Commentary

Most physicians can recall the impressive x-ray of the rickets rosary or the flared radial head seen in medical school. On almost every exam, there was an a reference to the infant who was solely breastfed which led to seizures and abnormal finding on physical exam, but in practice, most of us would be hard pressed to recall an infant that presented with any of those symptoms.

With recent guideline changes to require that all infants be supplemented with vitamin D from birth, extreme presentations of vitamin D deficiency such as rickets are rare, but has vitamin D deficiency really gone away?

It is hard to pin down the prevalence of vitamin D deficiency in adolescents; it depends on the cut-off you use. In one study of 307 healthy Boston adolescents presenting for primary care, 24% were vitamin D deficient (serum 25[OH]D level, ≤15 ng/mL); of these 4.6% were severely vitamin D deficient (25[OH]D level, ≤8 ng/mL) (Arch. Pediatr. Adolesc. Med. 2004;158:531-7). Broader studies have demonstrated the prevalence of vitamin D deficiency to be 7% for adolescent males aged 14-18 years and 10% for females that age (National Center for Health Statistics Data Brief No. 59, March 2011). This makes sense given that the natural sources of vitamin D are oily fishes such as salmon and sardines, cod liver oil, liver, egg yolk, and organ meat, none of which are big favorites in the adolescent population.

Other factors that contribute to the rise in D deficiency are the promotion of sunscreen use to block UV rays which are essential for cutaneous synthesis. Skin cancer prevention and the promotion of the use of sunscreen and a direct correlation of lower vitamin D levels have been identified(Am. J. Clin. Nutr. 2008;88:1519-27).

Obesity plays a unique role, in that it causes sequestration of the vitamin D into the fat cells. With the dramatic rise in adolescent obesity plus poor nutritional intake, vitamin D deficiency is the natural result.

Clinically it is easy for vitamin D deficiency to go unnoticed. Bones have mineralized, so the typical changes seen in the infant do not occur in the adolescent. But what is apparent is the generalized fatigue, muscle or bone pain, and increased upper respiratory infections. Adolescents with low vitamin D levels also are at increased risk for hypertension, elevated blood sugars, and metabolic syndrome.

Screening for vitamin D deficiency is imperative for the adolescent age group who have been identified to have risk factors because the deficiency can compound other illnesses, prevents appropriate bone mineralization, and decreases the patient’s generalized sense of well-being. Serum 25(OH)D has a long half-life and is a better predictor of serum levels (Am. J. Clin. Nutr. 2008;88:582S-6S).

Supplementation of Vitamin D should be in the form of D₃, which has been shown to be more efficient in raising the serum level (Am. J. Clin. Nutr. 2012;95:1357-64), and dose will vary depending on the severity. Complimenting it with a calcium supplement also will improve bone mineralization and absorption.

Vitamin D deficiency is not a thing of the past. A simple nutritional review with every encounter allows for the educational opportunity for healthy eating and appropriate supplementation. The patient with recurrent upper respiratory infections should be encouraged to maintain a daily intake of at least 600 IU, but in patients with increased risk factors an actual blood test should be done to determine the amount that should be prescribed.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com to view similar articles.

Most physicians can recall the impressive x-ray of the rickets rosary or the flared radial head seen in medical school. On almost every exam, there was an a reference to the infant who was solely breastfed which led to seizures and abnormal finding on physical exam, but in practice, most of us would be hard pressed to recall an infant that presented with any of those symptoms.

With recent guideline changes to require that all infants be supplemented with vitamin D from birth, extreme presentations of vitamin D deficiency such as rickets are rare, but has vitamin D deficiency really gone away?

It is hard to pin down the prevalence of vitamin D deficiency in adolescents; it depends on the cut-off you use. In one study of 307 healthy Boston adolescents presenting for primary care, 24% were vitamin D deficient (serum 25[OH]D level, ≤15 ng/mL); of these 4.6% were severely vitamin D deficient (25[OH]D level, ≤8 ng/mL) (Arch. Pediatr. Adolesc. Med. 2004;158:531-7). Broader studies have demonstrated the prevalence of vitamin D deficiency to be 7% for adolescent males aged 14-18 years and 10% for females that age (National Center for Health Statistics Data Brief No. 59, March 2011). This makes sense given that the natural sources of vitamin D are oily fishes such as salmon and sardines, cod liver oil, liver, egg yolk, and organ meat, none of which are big favorites in the adolescent population.

Other factors that contribute to the rise in D deficiency are the promotion of sunscreen use to block UV rays which are essential for cutaneous synthesis. Skin cancer prevention and the promotion of the use of sunscreen and a direct correlation of lower vitamin D levels have been identified(Am. J. Clin. Nutr. 2008;88:1519-27).

Obesity plays a unique role, in that it causes sequestration of the vitamin D into the fat cells. With the dramatic rise in adolescent obesity plus poor nutritional intake, vitamin D deficiency is the natural result.

Clinically it is easy for vitamin D deficiency to go unnoticed. Bones have mineralized, so the typical changes seen in the infant do not occur in the adolescent. But what is apparent is the generalized fatigue, muscle or bone pain, and increased upper respiratory infections. Adolescents with low vitamin D levels also are at increased risk for hypertension, elevated blood sugars, and metabolic syndrome.

Screening for vitamin D deficiency is imperative for the adolescent age group who have been identified to have risk factors because the deficiency can compound other illnesses, prevents appropriate bone mineralization, and decreases the patient’s generalized sense of well-being. Serum 25(OH)D has a long half-life and is a better predictor of serum levels (Am. J. Clin. Nutr. 2008;88:582S-6S).

Supplementation of Vitamin D should be in the form of D₃, which has been shown to be more efficient in raising the serum level (Am. J. Clin. Nutr. 2012;95:1357-64), and dose will vary depending on the severity. Complimenting it with a calcium supplement also will improve bone mineralization and absorption.

Vitamin D deficiency is not a thing of the past. A simple nutritional review with every encounter allows for the educational opportunity for healthy eating and appropriate supplementation. The patient with recurrent upper respiratory infections should be encouraged to maintain a daily intake of at least 600 IU, but in patients with increased risk factors an actual blood test should be done to determine the amount that should be prescribed.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com to view similar articles.

Most physicians can recall the impressive x-ray of the rickets rosary or the flared radial head seen in medical school. On almost every exam, there was an a reference to the infant who was solely breastfed which led to seizures and abnormal finding on physical exam, but in practice, most of us would be hard pressed to recall an infant that presented with any of those symptoms.

With recent guideline changes to require that all infants be supplemented with vitamin D from birth, extreme presentations of vitamin D deficiency such as rickets are rare, but has vitamin D deficiency really gone away?

It is hard to pin down the prevalence of vitamin D deficiency in adolescents; it depends on the cut-off you use. In one study of 307 healthy Boston adolescents presenting for primary care, 24% were vitamin D deficient (serum 25[OH]D level, ≤15 ng/mL); of these 4.6% were severely vitamin D deficient (25[OH]D level, ≤8 ng/mL) (Arch. Pediatr. Adolesc. Med. 2004;158:531-7). Broader studies have demonstrated the prevalence of vitamin D deficiency to be 7% for adolescent males aged 14-18 years and 10% for females that age (National Center for Health Statistics Data Brief No. 59, March 2011). This makes sense given that the natural sources of vitamin D are oily fishes such as salmon and sardines, cod liver oil, liver, egg yolk, and organ meat, none of which are big favorites in the adolescent population.

Other factors that contribute to the rise in D deficiency are the promotion of sunscreen use to block UV rays which are essential for cutaneous synthesis. Skin cancer prevention and the promotion of the use of sunscreen and a direct correlation of lower vitamin D levels have been identified(Am. J. Clin. Nutr. 2008;88:1519-27).

Obesity plays a unique role, in that it causes sequestration of the vitamin D into the fat cells. With the dramatic rise in adolescent obesity plus poor nutritional intake, vitamin D deficiency is the natural result.

