Commentary

“When I use a word, it means just what I choose it to mean…” – Humpty Dumpty

Even after all these years, I’m still surprised to learn new ways the words we use every day can mean different things to patients to whom we say them.

Take the word “biopsy.” To a dermatologist, it means “a test of a piece of tissue” (in our case, of skin), to help find out what the problem is.

I’ve always known that to many patients, the word “biopsy” suggests cancer, or at least the concern that there may be cancer, because cancer is the context in which most people hear the word: breast biopsy, prostate biopsy, and so on. It can therefore be useful to point out to patients when a biopsy is performed for diagnostic purposes and cancer is not even on the list of possibilities.

Lately, though, I’ve had a few encounters that highlighted other interesting ways the word “biopsy” can be misunderstood.

Case 1: Arnold the Irritated

“Arnold,” I say. “I need to biopsy this. Based on the results, it may need further treatment, but I doubt it.”

“I thought you were taking it off now,” says Arnold.

“No, I’m testing it, “I say.

“But I want it off,” says Arnold. “It gets irritated when I shave over it, so I want it off.”

“Yes,” I say, “but in order to remove it properly, I need to know what it is.”

“What?”

We have to go around a few more times before Arnold catches on.

Case 2: Gaetano the Outraged

“Gaetano is on the phone,” says my billing clerk. “He says you told him you weren’t going to biopsy his spot, and then he got a bill from the pathology lab.”

I call Gaetano. “You said you weren’t going to biopsy this,” he says. “You said you were sure you knew what it was, so you didn’t have to biopsy it.”

“First of all,” I explain, “I’m never totally sure. Your spot looked like a basal cell skin cancer, and that’s what it turned out to be. But I’ve had cases where the pathology results surprised me, and it turned out to be something less – or something more. So I have to check the biopsy.”

“I understand, Doctor” says Gaetano.

“In addition,” I go on, “what I actually meant to say was that I was not going to only take a biopsy of the spot. I was going to remove it completely, so that if my diagnosis was confirmed, you wouldn’t have to come back and have more done. Sorry if I didn’t make that clear.”

“So you biopsied it,” says Gaetano, but you didn’t just biopsy it. I get it. I think.”

Good for you, Gaetano. Next time I am going to – actually, next time I don’t know what I’ll do.

Case 3: Melvin the Clueless

“I understand your former dermatologist removed something from your arm,” I say to Melvin.

“Yes, they took a biopsy, and then they removed it,” says Melvin. “I just have one question.”

“What is that?” I ask.

“Which was the biopsy?” asks Melvin, “the first or the second?”

I didn’t let on, but inside I was shaking my head.

Even with the best will on both sides – and even if both are native speakers of the same language – there are just so many ways people can misunderstand each other. Humpty Dumpty was wrong. Words can mean what both the talker and the listener think they mean. Humpty Dumpty probably didn’t get out much.

Never biopsy an egg. 

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

“When I use a word, it means just what I choose it to mean…” – Humpty Dumpty

Even after all these years, I’m still surprised to learn new ways the words we use every day can mean different things to patients to whom we say them.

Take the word “biopsy.” To a dermatologist, it means “a test of a piece of tissue” (in our case, of skin), to help find out what the problem is.

I’ve always known that to many patients, the word “biopsy” suggests cancer, or at least the concern that there may be cancer, because cancer is the context in which most people hear the word: breast biopsy, prostate biopsy, and so on. It can therefore be useful to point out to patients when a biopsy is performed for diagnostic purposes and cancer is not even on the list of possibilities.

Lately, though, I’ve had a few encounters that highlighted other interesting ways the word “biopsy” can be misunderstood.

Case 1: Arnold the Irritated

“Arnold,” I say. “I need to biopsy this. Based on the results, it may need further treatment, but I doubt it.”

“I thought you were taking it off now,” says Arnold.

“No, I’m testing it, “I say.

“But I want it off,” says Arnold. “It gets irritated when I shave over it, so I want it off.”

“Yes,” I say, “but in order to remove it properly, I need to know what it is.”

“What?”

We have to go around a few more times before Arnold catches on.

Case 2: Gaetano the Outraged

“Gaetano is on the phone,” says my billing clerk. “He says you told him you weren’t going to biopsy his spot, and then he got a bill from the pathology lab.”

I call Gaetano. “You said you weren’t going to biopsy this,” he says. “You said you were sure you knew what it was, so you didn’t have to biopsy it.”

“First of all,” I explain, “I’m never totally sure. Your spot looked like a basal cell skin cancer, and that’s what it turned out to be. But I’ve had cases where the pathology results surprised me, and it turned out to be something less – or something more. So I have to check the biopsy.”

“I understand, Doctor” says Gaetano.

