Commentary

Recently, an article in JAMA Internal Medicine suggested that more than 50% of nursing home patients with advanced dementia are on “medications of questionable benefit.” The study went on to define those drugs as memantine, cholinesterase inhibitors, and statins.

Shocker, huh?

“Questionable benefit” is in the eyes of the beholder. Two of the above drugs have FDA indications for advanced dementia (statins for dyslipidemia), so you could argue there’s nothing “questionable” about it. The FDA says we can do it, so we will.

Right, but we all use drugs off label in this business without hesitation. So why should we think twice about using them on label?

It’s a valid point. Why do we prescribe these drugs to advanced dementia patients? How many of you have actually seen meaningful clinical benefit with them in this group, not just graphed points on a detail piece?

I use them, too, but I try to lower expectations with patients and their families. If all they see are direct-to-consumer ads, they’ll think this is a cure. Nope.

The fact is that the best we can do today is to slow progression ... somewhat. So if they’re already in end-stage disease, why bother? At some point, trying to keep these patients alive becomes more of an emotional torture for their families. All of us have seen these patients. How many of us want to live like that? I’m going to say none.

So, if their use in this population is “questionable,” I have to question why we do it at all.

This is where medicine gets hazy. On one side are those who claim that anyone with end-stage dementia should be treated with comfort care only. On the other are those who argue we need to do everything possible to keep them alive (usually politicians, not doctors). But most people are in a gray middle.

There’s also a big difference between what we can do and what we should do. This point, unfortunately, is often lost in the complex web of patient care. Advanced dementia patient = memantine + cholinesterase inhibitor. Medicine becomes a flowchart rather than a thinking specialty.

Then there’s the families. None of us wants to destroy hope. So we go with “Well, let’s try this medicine and see what happens.” It is, admittedly, easier than saying “I have nothing that will make a meaningful difference.” People see these advertised and want to believe these magical drugs will fix what ails grandma.

There’s also nursing staff, leaving Post-It notes on the chart that say “Patient has Alzheimer’s disease. Do you want to start Aricept?” I see that here and there, too. I think most of us okay it, because it’s easier than saying “What’s the point?”

Hiding in the background is, lastly, the specter of a malpractice suit. Even if the patient is beyond you making them worse, there’s always another neurologist out there willing to testify (for a fee) that by not prescribing these drugs, you fell beneath the standard of care.

The practice of using these drugs in end-stage dementia is indeed questionable. But the possible answers, and the dilemmas they put us in, often lead to doing what’s possible instead of simply necessary.

And when that happens, the only ones who benefit are the legal profession and drug companies.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, an article in JAMA Internal Medicine suggested that more than 50% of nursing home patients with advanced dementia are on “medications of questionable benefit.” The study went on to define those drugs as memantine, cholinesterase inhibitors, and statins.

Shocker, huh?

“Questionable benefit” is in the eyes of the beholder. Two of the above drugs have FDA indications for advanced dementia (statins for dyslipidemia), so you could argue there’s nothing “questionable” about it. The FDA says we can do it, so we will.

Right, but we all use drugs off label in this business without hesitation. So why should we think twice about using them on label?

It’s a valid point. Why do we prescribe these drugs to advanced dementia patients? How many of you have actually seen meaningful clinical benefit with them in this group, not just graphed points on a detail piece?

I use them, too, but I try to lower expectations with patients and their families. If all they see are direct-to-consumer ads, they’ll think this is a cure. Nope.

The fact is that the best we can do today is to slow progression ... somewhat. So if they’re already in end-stage disease, why bother? At some point, trying to keep these patients alive becomes more of an emotional torture for their families. All of us have seen these patients. How many of us want to live like that? I’m going to say none.

So, if their use in this population is “questionable,” I have to question why we do it at all.

This is where medicine gets hazy. On one side are those who claim that anyone with end-stage dementia should be treated with comfort care only. On the other are those who argue we need to do everything possible to keep them alive (usually politicians, not doctors). But most people are in a gray middle.

There’s also a big difference between what we can do and what we should do. This point, unfortunately, is often lost in the complex web of patient care. Advanced dementia patient = memantine + cholinesterase inhibitor. Medicine becomes a flowchart rather than a thinking specialty.

Then there’s the families. None of us wants to destroy hope. So we go with “Well, let’s try this medicine and see what happens.” It is, admittedly, easier than saying “I have nothing that will make a meaningful difference.” People see these advertised and want to believe these magical drugs will fix what ails grandma.

There’s also nursing staff, leaving Post-It notes on the chart that say “Patient has Alzheimer’s disease. Do you want to start Aricept?” I see that here and there, too. I think most of us okay it, because it’s easier than saying “What’s the point?”

Hiding in the background is, lastly, the specter of a malpractice suit. Even if the patient is beyond you making them worse, there’s always another neurologist out there willing to testify (for a fee) that by not prescribing these drugs, you fell beneath the standard of care.

The practice of using these drugs in end-stage dementia is indeed questionable. But the possible answers, and the dilemmas they put us in, often lead to doing what’s possible instead of simply necessary.

And when that happens, the only ones who benefit are the legal profession and drug companies.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, an article in JAMA Internal Medicine suggested that more than 50% of nursing home patients with advanced dementia are on “medications of questionable benefit.” The study went on to define those drugs as memantine, cholinesterase inhibitors, and statins.

Shocker, huh?

“Questionable benefit” is in the eyes of the beholder. Two of the above drugs have FDA indications for advanced dementia (statins for dyslipidemia), so you could argue there’s nothing “questionable” about it. The FDA says we can do it, so we will.

Right, but we all use drugs off label in this business without hesitation. So why should we think twice about using them on label?

It’s a valid point. Why do we prescribe these drugs to advanced dementia patients? How many of you have actually seen meaningful clinical benefit with them in this group, not just graphed points on a detail piece?

I use them, too, but I try to lower expectations with patients and their families. If all they see are direct-to-consumer ads, they’ll think this is a cure. Nope.

The fact is that the best we can do today is to slow progression ... somewhat. So if they’re already in end-stage disease, why bother? At some point, trying to keep these patients alive becomes more of an emotional torture for their families. All of us have seen these patients. How many of us want to live like that? I’m going to say none.

So, if their use in this population is “questionable,” I have to question why we do it at all.

This is where medicine gets hazy. On one side are those who claim that anyone with end-stage dementia should be treated with comfort care only. On the other are those who argue we need to do everything possible to keep them alive (usually politicians, not doctors). But most people are in a gray middle.

There’s also a big difference between what we can do and what we should do. This point, unfortunately, is often lost in the complex web of patient care. Advanced dementia patient = memantine + cholinesterase inhibitor. Medicine becomes a flowchart rather than a thinking specialty.

Then there’s the families. None of us wants to destroy hope. So we go with “Well, let’s try this medicine and see what happens.” It is, admittedly, easier than saying “I have nothing that will make a meaningful difference.” People see these advertised and want to believe these magical drugs will fix what ails grandma.

There’s also nursing staff, leaving Post-It notes on the chart that say “Patient has Alzheimer’s disease. Do you want to start Aricept?” I see that here and there, too. I think most of us okay it, because it’s easier than saying “What’s the point?”

Hiding in the background is, lastly, the specter of a malpractice suit. Even if the patient is beyond you making them worse, there’s always another neurologist out there willing to testify (for a fee) that by not prescribing these drugs, you fell beneath the standard of care.

The practice of using these drugs in end-stage dementia is indeed questionable. But the possible answers, and the dilemmas they put us in, often lead to doing what’s possible instead of simply necessary.

And when that happens, the only ones who benefit are the legal profession and drug companies.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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

Letter to the Editor

Universal Hepatitis C Screening
and Surgeon Safety

I read with interest the article “Risk of Hepatitis C Virus Exposure in Orthopedic Surgery: Is Universal Screening Needed?” by Dr. DelSole and colleagues (Am J Orthop. 2014;43(6):E117-E123). The authors make a compelling case for universal hepatitis C screening, and I agree that this program may have significant benefits, including risk stratification for elective surgery and identification of patients for antiviral treatment. However, based largely on personal experiences, I disagree that preoperative knowledge of the patient’s seropositive status will improve surgeon safety.

The authors list a number of interventions to decrease the risk of exposure, such as the use of Kevlar gloves, double gloving, eye protection, and others. However, perhaps the largest barrier to their use is their perceived inconvenience. Surgeons often cite decreased dexterity and sensation in their opposition to double or thick gloves, for instance. My concern is that with the advent of universal screening, many surgeons will abandon their universal approach and only wear Kevlar or double gloves on infected cases.