Clinically it is easy for vitamin D deficiency to go unnoticed. Bones have mineralized, so the typical changes seen in the infant do not occur in the adolescent. But what is apparent is the generalized fatigue, muscle or bone pain, and increased upper respiratory infections. Adolescents with low vitamin D levels also are at increased risk for hypertension, elevated blood sugars, and metabolic syndrome.

Screening for vitamin D deficiency is imperative for the adolescent age group who have been identified to have risk factors because the deficiency can compound other illnesses, prevents appropriate bone mineralization, and decreases the patient’s generalized sense of well-being. Serum 25(OH)D has a long half-life and is a better predictor of serum levels (Am. J. Clin. Nutr. 2008;88:582S-6S).

Supplementation of Vitamin D should be in the form of D₃, which has been shown to be more efficient in raising the serum level (Am. J. Clin. Nutr. 2012;95:1357-64), and dose will vary depending on the severity. Complimenting it with a calcium supplement also will improve bone mineralization and absorption.

Vitamin D deficiency is not a thing of the past. A simple nutritional review with every encounter allows for the educational opportunity for healthy eating and appropriate supplementation. The patient with recurrent upper respiratory infections should be encouraged to maintain a daily intake of at least 600 IU, but in patients with increased risk factors an actual blood test should be done to determine the amount that should be prescribed.

Dr. Pearce is a pediatrician in Frankfort, Ill. She had no relevant financial disclosures. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com to view similar articles.

In a recent column, I considered the different meanings some words we use every day can have when patients use them. The word I discussed was “biopsy.” There are, of course, many other words our patients use, or at least pronounce, differently than we do.

Many middle-aged men, for instance, have troubles with their prostrate.

Patients of both genders may be quite outgoing in general, but the cells in their skin cancers are squeamish.

And lots of people ask me to take a look at their molds. Or remove them. Or they write as a reason for “Why are you seeing the doctor today?” the answer “Check molds.”

Or sometimes patients tell me that the medicine I prescribed for their eczema not only hadn’t helped, but had exasperated things. (This works both ways. The other day a friend complained that his kids were really exacerbating him. As a parent, I can relate.)

And then there was Jim, who came in last month. “Dr. Skirball sent me over to have you look at this rash,” he said. “He wants you to do an autopsy.”

Well, Dr. Skirball was just going to have to wait, wasn’t he?

But then I saw Emma, who presented me with a linguistic insight I never heard before. Even after many years, patients can surprise you.

Emma is 17. She has acne. One glance showed that after 2 months of treatment, Emma wasn’t getting any better.

“Is the cream irritating you at all?” I asked.

“No,” she said. “I’m not using it, Doctor.”

OK, I thought. That happens often enough. I needed to find out why, though. Maybe I could convince her to try it after all.

“How come you didn’t use it?” I asked.

“I read the instructions that came with it,” Emma said, brightly. “And I followed them!”

“That’s great,” I said. “What do you mean?”

“Well, I read the small print at the end, and I saw that there was a warning: ‘Only for tropical use.’ ”

“What?”

“It said it was just for tropical use. And just around then it got kind of chilly, so I decided not to take a chance.”

I’ve seen plenty of people who read a label warning that says, “Avoid excessive sun exposure,” (whatever that means) and think they should stop the medicine every time the sun comes out. In fact, I always tell patients up front to ignore that warning, to follow routine sun precautions when relevant, and take the medicine.

And I’ve also heard plenty of people pronounce topical treatment, “tropical treatment.” Or refer to the branded version of desoximetasone as “Tropicort.”

But never, ever, had I met someone who not only mispronounced “topical” as “tropical,” but understood it as “of or pertaining to the tropics.” And then didn’t use the product, because they live in the temperate zone.

Besides, it’s late fall in Boston. What was Emma planning to do? Wait till next spring? Move to the Cayman Islands?

While we’re at it, why don’t many patients bother calling to tell us that the reason they’ve decided to stop using something we prescribed? But that’s another story.

“Emma,” I explained. “It’s not ‘tropical use.’ It’s ‘topical use.’ That just means you use it externally. On top of the skin.”

“Oh, I get it,” Emma said.

As I said, patients never cease to amaze. The weather’s gotten even chillier around here, but now that Emma will use the cream, we’ll see how she does. If she goes to Mexico for winter break, she’ll do even better.

Where is global warming when you need it?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

In a recent column, I considered the different meanings some words we use every day can have when patients use them. The word I discussed was “biopsy.” There are, of course, many other words our patients use, or at least pronounce, differently than we do.

Many middle-aged men, for instance, have troubles with their prostrate.

Patients of both genders may be quite outgoing in general, but the cells in their skin cancers are squeamish.

And lots of people ask me to take a look at their molds. Or remove them. Or they write as a reason for “Why are you seeing the doctor today?” the answer “Check molds.”

Or sometimes patients tell me that the medicine I prescribed for their eczema not only hadn’t helped, but had exasperated things. (This works both ways. The other day a friend complained that his kids were really exacerbating him. As a parent, I can relate.)

And then there was Jim, who came in last month. “Dr. Skirball sent me over to have you look at this rash,” he said. “He wants you to do an autopsy.”

Well, Dr. Skirball was just going to have to wait, wasn’t he?

But then I saw Emma, who presented me with a linguistic insight I never heard before. Even after many years, patients can surprise you.

Emma is 17. She has acne. One glance showed that after 2 months of treatment, Emma wasn’t getting any better.

“Is the cream irritating you at all?” I asked.

“No,” she said. “I’m not using it, Doctor.”

OK, I thought. That happens often enough. I needed to find out why, though. Maybe I could convince her to try it after all.

“How come you didn’t use it?” I asked.

“I read the instructions that came with it,” Emma said, brightly. “And I followed them!”

“That’s great,” I said. “What do you mean?”

“Well, I read the small print at the end, and I saw that there was a warning: ‘Only for tropical use.’ ”

“What?”

“It said it was just for tropical use. And just around then it got kind of chilly, so I decided not to take a chance.”

I’ve seen plenty of people who read a label warning that says, “Avoid excessive sun exposure,” (whatever that means) and think they should stop the medicine every time the sun comes out. In fact, I always tell patients up front to ignore that warning, to follow routine sun precautions when relevant, and take the medicine.

And I’ve also heard plenty of people pronounce topical treatment, “tropical treatment.” Or refer to the branded version of desoximetasone as “Tropicort.”

But never, ever, had I met someone who not only mispronounced “topical” as “tropical,” but understood it as “of or pertaining to the tropics.” And then didn’t use the product, because they live in the temperate zone.

Besides, it’s late fall in Boston. What was Emma planning to do? Wait till next spring? Move to the Cayman Islands?

While we’re at it, why don’t many patients bother calling to tell us that the reason they’ve decided to stop using something we prescribed? But that’s another story.

“Emma,” I explained. “It’s not ‘tropical use.’ It’s ‘topical use.’ That just means you use it externally. On top of the skin.”

“Oh, I get it,” Emma said.

As I said, patients never cease to amaze. The weather’s gotten even chillier around here, but now that Emma will use the cream, we’ll see how she does. If she goes to Mexico for winter break, she’ll do even better.

Where is global warming when you need it?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

In a recent column, I considered the different meanings some words we use every day can have when patients use them. The word I discussed was “biopsy.” There are, of course, many other words our patients use, or at least pronounce, differently than we do.

Many middle-aged men, for instance, have troubles with their prostrate.

Patients of both genders may be quite outgoing in general, but the cells in their skin cancers are squeamish.

And lots of people ask me to take a look at their molds. Or remove them. Or they write as a reason for “Why are you seeing the doctor today?” the answer “Check molds.”

Or sometimes patients tell me that the medicine I prescribed for their eczema not only hadn’t helped, but had exasperated things. (This works both ways. The other day a friend complained that his kids were really exacerbating him. As a parent, I can relate.)