“In addition,” I go on, “what I actually meant to say was that I was not going to only take a biopsy of the spot. I was going to remove it completely, so that if my diagnosis was confirmed, you wouldn’t have to come back and have more done. Sorry if I didn’t make that clear.”

“So you biopsied it,” says Gaetano, but you didn’t just biopsy it. I get it. I think.”

Good for you, Gaetano. Next time I am going to – actually, next time I don’t know what I’ll do.

Case 3: Melvin the Clueless

“I understand your former dermatologist removed something from your arm,” I say to Melvin.

“Yes, they took a biopsy, and then they removed it,” says Melvin. “I just have one question.”

“What is that?” I ask.

“Which was the biopsy?” asks Melvin, “the first or the second?”

I didn’t let on, but inside I was shaking my head.

Even with the best will on both sides – and even if both are native speakers of the same language – there are just so many ways people can misunderstand each other. Humpty Dumpty was wrong. Words can mean what both the talker and the listener think they mean. Humpty Dumpty probably didn’t get out much.

Never biopsy an egg. 

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

“When I use a word, it means just what I choose it to mean…” – Humpty Dumpty

Even after all these years, I’m still surprised to learn new ways the words we use every day can mean different things to patients to whom we say them.

Take the word “biopsy.” To a dermatologist, it means “a test of a piece of tissue” (in our case, of skin), to help find out what the problem is.

I’ve always known that to many patients, the word “biopsy” suggests cancer, or at least the concern that there may be cancer, because cancer is the context in which most people hear the word: breast biopsy, prostate biopsy, and so on. It can therefore be useful to point out to patients when a biopsy is performed for diagnostic purposes and cancer is not even on the list of possibilities.

Lately, though, I’ve had a few encounters that highlighted other interesting ways the word “biopsy” can be misunderstood.

Case 1: Arnold the Irritated

“Arnold,” I say. “I need to biopsy this. Based on the results, it may need further treatment, but I doubt it.”

“I thought you were taking it off now,” says Arnold.

“No, I’m testing it, “I say.

“But I want it off,” says Arnold. “It gets irritated when I shave over it, so I want it off.”

“Yes,” I say, “but in order to remove it properly, I need to know what it is.”

“What?”

We have to go around a few more times before Arnold catches on.

Case 2: Gaetano the Outraged

“Gaetano is on the phone,” says my billing clerk. “He says you told him you weren’t going to biopsy his spot, and then he got a bill from the pathology lab.”

I call Gaetano. “You said you weren’t going to biopsy this,” he says. “You said you were sure you knew what it was, so you didn’t have to biopsy it.”

“First of all,” I explain, “I’m never totally sure. Your spot looked like a basal cell skin cancer, and that’s what it turned out to be. But I’ve had cases where the pathology results surprised me, and it turned out to be something less – or something more. So I have to check the biopsy.”

“I understand, Doctor” says Gaetano.

“In addition,” I go on, “what I actually meant to say was that I was not going to only take a biopsy of the spot. I was going to remove it completely, so that if my diagnosis was confirmed, you wouldn’t have to come back and have more done. Sorry if I didn’t make that clear.”

“So you biopsied it,” says Gaetano, but you didn’t just biopsy it. I get it. I think.”

Good for you, Gaetano. Next time I am going to – actually, next time I don’t know what I’ll do.

Case 3: Melvin the Clueless

“I understand your former dermatologist removed something from your arm,” I say to Melvin.

“Yes, they took a biopsy, and then they removed it,” says Melvin. “I just have one question.”

“What is that?” I ask.

“Which was the biopsy?” asks Melvin, “the first or the second?”

I didn’t let on, but inside I was shaking my head.

Even with the best will on both sides – and even if both are native speakers of the same language – there are just so many ways people can misunderstand each other. Humpty Dumpty was wrong. Words can mean what both the talker and the listener think they mean. Humpty Dumpty probably didn’t get out much.

Never biopsy an egg. 

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

Question: Your office assistant misfiled a critical laboratory report showing dangerous hyperkalemia of 6.5 mEq/L. Unaware of the abnormality, you failed to notify the end-stage renal patient to return for treatment. In the meantime, the patient collapsed and died, and an autopsy revealed a fresh transmural myocardial infarct.

Which of the following statements is best?

A. You are negligent, because the standard of care is to promptly contact the patient.

B. Your office assistant is negligent, because she was the one who misfiled the report.

C. Liability rests with the laboratory, because it should have called the office immediately with the critical value.

D. Your lawyer will defend you on the legal theory that hyperkalemia was not the proximate cause of death.

E. All of the above.

Answer: E. In any negligence action, the plaintiff bears the burden of proof, on a balance of probabilities, that the defendant owes him/her a duty of care, the breach of which proximately caused the plaintiff’s injuries.

