Cutis® over the last 50 years, with the cover of the first issue (top) and the current issue (bottom).

In 2001, along with my colleagues Jeffrey M. Weinberg, MD, and Nanette B. Silverberg, MD, I was honored to join the staff of Cutis as the new Editor-in-Chief. On that occasion, we laid out what we hoped would be some changes in the journal’s structure, aesthetics, and content, but we also stated our intention to maintain what we considered to be the most important aspect of the journal: “to publish ORIGINAL and PRACTICAL articles.”³ We have continued to emphasize the publication of articles that describe the “clinical presentation, diagnosis, histopathology, therapy, and management of the more common entities.”³

Medicine and the specialty of dermatology have changed in our 13 years at the helm of Cutis. With the changes brought by the digital revolution, the ways physicians, both young and old, can access information have been broadened. Our editorial staff has expanded our reach with online exclusives that comprise the digital component of the journal (http://www.cutis.com). Our digital archive dates back to 2000. We have greatly increased our outreach to our young colleagues in training with a Resident Resources section on our Web site, and we also have expanded our online presence with our popular Photo Challenge as well as audio and video commentaries.

Because our specialty has become more and more complex, Cutis will be taking a new route in 2015, focusing solely on practicing dermatologists, dermatopathologists, dermatologic surgeons, dermatology nurse practitioners and physician assistants, and our resident colleagues. Loyal readers from other areas of medicine will still have full online access to the journal.

At this juncture, we look forward to a reinvigoration of our efforts and another 50 years! We wish to thank all of our Editorial Board members  for their continued dedication and support. Finally, my colleagues and I would like to thank all of the behind-the-scenes professionals that make the publication of this journal possible, with special thanks to the tireless efforts of our Senior Vice President/Group Publisher Sharon Finch and our Group Editor Melissa Steiger Sears. I would be remiss if I did not also thank our advertisers in the pharmaceutical industry; without their support publication would not be possible. And finally, in the words of Dr. McCarthy, “Most important of all is you, the reader.”²

Fifty years! It might not have been easy to imagine that a journal that is not supported by a medical group or society and is supplied free of charge to its audience could survive for half a century. But here we are, thanks to the continued interest of our readers and the hundreds of clinicians and scientists who have committed to the task of composing articles to educate their fellow physicians in the field of dermatology.

In the first issue of Cutis^® (Figure), Chief Editor Eugene F. Traub, MD, outlined what were, and still are, the goals of the journal: to provide articles “dealing with common dermatoses or those rarer diseases of great interest to all practitioners.”¹ Dr. Traub chose John T. McCarthy, MD, to conduct the day-to-day business of the journal as the Assistant Chief Editor. Dr. McCarthy then became Editor of Cutis in 1983 following Dr. Traub’s retirement and led the journal until his death in 2000. Dr. McCarthy loved his job and the journal, serving for an amazing 35 years, and could rightly be called “the father of Cutis.” In his 25th anniversary editorial entitled “Thank You,” he emphasized both the struggles and successes he experienced during his leadership and concluded by thanking the readers of Cutis for their support.² During this time, his great friend and colleague Joseph W. Burnett, MD, served as Senior Associate Editor.

The evolution of Cutis® over the last 50 years, with the cover of the first issue (top) and the current issue (bottom).

In 2001, along with my colleagues Jeffrey M. Weinberg, MD, and Nanette B. Silverberg, MD, I was honored to join the staff of Cutis as the new Editor-in-Chief. On that occasion, we laid out what we hoped would be some changes in the journal’s structure, aesthetics, and content, but we also stated our intention to maintain what we considered to be the most important aspect of the journal: “to publish ORIGINAL and PRACTICAL articles.”³ We have continued to emphasize the publication of articles that describe the “clinical presentation, diagnosis, histopathology, therapy, and management of the more common entities.”³

Medicine and the specialty of dermatology have changed in our 13 years at the helm of Cutis. With the changes brought by the digital revolution, the ways physicians, both young and old, can access information have been broadened. Our editorial staff has expanded our reach with online exclusives that comprise the digital component of the journal (http://www.cutis.com). Our digital archive dates back to 2000. We have greatly increased our outreach to our young colleagues in training with a Resident Resources section on our Web site, and we also have expanded our online presence with our popular Photo Challenge as well as audio and video commentaries.

Because our specialty has become more and more complex, Cutis will be taking a new route in 2015, focusing solely on practicing dermatologists, dermatopathologists, dermatologic surgeons, dermatology nurse practitioners and physician assistants, and our resident colleagues. Loyal readers from other areas of medicine will still have full online access to the journal.

At this juncture, we look forward to a reinvigoration of our efforts and another 50 years! We wish to thank all of our Editorial Board members  for their continued dedication and support. Finally, my colleagues and I would like to thank all of the behind-the-scenes professionals that make the publication of this journal possible, with special thanks to the tireless efforts of our Senior Vice President/Group Publisher Sharon Finch and our Group Editor Melissa Steiger Sears. I would be remiss if I did not also thank our advertisers in the pharmaceutical industry; without their support publication would not be possible. And finally, in the words of Dr. McCarthy, “Most important of all is you, the reader.”²

Does it seem a little dark around here to you? Could it be the cloud of discontent and disillusionment that is hovering over many of America’s physicians? There is a lot for doctors to fret about ... the uncertainty associated with the Affordable Care Act, time gobbling and attention diverting electronic medical records, and the ever-present threat of a malpractice suit – to name just a few.