And then there was Jim, who came in last month. “Dr. Skirball sent me over to have you look at this rash,” he said. “He wants you to do an autopsy.”

Well, Dr. Skirball was just going to have to wait, wasn’t he?

But then I saw Emma, who presented me with a linguistic insight I never heard before. Even after many years, patients can surprise you.

Emma is 17. She has acne. One glance showed that after 2 months of treatment, Emma wasn’t getting any better.

“Is the cream irritating you at all?” I asked.

“No,” she said. “I’m not using it, Doctor.”

OK, I thought. That happens often enough. I needed to find out why, though. Maybe I could convince her to try it after all.

“How come you didn’t use it?” I asked.

“I read the instructions that came with it,” Emma said, brightly. “And I followed them!”

“That’s great,” I said. “What do you mean?”

“Well, I read the small print at the end, and I saw that there was a warning: ‘Only for tropical use.’ ”

“What?”

“It said it was just for tropical use. And just around then it got kind of chilly, so I decided not to take a chance.”

I’ve seen plenty of people who read a label warning that says, “Avoid excessive sun exposure,” (whatever that means) and think they should stop the medicine every time the sun comes out. In fact, I always tell patients up front to ignore that warning, to follow routine sun precautions when relevant, and take the medicine.

And I’ve also heard plenty of people pronounce topical treatment, “tropical treatment.” Or refer to the branded version of desoximetasone as “Tropicort.”

But never, ever, had I met someone who not only mispronounced “topical” as “tropical,” but understood it as “of or pertaining to the tropics.” And then didn’t use the product, because they live in the temperate zone.

Besides, it’s late fall in Boston. What was Emma planning to do? Wait till next spring? Move to the Cayman Islands?

While we’re at it, why don’t many patients bother calling to tell us that the reason they’ve decided to stop using something we prescribed? But that’s another story.

“Emma,” I explained. “It’s not ‘tropical use.’ It’s ‘topical use.’ That just means you use it externally. On top of the skin.”

“Oh, I get it,” Emma said.

As I said, patients never cease to amaze. The weather’s gotten even chillier around here, but now that Emma will use the cream, we’ll see how she does. If she goes to Mexico for winter break, she’ll do even better.

Where is global warming when you need it?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Seems that none of my patients sleeps, or at least not very well. Indeed, population-based studies suggest that almost one-third of adults report difficulty initiating or maintaining sleep, waking up too early, and/or nonrestorative or poor quality of sleep.

Light-emitting electronic “e-readers” or “e-books” have exploded as a favorite medium for reading. Many of my patients tell me that when they are unable to sleep, they read. Much of this reading occurs on e-books. But artificial light can produce alerting effects and suppress melatonin. This might be causing or worsening the national insomnia epidemic.

Dr. Anne-Marie Chang and colleagues conducted a randomized, crossover study evaluating the impact of an e-book and a traditional book on sleep (PNAS 2014 Dec. 22 [doi:10.1073/pnas.1418490112]). In the study, 12 healthy young adults were randomized to two conditions: 1) reading an e-book for 4 hours before bedtime; or 2) reading a printed book for 4 hours before bedtime on 5 consecutive evenings. Participants then switched conditions.

The e-book suppressed evening levels of melatonin by 55%, whereas the printed book showed no suppression, and the e-book shifted the melatonin onset to more than 1.5 hours later. Compared with the printed book, the e-book also significantly increased sleep latency (10 minutes longer), decreased REM sleep by11 minutes, decreased evening sleepiness, and increased morning sleepiness.

But not all e-book readers are created equal. Screens of devices used in the current study emit blue light (wavelength 452 nm), the type of light most implicated in melatonin suppression. Newer “e-ink” readers do not emit this light and are “front lit,” with light cast inward rather than outward.

People struggling with insomnia should be encouraged to explore the e-ink options. The table included in the study can provide some guidance as to the type of e-book that may be most beneficial to our sleepy patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Seems that none of my patients sleeps, or at least not very well. Indeed, population-based studies suggest that almost one-third of adults report difficulty initiating or maintaining sleep, waking up too early, and/or nonrestorative or poor quality of sleep.

Light-emitting electronic “e-readers” or “e-books” have exploded as a favorite medium for reading. Many of my patients tell me that when they are unable to sleep, they read. Much of this reading occurs on e-books. But artificial light can produce alerting effects and suppress melatonin. This might be causing or worsening the national insomnia epidemic.

Dr. Anne-Marie Chang and colleagues conducted a randomized, crossover study evaluating the impact of an e-book and a traditional book on sleep (PNAS 2014 Dec. 22 [doi:10.1073/pnas.1418490112]). In the study, 12 healthy young adults were randomized to two conditions: 1) reading an e-book for 4 hours before bedtime; or 2) reading a printed book for 4 hours before bedtime on 5 consecutive evenings. Participants then switched conditions.

The e-book suppressed evening levels of melatonin by 55%, whereas the printed book showed no suppression, and the e-book shifted the melatonin onset to more than 1.5 hours later. Compared with the printed book, the e-book also significantly increased sleep latency (10 minutes longer), decreased REM sleep by11 minutes, decreased evening sleepiness, and increased morning sleepiness.

But not all e-book readers are created equal. Screens of devices used in the current study emit blue light (wavelength 452 nm), the type of light most implicated in melatonin suppression. Newer “e-ink” readers do not emit this light and are “front lit,” with light cast inward rather than outward.

People struggling with insomnia should be encouraged to explore the e-ink options. The table included in the study can provide some guidance as to the type of e-book that may be most beneficial to our sleepy patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Seems that none of my patients sleeps, or at least not very well. Indeed, population-based studies suggest that almost one-third of adults report difficulty initiating or maintaining sleep, waking up too early, and/or nonrestorative or poor quality of sleep.

Light-emitting electronic “e-readers” or “e-books” have exploded as a favorite medium for reading. Many of my patients tell me that when they are unable to sleep, they read. Much of this reading occurs on e-books. But artificial light can produce alerting effects and suppress melatonin. This might be causing or worsening the national insomnia epidemic.

Dr. Anne-Marie Chang and colleagues conducted a randomized, crossover study evaluating the impact of an e-book and a traditional book on sleep (PNAS 2014 Dec. 22 [doi:10.1073/pnas.1418490112]). In the study, 12 healthy young adults were randomized to two conditions: 1) reading an e-book for 4 hours before bedtime; or 2) reading a printed book for 4 hours before bedtime on 5 consecutive evenings. Participants then switched conditions.

The e-book suppressed evening levels of melatonin by 55%, whereas the printed book showed no suppression, and the e-book shifted the melatonin onset to more than 1.5 hours later. Compared with the printed book, the e-book also significantly increased sleep latency (10 minutes longer), decreased REM sleep by11 minutes, decreased evening sleepiness, and increased morning sleepiness.

But not all e-book readers are created equal. Screens of devices used in the current study emit blue light (wavelength 452 nm), the type of light most implicated in melatonin suppression. Newer “e-ink” readers do not emit this light and are “front lit,” with light cast inward rather than outward.

People struggling with insomnia should be encouraged to explore the e-ink options. The table included in the study can provide some guidance as to the type of e-book that may be most beneficial to our sleepy patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Question: A patient alleges that an ophthalmologist was negligent in performing blepharoplasty. The surgical site became infected and left the patient with a disfigured eye. An infectious disease specialist was to testify as plaintiff’s expert, but the defense, relying on a state statute, objected that the expert-to-be had no specialized training in ophthalmology.

Correct statements about expert medical testimony include the following, except:

A. The federal Rules of Evidence require that an expert possess the relevant knowledge, skill, education, training, or experience.

B. Only a few states have enacted statutes specifying that an expert must be in the same or similar specialty as the defendant.

C. Advocates contend that such statutes reduce frivolous lawsuits by limiting expert shopping and the use of “hired guns.”

D. It is the sitting judge, not the jury, who interprets the statute and decides whether a witness qualifies as an expert.

