Commentary

I don’t do meet-and-greets.

It is not that we get a huge number of calls for them. Maybe once a week a new patient will call, asking to “interview” me to see if we’re a good match and to review my credentials.

I’m not playing this game. My credentials are on my office website, as well as many rate-a-doc sites that I have no affiliation with. I’m not running a concierge practice where I ask you to pay up front.

My time is valuable. If you need a neurologist, I’m happy to see you and try to help. But your insurance doesn’t pay me to do “interviews.” And when we’ve quoted people a fee for the time, they get indignant and hang up. They tell my secretary they’ll take their business elsewhere, which is fine with me.

I have to wonder how many other neurologists they go through with this routine. I don’t know any who do this, at least in my area of town. By the time they call my office, they’ve likely already tried five other neurologists.

I suppose some will argue in favor of it, maybe as a way of weeding out people who you really don’t want in your practice or with whom you are genuinely a bad personality match. To me, it’s not worth it.

Unfortunately, modern medicine is trying to squeeze as many dollars out of the limited office time you have. I already work through lunch. I’m not going to take unpaid visits just so that people can decide if my dress habits, hygiene, or personality are up to their standards.

I see patients as they come. If they don’t like me, nobody is forcing them to stay. But I’m not going to do a complimentary meet-and-greet so they can judge me or try to get free medical advice.

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

I don’t do meet-and-greets.

It is not that we get a huge number of calls for them. Maybe once a week a new patient will call, asking to “interview” me to see if we’re a good match and to review my credentials.

I’m not playing this game. My credentials are on my office website, as well as many rate-a-doc sites that I have no affiliation with. I’m not running a concierge practice where I ask you to pay up front.

My time is valuable. If you need a neurologist, I’m happy to see you and try to help. But your insurance doesn’t pay me to do “interviews.” And when we’ve quoted people a fee for the time, they get indignant and hang up. They tell my secretary they’ll take their business elsewhere, which is fine with me.

I have to wonder how many other neurologists they go through with this routine. I don’t know any who do this, at least in my area of town. By the time they call my office, they’ve likely already tried five other neurologists.

I suppose some will argue in favor of it, maybe as a way of weeding out people who you really don’t want in your practice or with whom you are genuinely a bad personality match. To me, it’s not worth it.

Unfortunately, modern medicine is trying to squeeze as many dollars out of the limited office time you have. I already work through lunch. I’m not going to take unpaid visits just so that people can decide if my dress habits, hygiene, or personality are up to their standards.

I see patients as they come. If they don’t like me, nobody is forcing them to stay. But I’m not going to do a complimentary meet-and-greet so they can judge me or try to get free medical advice.

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

I don’t do meet-and-greets.

It is not that we get a huge number of calls for them. Maybe once a week a new patient will call, asking to “interview” me to see if we’re a good match and to review my credentials.

I’m not playing this game. My credentials are on my office website, as well as many rate-a-doc sites that I have no affiliation with. I’m not running a concierge practice where I ask you to pay up front.

My time is valuable. If you need a neurologist, I’m happy to see you and try to help. But your insurance doesn’t pay me to do “interviews.” And when we’ve quoted people a fee for the time, they get indignant and hang up. They tell my secretary they’ll take their business elsewhere, which is fine with me.

I have to wonder how many other neurologists they go through with this routine. I don’t know any who do this, at least in my area of town. By the time they call my office, they’ve likely already tried five other neurologists.

I suppose some will argue in favor of it, maybe as a way of weeding out people who you really don’t want in your practice or with whom you are genuinely a bad personality match. To me, it’s not worth it.

Unfortunately, modern medicine is trying to squeeze as many dollars out of the limited office time you have. I already work through lunch. I’m not going to take unpaid visits just so that people can decide if my dress habits, hygiene, or personality are up to their standards.

I see patients as they come. If they don’t like me, nobody is forcing them to stay. But I’m not going to do a complimentary meet-and-greet so they can judge me or try to get free medical advice.

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

Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.

From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.

Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.

We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.

On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.

On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.

More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.

Here in the United States, people from Africa report stigma and discrimination.

What is the middle ground?

• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.

• Acknowledge that this is a major issue, not only for West Africa but for the world.

• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.

• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.

• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.

• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.

• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.

• Encourage social distancing from people who might have been exposed to Ebola in community settings.

Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.

Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.

Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.

Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.

From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.

Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.

We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.

On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.

On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.

More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.

Here in the United States, people from Africa report stigma and discrimination.