I have observed first-hand such a policy this year, when I spent 3 months in orthopedic centers in Russia. In Russia, all patients undergo routine preoperative testing for both hepatitis C virus and human immunodeficiency virus (HIV). While the policy of standard precautions exists, the majority of surgeons used single gloves and did not use eye protection for most cases, but took additional measures when operating on seropositive patients. Paradoxically, I witnessed numerous needle sticks during those cases, precisely because the surgeons and staff were not comfortable with wearing double gloves or hands-free passing of sharp instruments. Even goggles often ended up being removed during the cases, because the surgeons were not accustomed to using them.

Like any surgical skill, standard precautions require repetition and practice. Therefore, I am concerned that with adoption of universal screening in the United States, we will become complacent and accustomed to unsafe practices, which may paradoxically increase the risk of operating on infected patients.

Igor Immerman, MD

Pleasanton, CA

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this letter.

Author’s Response

Edward M. DelSole, MD

We appreciate the response of the reader. This is indeed an interesting paradox—that an effort to improve safety in the operating room might yield the opposite effect owing to a heightened sense of protection, which induces a laxity in adhering to standard precautions. This possibility does create a real concern for the safety of the surgical team. Although we do recommend preoperative screening for hepatitis C virus (HCV), our intent was not in any way to diminish the need for adhering to standard precautions.

The foundation of standard precautions rests upon the universal assumption of infectivity of blood exposures—this is why the precautions are “standard” and should be adhered to during all operative procedures.

First and foremost, identification of patients with hepatitis C infection offers the chance for referral for care, which in many cases is curative thanks to recent advances in hepatitis C therapy. Whether or not the patient accepts the referral for hepatitis C treatment should not, as we emphasize in our paper, affect the plan for surgery.

Secondly, a negative preoperative test should in no way alter normal intraoperative safety practices. The test results could be falsely negative due to human or mechanical error. In addition, the patient could have other transmissible diseases such as HIV, hepatitis B, or other less common yet transmissible viral infections. Importantly, given the historical narratives of the HIV and HCV epidemics, we as surgeons hold the responsibility to never be complacent about the next “unknown” novel viral agent that has yet to reveal itself.

Thirdly, perceived inconvenience of protective equipment is largely a matter of training. At our institution residents infrequently wear single layers of gloves, masks without eye protection, body suits for arthroplasty, lead vests without thyroid shields, etc. We suspect similar practice occurs at other teaching hospitals as well. As today’s residents learn the craft in an environment of heightened protection, it is our hope that they will carry these good habits into their own practice as orthopedic surgeons and that patient outcomes will not differ.

The goal of screening is to create an improved environment of safety and health awareness for the patient and the surgical team, the foundation of which is standard precautions in the operating room. We advocate strongly that standard precautions continue to be the basis of intraoperative safety and that they be used for all patients indiscriminately.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this letter.

The journal welcomes Letters to the Editor. Letters are not peer reviewed. Opinions expressed in letters published here do not necessarily reflect those of the editorial board or the publishing company and its employees.

Letter to the Editor

Universal Hepatitis C Screening
and Surgeon Safety

I read with interest the article “Risk of Hepatitis C Virus Exposure in Orthopedic Surgery: Is Universal Screening Needed?” by Dr. DelSole and colleagues (Am J Orthop. 2014;43(6):E117-E123). The authors make a compelling case for universal hepatitis C screening, and I agree that this program may have significant benefits, including risk stratification for elective surgery and identification of patients for antiviral treatment. However, based largely on personal experiences, I disagree that preoperative knowledge of the patient’s seropositive status will improve surgeon safety.

The authors list a number of interventions to decrease the risk of exposure, such as the use of Kevlar gloves, double gloving, eye protection, and others. However, perhaps the largest barrier to their use is their perceived inconvenience. Surgeons often cite decreased dexterity and sensation in their opposition to double or thick gloves, for instance. My concern is that with the advent of universal screening, many surgeons will abandon their universal approach and only wear Kevlar or double gloves on infected cases.

I have observed first-hand such a policy this year, when I spent 3 months in orthopedic centers in Russia. In Russia, all patients undergo routine preoperative testing for both hepatitis C virus and human immunodeficiency virus (HIV). While the policy of standard precautions exists, the majority of surgeons used single gloves and did not use eye protection for most cases, but took additional measures when operating on seropositive patients. Paradoxically, I witnessed numerous needle sticks during those cases, precisely because the surgeons and staff were not comfortable with wearing double gloves or hands-free passing of sharp instruments. Even goggles often ended up being removed during the cases, because the surgeons were not accustomed to using them.

Like any surgical skill, standard precautions require repetition and practice. Therefore, I am concerned that with adoption of universal screening in the United States, we will become complacent and accustomed to unsafe practices, which may paradoxically increase the risk of operating on infected patients.

Igor Immerman, MD

Pleasanton, CA

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this letter.

Author’s Response

Edward M. DelSole, MD

We appreciate the response of the reader. This is indeed an interesting paradox—that an effort to improve safety in the operating room might yield the opposite effect owing to a heightened sense of protection, which induces a laxity in adhering to standard precautions. This possibility does create a real concern for the safety of the surgical team. Although we do recommend preoperative screening for hepatitis C virus (HCV), our intent was not in any way to diminish the need for adhering to standard precautions.

The foundation of standard precautions rests upon the universal assumption of infectivity of blood exposures—this is why the precautions are “standard” and should be adhered to during all operative procedures.

First and foremost, identification of patients with hepatitis C infection offers the chance for referral for care, which in many cases is curative thanks to recent advances in hepatitis C therapy. Whether or not the patient accepts the referral for hepatitis C treatment should not, as we emphasize in our paper, affect the plan for surgery.

Secondly, a negative preoperative test should in no way alter normal intraoperative safety practices. The test results could be falsely negative due to human or mechanical error. In addition, the patient could have other transmissible diseases such as HIV, hepatitis B, or other less common yet transmissible viral infections. Importantly, given the historical narratives of the HIV and HCV epidemics, we as surgeons hold the responsibility to never be complacent about the next “unknown” novel viral agent that has yet to reveal itself.

Thirdly, perceived inconvenience of protective equipment is largely a matter of training. At our institution residents infrequently wear single layers of gloves, masks without eye protection, body suits for arthroplasty, lead vests without thyroid shields, etc. We suspect similar practice occurs at other teaching hospitals as well. As today’s residents learn the craft in an environment of heightened protection, it is our hope that they will carry these good habits into their own practice as orthopedic surgeons and that patient outcomes will not differ.

The goal of screening is to create an improved environment of safety and health awareness for the patient and the surgical team, the foundation of which is standard precautions in the operating room. We advocate strongly that standard precautions continue to be the basis of intraoperative safety and that they be used for all patients indiscriminately.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this letter.

The journal welcomes Letters to the Editor. Letters are not peer reviewed. Opinions expressed in letters published here do not necessarily reflect those of the editorial board or the publishing company and its employees.

Letter to the Editor

Universal Hepatitis C Screening
and Surgeon Safety

I read with interest the article “Risk of Hepatitis C Virus Exposure in Orthopedic Surgery: Is Universal Screening Needed?” by Dr. DelSole and colleagues (Am J Orthop. 2014;43(6):E117-E123). The authors make a compelling case for universal hepatitis C screening, and I agree that this program may have significant benefits, including risk stratification for elective surgery and identification of patients for antiviral treatment. However, based largely on personal experiences, I disagree that preoperative knowledge of the patient’s seropositive status will improve surgeon safety.

The authors list a number of interventions to decrease the risk of exposure, such as the use of Kevlar gloves, double gloving, eye protection, and others. However, perhaps the largest barrier to their use is their perceived inconvenience. Surgeons often cite decreased dexterity and sensation in their opposition to double or thick gloves, for instance. My concern is that with the advent of universal screening, many surgeons will abandon their universal approach and only wear Kevlar or double gloves on infected cases.

I have observed first-hand such a policy this year, when I spent 3 months in orthopedic centers in Russia. In Russia, all patients undergo routine preoperative testing for both hepatitis C virus and human immunodeficiency virus (HIV). While the policy of standard precautions exists, the majority of surgeons used single gloves and did not use eye protection for most cases, but took additional measures when operating on seropositive patients. Paradoxically, I witnessed numerous needle sticks during those cases, precisely because the surgeons and staff were not comfortable with wearing double gloves or hands-free passing of sharp instruments. Even goggles often ended up being removed during the cases, because the surgeons were not accustomed to using them.