E. In some cases, a nondoctor such as a nurse or pharmacist may be allowed to offer expert testimony against a doctor.

Answer: B. Lay testimony is usually insufficient to define the standard of care in a claim of medical malpractice, and “the question of negligence must be decided by reference to relevant medical standards of care for which the plaintiff carries the burden of proving through expert medical testimony” (Craft v. Peebles, 893 P.2d 138 [Haw.1995]). Court rules of evidence dictate that the expert must possess the knowledge, skill, experience, training, or education for establishing that standard.

In coming to an opinion, the expert may rely on external evidence in the form of a book, treatise, or article; and although these sources represent hearsay evidence, they are admissible to enable the expert witness to form his/her opinion.

The facts of the multiple-choice question above are taken from a recent case (Edwards v. Sunrise Ophthalmology ASC, LLC, 134 So. 3d 1056 [Fla. 4th DCA 2013]), whose appeal is yet to be heard by the Florida Supreme Court. The plaintiff alleged that the surgical site was infected with nocardia during a lower-lid blepharoplasty, which caused her to undergo additional surgery with resulting disfigurement of the eye.

A lower court disqualified the plaintiff’s expert, an infectious disease specialist, based on a Florida statute stipulating that expert medical opinion can be offered only by one in the “same or similar specialty” (Section 766.102, Florida Statutes (2009)). In the words of the court, “Simply put, the infectious disease doctor is not an eye surgeon, nor is the ophthalmologist an infectious disease doctor.”

More than half of all the states have a medical-expert law, many with language comparable to the Florida statute. The idea behind such a statute, frequently enacted as part of a state’s tort reform, is to limit expert shopping and the use of hired guns and “junk science.”

Unsurprisingly, litigation abounds over the statutory language.

For example, a Maryland court ruled that a vascular surgeon was qualified to set the standard of care when an orthopedic surgeon’s alleged negligence caused a patient to lose a leg following knee surgery. The court found the two specialties to be “related,” because the orthopedic complication was vascular in origin.

In some jurisdictions without strict statutory requirements, doctors are more likely to be allowed to testify outside their specialty.

Instances of professionals of unlike specialties qualifying as experts include a nephrologist testifying against a urologist, an infectious disease specialist offering an expert opinion in a stroke case, a pharmacist testifying on the issue of a medication side effect, and a nurse on bedsores. Georgia requires only that an expert show significant familiarity with the area of practice in which the expert opinion is to be given. Still, in a sleep apnea case (Nathans v. Diamond, 654 S.E.2d 121 [Ga. 2007]), the court held that a pulmonologist was not qualified to testify on the standard of surgical care provided by an otolaryngologist.

Besides arguing over the statutory language, litigants have also raised questions of constitutionality. For example, Arizona’s statute ARS §12-2604 (A) requires a medical expert to be a specialist who is actively practicing or teaching in that area of medicine. The state court of appeals held that this violated the separation of powers doctrine (conflicting with Arizona Rule of Evidence 702), but the Supreme Court of Arizona subsequently reversed and reinstated the law (Seisinger v. Siebel, 203 P.3d 483 [Ariz. 2009]).

More recently, the same court upheld the constitutionality of the requirement that an expert share “the same specialty” as the treating physician, and disqualified an adult hematologist from serving as an expert because the defendant was a pediatric hematologist, not an adult hematologist (Baker v. University Physicians Healthcare, 296 P.3d 42 [Ariz. 2013]).

Another issue deals with the locality rule. In an Illinois case, the court accepted an out-of-state plaintiff expert based on his qualifications, competency, and familiarity with standards in the defendant’s community. The case dealt with the development of a rectovaginal fistula that complicated an episiotomy during delivery (Purtill v. Hess, 489 N.E.2d 867 [Ill. 1986]).

The defense attempted to exclude the expert, alleging the lack of familiarity with the standards in the community (Rantoul, Ill.). However, the expert stated that he was familiar with the minimum standards of medical practice in relation to the diagnosis and treatment of rectovaginal fistulae, and those minimum standards were uniform throughout the country.

It is not necessary that the expert witness has the highest possible qualifications to testify about a particular matter. Still, in Domingo v. T.K. (289 F.3d 600 [9th Cir. 2002]), a federal court excluded the testimony of the plaintiff’s expert witness, because it lacked reliability. The plaintiff developed brain damage from fat embolism following hip surgery, and alleged that prolonged malleting of a hip prosthesis was the cause of the fat embolism syndrome (FES).

The court found that “there was no evidence of widespread acceptance of Dr. Harrington’s theory linking extended malleting to FES; indeed, no theory linking extensive malleting to FES had ever been published.” It also noted the lack of any objective source, peer review, clinical tests, establishment of an error rate or other evidence to show that Dr. Harrington followed a valid, scientific method in developing his theory.

Being disqualified as an expert is one thing, but a recent case goes further. In addition to dismissing an expert’s testimony, a state judge barred the expert from ever testifying in his courtroom after it was determined that the testimony was untruthful.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected]

Question: A patient alleges that an ophthalmologist was negligent in performing blepharoplasty. The surgical site became infected and left the patient with a disfigured eye. An infectious disease specialist was to testify as plaintiff’s expert, but the defense, relying on a state statute, objected that the expert-to-be had no specialized training in ophthalmology.

Correct statements about expert medical testimony include the following, except:

A. The federal Rules of Evidence require that an expert possess the relevant knowledge, skill, education, training, or experience.

B. Only a few states have enacted statutes specifying that an expert must be in the same or similar specialty as the defendant.

C. Advocates contend that such statutes reduce frivolous lawsuits by limiting expert shopping and the use of “hired guns.”

D. It is the sitting judge, not the jury, who interprets the statute and decides whether a witness qualifies as an expert.

E. In some cases, a nondoctor such as a nurse or pharmacist may be allowed to offer expert testimony against a doctor.

Answer: B. Lay testimony is usually insufficient to define the standard of care in a claim of medical malpractice, and “the question of negligence must be decided by reference to relevant medical standards of care for which the plaintiff carries the burden of proving through expert medical testimony” (Craft v. Peebles, 893 P.2d 138 [Haw.1995]). Court rules of evidence dictate that the expert must possess the knowledge, skill, experience, training, or education for establishing that standard.

In coming to an opinion, the expert may rely on external evidence in the form of a book, treatise, or article; and although these sources represent hearsay evidence, they are admissible to enable the expert witness to form his/her opinion.

The facts of the multiple-choice question above are taken from a recent case (Edwards v. Sunrise Ophthalmology ASC, LLC, 134 So. 3d 1056 [Fla. 4th DCA 2013]), whose appeal is yet to be heard by the Florida Supreme Court. The plaintiff alleged that the surgical site was infected with nocardia during a lower-lid blepharoplasty, which caused her to undergo additional surgery with resulting disfigurement of the eye.

A lower court disqualified the plaintiff’s expert, an infectious disease specialist, based on a Florida statute stipulating that expert medical opinion can be offered only by one in the “same or similar specialty” (Section 766.102, Florida Statutes (2009)). In the words of the court, “Simply put, the infectious disease doctor is not an eye surgeon, nor is the ophthalmologist an infectious disease doctor.”

More than half of all the states have a medical-expert law, many with language comparable to the Florida statute. The idea behind such a statute, frequently enacted as part of a state’s tort reform, is to limit expert shopping and the use of hired guns and “junk science.”

Unsurprisingly, litigation abounds over the statutory language.

For example, a Maryland court ruled that a vascular surgeon was qualified to set the standard of care when an orthopedic surgeon’s alleged negligence caused a patient to lose a leg following knee surgery. The court found the two specialties to be “related,” because the orthopedic complication was vascular in origin.

In some jurisdictions without strict statutory requirements, doctors are more likely to be allowed to testify outside their specialty.