Among the complaints that I hear most often is “Medicine is becoming a business.” Well, folks, let’s rethink this. Practicing medicine has always been a business. Of course, medicine is a bit of an odd duck – 30% science and 70% art. And while we may like to believe that our goal to alleviate suffering is nobler than are those of other professions, medicine is still a business. Very few of us have the luxury of practicing without hope of financial return.

However, what has changed over the last quarter-century is that many of us have sold the business. For a variety of reasons, many of them falling under the umbrella of “quality of life issues,” we have changed roles from being owner to that of employee. Not surprisingly, most of us are chaffing in the traces of that new role. Individuals who aspire to be physicians are generally not the kind of people who will happily give up control of anything. But becoming an employee means giving up control of a big chunk of one’s professional life. As health care delivery entities continue to grow in size encouraged by the Affordable Care Act, that increase in size will shrink what little power the employee has even further.

A few physicians are trying to buck the trend by remaining owner/operators of either “slow medicine” or “boutique” practices. However, the massive burden of medical school debt will continue to crush the entrepreneurial spirit of even the most idealistic young graduates, and I don’t foresee a time when the majority of physicians will again own their practices.

Even if there is a revolutionary change in how we fund medical education, it’s time for physicians to accept the fact that they are employees. But instead of quietly grumbling about the situation, maybe it’s time for physicians to join together and become activist employees.

I can hear you gasp, “Is he talking about forming unions and going out on strike?” Well, kind of. I know that sounds so ugly and is beneath you as a professional, something the French might do, but not us here in “the Land of the Free.”

Organizing and taking action is not totally foreign to American physicians. You may feel you were underpaid as a house officer. But your compensation would have been far less robust had it not been for a group of 450 residents at the Boston City Hospital who in 1967 organized a work action that resulted in a raise in the base pay for interns from $3,600 to $6,600. Instead of a strike, the house officers initiated a “heal-in” in which they were more liberal in admitting patients and raised the intensity of the care for inpatients. The resulting congestion in the hospital forced the administrators to yield to their demands for a reasonable salary.

You may not be sufficiently dissatisfied to feel like joining other physicians in a work action, but I sense there are some pockets of physician unrest in this country such that forming a union may begin appearing on their list of options.

While you may tend to see strikes as being mostly about the money, employees are often more concerned about their working conditions. If the company you work for has just “upgraded” your computer system so that it now takes you an extra hour each day to see just twenty patients, you might legitimately complain that your working conditions have become so intolerable that you are ready to join up and take action.

Remember, it doesn’t have to be a strike. It could be a “slowdown” or a “speedup” designed to create enough chaos for your employer to get its attention. Could it negatively affect some patients? The honest answer is yes. I doubt that there has ever been a successful work action that hasn’t resulted in some collateral damage.

But is it worth the risks? That’s for you to decide. I’m simply observing that the shift in the landscape has given physicians who want more of a say in their work environments few options. Maybe it’s time for you to think beyond the familiar boundaries of the profession and add a little bite to your growl.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” E-mail him at [email protected].

Does it seem a little dark around here to you? Could it be the cloud of discontent and disillusionment that is hovering over many of America’s physicians? There is a lot for doctors to fret about ... the uncertainty associated with the Affordable Care Act, time gobbling and attention diverting electronic medical records, and the ever-present threat of a malpractice suit – to name just a few.

Among the complaints that I hear most often is “Medicine is becoming a business.” Well, folks, let’s rethink this. Practicing medicine has always been a business. Of course, medicine is a bit of an odd duck – 30% science and 70% art. And while we may like to believe that our goal to alleviate suffering is nobler than are those of other professions, medicine is still a business. Very few of us have the luxury of practicing without hope of financial return.

However, what has changed over the last quarter-century is that many of us have sold the business. For a variety of reasons, many of them falling under the umbrella of “quality of life issues,” we have changed roles from being owner to that of employee. Not surprisingly, most of us are chaffing in the traces of that new role. Individuals who aspire to be physicians are generally not the kind of people who will happily give up control of anything. But becoming an employee means giving up control of a big chunk of one’s professional life. As health care delivery entities continue to grow in size encouraged by the Affordable Care Act, that increase in size will shrink what little power the employee has even further.

A few physicians are trying to buck the trend by remaining owner/operators of either “slow medicine” or “boutique” practices. However, the massive burden of medical school debt will continue to crush the entrepreneurial spirit of even the most idealistic young graduates, and I don’t foresee a time when the majority of physicians will again own their practices.

Even if there is a revolutionary change in how we fund medical education, it’s time for physicians to accept the fact that they are employees. But instead of quietly grumbling about the situation, maybe it’s time for physicians to join together and become activist employees.