Like any surgical skill, standard precautions require repetition and practice. Therefore, I am concerned that with adoption of universal screening in the United States, we will become complacent and accustomed to unsafe practices, which may paradoxically increase the risk of operating on infected patients.

Igor Immerman, MD

Pleasanton, CA

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this letter.

Author’s Response

Edward M. DelSole, MD

We appreciate the response of the reader. This is indeed an interesting paradox—that an effort to improve safety in the operating room might yield the opposite effect owing to a heightened sense of protection, which induces a laxity in adhering to standard precautions. This possibility does create a real concern for the safety of the surgical team. Although we do recommend preoperative screening for hepatitis C virus (HCV), our intent was not in any way to diminish the need for adhering to standard precautions.

The foundation of standard precautions rests upon the universal assumption of infectivity of blood exposures—this is why the precautions are “standard” and should be adhered to during all operative procedures.

First and foremost, identification of patients with hepatitis C infection offers the chance for referral for care, which in many cases is curative thanks to recent advances in hepatitis C therapy. Whether or not the patient accepts the referral for hepatitis C treatment should not, as we emphasize in our paper, affect the plan for surgery.

Secondly, a negative preoperative test should in no way alter normal intraoperative safety practices. The test results could be falsely negative due to human or mechanical error. In addition, the patient could have other transmissible diseases such as HIV, hepatitis B, or other less common yet transmissible viral infections. Importantly, given the historical narratives of the HIV and HCV epidemics, we as surgeons hold the responsibility to never be complacent about the next “unknown” novel viral agent that has yet to reveal itself.

Thirdly, perceived inconvenience of protective equipment is largely a matter of training. At our institution residents infrequently wear single layers of gloves, masks without eye protection, body suits for arthroplasty, lead vests without thyroid shields, etc. We suspect similar practice occurs at other teaching hospitals as well. As today’s residents learn the craft in an environment of heightened protection, it is our hope that they will carry these good habits into their own practice as orthopedic surgeons and that patient outcomes will not differ.

The goal of screening is to create an improved environment of safety and health awareness for the patient and the surgical team, the foundation of which is standard precautions in the operating room. We advocate strongly that standard precautions continue to be the basis of intraoperative safety and that they be used for all patients indiscriminately.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this letter.

The journal welcomes Letters to the Editor. Letters are not peer reviewed. Opinions expressed in letters published here do not necessarily reflect those of the editorial board or the publishing company and its employees.

Technology creates change, and change is moving fast and is relentless. Physicians, on the other hand, are generally slow to change. Wisely, we question change—we observe it, we study it, and we try to ensure our patients will benefit from it over time. Maybe as a result of this or as a consequence of our often myopic view of the world, we mistakenly let others lead the way and dictate how we must change and what our practices must absorb. We must turn this around and be the agents of change for our profession so we can appropriately use the available technology and create systems for managing the demands of a society that expects instant answers with fewer doctor resources devoted to the answer. The insurance industry is encouraging a wholesale dismantling of the classic patient visit to be replaced by nonphysician interactions, virtual diagnostics, and electronic medical records. We must not allow this and must ensure that we safeguard our profession by employing traditional skills, utilizing our 5 senses, and incorporating technology as a tool for better diagnosis and treatment but not as a substitute for the same.  

Great doctors are often described as having a sixth sense—an intuition that guides them in diagnosing and treating patients. It is assumed, therefore, that the good doctor will have the benefit of 5 senses: sight, sound, touch, smell, and taste. Sound: What does the patient tell or neglect to tell the doctor? What sounds does a joint produce when it moves? Sight: How does the patient present? Are they weary from pain or chronic disease? Touch: What does the joint feel like? How does it move? What is the patient’s response to stabilization of a joint? Smell: Is there an odor that helps detect the presence of infection or decay? Is the patient coming into contact with a substance causing harm or preventing healing?

A good doctor must employ these senses first to understand the patient’s needs and then to treat the patient. The sixth sense is a gift, one that comes from years of experience, an attention to detail, and a commitment to the craft of medicine. A recent trend toward virtual medicine is a dangerous path that must be walked with care and discretion so that the 6 senses are maintained and nurtured. Technology must be used to enhance and not limit these senses. The patient cannot be reduced to a 2-dimensional version of his/herself so that the doctor’s powers of diagnosis and healing are similarly limited.

Change in the office has occurred with mandates for electronic medical records and work-hour restrictions for residents. Data do not support that either change has resulted in a net benefit to patients. We are mandated to invest scarce capital to support new technology, resulting in increased pressure to recoup investment. Where there is a cap on revenue, the only way to increase net profit is to increase volume and decrease services. Physician time is the variable and can be streamlined by performing video conferences or smartphone consultations. Change may bring higher order, as the English philosopher John Locke said, but it is time for all of us as physicians to step back and question that this type of change is the path we must take. An office with a schedule of 80 patients seen at 5-minute intervals by physician assistants has no place in medicine. The pressure imposed by the insurance industry or hospital administrators to meet quotas has gotten out of hand and the time is now to say with a strong but fair voice a resounding NO!

The office visit with a history and physical examination is the most exciting and effective time to meet, console, and relate to our patients. The use of the 5 senses is critical. We must not let technological advancements (eg, smartphones, the Internet, and electronic medical records) destroy what was created and taught to us all through our training. The reward that is accomplished by placing one’s hand on a patient’s knee to understand its warmth and swelling, the tactile feeling of a fluid wave, or performing carefully with compassion a provocative maneuver that gives by sight a grimace of discomfort can tell so much more than a status update on the phone. We must not allow ourselves to be replaced by ancillary services for so-called efficiency and cost saving. Rather, we must be innovative and sharp. We must find the way to use the wonders of the virtual world without giving up the human consult.

Imagine that you are able to travel to Iguazu Falls, South America, to see one of the wonders of our world. You sit in that life raft moving upstream to feel the heat from the water as it crushes the rocks below, and you feel the mist on your face. You see the majesty and hear the screams and breadth of excitement of those around you, while you listen to the deafening sounds created by this waterfall. Now imagine you are required to report on this same experience through a video or some form of technology that the world has convinced us is the best and far cheaper substitute. This is our electronic medical record. A tool we are forced to use, and while it has a purpose, it is a sterile tool that fails to provide information that will give clues to awaken the sixth sense. It is a checklist that could allow for completion of a task—like how to fix a leaky faucet.

How then do we accomplish walking the fine line of working with nonphysicians and technology and yet delivering pinnacle care? The answer isn’t simple but it must include education and a commitment to the profession. We must make the public aware that we are one of the few professions that dedicate our lives to others by promoting health and advancing research. My colleagues, the pendulum has swung too far; it is time to take back our great profession through education of ourselves and the public. While technology may help the world connect, it has a limited role unless we first use our 6 senses to help our patients. We must not submit to a compassionless and callous approach that is the inevitable outcome of virtual medicine done with speed. We must maintain our dignity and let the public understand how many years of sacrifice has taken place to earn a sixth sense and not allow a third party to take it away. We are the only source of protection for our patients and we need each one of our senses to perform this task.

Advancing research has been a cornerstone for the orthopedic surgeon. Position statements through meta-analyses and systematic reviews of the literature have recently been utilized with increasing frequency. Combining data of potentially flawed studies can often lead to erroneous conclusions and may stray away from best practices. Is this where we want evidence-based medicine to go? The end result is that decisions are made by insurance companies who rely on these flawed studies to force clinical decisions on the physician, as was most recently seen by the investigation of viscosupplementation for knee osteoarthritis.¹

In a 2007 study published in JAMA (The Journal of the American Medical Association), only 62% of residents could appropriately interpret a P value.² How can we expect young clinicians to evaluate, interpret, and apply the multitude of evidence in the literature to everyday practice? We must marry the use of best evidence with our expertise to make the most informed decision while managing the expectations of our patients. In order to achieve that balance, we must rely on our intuition, our sixth sense. There is too much patient individuality and complexity surrounding each individual’s situation for a one-size-fits-all approach and for wholesale reliance on research to address each unique situation.

If Nathan Davis in 1845 was able to convince the New York Medical Society to establish a nationwide professional association to assist in regulating the practice of medicine, then it is time for all of us to stand up and insist on a code of ethics that is unrelenting and uncompromising. Our wise leaders of the American Orthopaedic Association (AOA) who founded the formation of orthopedics in America knew guidelines were needed to “foster advances in the care of patients, improve the teaching of orthopaedic surgery in medical schools and formal orthopaedic training, and to promote orthopaedic surgery as a surgical discipline worldwide.”³ It is now our turn to renew the guidelines and encourage our leaders to help educate ourselves and patients as we work with technology and administrators, nurses and physician assistants to deliver pinnacle care. We must reform medical education and the practice of medicine so that technology is used as a companion but not a substitute for our 6 senses.