Instances of professionals of unlike specialties qualifying as experts include a nephrologist testifying against a urologist, an infectious disease specialist offering an expert opinion in a stroke case, a pharmacist testifying on the issue of a medication side effect, and a nurse on bedsores. Georgia requires only that an expert show significant familiarity with the area of practice in which the expert opinion is to be given. Still, in a sleep apnea case (Nathans v. Diamond, 654 S.E.2d 121 [Ga. 2007]), the court held that a pulmonologist was not qualified to testify on the standard of surgical care provided by an otolaryngologist.

Besides arguing over the statutory language, litigants have also raised questions of constitutionality. For example, Arizona’s statute ARS §12-2604 (A) requires a medical expert to be a specialist who is actively practicing or teaching in that area of medicine. The state court of appeals held that this violated the separation of powers doctrine (conflicting with Arizona Rule of Evidence 702), but the Supreme Court of Arizona subsequently reversed and reinstated the law (Seisinger v. Siebel, 203 P.3d 483 [Ariz. 2009]).

More recently, the same court upheld the constitutionality of the requirement that an expert share “the same specialty” as the treating physician, and disqualified an adult hematologist from serving as an expert because the defendant was a pediatric hematologist, not an adult hematologist (Baker v. University Physicians Healthcare, 296 P.3d 42 [Ariz. 2013]).

Another issue deals with the locality rule. In an Illinois case, the court accepted an out-of-state plaintiff expert based on his qualifications, competency, and familiarity with standards in the defendant’s community. The case dealt with the development of a rectovaginal fistula that complicated an episiotomy during delivery (Purtill v. Hess, 489 N.E.2d 867 [Ill. 1986]).

The defense attempted to exclude the expert, alleging the lack of familiarity with the standards in the community (Rantoul, Ill.). However, the expert stated that he was familiar with the minimum standards of medical practice in relation to the diagnosis and treatment of rectovaginal fistulae, and those minimum standards were uniform throughout the country.

It is not necessary that the expert witness has the highest possible qualifications to testify about a particular matter. Still, in Domingo v. T.K. (289 F.3d 600 [9th Cir. 2002]), a federal court excluded the testimony of the plaintiff’s expert witness, because it lacked reliability. The plaintiff developed brain damage from fat embolism following hip surgery, and alleged that prolonged malleting of a hip prosthesis was the cause of the fat embolism syndrome (FES).

The court found that “there was no evidence of widespread acceptance of Dr. Harrington’s theory linking extended malleting to FES; indeed, no theory linking extensive malleting to FES had ever been published.” It also noted the lack of any objective source, peer review, clinical tests, establishment of an error rate or other evidence to show that Dr. Harrington followed a valid, scientific method in developing his theory.

Being disqualified as an expert is one thing, but a recent case goes further. In addition to dismissing an expert’s testimony, a state judge barred the expert from ever testifying in his courtroom after it was determined that the testimony was untruthful.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected]

Question: A patient alleges that an ophthalmologist was negligent in performing blepharoplasty. The surgical site became infected and left the patient with a disfigured eye. An infectious disease specialist was to testify as plaintiff’s expert, but the defense, relying on a state statute, objected that the expert-to-be had no specialized training in ophthalmology.

Correct statements about expert medical testimony include the following, except:

A. The federal Rules of Evidence require that an expert possess the relevant knowledge, skill, education, training, or experience.

B. Only a few states have enacted statutes specifying that an expert must be in the same or similar specialty as the defendant.

C. Advocates contend that such statutes reduce frivolous lawsuits by limiting expert shopping and the use of “hired guns.”

D. It is the sitting judge, not the jury, who interprets the statute and decides whether a witness qualifies as an expert.

E. In some cases, a nondoctor such as a nurse or pharmacist may be allowed to offer expert testimony against a doctor.

Answer: B. Lay testimony is usually insufficient to define the standard of care in a claim of medical malpractice, and “the question of negligence must be decided by reference to relevant medical standards of care for which the plaintiff carries the burden of proving through expert medical testimony” (Craft v. Peebles, 893 P.2d 138 [Haw.1995]). Court rules of evidence dictate that the expert must possess the knowledge, skill, experience, training, or education for establishing that standard.

In coming to an opinion, the expert may rely on external evidence in the form of a book, treatise, or article; and although these sources represent hearsay evidence, they are admissible to enable the expert witness to form his/her opinion.

The facts of the multiple-choice question above are taken from a recent case (Edwards v. Sunrise Ophthalmology ASC, LLC, 134 So. 3d 1056 [Fla. 4th DCA 2013]), whose appeal is yet to be heard by the Florida Supreme Court. The plaintiff alleged that the surgical site was infected with nocardia during a lower-lid blepharoplasty, which caused her to undergo additional surgery with resulting disfigurement of the eye.

A lower court disqualified the plaintiff’s expert, an infectious disease specialist, based on a Florida statute stipulating that expert medical opinion can be offered only by one in the “same or similar specialty” (Section 766.102, Florida Statutes (2009)). In the words of the court, “Simply put, the infectious disease doctor is not an eye surgeon, nor is the ophthalmologist an infectious disease doctor.”

More than half of all the states have a medical-expert law, many with language comparable to the Florida statute. The idea behind such a statute, frequently enacted as part of a state’s tort reform, is to limit expert shopping and the use of hired guns and “junk science.”

Unsurprisingly, litigation abounds over the statutory language.

For example, a Maryland court ruled that a vascular surgeon was qualified to set the standard of care when an orthopedic surgeon’s alleged negligence caused a patient to lose a leg following knee surgery. The court found the two specialties to be “related,” because the orthopedic complication was vascular in origin.

In some jurisdictions without strict statutory requirements, doctors are more likely to be allowed to testify outside their specialty.

Instances of professionals of unlike specialties qualifying as experts include a nephrologist testifying against a urologist, an infectious disease specialist offering an expert opinion in a stroke case, a pharmacist testifying on the issue of a medication side effect, and a nurse on bedsores. Georgia requires only that an expert show significant familiarity with the area of practice in which the expert opinion is to be given. Still, in a sleep apnea case (Nathans v. Diamond, 654 S.E.2d 121 [Ga. 2007]), the court held that a pulmonologist was not qualified to testify on the standard of surgical care provided by an otolaryngologist.

Besides arguing over the statutory language, litigants have also raised questions of constitutionality. For example, Arizona’s statute ARS §12-2604 (A) requires a medical expert to be a specialist who is actively practicing or teaching in that area of medicine. The state court of appeals held that this violated the separation of powers doctrine (conflicting with Arizona Rule of Evidence 702), but the Supreme Court of Arizona subsequently reversed and reinstated the law (Seisinger v. Siebel, 203 P.3d 483 [Ariz. 2009]).

More recently, the same court upheld the constitutionality of the requirement that an expert share “the same specialty” as the treating physician, and disqualified an adult hematologist from serving as an expert because the defendant was a pediatric hematologist, not an adult hematologist (Baker v. University Physicians Healthcare, 296 P.3d 42 [Ariz. 2013]).

Another issue deals with the locality rule. In an Illinois case, the court accepted an out-of-state plaintiff expert based on his qualifications, competency, and familiarity with standards in the defendant’s community. The case dealt with the development of a rectovaginal fistula that complicated an episiotomy during delivery (Purtill v. Hess, 489 N.E.2d 867 [Ill. 1986]).

The defense attempted to exclude the expert, alleging the lack of familiarity with the standards in the community (Rantoul, Ill.). However, the expert stated that he was familiar with the minimum standards of medical practice in relation to the diagnosis and treatment of rectovaginal fistulae, and those minimum standards were uniform throughout the country.

It is not necessary that the expert witness has the highest possible qualifications to testify about a particular matter. Still, in Domingo v. T.K. (289 F.3d 600 [9th Cir. 2002]), a federal court excluded the testimony of the plaintiff’s expert witness, because it lacked reliability. The plaintiff developed brain damage from fat embolism following hip surgery, and alleged that prolonged malleting of a hip prosthesis was the cause of the fat embolism syndrome (FES).