I can hear you gasp, “Is he talking about forming unions and going out on strike?” Well, kind of. I know that sounds so ugly and is beneath you as a professional, something the French might do, but not us here in “the Land of the Free.”

Organizing and taking action is not totally foreign to American physicians. You may feel you were underpaid as a house officer. But your compensation would have been far less robust had it not been for a group of 450 residents at the Boston City Hospital who in 1967 organized a work action that resulted in a raise in the base pay for interns from $3,600 to $6,600. Instead of a strike, the house officers initiated a “heal-in” in which they were more liberal in admitting patients and raised the intensity of the care for inpatients. The resulting congestion in the hospital forced the administrators to yield to their demands for a reasonable salary.

You may not be sufficiently dissatisfied to feel like joining other physicians in a work action, but I sense there are some pockets of physician unrest in this country such that forming a union may begin appearing on their list of options.

While you may tend to see strikes as being mostly about the money, employees are often more concerned about their working conditions. If the company you work for has just “upgraded” your computer system so that it now takes you an extra hour each day to see just twenty patients, you might legitimately complain that your working conditions have become so intolerable that you are ready to join up and take action.

Remember, it doesn’t have to be a strike. It could be a “slowdown” or a “speedup” designed to create enough chaos for your employer to get its attention. Could it negatively affect some patients? The honest answer is yes. I doubt that there has ever been a successful work action that hasn’t resulted in some collateral damage.

But is it worth the risks? That’s for you to decide. I’m simply observing that the shift in the landscape has given physicians who want more of a say in their work environments few options. Maybe it’s time for you to think beyond the familiar boundaries of the profession and add a little bite to your growl.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” E-mail him at [email protected].

Does it seem a little dark around here to you? Could it be the cloud of discontent and disillusionment that is hovering over many of America’s physicians? There is a lot for doctors to fret about ... the uncertainty associated with the Affordable Care Act, time gobbling and attention diverting electronic medical records, and the ever-present threat of a malpractice suit – to name just a few.

Among the complaints that I hear most often is “Medicine is becoming a business.” Well, folks, let’s rethink this. Practicing medicine has always been a business. Of course, medicine is a bit of an odd duck – 30% science and 70% art. And while we may like to believe that our goal to alleviate suffering is nobler than are those of other professions, medicine is still a business. Very few of us have the luxury of practicing without hope of financial return.

However, what has changed over the last quarter-century is that many of us have sold the business. For a variety of reasons, many of them falling under the umbrella of “quality of life issues,” we have changed roles from being owner to that of employee. Not surprisingly, most of us are chaffing in the traces of that new role. Individuals who aspire to be physicians are generally not the kind of people who will happily give up control of anything. But becoming an employee means giving up control of a big chunk of one’s professional life. As health care delivery entities continue to grow in size encouraged by the Affordable Care Act, that increase in size will shrink what little power the employee has even further.

A few physicians are trying to buck the trend by remaining owner/operators of either “slow medicine” or “boutique” practices. However, the massive burden of medical school debt will continue to crush the entrepreneurial spirit of even the most idealistic young graduates, and I don’t foresee a time when the majority of physicians will again own their practices.

Even if there is a revolutionary change in how we fund medical education, it’s time for physicians to accept the fact that they are employees. But instead of quietly grumbling about the situation, maybe it’s time for physicians to join together and become activist employees.

I can hear you gasp, “Is he talking about forming unions and going out on strike?” Well, kind of. I know that sounds so ugly and is beneath you as a professional, something the French might do, but not us here in “the Land of the Free.”

Organizing and taking action is not totally foreign to American physicians. You may feel you were underpaid as a house officer. But your compensation would have been far less robust had it not been for a group of 450 residents at the Boston City Hospital who in 1967 organized a work action that resulted in a raise in the base pay for interns from $3,600 to $6,600. Instead of a strike, the house officers initiated a “heal-in” in which they were more liberal in admitting patients and raised the intensity of the care for inpatients. The resulting congestion in the hospital forced the administrators to yield to their demands for a reasonable salary.

You may not be sufficiently dissatisfied to feel like joining other physicians in a work action, but I sense there are some pockets of physician unrest in this country such that forming a union may begin appearing on their list of options.

While you may tend to see strikes as being mostly about the money, employees are often more concerned about their working conditions. If the company you work for has just “upgraded” your computer system so that it now takes you an extra hour each day to see just twenty patients, you might legitimately complain that your working conditions have become so intolerable that you are ready to join up and take action.

Remember, it doesn’t have to be a strike. It could be a “slowdown” or a “speedup” designed to create enough chaos for your employer to get its attention. Could it negatively affect some patients? The honest answer is yes. I doubt that there has ever been a successful work action that hasn’t resulted in some collateral damage.

But is it worth the risks? That’s for you to decide. I’m simply observing that the shift in the landscape has given physicians who want more of a say in their work environments few options. Maybe it’s time for you to think beyond the familiar boundaries of the profession and add a little bite to your growl.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” E-mail him at [email protected].