The next time a patient comes into the exam room, sit down, look the patient in the eye, listen, touch, console anxiety, make a human connection, and form a lasting relationship. By all means apologize to your patients as you fill out the electronic medical record and insurance forms. Discuss how we are in the same crisis together and ask for their help as they have come to you for yours.

Technology creates change, and change is moving fast and is relentless. Physicians, on the other hand, are generally slow to change. Wisely, we question change—we observe it, we study it, and we try to ensure our patients will benefit from it over time. Maybe as a result of this or as a consequence of our often myopic view of the world, we mistakenly let others lead the way and dictate how we must change and what our practices must absorb. We must turn this around and be the agents of change for our profession so we can appropriately use the available technology and create systems for managing the demands of a society that expects instant answers with fewer doctor resources devoted to the answer. The insurance industry is encouraging a wholesale dismantling of the classic patient visit to be replaced by nonphysician interactions, virtual diagnostics, and electronic medical records. We must not allow this and must ensure that we safeguard our profession by employing traditional skills, utilizing our 5 senses, and incorporating technology as a tool for better diagnosis and treatment but not as a substitute for the same.  

Great doctors are often described as having a sixth sense—an intuition that guides them in diagnosing and treating patients. It is assumed, therefore, that the good doctor will have the benefit of 5 senses: sight, sound, touch, smell, and taste. Sound: What does the patient tell or neglect to tell the doctor? What sounds does a joint produce when it moves? Sight: How does the patient present? Are they weary from pain or chronic disease? Touch: What does the joint feel like? How does it move? What is the patient’s response to stabilization of a joint? Smell: Is there an odor that helps detect the presence of infection or decay? Is the patient coming into contact with a substance causing harm or preventing healing?

A good doctor must employ these senses first to understand the patient’s needs and then to treat the patient. The sixth sense is a gift, one that comes from years of experience, an attention to detail, and a commitment to the craft of medicine. A recent trend toward virtual medicine is a dangerous path that must be walked with care and discretion so that the 6 senses are maintained and nurtured. Technology must be used to enhance and not limit these senses. The patient cannot be reduced to a 2-dimensional version of his/herself so that the doctor’s powers of diagnosis and healing are similarly limited.

Change in the office has occurred with mandates for electronic medical records and work-hour restrictions for residents. Data do not support that either change has resulted in a net benefit to patients. We are mandated to invest scarce capital to support new technology, resulting in increased pressure to recoup investment. Where there is a cap on revenue, the only way to increase net profit is to increase volume and decrease services. Physician time is the variable and can be streamlined by performing video conferences or smartphone consultations. Change may bring higher order, as the English philosopher John Locke said, but it is time for all of us as physicians to step back and question that this type of change is the path we must take. An office with a schedule of 80 patients seen at 5-minute intervals by physician assistants has no place in medicine. The pressure imposed by the insurance industry or hospital administrators to meet quotas has gotten out of hand and the time is now to say with a strong but fair voice a resounding NO!

The office visit with a history and physical examination is the most exciting and effective time to meet, console, and relate to our patients. The use of the 5 senses is critical. We must not let technological advancements (eg, smartphones, the Internet, and electronic medical records) destroy what was created and taught to us all through our training. The reward that is accomplished by placing one’s hand on a patient’s knee to understand its warmth and swelling, the tactile feeling of a fluid wave, or performing carefully with compassion a provocative maneuver that gives by sight a grimace of discomfort can tell so much more than a status update on the phone. We must not allow ourselves to be replaced by ancillary services for so-called efficiency and cost saving. Rather, we must be innovative and sharp. We must find the way to use the wonders of the virtual world without giving up the human consult.

Imagine that you are able to travel to Iguazu Falls, South America, to see one of the wonders of our world. You sit in that life raft moving upstream to feel the heat from the water as it crushes the rocks below, and you feel the mist on your face. You see the majesty and hear the screams and breadth of excitement of those around you, while you listen to the deafening sounds created by this waterfall. Now imagine you are required to report on this same experience through a video or some form of technology that the world has convinced us is the best and far cheaper substitute. This is our electronic medical record. A tool we are forced to use, and while it has a purpose, it is a sterile tool that fails to provide information that will give clues to awaken the sixth sense. It is a checklist that could allow for completion of a task—like how to fix a leaky faucet.

How then do we accomplish walking the fine line of working with nonphysicians and technology and yet delivering pinnacle care? The answer isn’t simple but it must include education and a commitment to the profession. We must make the public aware that we are one of the few professions that dedicate our lives to others by promoting health and advancing research. My colleagues, the pendulum has swung too far; it is time to take back our great profession through education of ourselves and the public. While technology may help the world connect, it has a limited role unless we first use our 6 senses to help our patients. We must not submit to a compassionless and callous approach that is the inevitable outcome of virtual medicine done with speed. We must maintain our dignity and let the public understand how many years of sacrifice has taken place to earn a sixth sense and not allow a third party to take it away. We are the only source of protection for our patients and we need each one of our senses to perform this task.

Advancing research has been a cornerstone for the orthopedic surgeon. Position statements through meta-analyses and systematic reviews of the literature have recently been utilized with increasing frequency. Combining data of potentially flawed studies can often lead to erroneous conclusions and may stray away from best practices. Is this where we want evidence-based medicine to go? The end result is that decisions are made by insurance companies who rely on these flawed studies to force clinical decisions on the physician, as was most recently seen by the investigation of viscosupplementation for knee osteoarthritis.¹

In a 2007 study published in JAMA (The Journal of the American Medical Association), only 62% of residents could appropriately interpret a P value.² How can we expect young clinicians to evaluate, interpret, and apply the multitude of evidence in the literature to everyday practice? We must marry the use of best evidence with our expertise to make the most informed decision while managing the expectations of our patients. In order to achieve that balance, we must rely on our intuition, our sixth sense. There is too much patient individuality and complexity surrounding each individual’s situation for a one-size-fits-all approach and for wholesale reliance on research to address each unique situation.

If Nathan Davis in 1845 was able to convince the New York Medical Society to establish a nationwide professional association to assist in regulating the practice of medicine, then it is time for all of us to stand up and insist on a code of ethics that is unrelenting and uncompromising. Our wise leaders of the American Orthopaedic Association (AOA) who founded the formation of orthopedics in America knew guidelines were needed to “foster advances in the care of patients, improve the teaching of orthopaedic surgery in medical schools and formal orthopaedic training, and to promote orthopaedic surgery as a surgical discipline worldwide.”³ It is now our turn to renew the guidelines and encourage our leaders to help educate ourselves and patients as we work with technology and administrators, nurses and physician assistants to deliver pinnacle care. We must reform medical education and the practice of medicine so that technology is used as a companion but not a substitute for our 6 senses.

The next time a patient comes into the exam room, sit down, look the patient in the eye, listen, touch, console anxiety, make a human connection, and form a lasting relationship. By all means apologize to your patients as you fill out the electronic medical record and insurance forms. Discuss how we are in the same crisis together and ask for their help as they have come to you for yours.

Technology creates change, and change is moving fast and is relentless. Physicians, on the other hand, are generally slow to change. Wisely, we question change—we observe it, we study it, and we try to ensure our patients will benefit from it over time. Maybe as a result of this or as a consequence of our often myopic view of the world, we mistakenly let others lead the way and dictate how we must change and what our practices must absorb. We must turn this around and be the agents of change for our profession so we can appropriately use the available technology and create systems for managing the demands of a society that expects instant answers with fewer doctor resources devoted to the answer. The insurance industry is encouraging a wholesale dismantling of the classic patient visit to be replaced by nonphysician interactions, virtual diagnostics, and electronic medical records. We must not allow this and must ensure that we safeguard our profession by employing traditional skills, utilizing our 5 senses, and incorporating technology as a tool for better diagnosis and treatment but not as a substitute for the same.  

Great doctors are often described as having a sixth sense—an intuition that guides them in diagnosing and treating patients. It is assumed, therefore, that the good doctor will have the benefit of 5 senses: sight, sound, touch, smell, and taste. Sound: What does the patient tell or neglect to tell the doctor? What sounds does a joint produce when it moves? Sight: How does the patient present? Are they weary from pain or chronic disease? Touch: What does the joint feel like? How does it move? What is the patient’s response to stabilization of a joint? Smell: Is there an odor that helps detect the presence of infection or decay? Is the patient coming into contact with a substance causing harm or preventing healing?