The court found that “there was no evidence of widespread acceptance of Dr. Harrington’s theory linking extended malleting to FES; indeed, no theory linking extensive malleting to FES had ever been published.” It also noted the lack of any objective source, peer review, clinical tests, establishment of an error rate or other evidence to show that Dr. Harrington followed a valid, scientific method in developing his theory.

Being disqualified as an expert is one thing, but a recent case goes further. In addition to dismissing an expert’s testimony, a state judge barred the expert from ever testifying in his courtroom after it was determined that the testimony was untruthful.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected]

Embryogenesis is an incredible phenomenon. It begins with fertilization and implantation of the blastocyst into the uterine wall, followed by development of the extraembryonic membrane which gives rise to the placenta, which is, literally, the lifeblood of the fetus. Although physicians often focus on the health of the placenta during pregnancy, the umbilical cord is an equally important organ.

The umbilical cord acts as a conduit through which metabolic products and biproducts, such as nutrients, antibodies, iron, and blood, pass bidirectionally between a mother and her baby. Many problems can arise if the cord becomes altered. For example, true umbilical cord knot is associated with small-for-gestational-age fetuses, premature birth, neonatal intensive care unit admissions, and fetal death (Int. J. Gynaecol. Obstet. 2013;122:18-21). In addition, short or long cord length may lead to fetal heart rate anomalies and higher risk for birth asphyxia (J. Obstet. Gynaecol. India. 2012;62:520-5).

While the health of the umbilical cord during pregnancy closely correlates to successful outcomes, the cord’s functions conclude at birth. Physicians clamp the umbilical cord at parturition as a routine part of the delivery process. Many ob.gyns. may not even stop to think about cord clamping. To borrow the phrase from the old Nike slogan, they “just do it.”

However, exactly when physicians should clamp the umbilical cord remains a topic for debate. Should ob.gyns. clamp the cord immediately or shortly after birth? Proponents of immediate clamping might argue that waiting too long could cause an influx of placental* blood in the neonate, leading to risk for jaundice. Those on the side of delayed cord clamping might say that waiting to terminate the cord prevents the baby’s oxygen supply from being prematurely cut off. Also, how long should the delay last: One minute? Two minutes? More? Less?

Clearly, the issue of cord clamping requires discussion. Therefore, we have devoted the first Master Class of 2015 to this important topic. We have invited Dr. George A. Macones, the Mitchell and Elaine Yanow Professor and Chair, and director of the division of maternal-fetal medicine and ultrasound in the department of obstetrics and gynecology at Washington University, St. Louis, to explore the debate. As the recent vice chair for the Committee on Practice Bulletins – Obstetrics for the American College of Obstetricians and Gynecologists, Dr. Macones has a unique perspective on the arguments for and against immediate or delayed cord clamping, as well as significant experience as a practicing ob.gyn. and leader at a vibrant academic medical center.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Correction, 4/14/15: An earlier version of this article misstated the potential consequences of waiting too long to clamp the umbilical cord.

Embryogenesis is an incredible phenomenon. It begins with fertilization and implantation of the blastocyst into the uterine wall, followed by development of the extraembryonic membrane which gives rise to the placenta, which is, literally, the lifeblood of the fetus. Although physicians often focus on the health of the placenta during pregnancy, the umbilical cord is an equally important organ.

The umbilical cord acts as a conduit through which metabolic products and biproducts, such as nutrients, antibodies, iron, and blood, pass bidirectionally between a mother and her baby. Many problems can arise if the cord becomes altered. For example, true umbilical cord knot is associated with small-for-gestational-age fetuses, premature birth, neonatal intensive care unit admissions, and fetal death (Int. J. Gynaecol. Obstet. 2013;122:18-21). In addition, short or long cord length may lead to fetal heart rate anomalies and higher risk for birth asphyxia (J. Obstet. Gynaecol. India. 2012;62:520-5).

While the health of the umbilical cord during pregnancy closely correlates to successful outcomes, the cord’s functions conclude at birth. Physicians clamp the umbilical cord at parturition as a routine part of the delivery process. Many ob.gyns. may not even stop to think about cord clamping. To borrow the phrase from the old Nike slogan, they “just do it.”

However, exactly when physicians should clamp the umbilical cord remains a topic for debate. Should ob.gyns. clamp the cord immediately or shortly after birth? Proponents of immediate clamping might argue that waiting too long could cause an influx of placental* blood in the neonate, leading to risk for jaundice. Those on the side of delayed cord clamping might say that waiting to terminate the cord prevents the baby’s oxygen supply from being prematurely cut off. Also, how long should the delay last: One minute? Two minutes? More? Less?

Clearly, the issue of cord clamping requires discussion. Therefore, we have devoted the first Master Class of 2015 to this important topic. We have invited Dr. George A. Macones, the Mitchell and Elaine Yanow Professor and Chair, and director of the division of maternal-fetal medicine and ultrasound in the department of obstetrics and gynecology at Washington University, St. Louis, to explore the debate. As the recent vice chair for the Committee on Practice Bulletins – Obstetrics for the American College of Obstetricians and Gynecologists, Dr. Macones has a unique perspective on the arguments for and against immediate or delayed cord clamping, as well as significant experience as a practicing ob.gyn. and leader at a vibrant academic medical center.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Correction, 4/14/15: An earlier version of this article misstated the potential consequences of waiting too long to clamp the umbilical cord.

Embryogenesis is an incredible phenomenon. It begins with fertilization and implantation of the blastocyst into the uterine wall, followed by development of the extraembryonic membrane which gives rise to the placenta, which is, literally, the lifeblood of the fetus. Although physicians often focus on the health of the placenta during pregnancy, the umbilical cord is an equally important organ.

The umbilical cord acts as a conduit through which metabolic products and biproducts, such as nutrients, antibodies, iron, and blood, pass bidirectionally between a mother and her baby. Many problems can arise if the cord becomes altered. For example, true umbilical cord knot is associated with small-for-gestational-age fetuses, premature birth, neonatal intensive care unit admissions, and fetal death (Int. J. Gynaecol. Obstet. 2013;122:18-21). In addition, short or long cord length may lead to fetal heart rate anomalies and higher risk for birth asphyxia (J. Obstet. Gynaecol. India. 2012;62:520-5).

While the health of the umbilical cord during pregnancy closely correlates to successful outcomes, the cord’s functions conclude at birth. Physicians clamp the umbilical cord at parturition as a routine part of the delivery process. Many ob.gyns. may not even stop to think about cord clamping. To borrow the phrase from the old Nike slogan, they “just do it.”

However, exactly when physicians should clamp the umbilical cord remains a topic for debate. Should ob.gyns. clamp the cord immediately or shortly after birth? Proponents of immediate clamping might argue that waiting too long could cause an influx of placental* blood in the neonate, leading to risk for jaundice. Those on the side of delayed cord clamping might say that waiting to terminate the cord prevents the baby’s oxygen supply from being prematurely cut off. Also, how long should the delay last: One minute? Two minutes? More? Less?

Clearly, the issue of cord clamping requires discussion. Therefore, we have devoted the first Master Class of 2015 to this important topic. We have invited Dr. George A. Macones, the Mitchell and Elaine Yanow Professor and Chair, and director of the division of maternal-fetal medicine and ultrasound in the department of obstetrics and gynecology at Washington University, St. Louis, to explore the debate. As the recent vice chair for the Committee on Practice Bulletins – Obstetrics for the American College of Obstetricians and Gynecologists, Dr. Macones has a unique perspective on the arguments for and against immediate or delayed cord clamping, as well as significant experience as a practicing ob.gyn. and leader at a vibrant academic medical center.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Correction, 4/14/15: An earlier version of this article misstated the potential consequences of waiting too long to clamp the umbilical cord.