One begins with an inquiry into whether a duty exists and whether a breach has occurred. Generally, doctors owe a legal duty of due care to their patients arising out of the doctor-patient relationship. By “missing” the laboratory report, especially one of urgency, and not immediately notifying the patient, the doctor has likely breached his/her duty. Another way of putting it is to ask whether the conduct has fallen below what is ordinarily expected of a practitioner in a similar situation.

The doctor will likely blame the office assistant for misfiling the report, and the assistant is indeed liable, as he/she also owes a direct legal duty to the patient. However, such liability will then fall upon the doctor under “respondeat superior” or “let the master answer,” which is the legal doctrine underpinning vicarious liability. This is characteristically seen in an employer-employee situation, where liability is imputed to the employer despite the tortious act being committed only by the employee.

The idea behind this rule is to ensure that the employer, as supervisor, will enforce proper work conditions to avoid risk of harm. The employer also is better able to shoulder the cost of compensating the victim.

For vicarious liability to arise, the employee’s act must have occurred during and within the scope of employment, and the risk of harm must be foreseeable. Under the facts of this hypothetical scenario, it is easy to see that the doctor will be vicariously liable for the negligent act of the assistant.

The clinical laboratory also owes an independent duty to the patient, which includes, among other things, assuring the proper standards in specimen collection and test performance. The duty extends to timely and accurate reporting of the results, including calling the physician when there is a critically high or low value if that is the standard of care in the community, as it generally is.

Thus, the laboratory in this case will likely be named as a codefendant. This is called joint and several liability, where more than one defendant has concurrently or successively caused a plaintiff’s indivisible injury, and the latter can recover all damages from any of the wrongdoers irrespective of degree of fault, as long as causation is proven. However, the plaintiff is not entitled to double recovery, and a defendant can proceed against the other liable parties for contribution.

Proving existence and breach of duty are necessary but insufficient steps toward winning the lawsuit. The plaintiff must also establish causation, i.e., that the substandard care caused the injury.

Causation inquires into both cause-in-fact and cause-in-law, and the term “proximate cause” is used to cover both of these aspects of causation. Cause-in-fact is established with the “but for” test – whether it can be said that had it not been for the defendant’s actions, the plaintiff would not have suffered the injury.

In this scenario, the doctor’s attorney will argue that the cause of death, a myocardial infarct, was preexisting atherosclerotic heart disease, rather than hyperkalemia. Besides, the chronic renal patient typically adapts to hyperkalemia and can tolerate elevated levels better than nonrenal patients. Of course, the counterargument is that the patient’s cardiac injury was a likely consequence of hyperkalemia-induced ventricular arrhythmia.

The doctor, the nurse, and the laboratory will all be named as codefendants. However, the laboratory will attempt to escape liability by arguing that its negligence, if any, was superseded by the doctor’s own negligent failure to read the report. Cause-in-law analysis examines whether a new independent event has intervened between the negligent act and the outcome, which may have been aggravated by the new event.

It naturally raises the question whether the original wrongdoer – in this case, the laboratory – continues to be liable, or whether the chain of causation has been broken by the intervening cause (the doctor’s negligence).

In a federal case, the Florida District Court of Appeals found several doctors liable for missing the diagnosis of tuberculous meningitis (Hadley v. Terwilleger, 873 So.2d 378 (Fl. 2004)). The doctors had seen the patient at various times in a sequential manner. The court held that the plaintiff was entitled to concurring-cause, rather than superseding-cause, jury instructions. The purpose of such instruction was to negate the idea that a defendant is excused from the consequences of his or her negligence by reason of some other cause concurring in time and contributing to the same injury.

Overlooked, misfiled, or otherwise “missed” laboratory or x-ray reports are commonly encountered in medical practice, and may lead in some instances to serious patient injury. They are typically systems errors rather than the fault of any single individual, and like most medical errors, largely preventable.

Physicians and health care institutions should put in place tested protocols that protect patients from risk of harm, and, as the Institute of Medicine stated in its 2000 report, “To Err Is Human: Building a Safer Health System,” move away from “a culture of blame to a culture of safety.”

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 s[email protected].

Question: Your office assistant misfiled a critical laboratory report showing dangerous hyperkalemia of 6.5 mEq/L. Unaware of the abnormality, you failed to notify the end-stage renal patient to return for treatment. In the meantime, the patient collapsed and died, and an autopsy revealed a fresh transmural myocardial infarct.

Which of the following statements is best?

A. You are negligent, because the standard of care is to promptly contact the patient.

B. Your office assistant is negligent, because she was the one who misfiled the report.

C. Liability rests with the laboratory, because it should have called the office immediately with the critical value.

D. Your lawyer will defend you on the legal theory that hyperkalemia was not the proximate cause of death.

E. All of the above.

Answer: E. In any negligence action, the plaintiff bears the burden of proof, on a balance of probabilities, that the defendant owes him/her a duty of care, the breach of which proximately caused the plaintiff’s injuries.