A good doctor must employ these senses first to understand the patient’s needs and then to treat the patient. The sixth sense is a gift, one that comes from years of experience, an attention to detail, and a commitment to the craft of medicine. A recent trend toward virtual medicine is a dangerous path that must be walked with care and discretion so that the 6 senses are maintained and nurtured. Technology must be used to enhance and not limit these senses. The patient cannot be reduced to a 2-dimensional version of his/herself so that the doctor’s powers of diagnosis and healing are similarly limited.

Change in the office has occurred with mandates for electronic medical records and work-hour restrictions for residents. Data do not support that either change has resulted in a net benefit to patients. We are mandated to invest scarce capital to support new technology, resulting in increased pressure to recoup investment. Where there is a cap on revenue, the only way to increase net profit is to increase volume and decrease services. Physician time is the variable and can be streamlined by performing video conferences or smartphone consultations. Change may bring higher order, as the English philosopher John Locke said, but it is time for all of us as physicians to step back and question that this type of change is the path we must take. An office with a schedule of 80 patients seen at 5-minute intervals by physician assistants has no place in medicine. The pressure imposed by the insurance industry or hospital administrators to meet quotas has gotten out of hand and the time is now to say with a strong but fair voice a resounding NO!

The office visit with a history and physical examination is the most exciting and effective time to meet, console, and relate to our patients. The use of the 5 senses is critical. We must not let technological advancements (eg, smartphones, the Internet, and electronic medical records) destroy what was created and taught to us all through our training. The reward that is accomplished by placing one’s hand on a patient’s knee to understand its warmth and swelling, the tactile feeling of a fluid wave, or performing carefully with compassion a provocative maneuver that gives by sight a grimace of discomfort can tell so much more than a status update on the phone. We must not allow ourselves to be replaced by ancillary services for so-called efficiency and cost saving. Rather, we must be innovative and sharp. We must find the way to use the wonders of the virtual world without giving up the human consult.

Imagine that you are able to travel to Iguazu Falls, South America, to see one of the wonders of our world. You sit in that life raft moving upstream to feel the heat from the water as it crushes the rocks below, and you feel the mist on your face. You see the majesty and hear the screams and breadth of excitement of those around you, while you listen to the deafening sounds created by this waterfall. Now imagine you are required to report on this same experience through a video or some form of technology that the world has convinced us is the best and far cheaper substitute. This is our electronic medical record. A tool we are forced to use, and while it has a purpose, it is a sterile tool that fails to provide information that will give clues to awaken the sixth sense. It is a checklist that could allow for completion of a task—like how to fix a leaky faucet.

How then do we accomplish walking the fine line of working with nonphysicians and technology and yet delivering pinnacle care? The answer isn’t simple but it must include education and a commitment to the profession. We must make the public aware that we are one of the few professions that dedicate our lives to others by promoting health and advancing research. My colleagues, the pendulum has swung too far; it is time to take back our great profession through education of ourselves and the public. While technology may help the world connect, it has a limited role unless we first use our 6 senses to help our patients. We must not submit to a compassionless and callous approach that is the inevitable outcome of virtual medicine done with speed. We must maintain our dignity and let the public understand how many years of sacrifice has taken place to earn a sixth sense and not allow a third party to take it away. We are the only source of protection for our patients and we need each one of our senses to perform this task.

Advancing research has been a cornerstone for the orthopedic surgeon. Position statements through meta-analyses and systematic reviews of the literature have recently been utilized with increasing frequency. Combining data of potentially flawed studies can often lead to erroneous conclusions and may stray away from best practices. Is this where we want evidence-based medicine to go? The end result is that decisions are made by insurance companies who rely on these flawed studies to force clinical decisions on the physician, as was most recently seen by the investigation of viscosupplementation for knee osteoarthritis.¹

In a 2007 study published in JAMA (The Journal of the American Medical Association), only 62% of residents could appropriately interpret a P value.² How can we expect young clinicians to evaluate, interpret, and apply the multitude of evidence in the literature to everyday practice? We must marry the use of best evidence with our expertise to make the most informed decision while managing the expectations of our patients. In order to achieve that balance, we must rely on our intuition, our sixth sense. There is too much patient individuality and complexity surrounding each individual’s situation for a one-size-fits-all approach and for wholesale reliance on research to address each unique situation.

If Nathan Davis in 1845 was able to convince the New York Medical Society to establish a nationwide professional association to assist in regulating the practice of medicine, then it is time for all of us to stand up and insist on a code of ethics that is unrelenting and uncompromising. Our wise leaders of the American Orthopaedic Association (AOA) who founded the formation of orthopedics in America knew guidelines were needed to “foster advances in the care of patients, improve the teaching of orthopaedic surgery in medical schools and formal orthopaedic training, and to promote orthopaedic surgery as a surgical discipline worldwide.”³ It is now our turn to renew the guidelines and encourage our leaders to help educate ourselves and patients as we work with technology and administrators, nurses and physician assistants to deliver pinnacle care. We must reform medical education and the practice of medicine so that technology is used as a companion but not a substitute for our 6 senses.

The next time a patient comes into the exam room, sit down, look the patient in the eye, listen, touch, console anxiety, make a human connection, and form a lasting relationship. By all means apologize to your patients as you fill out the electronic medical record and insurance forms. Discuss how we are in the same crisis together and ask for their help as they have come to you for yours.

What makes some groups better to work with than others? What makes the work dynamic in some groups more optimistic?

It starts with leadership. Leaders must first know themselves. They must first know their limits and their strengths. They must work on the former while celebrating the latter. A leader must lead. At times a leader can be (and should be) an advocate for the group. But simply advocating for a group is not enough. A leader must take the group down new avenues. A leader must coach the group to better practices. A leader must be the one pioneering new ways of doing things with the intent of improving patient care and provider satisfaction.

Leaders need to be clear with their expectations for hospital medicine. This gives the group the ability to make a conscious choice as to whether or not they wish to stay within the group. If they stay, then it provides the structure for which the group functions. Examples can range from small to big: I expect that you will be at meetings on time; it’s our group’s expectation that you will greet each patient with a smile, handshake, and business card for the first meeting. With the group understanding these expectations, a leader can manage performance and hold providers accountable.

Clear expectations and objectives should be communicated early. They need to be communicated often. In certain instances goals may change. It may be institutional change or changes with Medicare. I often will communicate this change in person once; send an e-mail once and then have a follow-up communication over lunch to answer any questions regarding the change and its implementation. This trio of communication allows me to get the majority of the audience that I need to reach. It gives the audience a “hard copy” in the form of an e-mail to read and also gives the opportunity to answer any questions that I may have overlooked or was not clear with in the other forms of communication.

Ideally, the best time to communicate expectations and objectives is when new providers are hired. New physicians starting in practice need to be trained and adjusted into the team. They need on-boarding, mentors, career coaches, and the opportunity to practice applicable CME early on in the new job. These new additions need to be challenged about their future goals and supported in attaining them. Usually new hospitalists want to get involved in education (medical students or residents), administration, and quality care, or sometimes they just want to practice at becoming better physicians. We all should strive to do the latter always, but some may only want to be clinicians. Either way, all of these goals should be nurtured.

Good training leads to physician participation as an expectation. Participation should not be the stick for which the carrot hangs. Hospitalists need to be on committees and need to have representation at all levels of hospital logistics and tasks. This is how respect and autonomy are gained. And if done properly, this autonomy will receive the support from the highest levels of hospital administration.

With each individual supporting the team (because they are expected to speak on behalf of the group and report back to the group about their findings), the bunch of individuals will start to form a team. What does that mean? An individual hospitalist has her own set of beliefs and practices that makes her unique. If you take a random sampling of hospitalists from many different backgrounds and educational experiences from all over the country (which is any typical hospitalist group), you will have a bunch of individuals. Each hospitalist will come equipped with their own talents and struggles. Now if you take that bunch of individuals and train them in the ways of best practices with good leadership, you can begin to build a functional team. I want to avoid sports analogies, but I think the picture is clearer now than before. See Bad News Bears or Coach Carter. Any team that has clearly stated objectives (expectations/mission statement), that also has good on-boarding and training, will be successful. When the on-boarding process involves mentoring and coaching to help individuals become better administrators, leaders, educators, quality improvers et cetera the team develops together.