What is the middle ground?

• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.

• Acknowledge that this is a major issue, not only for West Africa but for the world.

• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.

• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.

• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.

• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.

• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.

• Encourage social distancing from people who might have been exposed to Ebola in community settings.

Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.

Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.

Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.

Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.

From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.

Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.

We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.

On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.

On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.

More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.

Here in the United States, people from Africa report stigma and discrimination.

What is the middle ground?

• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.

• Acknowledge that this is a major issue, not only for West Africa but for the world.

• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.

• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.

• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.

• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.

• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.

• Encourage social distancing from people who might have been exposed to Ebola in community settings.

Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.

Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.

Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.

Faithful readers may recall from previous editorials that I’m not particularly happy with the new hypertension guidelines issued recently by the JNC 8 authors. I am especially concerned that the new recommendations of a blood pressure goal of < 150/90 mm Hg for people aged > 60 years, like myself, could lead to a real deterioration in blood pressure control. We know that adherence to the previous goal of < 140/90 mm Hg for this age group has hardly been optimal, so why in the world would we want to relax our targets even further? I have confronted several of the JNC 8 writers with my concerns, and they have reluctantly acknowledged that I am hardly alone in my worries.

But one thing I never saw coming was that the new guidelines would confound one of the important clinical trials I’ve been participating in over the past 4 years. I’m referring to the National Institutes of Health-funded Systolic Blood Pressure Intervention Trial (SPRINT), which was designed to compare 2 systolic blood pressure goals, the traditional 140 mm Hg goal and a more aggressive 120 mm Hg goal.

One thing that is particularly confounding in the context of the new guidelines for those aged > 60 years is that we SPRINT investigators were instructed specifically to recruit as many patients as possible aged > 75 years, so that we could get a clear sense of what the systolic goal should be in this particularly high-risk population. The study architects didn’t even consider testing a goal of 150 mm Hg systolic. In a similar vein, we also worked very hard to over-recruit 2 other groups of high-risk patients, those who had already had a cardiovascular event and those with mild renal insufficiency.

The new guidelines wound up impacting my conduct of the SPRINT trial. An intellectually curious trial subject in his late 70s took a keen interest in the question: What is the optimal systolic blood pressure goal? As it turns out, he was among those who had been randomized to the more aggressive systolic goal of 120 mm Hg. At his most recent visit, he caught me off guard by asking why we were testing a blood pressure goal of 120 mm Hg in someone of his age. He had read that people aged > 60 years needed a blood pressure goal of only 150 mm Hg,according to the latest expert recommendations.

Initially I was flummoxed by his question. Perhaps I should have anticipated that some of our subjects might have questions, but I have to admit that the thought had not occurred to me. I was pleased to see that he was not at all agitated at the apparent disconnect. He was merely curious as to how there could be such a discrepancy between guidelines intended for the general public and the study goal of 120 mm Hg. This proved to be an important teachable moment. After gathering my wits, I was able to explain the difference between guidelines and hypotheses that are carefully tested in clinical trials. I was especially eager to let him know that the true science of a clinical trial trumps the value of clinical guidelines, which are based on the best clinical judgments and guesstimates of leaders in the field.

The key to understanding the role of clinical guidelines is to recognize that they simply represent the most informed opinions available, given the sum total of clinical information that is available at that time. Clinical guidelines are based on evidence as much as is humanly possible, but there are often gaps in what we have learned from published clinical trials. Such trials are inherently limited with respect to the insights they can provide, because funding limitations invariably dictate that hard choices must be made in terms of the hypotheses that can be tested and the populations that can be studied. So the total amount of available data from clinical trials is almost invariably insufficient to answer a significant number of clinical questions definitively.

And that’s why a well-designed clinical trial trumps whatever expert guidelines may seem pertinent to the clinical question at stake. Yes, the JNC 8 authors may have determined (albeit with a significant contrarian minority report) that their best reading of the available literature was that there was no definitive evidence supporting a blood pressure goal of < 150/90 mm Hg in those aged > 60 years. But it must be recognized that the absence of such definitive evidence to date does not at all mean that a lower goal might one day be shown to be superior to the JNC 8 recommendations. And that’s where the SPRINT trial comes in: It’s specifically designed to test the hypothesis that a lower systolic goal of 120 mm Hg might be superior in terms of clinical outcomes to the higher goal of 140 mm Hg. Well-designed clinical trials are the mechanism through which meaningful clinical data are accrued; those data can then inform clinical guidelines.