When technology is mentioned in the context of health care, it is often received as an impersonal, profit- or regulatory-driven interface between a provider and patient. If designed – hopefully with a clinician involved – with the purpose of actually solving a problem, digital technology will ultimately gain favor. Examples of such tools include links and apps which provide reference information. Epocrates and doximity on the provider side and WebMD on the consumer/patient side are prime examples. There are increasingly more digital tools for patients and caregivers to help them improve self-participation in their health care as well as to navigate the system. The challenge in the health care technology space is to make people (both providers and patients) aware of them, to facilitate use, and to incorporate relevant and actionable data seamlessly into the patient’s electronic record. Technology needs to be designed in a way in which it conforms to the clinical work flow between the patient and provider. I will give examples of available tools that can improve a patient’s daunting journey. I do not have any financial or other affiliation with any companies mentioned.

1. They can help prepare for the office visit.

I don’t know why, but patients have evolved a belief that they need to present a self-diagnosed condition at the office visit. They often feel guilty not providing the diagnosis. I believe firmly (and tell patients) that their responsibility is to know when something isn’t right and to call the provider. Notwithstanding this, I encourage patients to do online research into their symptoms. Tools found at FamilyDoctor.org, the Mayo Clinic Symptom Checker, or iTriage can help frame thoughts or prompt a discussion with a caregiver prior to a visit, which can then serve as a foundation for the office encounter.

2. Patient education content.

The term “patient engagement” is used commonly today. It implies the active participation of the patient in health care and disease management. Many believe that patient engagement should be focused on medication adherence. While this is critical, it remains a reflection of a patient’s understanding of diagnosis; long-term treatment goals (which need be personalized per a discussion about them); and the components of the treatment itself, which include lifestyle changes and nontraditional pharmacologic therapies as well. Seeing disease through a patient’s eyes (empathy) is the key to good relationships that in turn promote engagement. Excellent digital patient education tools are now available for download and review by patients and caregivers. They explain diagnoses, tests, procedures, and medications. Some are proprietary and made by pharmaceutical and medical device companies, while others are produced by third-party companies that allow the provider to white label the product or even customize the content. One excellent example is Liberate Health. (Ed. note: This publication’s parent company has a relationship with Liberate Health.)

3. Social media.

This is where the patients and caregivers are. It follows then that social media is where providers should be. There are some excellent online patient communities that contain disease-specific groups. Examples are Smart Patients and Treatment Diaries. Social media is a big part of motivating patients and giving support to them and to caregivers. It allows for information exchange in a convenient, relaxing, and nonthreatening setting. While skeptics might question the validity of medical information and advice on these sites, I would say that encouraging patients to participate shows empathy. If a disclaimer is offered stating that this is not a substitute for a health care provider, it can be a significant source of support.

4. Connections to caregivers.

Caregivers are left out of many digital health tools. A good working definition of a caregiver is “an unpaid individual (a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks.” About 29% of the U.S. adult population (65.7 million) provides care to someone who is ill, disabled, or aged. Other statistics about caregivers are more impressive. Health and medical apps are promising tools that can be offered to patients. The rubber has yet to fully meet the road in this arena for a few reasons, many of which are tied to the reputation, usability, and priorities of present electronic health record vendors who represent the face of digital health technology to most physicians and other health care providers. However, there is little denial that they (and other mobile health tools) will play an important role in health care’s future. Both patients and caregivers have expressed what is desired in a mobile app. As aging at home becomes a necessary goal of health care from social, financial, and societal standpoints, caregivers will assume an even greater portion of care.

5. Provide for better continuity of care.

Lack of continuity of care leading to medical errors is not a new topic of discussion. This is relevant in both the inpatient and the outpatient setting. Mobile digital technologies can reduce errors by improving communication to both providers and patients as well as among providers themselves. Use of digital tablets at the bedside by patients can improve provider-patient communication and decrease errors. Handoff of patients among providers is another opportunity for mobile health tools to decrease errors. One such app is Smart Sign Out. Ultimately, any tool that decreases errors is a patient advocate tool.

While some physicians believe that patient advocacy is distinct from patient care, I submit that patient advocacy is something any good physician does every day with every patient, including conveying empathy, providing easy to understand explanations of conditions, and offering advice to be considered in a shared decision-making process. We all enter the field of medicine because we want to contribute to the well-being of others. Let’s not lose sight of that, and let’s look to available and emerging technologies to assist us in this mission.

Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.

When technology is mentioned in the context of health care, it is often received as an impersonal, profit- or regulatory-driven interface between a provider and patient. If designed – hopefully with a clinician involved – with the purpose of actually solving a problem, digital technology will ultimately gain favor. Examples of such tools include links and apps which provide reference information. Epocrates and doximity on the provider side and WebMD on the consumer/patient side are prime examples. There are increasingly more digital tools for patients and caregivers to help them improve self-participation in their health care as well as to navigate the system. The challenge in the health care technology space is to make people (both providers and patients) aware of them, to facilitate use, and to incorporate relevant and actionable data seamlessly into the patient’s electronic record. Technology needs to be designed in a way in which it conforms to the clinical work flow between the patient and provider. I will give examples of available tools that can improve a patient’s daunting journey. I do not have any financial or other affiliation with any companies mentioned.

1. They can help prepare for the office visit.

I don’t know why, but patients have evolved a belief that they need to present a self-diagnosed condition at the office visit. They often feel guilty not providing the diagnosis. I believe firmly (and tell patients) that their responsibility is to know when something isn’t right and to call the provider. Notwithstanding this, I encourage patients to do online research into their symptoms. Tools found at FamilyDoctor.org, the Mayo Clinic Symptom Checker, or iTriage can help frame thoughts or prompt a discussion with a caregiver prior to a visit, which can then serve as a foundation for the office encounter.

2. Patient education content.

The term “patient engagement” is used commonly today. It implies the active participation of the patient in health care and disease management. Many believe that patient engagement should be focused on medication adherence. While this is critical, it remains a reflection of a patient’s understanding of diagnosis; long-term treatment goals (which need be personalized per a discussion about them); and the components of the treatment itself, which include lifestyle changes and nontraditional pharmacologic therapies as well. Seeing disease through a patient’s eyes (empathy) is the key to good relationships that in turn promote engagement. Excellent digital patient education tools are now available for download and review by patients and caregivers. They explain diagnoses, tests, procedures, and medications. Some are proprietary and made by pharmaceutical and medical device companies, while others are produced by third-party companies that allow the provider to white label the product or even customize the content. One excellent example is Liberate Health. (Ed. note: This publication’s parent company has a relationship with Liberate Health.)

3. Social media.

This is where the patients and caregivers are. It follows then that social media is where providers should be. There are some excellent online patient communities that contain disease-specific groups. Examples are Smart Patients and Treatment Diaries. Social media is a big part of motivating patients and giving support to them and to caregivers. It allows for information exchange in a convenient, relaxing, and nonthreatening setting. While skeptics might question the validity of medical information and advice on these sites, I would say that encouraging patients to participate shows empathy. If a disclaimer is offered stating that this is not a substitute for a health care provider, it can be a significant source of support.

4. Connections to caregivers.

Caregivers are left out of many digital health tools. A good working definition of a caregiver is “an unpaid individual (a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks.” About 29% of the U.S. adult population (65.7 million) provides care to someone who is ill, disabled, or aged. Other statistics about caregivers are more impressive. Health and medical apps are promising tools that can be offered to patients. The rubber has yet to fully meet the road in this arena for a few reasons, many of which are tied to the reputation, usability, and priorities of present electronic health record vendors who represent the face of digital health technology to most physicians and other health care providers. However, there is little denial that they (and other mobile health tools) will play an important role in health care’s future. Both patients and caregivers have expressed what is desired in a mobile app. As aging at home becomes a necessary goal of health care from social, financial, and societal standpoints, caregivers will assume an even greater portion of care.