One thing that I’ve left out is the logistics of having a good team. Great teams have things like salary, time off, and other benefits included as part of the package. With money and benefits taken off of the table as an issue, the group can focus on things they’ve been trained to focus on: quality patient care. It’s been my opinion that using money to motivate anyone will get the bare minimum performance needed to get the result that leads to the money. So why not take that form of motivation out of the equation? If groups invest in their members, the rewards are greater than rewarding individuals for how many widgets they can churn out of a factory.

With these tools of good leadership, team training and development, excellent communication, and a good salary with benefits, then the expectation of participation and positive feedback should be the norm. A good positive dynamic will develop, and the team will work to support itself. Eventually, a team like this one could become a work-family that could be deployed for specialty care (such as head bleeds and gunshot wounds) as the institution needs it to be deployed. This is provided that this kind of work-family already vetted its concerns and could adapt to those needs. These work-families rely less on the leader to hold everyone accountable and allows the unit to relax together and venture off into creative endeavors for the future. That article is for another time.

Dr. Bitetto is chief for the section of Hospital Medicine at Lehigh Valley Hospital, Allentown, Pa.

What makes some groups better to work with than others? What makes the work dynamic in some groups more optimistic?

It starts with leadership. Leaders must first know themselves. They must first know their limits and their strengths. They must work on the former while celebrating the latter. A leader must lead. At times a leader can be (and should be) an advocate for the group. But simply advocating for a group is not enough. A leader must take the group down new avenues. A leader must coach the group to better practices. A leader must be the one pioneering new ways of doing things with the intent of improving patient care and provider satisfaction.

Leaders need to be clear with their expectations for hospital medicine. This gives the group the ability to make a conscious choice as to whether or not they wish to stay within the group. If they stay, then it provides the structure for which the group functions. Examples can range from small to big: I expect that you will be at meetings on time; it’s our group’s expectation that you will greet each patient with a smile, handshake, and business card for the first meeting. With the group understanding these expectations, a leader can manage performance and hold providers accountable.

Clear expectations and objectives should be communicated early. They need to be communicated often. In certain instances goals may change. It may be institutional change or changes with Medicare. I often will communicate this change in person once; send an e-mail once and then have a follow-up communication over lunch to answer any questions regarding the change and its implementation. This trio of communication allows me to get the majority of the audience that I need to reach. It gives the audience a “hard copy” in the form of an e-mail to read and also gives the opportunity to answer any questions that I may have overlooked or was not clear with in the other forms of communication.

Ideally, the best time to communicate expectations and objectives is when new providers are hired. New physicians starting in practice need to be trained and adjusted into the team. They need on-boarding, mentors, career coaches, and the opportunity to practice applicable CME early on in the new job. These new additions need to be challenged about their future goals and supported in attaining them. Usually new hospitalists want to get involved in education (medical students or residents), administration, and quality care, or sometimes they just want to practice at becoming better physicians. We all should strive to do the latter always, but some may only want to be clinicians. Either way, all of these goals should be nurtured.

Good training leads to physician participation as an expectation. Participation should not be the stick for which the carrot hangs. Hospitalists need to be on committees and need to have representation at all levels of hospital logistics and tasks. This is how respect and autonomy are gained. And if done properly, this autonomy will receive the support from the highest levels of hospital administration.

With each individual supporting the team (because they are expected to speak on behalf of the group and report back to the group about their findings), the bunch of individuals will start to form a team. What does that mean? An individual hospitalist has her own set of beliefs and practices that makes her unique. If you take a random sampling of hospitalists from many different backgrounds and educational experiences from all over the country (which is any typical hospitalist group), you will have a bunch of individuals. Each hospitalist will come equipped with their own talents and struggles. Now if you take that bunch of individuals and train them in the ways of best practices with good leadership, you can begin to build a functional team. I want to avoid sports analogies, but I think the picture is clearer now than before. See Bad News Bears or Coach Carter. Any team that has clearly stated objectives (expectations/mission statement), that also has good on-boarding and training, will be successful. When the on-boarding process involves mentoring and coaching to help individuals become better administrators, leaders, educators, quality improvers et cetera the team develops together.

One thing that I’ve left out is the logistics of having a good team. Great teams have things like salary, time off, and other benefits included as part of the package. With money and benefits taken off of the table as an issue, the group can focus on things they’ve been trained to focus on: quality patient care. It’s been my opinion that using money to motivate anyone will get the bare minimum performance needed to get the result that leads to the money. So why not take that form of motivation out of the equation? If groups invest in their members, the rewards are greater than rewarding individuals for how many widgets they can churn out of a factory.

With these tools of good leadership, team training and development, excellent communication, and a good salary with benefits, then the expectation of participation and positive feedback should be the norm. A good positive dynamic will develop, and the team will work to support itself. Eventually, a team like this one could become a work-family that could be deployed for specialty care (such as head bleeds and gunshot wounds) as the institution needs it to be deployed. This is provided that this kind of work-family already vetted its concerns and could adapt to those needs. These work-families rely less on the leader to hold everyone accountable and allows the unit to relax together and venture off into creative endeavors for the future. That article is for another time.

Dr. Bitetto is chief for the section of Hospital Medicine at Lehigh Valley Hospital, Allentown, Pa.

What makes some groups better to work with than others? What makes the work dynamic in some groups more optimistic?

It starts with leadership. Leaders must first know themselves. They must first know their limits and their strengths. They must work on the former while celebrating the latter. A leader must lead. At times a leader can be (and should be) an advocate for the group. But simply advocating for a group is not enough. A leader must take the group down new avenues. A leader must coach the group to better practices. A leader must be the one pioneering new ways of doing things with the intent of improving patient care and provider satisfaction.

Leaders need to be clear with their expectations for hospital medicine. This gives the group the ability to make a conscious choice as to whether or not they wish to stay within the group. If they stay, then it provides the structure for which the group functions. Examples can range from small to big: I expect that you will be at meetings on time; it’s our group’s expectation that you will greet each patient with a smile, handshake, and business card for the first meeting. With the group understanding these expectations, a leader can manage performance and hold providers accountable.

Clear expectations and objectives should be communicated early. They need to be communicated often. In certain instances goals may change. It may be institutional change or changes with Medicare. I often will communicate this change in person once; send an e-mail once and then have a follow-up communication over lunch to answer any questions regarding the change and its implementation. This trio of communication allows me to get the majority of the audience that I need to reach. It gives the audience a “hard copy” in the form of an e-mail to read and also gives the opportunity to answer any questions that I may have overlooked or was not clear with in the other forms of communication.

Ideally, the best time to communicate expectations and objectives is when new providers are hired. New physicians starting in practice need to be trained and adjusted into the team. They need on-boarding, mentors, career coaches, and the opportunity to practice applicable CME early on in the new job. These new additions need to be challenged about their future goals and supported in attaining them. Usually new hospitalists want to get involved in education (medical students or residents), administration, and quality care, or sometimes they just want to practice at becoming better physicians. We all should strive to do the latter always, but some may only want to be clinicians. Either way, all of these goals should be nurtured.

Good training leads to physician participation as an expectation. Participation should not be the stick for which the carrot hangs. Hospitalists need to be on committees and need to have representation at all levels of hospital logistics and tasks. This is how respect and autonomy are gained. And if done properly, this autonomy will receive the support from the highest levels of hospital administration.

With each individual supporting the team (because they are expected to speak on behalf of the group and report back to the group about their findings), the bunch of individuals will start to form a team. What does that mean? An individual hospitalist has her own set of beliefs and practices that makes her unique. If you take a random sampling of hospitalists from many different backgrounds and educational experiences from all over the country (which is any typical hospitalist group), you will have a bunch of individuals. Each hospitalist will come equipped with their own talents and struggles. Now if you take that bunch of individuals and train them in the ways of best practices with good leadership, you can begin to build a functional team. I want to avoid sports analogies, but I think the picture is clearer now than before. See Bad News Bears or Coach Carter. Any team that has clearly stated objectives (expectations/mission statement), that also has good on-boarding and training, will be successful. When the on-boarding process involves mentoring and coaching to help individuals become better administrators, leaders, educators, quality improvers et cetera the team develops together.

One thing that I’ve left out is the logistics of having a good team. Great teams have things like salary, time off, and other benefits included as part of the package. With money and benefits taken off of the table as an issue, the group can focus on things they’ve been trained to focus on: quality patient care. It’s been my opinion that using money to motivate anyone will get the bare minimum performance needed to get the result that leads to the money. So why not take that form of motivation out of the equation? If groups invest in their members, the rewards are greater than rewarding individuals for how many widgets they can churn out of a factory.