One begins with an inquiry into whether a duty exists and whether a breach has occurred. Generally, doctors owe a legal duty of due care to their patients arising out of the doctor-patient relationship. By “missing” the laboratory report, especially one of urgency, and not immediately notifying the patient, the doctor has likely breached his/her duty. Another way of putting it is to ask whether the conduct has fallen below what is ordinarily expected of a practitioner in a similar situation.

The doctor will likely blame the office assistant for misfiling the report, and the assistant is indeed liable, as he/she also owes a direct legal duty to the patient. However, such liability will then fall upon the doctor under “respondeat superior” or “let the master answer,” which is the legal doctrine underpinning vicarious liability. This is characteristically seen in an employer-employee situation, where liability is imputed to the employer despite the tortious act being committed only by the employee.

The idea behind this rule is to ensure that the employer, as supervisor, will enforce proper work conditions to avoid risk of harm. The employer also is better able to shoulder the cost of compensating the victim.

For vicarious liability to arise, the employee’s act must have occurred during and within the scope of employment, and the risk of harm must be foreseeable. Under the facts of this hypothetical scenario, it is easy to see that the doctor will be vicariously liable for the negligent act of the assistant.

The clinical laboratory also owes an independent duty to the patient, which includes, among other things, assuring the proper standards in specimen collection and test performance. The duty extends to timely and accurate reporting of the results, including calling the physician when there is a critically high or low value if that is the standard of care in the community, as it generally is.

Thus, the laboratory in this case will likely be named as a codefendant. This is called joint and several liability, where more than one defendant has concurrently or successively caused a plaintiff’s indivisible injury, and the latter can recover all damages from any of the wrongdoers irrespective of degree of fault, as long as causation is proven. However, the plaintiff is not entitled to double recovery, and a defendant can proceed against the other liable parties for contribution.

Proving existence and breach of duty are necessary but insufficient steps toward winning the lawsuit. The plaintiff must also establish causation, i.e., that the substandard care caused the injury.

Causation inquires into both cause-in-fact and cause-in-law, and the term “proximate cause” is used to cover both of these aspects of causation. Cause-in-fact is established with the “but for” test – whether it can be said that had it not been for the defendant’s actions, the plaintiff would not have suffered the injury.

In this scenario, the doctor’s attorney will argue that the cause of death, a myocardial infarct, was preexisting atherosclerotic heart disease, rather than hyperkalemia. Besides, the chronic renal patient typically adapts to hyperkalemia and can tolerate elevated levels better than nonrenal patients. Of course, the counterargument is that the patient’s cardiac injury was a likely consequence of hyperkalemia-induced ventricular arrhythmia.

The doctor, the nurse, and the laboratory will all be named as codefendants. However, the laboratory will attempt to escape liability by arguing that its negligence, if any, was superseded by the doctor’s own negligent failure to read the report. Cause-in-law analysis examines whether a new independent event has intervened between the negligent act and the outcome, which may have been aggravated by the new event.

It naturally raises the question whether the original wrongdoer – in this case, the laboratory – continues to be liable, or whether the chain of causation has been broken by the intervening cause (the doctor’s negligence).

In a federal case, the Florida District Court of Appeals found several doctors liable for missing the diagnosis of tuberculous meningitis (Hadley v. Terwilleger, 873 So.2d 378 (Fl. 2004)). The doctors had seen the patient at various times in a sequential manner. The court held that the plaintiff was entitled to concurring-cause, rather than superseding-cause, jury instructions. The purpose of such instruction was to negate the idea that a defendant is excused from the consequences of his or her negligence by reason of some other cause concurring in time and contributing to the same injury.

Overlooked, misfiled, or otherwise “missed” laboratory or x-ray reports are commonly encountered in medical practice, and may lead in some instances to serious patient injury. They are typically systems errors rather than the fault of any single individual, and like most medical errors, largely preventable.

Physicians and health care institutions should put in place tested protocols that protect patients from risk of harm, and, as the Institute of Medicine stated in its 2000 report, “To Err Is Human: Building a Safer Health System,” move away from “a culture of blame to a culture of safety.”

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 s[email protected].

Question: Your office assistant misfiled a critical laboratory report showing dangerous hyperkalemia of 6.5 mEq/L. Unaware of the abnormality, you failed to notify the end-stage renal patient to return for treatment. In the meantime, the patient collapsed and died, and an autopsy revealed a fresh transmural myocardial infarct.

Which of the following statements is best?

A. You are negligent, because the standard of care is to promptly contact the patient.

B. Your office assistant is negligent, because she was the one who misfiled the report.

C. Liability rests with the laboratory, because it should have called the office immediately with the critical value.

D. Your lawyer will defend you on the legal theory that hyperkalemia was not the proximate cause of death.

E. All of the above.

Answer: E. In any negligence action, the plaintiff bears the burden of proof, on a balance of probabilities, that the defendant owes him/her a duty of care, the breach of which proximately caused the plaintiff’s injuries.