I am happy to report that my alert SPRINT subject grasped the point rather quickly. As a retired engineer, he understood the importance of obtaining definitive data rather than relying forevermore upon the best guesses of well-meaning experts in the field. Clinical guidelines are useful as far as they go, but they are heavily dependent upon the generation of clinically valid data from randomized clinical trials. My SPRINT subject left the clinic with a renewed commitment to getting his systolic blood pressure down to the assigned goal of 120 mm Hg. All of us should follow his example and try mightily to keep in mind the distinction between clinical guidelines and actual data generated from randomized clinical trials. 

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

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

Faithful readers may recall from previous editorials that I’m not particularly happy with the new hypertension guidelines issued recently by the JNC 8 authors. I am especially concerned that the new recommendations of a blood pressure goal of < 150/90 mm Hg for people aged > 60 years, like myself, could lead to a real deterioration in blood pressure control. We know that adherence to the previous goal of < 140/90 mm Hg for this age group has hardly been optimal, so why in the world would we want to relax our targets even further? I have confronted several of the JNC 8 writers with my concerns, and they have reluctantly acknowledged that I am hardly alone in my worries.

But one thing I never saw coming was that the new guidelines would confound one of the important clinical trials I’ve been participating in over the past 4 years. I’m referring to the National Institutes of Health-funded Systolic Blood Pressure Intervention Trial (SPRINT), which was designed to compare 2 systolic blood pressure goals, the traditional 140 mm Hg goal and a more aggressive 120 mm Hg goal.

One thing that is particularly confounding in the context of the new guidelines for those aged > 60 years is that we SPRINT investigators were instructed specifically to recruit as many patients as possible aged > 75 years, so that we could get a clear sense of what the systolic goal should be in this particularly high-risk population. The study architects didn’t even consider testing a goal of 150 mm Hg systolic. In a similar vein, we also worked very hard to over-recruit 2 other groups of high-risk patients, those who had already had a cardiovascular event and those with mild renal insufficiency.

The new guidelines wound up impacting my conduct of the SPRINT trial. An intellectually curious trial subject in his late 70s took a keen interest in the question: What is the optimal systolic blood pressure goal? As it turns out, he was among those who had been randomized to the more aggressive systolic goal of 120 mm Hg. At his most recent visit, he caught me off guard by asking why we were testing a blood pressure goal of 120 mm Hg in someone of his age. He had read that people aged > 60 years needed a blood pressure goal of only 150 mm Hg,according to the latest expert recommendations.

Initially I was flummoxed by his question. Perhaps I should have anticipated that some of our subjects might have questions, but I have to admit that the thought had not occurred to me. I was pleased to see that he was not at all agitated at the apparent disconnect. He was merely curious as to how there could be such a discrepancy between guidelines intended for the general public and the study goal of 120 mm Hg. This proved to be an important teachable moment. After gathering my wits, I was able to explain the difference between guidelines and hypotheses that are carefully tested in clinical trials. I was especially eager to let him know that the true science of a clinical trial trumps the value of clinical guidelines, which are based on the best clinical judgments and guesstimates of leaders in the field.

The key to understanding the role of clinical guidelines is to recognize that they simply represent the most informed opinions available, given the sum total of clinical information that is available at that time. Clinical guidelines are based on evidence as much as is humanly possible, but there are often gaps in what we have learned from published clinical trials. Such trials are inherently limited with respect to the insights they can provide, because funding limitations invariably dictate that hard choices must be made in terms of the hypotheses that can be tested and the populations that can be studied. So the total amount of available data from clinical trials is almost invariably insufficient to answer a significant number of clinical questions definitively.

And that’s why a well-designed clinical trial trumps whatever expert guidelines may seem pertinent to the clinical question at stake. Yes, the JNC 8 authors may have determined (albeit with a significant contrarian minority report) that their best reading of the available literature was that there was no definitive evidence supporting a blood pressure goal of < 150/90 mm Hg in those aged > 60 years. But it must be recognized that the absence of such definitive evidence to date does not at all mean that a lower goal might one day be shown to be superior to the JNC 8 recommendations. And that’s where the SPRINT trial comes in: It’s specifically designed to test the hypothesis that a lower systolic goal of 120 mm Hg might be superior in terms of clinical outcomes to the higher goal of 140 mm Hg. Well-designed clinical trials are the mechanism through which meaningful clinical data are accrued; those data can then inform clinical guidelines.