With these tools of good leadership, team training and development, excellent communication, and a good salary with benefits, then the expectation of participation and positive feedback should be the norm. A good positive dynamic will develop, and the team will work to support itself. Eventually, a team like this one could become a work-family that could be deployed for specialty care (such as head bleeds and gunshot wounds) as the institution needs it to be deployed. This is provided that this kind of work-family already vetted its concerns and could adapt to those needs. These work-families rely less on the leader to hold everyone accountable and allows the unit to relax together and venture off into creative endeavors for the future. That article is for another time.

Dr. Bitetto is chief for the section of Hospital Medicine at Lehigh Valley Hospital, Allentown, Pa.

In December 2010, unsettled by the seemingly epidemic proportions of school and workplace violence, I wrote an editorial on the subject.¹ Almost four years later, I find that recent behavior by well-known people compels me to write again, because I'm concerned that the problem of violence—this time, domestic—is pandemic and we as a society are so out of control that we have lost our moral compass.

In the latter part of this summer, it seemed that every television, newspaper, and radio announcement included at least one incident of a professional athlete and his abusive behavior toward a team member, a spouse, or a child. The behavior was so outrageous that just hearing about it made me nauseous. To add insult to the injuries inflicted on the victims, the coaches, bosses, and teammates of the alleged perpetrators ostensibly ignored the events.

In the National Football League (NFL) alone, dozens of players have been arrested for domestic violence (DV) in the past few years.² Moreover, these repeated incidents of abuse occurred with little or no repercussions for the players' atrocious behavior. As the most recent incidents involving Ray Rice and Adrian Peterson were being disclosed, the unbalanced approach to applying sanctions for off-field conduct was revealed. Apparently, to the NFL, DV has been a lesser offense than substance abuse, so the number of games' suspension is fewer for DV.  

Regardless of how the NFL has sanctioned off-field (mis)conduct, what do the actions of these players portray to the younger generation? In addition, what is the approach of essentially tolerating these bad behaviors teaching young men (and women) about DV? We know that the problem of DV is not isolated to professional athletes. Nevertheless, we need to know more about the problem—and more importantly, how to stop it.

I believe that the first step is to recognize that children who witness domestic violence are more likely to be abusive than children who do not.³ Second, we need to change our perception of who the victims of DV are. Data on DV tend to focus on women; however, a national survey conducted by the CDC and the US Department of Justice revealed that in 2011, more men than women were victims of intimate partner physical violence, with more than 40% of severe physical violence directed at men.^4,5 In addition to recognizing the demographics of DV, we must realize the associated financial costs. In the US alone, the cost of DV exceeds $5 billion annually: $4.1 billion for direct health care services and $1.8 billion in lost productivity.³

DV is one of the most pressing issues in our society. A human problem, it includes intimate partner violence (IPV), sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect.⁶ On average, 20 people per minute in the US are victims of physical violence by an intimate partner.⁷

While reports of DV among our "rich and famous" make headlines, those incidents are just the tip of the iceberg. DV/IPV is an insidious and frequently deadly social problem that crosses economic and geographic boundaries. Globally, approximately 520,000 people die each year as a result of DV/IPV. That translates to 1,400 deaths per day, the "equivalent of three long-haul commercial aircraft crashing every single day, week in and week out, year after year."⁸

In recent weeks, as I brooded (and pontificated) about the Rice and Peterson incidents and listened to the NFL address their policies and programs relating to DV and sexual assault, I wondered what was being done (or could be done), and what role we have in reducing this epidemic. Searching for an answer, I discovered a program dedicated to DV/IPV prevention (although it saddens me to think we actually need a dedicated program for this).

In 2002, authorized by the Family Violence Prevention Services Act, the CDC developed the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program (see box).⁹ The focus is on primary prevention to reduce the incidence of DV/IPV by stopping it before it occurs. Prevention requires understanding the circumstances and factors that influence violence. Understanding risk and protective factors is important, because comprehending the complexity of those factors can assist in violence prevention in our communities.

However, understanding is not enough—we need to advocate for more training and educational programs in our schools and sports programs that can help address the problem at its roots. We need programs and professionals to teach and promote interpersonal respect, healthy relationships, and positive role modeling. We need to develop a comprehensive, coordinated approach to reducing all DV/IPV.

Professional sports leagues and players are in the spotlight; they have the opportunity to lead by positive example and help catalyze change.¹⁰ Let's call "time out" on DV and stop tolerating any form of violence, on or off the field.

REFERENCES
1.  Onieal M-E. Conduct unbecoming. Clinician Reviews. 2010;20(12):C2, 8-10.

2.  NFL player arrests: arrest database. USA Today. www.usatoday.com/sports/nfl/arrests. Accessed October 19, 2014.

3.  Domestic Violence Statistics. http://domes ticviolencestatistics.org/domestic-violence-statistics/. Accessed October 19, 2014.

4.  Hoff BH. National study: more men than women victims of intimate partner physical violence, psychological aggression. MenWeb online Journal (ISSN: 1095‐5240). www.bat teredmen.com/NISVS.htm. Accessed October 19, 2014.

5.  Hines DA, Brown J, Dunning E. Characteristics of callers to the domestic abuse helpline for men. J Fam Viol. 2007;22:63–72.

6.  Wilkins N. Tsao B, Hertz M, et al. Connecting the Dots: an Overview of the Links Among Multiple Forms of Violence. 2014. Atlanta, GA: National Center for Injury Prevention and Control, CDC, and Oakland, CA: Prevention Institute.

7.  CDC. The National Intimate Partner and Sexual Violence Survey. www.cdc.gov/violen ceprevention/nisvs/index.html. Accessed October 19, 2014.

8.  Butchart A, Phinney A, Check P, Villaveces A. Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health. 2004. Geneva: World Health Organization.

9.  CDC. Domestic Violence Prevention Enhancement and Leadership Through Alliances. www.cdc.gov/violenceprevention/delta/index.html. Accessed October 19, 2014.

10.  Brisbo L. Let's call "time out" on domestic violence. Futures Without Violence blog. September 22, 2014. www.futureswithout violence.org/movements-are-made-of-momentslets-call-time-out-on-domestic-violence/. Accessed October 19, 2014.

In December 2010, unsettled by the seemingly epidemic proportions of school and workplace violence, I wrote an editorial on the subject.¹ Almost four years later, I find that recent behavior by well-known people compels me to write again, because I'm concerned that the problem of violence—this time, domestic—is pandemic and we as a society are so out of control that we have lost our moral compass.

In the latter part of this summer, it seemed that every television, newspaper, and radio announcement included at least one incident of a professional athlete and his abusive behavior toward a team member, a spouse, or a child. The behavior was so outrageous that just hearing about it made me nauseous. To add insult to the injuries inflicted on the victims, the coaches, bosses, and teammates of the alleged perpetrators ostensibly ignored the events.

In the National Football League (NFL) alone, dozens of players have been arrested for domestic violence (DV) in the past few years.² Moreover, these repeated incidents of abuse occurred with little or no repercussions for the players' atrocious behavior. As the most recent incidents involving Ray Rice and Adrian Peterson were being disclosed, the unbalanced approach to applying sanctions for off-field conduct was revealed. Apparently, to the NFL, DV has been a lesser offense than substance abuse, so the number of games' suspension is fewer for DV.  

Regardless of how the NFL has sanctioned off-field (mis)conduct, what do the actions of these players portray to the younger generation? In addition, what is the approach of essentially tolerating these bad behaviors teaching young men (and women) about DV? We know that the problem of DV is not isolated to professional athletes. Nevertheless, we need to know more about the problem—and more importantly, how to stop it.

I believe that the first step is to recognize that children who witness domestic violence are more likely to be abusive than children who do not.³ Second, we need to change our perception of who the victims of DV are. Data on DV tend to focus on women; however, a national survey conducted by the CDC and the US Department of Justice revealed that in 2011, more men than women were victims of intimate partner physical violence, with more than 40% of severe physical violence directed at men.^4,5 In addition to recognizing the demographics of DV, we must realize the associated financial costs. In the US alone, the cost of DV exceeds $5 billion annually: $4.1 billion for direct health care services and $1.8 billion in lost productivity.³

DV is one of the most pressing issues in our society. A human problem, it includes intimate partner violence (IPV), sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect.⁶ On average, 20 people per minute in the US are victims of physical violence by an intimate partner.⁷

While reports of DV among our "rich and famous" make headlines, those incidents are just the tip of the iceberg. DV/IPV is an insidious and frequently deadly social problem that crosses economic and geographic boundaries. Globally, approximately 520,000 people die each year as a result of DV/IPV. That translates to 1,400 deaths per day, the "equivalent of three long-haul commercial aircraft crashing every single day, week in and week out, year after year."⁸

In recent weeks, as I brooded (and pontificated) about the Rice and Peterson incidents and listened to the NFL address their policies and programs relating to DV and sexual assault, I wondered what was being done (or could be done), and what role we have in reducing this epidemic. Searching for an answer, I discovered a program dedicated to DV/IPV prevention (although it saddens me to think we actually need a dedicated program for this).