One begins with an inquiry into whether a duty exists and whether a breach has occurred. Generally, doctors owe a legal duty of due care to their patients arising out of the doctor-patient relationship. By “missing” the laboratory report, especially one of urgency, and not immediately notifying the patient, the doctor has likely breached his/her duty. Another way of putting it is to ask whether the conduct has fallen below what is ordinarily expected of a practitioner in a similar situation.

The doctor will likely blame the office assistant for misfiling the report, and the assistant is indeed liable, as he/she also owes a direct legal duty to the patient. However, such liability will then fall upon the doctor under “respondeat superior” or “let the master answer,” which is the legal doctrine underpinning vicarious liability. This is characteristically seen in an employer-employee situation, where liability is imputed to the employer despite the tortious act being committed only by the employee.

The idea behind this rule is to ensure that the employer, as supervisor, will enforce proper work conditions to avoid risk of harm. The employer also is better able to shoulder the cost of compensating the victim.

For vicarious liability to arise, the employee’s act must have occurred during and within the scope of employment, and the risk of harm must be foreseeable. Under the facts of this hypothetical scenario, it is easy to see that the doctor will be vicariously liable for the negligent act of the assistant.

The clinical laboratory also owes an independent duty to the patient, which includes, among other things, assuring the proper standards in specimen collection and test performance. The duty extends to timely and accurate reporting of the results, including calling the physician when there is a critically high or low value if that is the standard of care in the community, as it generally is.

Thus, the laboratory in this case will likely be named as a codefendant. This is called joint and several liability, where more than one defendant has concurrently or successively caused a plaintiff’s indivisible injury, and the latter can recover all damages from any of the wrongdoers irrespective of degree of fault, as long as causation is proven. However, the plaintiff is not entitled to double recovery, and a defendant can proceed against the other liable parties for contribution.

Proving existence and breach of duty are necessary but insufficient steps toward winning the lawsuit. The plaintiff must also establish causation, i.e., that the substandard care caused the injury.

Causation inquires into both cause-in-fact and cause-in-law, and the term “proximate cause” is used to cover both of these aspects of causation. Cause-in-fact is established with the “but for” test – whether it can be said that had it not been for the defendant’s actions, the plaintiff would not have suffered the injury.

In this scenario, the doctor’s attorney will argue that the cause of death, a myocardial infarct, was preexisting atherosclerotic heart disease, rather than hyperkalemia. Besides, the chronic renal patient typically adapts to hyperkalemia and can tolerate elevated levels better than nonrenal patients. Of course, the counterargument is that the patient’s cardiac injury was a likely consequence of hyperkalemia-induced ventricular arrhythmia.

The doctor, the nurse, and the laboratory will all be named as codefendants. However, the laboratory will attempt to escape liability by arguing that its negligence, if any, was superseded by the doctor’s own negligent failure to read the report. Cause-in-law analysis examines whether a new independent event has intervened between the negligent act and the outcome, which may have been aggravated by the new event.

It naturally raises the question whether the original wrongdoer – in this case, the laboratory – continues to be liable, or whether the chain of causation has been broken by the intervening cause (the doctor’s negligence).

In a federal case, the Florida District Court of Appeals found several doctors liable for missing the diagnosis of tuberculous meningitis (Hadley v. Terwilleger, 873 So.2d 378 (Fl. 2004)). The doctors had seen the patient at various times in a sequential manner. The court held that the plaintiff was entitled to concurring-cause, rather than superseding-cause, jury instructions. The purpose of such instruction was to negate the idea that a defendant is excused from the consequences of his or her negligence by reason of some other cause concurring in time and contributing to the same injury.

Overlooked, misfiled, or otherwise “missed” laboratory or x-ray reports are commonly encountered in medical practice, and may lead in some instances to serious patient injury. They are typically systems errors rather than the fault of any single individual, and like most medical errors, largely preventable.

Physicians and health care institutions should put in place tested protocols that protect patients from risk of harm, and, as the Institute of Medicine stated in its 2000 report, “To Err Is Human: Building a Safer Health System,” move away from “a culture of blame to a culture of safety.”

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 s[email protected].

Dr. Hickner’s editorial “EHRs: Something’s gotta give” (J Fam Pract. 2014;63:558) prompted me to reflect on the elements of electronic health records (EHRs) that cannot change and the ones that can.

The EHR system I use allows the EHR to serve as a 
quality recorder, and it appears 
this is the most important part,
 because the reminders of what
 needs to be documented come first and are color-coded. From a reimbursement point of view, what is important is not the narrative, but the expanded “elements” that make it a billing document. I believe this will not change.