I am happy to report that my alert SPRINT subject grasped the point rather quickly. As a retired engineer, he understood the importance of obtaining definitive data rather than relying forevermore upon the best guesses of well-meaning experts in the field. Clinical guidelines are useful as far as they go, but they are heavily dependent upon the generation of clinically valid data from randomized clinical trials. My SPRINT subject left the clinic with a renewed commitment to getting his systolic blood pressure down to the assigned goal of 120 mm Hg. All of us should follow his example and try mightily to keep in mind the distinction between clinical guidelines and actual data generated from randomized clinical trials. 

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

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

Faithful readers may recall from previous editorials that I’m not particularly happy with the new hypertension guidelines issued recently by the JNC 8 authors. I am especially concerned that the new recommendations of a blood pressure goal of < 150/90 mm Hg for people aged > 60 years, like myself, could lead to a real deterioration in blood pressure control. We know that adherence to the previous goal of < 140/90 mm Hg for this age group has hardly been optimal, so why in the world would we want to relax our targets even further? I have confronted several of the JNC 8 writers with my concerns, and they have reluctantly acknowledged that I am hardly alone in my worries.

But one thing I never saw coming was that the new guidelines would confound one of the important clinical trials I’ve been participating in over the past 4 years. I’m referring to the National Institutes of Health-funded Systolic Blood Pressure Intervention Trial (SPRINT), which was designed to compare 2 systolic blood pressure goals, the traditional 140 mm Hg goal and a more aggressive 120 mm Hg goal.

One thing that is particularly confounding in the context of the new guidelines for those aged > 60 years is that we SPRINT investigators were instructed specifically to recruit as many patients as possible aged > 75 years, so that we could get a clear sense of what the systolic goal should be in this particularly high-risk population. The study architects didn’t even consider testing a goal of 150 mm Hg systolic. In a similar vein, we also worked very hard to over-recruit 2 other groups of high-risk patients, those who had already had a cardiovascular event and those with mild renal insufficiency.

The new guidelines wound up impacting my conduct of the SPRINT trial. An intellectually curious trial subject in his late 70s took a keen interest in the question: What is the optimal systolic blood pressure goal? As it turns out, he was among those who had been randomized to the more aggressive systolic goal of 120 mm Hg. At his most recent visit, he caught me off guard by asking why we were testing a blood pressure goal of 120 mm Hg in someone of his age. He had read that people aged > 60 years needed a blood pressure goal of only 150 mm Hg,according to the latest expert recommendations.

Initially I was flummoxed by his question. Perhaps I should have anticipated that some of our subjects might have questions, but I have to admit that the thought had not occurred to me. I was pleased to see that he was not at all agitated at the apparent disconnect. He was merely curious as to how there could be such a discrepancy between guidelines intended for the general public and the study goal of 120 mm Hg. This proved to be an important teachable moment. After gathering my wits, I was able to explain the difference between guidelines and hypotheses that are carefully tested in clinical trials. I was especially eager to let him know that the true science of a clinical trial trumps the value of clinical guidelines, which are based on the best clinical judgments and guesstimates of leaders in the field.

The key to understanding the role of clinical guidelines is to recognize that they simply represent the most informed opinions available, given the sum total of clinical information that is available at that time. Clinical guidelines are based on evidence as much as is humanly possible, but there are often gaps in what we have learned from published clinical trials. Such trials are inherently limited with respect to the insights they can provide, because funding limitations invariably dictate that hard choices must be made in terms of the hypotheses that can be tested and the populations that can be studied. So the total amount of available data from clinical trials is almost invariably insufficient to answer a significant number of clinical questions definitively.

And that’s why a well-designed clinical trial trumps whatever expert guidelines may seem pertinent to the clinical question at stake. Yes, the JNC 8 authors may have determined (albeit with a significant contrarian minority report) that their best reading of the available literature was that there was no definitive evidence supporting a blood pressure goal of < 150/90 mm Hg in those aged > 60 years. But it must be recognized that the absence of such definitive evidence to date does not at all mean that a lower goal might one day be shown to be superior to the JNC 8 recommendations. And that’s where the SPRINT trial comes in: It’s specifically designed to test the hypothesis that a lower systolic goal of 120 mm Hg might be superior in terms of clinical outcomes to the higher goal of 140 mm Hg. Well-designed clinical trials are the mechanism through which meaningful clinical data are accrued; those data can then inform clinical guidelines.