In 2002, authorized by the Family Violence Prevention Services Act, the CDC developed the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program (see box).⁹ The focus is on primary prevention to reduce the incidence of DV/IPV by stopping it before it occurs. Prevention requires understanding the circumstances and factors that influence violence. Understanding risk and protective factors is important, because comprehending the complexity of those factors can assist in violence prevention in our communities.

However, understanding is not enough—we need to advocate for more training and educational programs in our schools and sports programs that can help address the problem at its roots. We need programs and professionals to teach and promote interpersonal respect, healthy relationships, and positive role modeling. We need to develop a comprehensive, coordinated approach to reducing all DV/IPV.

Professional sports leagues and players are in the spotlight; they have the opportunity to lead by positive example and help catalyze change.¹⁰ Let's call "time out" on DV and stop tolerating any form of violence, on or off the field.

REFERENCES
1.  Onieal M-E. Conduct unbecoming. Clinician Reviews. 2010;20(12):C2, 8-10.

2.  NFL player arrests: arrest database. USA Today. www.usatoday.com/sports/nfl/arrests. Accessed October 19, 2014.

3.  Domestic Violence Statistics. http://domes ticviolencestatistics.org/domestic-violence-statistics/. Accessed October 19, 2014.

4.  Hoff BH. National study: more men than women victims of intimate partner physical violence, psychological aggression. MenWeb online Journal (ISSN: 1095‐5240). www.bat teredmen.com/NISVS.htm. Accessed October 19, 2014.

5.  Hines DA, Brown J, Dunning E. Characteristics of callers to the domestic abuse helpline for men. J Fam Viol. 2007;22:63–72.

6.  Wilkins N. Tsao B, Hertz M, et al. Connecting the Dots: an Overview of the Links Among Multiple Forms of Violence. 2014. Atlanta, GA: National Center for Injury Prevention and Control, CDC, and Oakland, CA: Prevention Institute.

7.  CDC. The National Intimate Partner and Sexual Violence Survey. www.cdc.gov/violen ceprevention/nisvs/index.html. Accessed October 19, 2014.

8.  Butchart A, Phinney A, Check P, Villaveces A. Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health. 2004. Geneva: World Health Organization.

9.  CDC. Domestic Violence Prevention Enhancement and Leadership Through Alliances. www.cdc.gov/violenceprevention/delta/index.html. Accessed October 19, 2014.

10.  Brisbo L. Let's call "time out" on domestic violence. Futures Without Violence blog. September 22, 2014. www.futureswithout violence.org/movements-are-made-of-momentslets-call-time-out-on-domestic-violence/. Accessed October 19, 2014.

In December 2010, unsettled by the seemingly epidemic proportions of school and workplace violence, I wrote an editorial on the subject.¹ Almost four years later, I find that recent behavior by well-known people compels me to write again, because I'm concerned that the problem of violence—this time, domestic—is pandemic and we as a society are so out of control that we have lost our moral compass.

In the latter part of this summer, it seemed that every television, newspaper, and radio announcement included at least one incident of a professional athlete and his abusive behavior toward a team member, a spouse, or a child. The behavior was so outrageous that just hearing about it made me nauseous. To add insult to the injuries inflicted on the victims, the coaches, bosses, and teammates of the alleged perpetrators ostensibly ignored the events.

In the National Football League (NFL) alone, dozens of players have been arrested for domestic violence (DV) in the past few years.² Moreover, these repeated incidents of abuse occurred with little or no repercussions for the players' atrocious behavior. As the most recent incidents involving Ray Rice and Adrian Peterson were being disclosed, the unbalanced approach to applying sanctions for off-field conduct was revealed. Apparently, to the NFL, DV has been a lesser offense than substance abuse, so the number of games' suspension is fewer for DV.  

Regardless of how the NFL has sanctioned off-field (mis)conduct, what do the actions of these players portray to the younger generation? In addition, what is the approach of essentially tolerating these bad behaviors teaching young men (and women) about DV? We know that the problem of DV is not isolated to professional athletes. Nevertheless, we need to know more about the problem—and more importantly, how to stop it.

I believe that the first step is to recognize that children who witness domestic violence are more likely to be abusive than children who do not.³ Second, we need to change our perception of who the victims of DV are. Data on DV tend to focus on women; however, a national survey conducted by the CDC and the US Department of Justice revealed that in 2011, more men than women were victims of intimate partner physical violence, with more than 40% of severe physical violence directed at men.^4,5 In addition to recognizing the demographics of DV, we must realize the associated financial costs. In the US alone, the cost of DV exceeds $5 billion annually: $4.1 billion for direct health care services and $1.8 billion in lost productivity.³

DV is one of the most pressing issues in our society. A human problem, it includes intimate partner violence (IPV), sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect.⁶ On average, 20 people per minute in the US are victims of physical violence by an intimate partner.⁷

While reports of DV among our "rich and famous" make headlines, those incidents are just the tip of the iceberg. DV/IPV is an insidious and frequently deadly social problem that crosses economic and geographic boundaries. Globally, approximately 520,000 people die each year as a result of DV/IPV. That translates to 1,400 deaths per day, the "equivalent of three long-haul commercial aircraft crashing every single day, week in and week out, year after year."⁸

In recent weeks, as I brooded (and pontificated) about the Rice and Peterson incidents and listened to the NFL address their policies and programs relating to DV and sexual assault, I wondered what was being done (or could be done), and what role we have in reducing this epidemic. Searching for an answer, I discovered a program dedicated to DV/IPV prevention (although it saddens me to think we actually need a dedicated program for this).

In 2002, authorized by the Family Violence Prevention Services Act, the CDC developed the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program (see box).⁹ The focus is on primary prevention to reduce the incidence of DV/IPV by stopping it before it occurs. Prevention requires understanding the circumstances and factors that influence violence. Understanding risk and protective factors is important, because comprehending the complexity of those factors can assist in violence prevention in our communities.

However, understanding is not enough—we need to advocate for more training and educational programs in our schools and sports programs that can help address the problem at its roots. We need programs and professionals to teach and promote interpersonal respect, healthy relationships, and positive role modeling. We need to develop a comprehensive, coordinated approach to reducing all DV/IPV.

Professional sports leagues and players are in the spotlight; they have the opportunity to lead by positive example and help catalyze change.¹⁰ Let's call "time out" on DV and stop tolerating any form of violence, on or off the field.

REFERENCES
1.  Onieal M-E. Conduct unbecoming. Clinician Reviews. 2010;20(12):C2, 8-10.

2.  NFL player arrests: arrest database. USA Today. www.usatoday.com/sports/nfl/arrests. Accessed October 19, 2014.

3.  Domestic Violence Statistics. http://domes ticviolencestatistics.org/domestic-violence-statistics/. Accessed October 19, 2014.

4.  Hoff BH. National study: more men than women victims of intimate partner physical violence, psychological aggression. MenWeb online Journal (ISSN: 1095‐5240). www.bat teredmen.com/NISVS.htm. Accessed October 19, 2014.

5.  Hines DA, Brown J, Dunning E. Characteristics of callers to the domestic abuse helpline for men. J Fam Viol. 2007;22:63–72.

6.  Wilkins N. Tsao B, Hertz M, et al. Connecting the Dots: an Overview of the Links Among Multiple Forms of Violence. 2014. Atlanta, GA: National Center for Injury Prevention and Control, CDC, and Oakland, CA: Prevention Institute.

7.  CDC. The National Intimate Partner and Sexual Violence Survey. www.cdc.gov/violen ceprevention/nisvs/index.html. Accessed October 19, 2014.

8.  Butchart A, Phinney A, Check P, Villaveces A. Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health. 2004. Geneva: World Health Organization.

9.  CDC. Domestic Violence Prevention Enhancement and Leadership Through Alliances. www.cdc.gov/violenceprevention/delta/index.html. Accessed October 19, 2014.

10.  Brisbo L. Let's call "time out" on domestic violence. Futures Without Violence blog. September 22, 2014. www.futureswithout violence.org/movements-are-made-of-momentslets-call-time-out-on-domestic-violence/. Accessed October 19, 2014.