5. Provide for better continuity of care.

Lack of continuity of care leading to medical errors is not a new topic of discussion. This is relevant in both the inpatient and the outpatient setting. Mobile digital technologies can reduce errors by improving communication to both providers and patients as well as among providers themselves. Use of digital tablets at the bedside by patients can improve provider-patient communication and decrease errors. Handoff of patients among providers is another opportunity for mobile health tools to decrease errors. One such app is Smart Sign Out. Ultimately, any tool that decreases errors is a patient advocate tool.

While some physicians believe that patient advocacy is distinct from patient care, I submit that patient advocacy is something any good physician does every day with every patient, including conveying empathy, providing easy to understand explanations of conditions, and offering advice to be considered in a shared decision-making process. We all enter the field of medicine because we want to contribute to the well-being of others. Let’s not lose sight of that, and let’s look to available and emerging technologies to assist us in this mission.

Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.

When technology is mentioned in the context of health care, it is often received as an impersonal, profit- or regulatory-driven interface between a provider and patient. If designed – hopefully with a clinician involved – with the purpose of actually solving a problem, digital technology will ultimately gain favor. Examples of such tools include links and apps which provide reference information. Epocrates and doximity on the provider side and WebMD on the consumer/patient side are prime examples. There are increasingly more digital tools for patients and caregivers to help them improve self-participation in their health care as well as to navigate the system. The challenge in the health care technology space is to make people (both providers and patients) aware of them, to facilitate use, and to incorporate relevant and actionable data seamlessly into the patient’s electronic record. Technology needs to be designed in a way in which it conforms to the clinical work flow between the patient and provider. I will give examples of available tools that can improve a patient’s daunting journey. I do not have any financial or other affiliation with any companies mentioned.

1. They can help prepare for the office visit.

I don’t know why, but patients have evolved a belief that they need to present a self-diagnosed condition at the office visit. They often feel guilty not providing the diagnosis. I believe firmly (and tell patients) that their responsibility is to know when something isn’t right and to call the provider. Notwithstanding this, I encourage patients to do online research into their symptoms. Tools found at FamilyDoctor.org, the Mayo Clinic Symptom Checker, or iTriage can help frame thoughts or prompt a discussion with a caregiver prior to a visit, which can then serve as a foundation for the office encounter.

2. Patient education content.

The term “patient engagement” is used commonly today. It implies the active participation of the patient in health care and disease management. Many believe that patient engagement should be focused on medication adherence. While this is critical, it remains a reflection of a patient’s understanding of diagnosis; long-term treatment goals (which need be personalized per a discussion about them); and the components of the treatment itself, which include lifestyle changes and nontraditional pharmacologic therapies as well. Seeing disease through a patient’s eyes (empathy) is the key to good relationships that in turn promote engagement. Excellent digital patient education tools are now available for download and review by patients and caregivers. They explain diagnoses, tests, procedures, and medications. Some are proprietary and made by pharmaceutical and medical device companies, while others are produced by third-party companies that allow the provider to white label the product or even customize the content. One excellent example is Liberate Health. (Ed. note: This publication’s parent company has a relationship with Liberate Health.)

3. Social media.

This is where the patients and caregivers are. It follows then that social media is where providers should be. There are some excellent online patient communities that contain disease-specific groups. Examples are Smart Patients and Treatment Diaries. Social media is a big part of motivating patients and giving support to them and to caregivers. It allows for information exchange in a convenient, relaxing, and nonthreatening setting. While skeptics might question the validity of medical information and advice on these sites, I would say that encouraging patients to participate shows empathy. If a disclaimer is offered stating that this is not a substitute for a health care provider, it can be a significant source of support.

4. Connections to caregivers.

Caregivers are left out of many digital health tools. A good working definition of a caregiver is “an unpaid individual (a spouse, partner, family member, friend, or neighbor) involved in assisting others with activities of daily living and/or medical tasks.” About 29% of the U.S. adult population (65.7 million) provides care to someone who is ill, disabled, or aged. Other statistics about caregivers are more impressive. Health and medical apps are promising tools that can be offered to patients. The rubber has yet to fully meet the road in this arena for a few reasons, many of which are tied to the reputation, usability, and priorities of present electronic health record vendors who represent the face of digital health technology to most physicians and other health care providers. However, there is little denial that they (and other mobile health tools) will play an important role in health care’s future. Both patients and caregivers have expressed what is desired in a mobile app. As aging at home becomes a necessary goal of health care from social, financial, and societal standpoints, caregivers will assume an even greater portion of care.

5. Provide for better continuity of care.

Lack of continuity of care leading to medical errors is not a new topic of discussion. This is relevant in both the inpatient and the outpatient setting. Mobile digital technologies can reduce errors by improving communication to both providers and patients as well as among providers themselves. Use of digital tablets at the bedside by patients can improve provider-patient communication and decrease errors. Handoff of patients among providers is another opportunity for mobile health tools to decrease errors. One such app is Smart Sign Out. Ultimately, any tool that decreases errors is a patient advocate tool.

While some physicians believe that patient advocacy is distinct from patient care, I submit that patient advocacy is something any good physician does every day with every patient, including conveying empathy, providing easy to understand explanations of conditions, and offering advice to be considered in a shared decision-making process. We all enter the field of medicine because we want to contribute to the well-being of others. Let’s not lose sight of that, and let’s look to available and emerging technologies to assist us in this mission.

Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.

After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.

In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.

This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.

Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.

WHY ARE CONSULT NOTES SO LONG?

The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.¹ Physicians are under constant pressure from professional fee-coders to meet these requirements.

Avoid repeating what is already in the record, but include your reasoning and teaching points

Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.

Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,^2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.^2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,¹³ including, in my experience, in consultations.

WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?

Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.

An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.^14,15 The educational value of the consultation is especially important in teaching hospitals.

If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.

HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?

The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.

The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.

The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.

The main part should consist of a detailed assessment and recommendations section

The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy^4,14 and thereby contribute to cost-saving.

My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.

A CASE VIGNETTE

The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.

A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.

He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.

In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.

Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:

• Prerenal azotemia due to volume depletion
• Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
• Obstructive uropathy to be ruled out.

Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.

Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).

FINAL THOUGHTS

The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.

Accountable-care organizations are an important part of the Affordable Care Act,¹⁶ which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.¹⁷

Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.

After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.

In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.

This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.

Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.

WHY ARE CONSULT NOTES SO LONG?

The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.¹ Physicians are under constant pressure from professional fee-coders to meet these requirements.

Avoid repeating what is already in the record, but include your reasoning and teaching points

Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.

Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,^2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.^2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,¹³ including, in my experience, in consultations.

WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?

Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.

An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.^14,15 The educational value of the consultation is especially important in teaching hospitals.

If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.

HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?

The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.

The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.

The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.

The main part should consist of a detailed assessment and recommendations section

The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy^4,14 and thereby contribute to cost-saving.

My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.

A CASE VIGNETTE

The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.

A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.

He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.

In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.

Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:

• Prerenal azotemia due to volume depletion
• Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
• Obstructive uropathy to be ruled out.

Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.

Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).

FINAL THOUGHTS

The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.

Accountable-care organizations are an important part of the Affordable Care Act,¹⁶ which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.¹⁷

Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.

After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.

In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.

This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.

Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.

WHY ARE CONSULT NOTES SO LONG?

The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.¹ Physicians are under constant pressure from professional fee-coders to meet these requirements.

Avoid repeating what is already in the record, but include your reasoning and teaching points

Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.

Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,^2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.^2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,¹³ including, in my experience, in consultations.

WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?

Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.

An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.^14,15 The educational value of the consultation is especially important in teaching hospitals.

If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.

HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?

The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.

The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.

The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.

The main part should consist of a detailed assessment and recommendations section

The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy^4,14 and thereby contribute to cost-saving.

My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.

A CASE VIGNETTE

The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.

A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.

He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.

In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.

Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:

• Prerenal azotemia due to volume depletion
• Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
• Obstructive uropathy to be ruled out.

Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.

Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).

FINAL THOUGHTS

The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.

Accountable-care organizations are an important part of the Affordable Care Act,¹⁶ which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.¹⁷

Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.