What can change is how the note information is organized, and I think the organization should be different for specific roles. At intake, a medical assistant can review allergies, medication lists, and preventive services; update family history; and take vital signs and history of present illness (HPI). As the physician, I want the note to show the information in the order that I process it during the visit: 1) allergies/medication list, 2) concerns/complaints with brief documentation, 3) vitals, 4) physical, 5) assessment, and 6) plan.

After the note is signed off on, I want a different format for review purposes: 1) assessment/plan (because this is what I look at first for follow-up), 2) HPI/review of systems, 3) physical, 4) allergies, 5) medication list, 6) past medical history, and 7) quality reminders (if they show up at all after the visit is complete).

Is it asking too much for a programmer to make the EHR organize information in this manner?

Edward Friedler, MD
Annandale, Va

I still dictate my notes and they very much tell a story that an EHR cannot. I have been audited repeatedly and I always have all the bullet points and essentials that the insurance company wants, but this information is in a format that everyone—including patients—can read and appreciate.

The move to APSO (assessment, plan, subjective, objective) from SOAP (subjective, objective, assessment, plan) is an example of the tail wagging the dog. Rather than fix the note so the time-honored SOAP format works, we acknowledge that no one actually reads the long template notes and they want to get to the bottom line (ie, the assessment and plan).

My dream is to return to the days when we only listed the positive findings, the assumption being that a competent physician did the exam that was required and it’s unnecessary to state that the examined anatomy was normal. Unfortunately, so much of what we must do is driven by lawyers and insurance companies—not by doctors.

David M. Brill, DO
Rocky River, Ohio

I now take photos of all of the ludicrous choices our EHR tosses at me, such as “laceration of third eyelid” or “injury, crushed by falling aircraft due to terrorist.” Most of my EHR entries now say, “See scanned handwritten note for accuracy.”

The issue of EHRs needs to be kept on the front burner. It is destroying doctor/patient relationships and quality diagnostic care while hiding the important findings in the garbage.

Jay Hammett, MD
Knoxville, Tenn

I’m in a group practice of 10 family physicians and in a typical workday, each of us sees 23 to 25 patients, answers e-mails/phone calls, and reviews labs/studies, which leaves no time for anything else. There’s a constant struggle to stay on top of the quality of the notes. I have preserved the quality of my own notes by free typing. I free type a differential next to my assessment or on the first line of the plan. I don’t use templates; they slow me down too much.

Kelly Luba, DO
Phoenix, Ariz

I was a civil service physician working for the Department of the Navy in 2005 when EHRs were thrust upon me. The system was not particularly user-friendly. Free texting was highly discouraged and it was strongly preferred that we used structured text embedded in the program.

I couldn’t use the program as envisioned, so I found a work-around. I would paste the 4 sections of the SOAP note directly into the appropriate free text sections of the electronic record. My assessment included the correct diagnosis, and I would pick a general EHR diagnosis from the dropdown list. Visually, my records did not look any different from those of other health care providers who used structured text.

I used this method until my civil service retirement in 2014. All of my record peer reviews were outstanding, and I was told that my records were easy to understand. I finally let on to all that I never used structured text and that all of my records were really written the old-fashioned way. I still used a clipboard during the patient visit, and completed all records after the patient left.

David F. Scaccia, DO, MPH
Kittery, Maine

Dr. Hickner’s editorial “EHRs: Something’s gotta give” (J Fam Pract. 2014;63:558) prompted me to reflect on the elements of electronic health records (EHRs) that cannot change and the ones that can.

The EHR system I use allows the EHR to serve as a 
quality recorder, and it appears 
this is the most important part,
 because the reminders of what
 needs to be documented come first and are color-coded. From a reimbursement point of view, what is important is not the narrative, but the expanded “elements” that make it a billing document. I believe this will not change.

What can change is how the note information is organized, and I think the organization should be different for specific roles. At intake, a medical assistant can review allergies, medication lists, and preventive services; update family history; and take vital signs and history of present illness (HPI). As the physician, I want the note to show the information in the order that I process it during the visit: 1) allergies/medication list, 2) concerns/complaints with brief documentation, 3) vitals, 4) physical, 5) assessment, and 6) plan.

After the note is signed off on, I want a different format for review purposes: 1) assessment/plan (because this is what I look at first for follow-up), 2) HPI/review of systems, 3) physical, 4) allergies, 5) medication list, 6) past medical history, and 7) quality reminders (if they show up at all after the visit is complete).

Is it asking too much for a programmer to make the EHR organize information in this manner?

Edward Friedler, MD
Annandale, Va

I still dictate my notes and they very much tell a story that an EHR cannot. I have been audited repeatedly and I always have all the bullet points and essentials that the insurance company wants, but this information is in a format that everyone—including patients—can read and appreciate.

The move to APSO (assessment, plan, subjective, objective) from SOAP (subjective, objective, assessment, plan) is an example of the tail wagging the dog. Rather than fix the note so the time-honored SOAP format works, we acknowledge that no one actually reads the long template notes and they want to get to the bottom line (ie, the assessment and plan).

My dream is to return to the days when we only listed the positive findings, the assumption being that a competent physician did the exam that was required and it’s unnecessary to state that the examined anatomy was normal. Unfortunately, so much of what we must do is driven by lawyers and insurance companies—not by doctors.

David M. Brill, DO
Rocky River, Ohio

I now take photos of all of the ludicrous choices our EHR tosses at me, such as “laceration of third eyelid” or “injury, crushed by falling aircraft due to terrorist.” Most of my EHR entries now say, “See scanned handwritten note for accuracy.”

The issue of EHRs needs to be kept on the front burner. It is destroying doctor/patient relationships and quality diagnostic care while hiding the important findings in the garbage.

Jay Hammett, MD
Knoxville, Tenn

I’m in a group practice of 10 family physicians and in a typical workday, each of us sees 23 to 25 patients, answers e-mails/phone calls, and reviews labs/studies, which leaves no time for anything else. There’s a constant struggle to stay on top of the quality of the notes. I have preserved the quality of my own notes by free typing. I free type a differential next to my assessment or on the first line of the plan. I don’t use templates; they slow me down too much.

Kelly Luba, DO
Phoenix, Ariz

I was a civil service physician working for the Department of the Navy in 2005 when EHRs were thrust upon me. The system was not particularly user-friendly. Free texting was highly discouraged and it was strongly preferred that we used structured text embedded in the program.

I couldn’t use the program as envisioned, so I found a work-around. I would paste the 4 sections of the SOAP note directly into the appropriate free text sections of the electronic record. My assessment included the correct diagnosis, and I would pick a general EHR diagnosis from the dropdown list. Visually, my records did not look any different from those of other health care providers who used structured text.

I used this method until my civil service retirement in 2014. All of my record peer reviews were outstanding, and I was told that my records were easy to understand. I finally let on to all that I never used structured text and that all of my records were really written the old-fashioned way. I still used a clipboard during the patient visit, and completed all records after the patient left.

David F. Scaccia, DO, MPH
Kittery, Maine

Dr. Hickner’s editorial “EHRs: Something’s gotta give” (J Fam Pract. 2014;63:558) prompted me to reflect on the elements of electronic health records (EHRs) that cannot change and the ones that can.

The EHR system I use allows the EHR to serve as a 
quality recorder, and it appears 
this is the most important part,
 because the reminders of what
 needs to be documented come first and are color-coded. From a reimbursement point of view, what is important is not the narrative, but the expanded “elements” that make it a billing document. I believe this will not change.

What can change is how the note information is organized, and I think the organization should be different for specific roles. At intake, a medical assistant can review allergies, medication lists, and preventive services; update family history; and take vital signs and history of present illness (HPI). As the physician, I want the note to show the information in the order that I process it during the visit: 1) allergies/medication list, 2) concerns/complaints with brief documentation, 3) vitals, 4) physical, 5) assessment, and 6) plan.

After the note is signed off on, I want a different format for review purposes: 1) assessment/plan (because this is what I look at first for follow-up), 2) HPI/review of systems, 3) physical, 4) allergies, 5) medication list, 6) past medical history, and 7) quality reminders (if they show up at all after the visit is complete).

Is it asking too much for a programmer to make the EHR organize information in this manner?

Edward Friedler, MD
Annandale, Va

I still dictate my notes and they very much tell a story that an EHR cannot. I have been audited repeatedly and I always have all the bullet points and essentials that the insurance company wants, but this information is in a format that everyone—including patients—can read and appreciate.

The move to APSO (assessment, plan, subjective, objective) from SOAP (subjective, objective, assessment, plan) is an example of the tail wagging the dog. Rather than fix the note so the time-honored SOAP format works, we acknowledge that no one actually reads the long template notes and they want to get to the bottom line (ie, the assessment and plan).

My dream is to return to the days when we only listed the positive findings, the assumption being that a competent physician did the exam that was required and it’s unnecessary to state that the examined anatomy was normal. Unfortunately, so much of what we must do is driven by lawyers and insurance companies—not by doctors.

David M. Brill, DO
Rocky River, Ohio

I now take photos of all of the ludicrous choices our EHR tosses at me, such as “laceration of third eyelid” or “injury, crushed by falling aircraft due to terrorist.” Most of my EHR entries now say, “See scanned handwritten note for accuracy.”

The issue of EHRs needs to be kept on the front burner. It is destroying doctor/patient relationships and quality diagnostic care while hiding the important findings in the garbage.

Jay Hammett, MD
Knoxville, Tenn

I’m in a group practice of 10 family physicians and in a typical workday, each of us sees 23 to 25 patients, answers e-mails/phone calls, and reviews labs/studies, which leaves no time for anything else. There’s a constant struggle to stay on top of the quality of the notes. I have preserved the quality of my own notes by free typing. I free type a differential next to my assessment or on the first line of the plan. I don’t use templates; they slow me down too much.

Kelly Luba, DO
Phoenix, Ariz

I was a civil service physician working for the Department of the Navy in 2005 when EHRs were thrust upon me. The system was not particularly user-friendly. Free texting was highly discouraged and it was strongly preferred that we used structured text embedded in the program.

I couldn’t use the program as envisioned, so I found a work-around. I would paste the 4 sections of the SOAP note directly into the appropriate free text sections of the electronic record. My assessment included the correct diagnosis, and I would pick a general EHR diagnosis from the dropdown list. Visually, my records did not look any different from those of other health care providers who used structured text.

I used this method until my civil service retirement in 2014. All of my record peer reviews were outstanding, and I was told that my records were easy to understand. I finally let on to all that I never used structured text and that all of my records were really written the old-fashioned way. I still used a clipboard during the patient visit, and completed all records after the patient left.

David F. Scaccia, DO, MPH
Kittery, Maine

Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.

Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.

The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.

When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.

Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.

Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.

If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.

Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.

Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).

Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.

Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.

Light therapy is also easy to implement. With the purchase of a lamp that costs less than $1,000, you can offer this treatment. Patients can come twice a week for 15-minute sessions for a total of eight sessions. The average cost for these treatments is $50-$75 per treatment. Combinations of peels and light therapy have great results with minimal risk and prevent families from having to wait the 3-6 months it takes to get to see the dermatologist.

Lastly, consider cosmeceuticals. There is no great mystery as to what is in the acne medications. You can create your own line using a compounding pharmacy such as MasterPharm or University Compounding Pharmacy . Or use a cosmeceuticals company that will provide you quality products at wholesale prices. Many of them don’t require you to stock the product. SkinMedica and SkinCeuticals ( are popular ones, but there are several more. As opposed to your patient going to the local pharmacy and guessing at which product is best, you can provide a full line of products that will give the best results.

Without compromising care, you can provide complete skin care to your patients and increase your revenue and your patient’s satisfaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. Dr. Pearce had no relevant financial disclosures. E-mail her at [email protected].

Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.

Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.

The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.

When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.

Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.

Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.

If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.

Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.

Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).

Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.

Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.

Light therapy is also easy to implement. With the purchase of a lamp that costs less than $1,000, you can offer this treatment. Patients can come twice a week for 15-minute sessions for a total of eight sessions. The average cost for these treatments is $50-$75 per treatment. Combinations of peels and light therapy have great results with minimal risk and prevent families from having to wait the 3-6 months it takes to get to see the dermatologist.

Lastly, consider cosmeceuticals. There is no great mystery as to what is in the acne medications. You can create your own line using a compounding pharmacy such as MasterPharm or University Compounding Pharmacy . Or use a cosmeceuticals company that will provide you quality products at wholesale prices. Many of them don’t require you to stock the product. SkinMedica and SkinCeuticals ( are popular ones, but there are several more. As opposed to your patient going to the local pharmacy and guessing at which product is best, you can provide a full line of products that will give the best results.

Without compromising care, you can provide complete skin care to your patients and increase your revenue and your patient’s satisfaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. Dr. Pearce had no relevant financial disclosures. E-mail her at [email protected].

Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.

Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.

The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.

When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.

Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.

Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.

If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.

Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.

Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).

Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.

Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.

Light therapy is also easy to implement. With the purchase of a lamp that costs less than $1,000, you can offer this treatment. Patients can come twice a week for 15-minute sessions for a total of eight sessions. The average cost for these treatments is $50-$75 per treatment. Combinations of peels and light therapy have great results with minimal risk and prevent families from having to wait the 3-6 months it takes to get to see the dermatologist.

Lastly, consider cosmeceuticals. There is no great mystery as to what is in the acne medications. You can create your own line using a compounding pharmacy such as MasterPharm or University Compounding Pharmacy . Or use a cosmeceuticals company that will provide you quality products at wholesale prices. Many of them don’t require you to stock the product. SkinMedica and SkinCeuticals ( are popular ones, but there are several more. As opposed to your patient going to the local pharmacy and guessing at which product is best, you can provide a full line of products that will give the best results.

Without compromising care, you can provide complete skin care to your patients and increase your revenue and your patient’s satisfaction.

Dr. Pearce is a pediatrician in Frankfort, Ill. Dr. Pearce had no relevant financial disclosures. E-mail her at [email protected].

Introduction

Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.

Case Summary

Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.

Discussion

While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?

A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.

Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.

The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.

There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at [email protected].

Introduction

Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.

Case Summary

Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.

Discussion

While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?

A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.

Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.

The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.

There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at [email protected].

Introduction

Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.

Case Summary

Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.

Discussion

While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?

A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.

Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.

The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.

There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at [email protected].