I am happy to report that my alert SPRINT subject grasped the point rather quickly. As a retired engineer, he understood the importance of obtaining definitive data rather than relying forevermore upon the best guesses of well-meaning experts in the field. Clinical guidelines are useful as far as they go, but they are heavily dependent upon the generation of clinically valid data from randomized clinical trials. My SPRINT subject left the clinic with a renewed commitment to getting his systolic blood pressure down to the assigned goal of 120 mm Hg. All of us should follow his example and try mightily to keep in mind the distinction between clinical guidelines and actual data generated from randomized clinical trials. 

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

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

You must ask these questions if you are going to avoid the top three reasons employed physicians quit down the road. Let me give you a big list of queries and a method you can use in your interview to make a quality decision about your contract.

(Note: If you are not searching for a job at the moment ... This is a very interesting set of questions to ask about your current job. The answers may surprise you and give you some ideas on how to improve the quality of your work day.)

Let’s set the stage

I assume you have avoided the physician job search No. 1 mistake and have actually created an Ideal Job Description ... Yes? You will dramatically increase the odds of finding a great position when you compare your Ideal Job Description to any offers you get.

In your interview, I am sure you will ask the usual questions ... things like:

• How do I get paid?

• What is the call schedule?

• What are my benefits, and how much time off do I get?

These questions are important, and they give you no idea of what your day-to-day work experience will be with this group, in this facility, in this larger organization. Remember that the top three reasons employed physicians quit are culture, the way the group makes decisions, and the quality of your immediate supervisor.

This question list is designed to help you understand these important issues.

How to ask your interview questions

1) Take the questions below as a written list.

Yep, take a clipboard and this list so you make sure to ask all the questions. There is a piece of you that is hesitant to do this and will want to memorize the questions. But you are working too hard and that is just a piece of your physician programming. Honest. Take the list with you and take notes about the answers.

2) Channel Columbo.

The people interviewing you will have never heard questions like this. They might say something like, “Wow, never heard that question before.” It helps to have a way to ask these questions in a very nonthreatening manner. The key is to channel Columbo.

You remember the detective in the TV series with the baggy coat and half-chewed cigar? When you channel Columbo ... you start your questions with ...

• I’m curious .....

• I’m confused here, maybe you can help me out ...

Be “curious” and “confused.” Ask them to help you understand. You will be surprised at the candor of their answers when you adopt this attitude.

© iStock / ThinkStockPhotos.com

The questions

These questions are intended to give you specific information about the three main reasons you might eventually quit this position ... up front where you need it the most. I suggest you use these questions as raw materials to craft specific questions you would be comfortable asking in your interview. Then put them on a written list, take them with you to the interview, and channel your best Columbo.

1) Group culture:

• How long has this group existed?

• Please tell me a little about its history.

• Is there a group mission statement?

• If so, do the doctors and staff and the quality of their lives appear in it?

• How would you describe the culture of this group?

• If there were one thing you could change about the group’s culture, what would that be?

• How well do you feel the group members like each other?

• Do group members hang out together when not in the office?

• How much do you feel your partners “have your back”?

• Please tell me about the compensation formula.

• What physician behaviors is this compensation formula intended to motivate?

•If I worked here and wanted to maximize my compensation ... what is the simplest way for me to do that?

• Which do you feel the group values more as a whole ... making money or the quality of the care you provide?

• How much does the group believe that having a balanced life outside of your medical practice is important?

• What is the process you use to bring a new physician on board? What training, mentoring, and coaching would I receive, from whom and for how long?

• Who are the physicians in the group currently in this onboarding process? May I speak with one of them?

2) How the group makes decisions:

• How does this group make decisions?

• How often does the group meet to discuss the practice and the systems used to deliver care?

• Has the group ever had a strategic planning retreat?

• If so, how long ago was the last one?

• Who are the leaders of the group and how are they selected/elected?

• What were the last three significant decisions the group made?

• What happens if one or more physicians disagree with a decision the group has made?

• What is the relationship between the physicians and the administration?

• What happens if the physicians have made a decision and the administration (CEO, board of directors, executive committee) disagrees?

• Who were the last three physicians to leave the group and why did they leave?

• May I have their contact information so I can ask them a few questions?

3) Your immediate supervisor:

• Who would be my immediate supervisor or “boss” or the person in this group / organization that I report directly to? May I speak with him or her, too?

• Are you a physician?

• Do you still see patients?

• How long have you been in this position?

• How would you describe your leadership style?

• Does the group pay you for your leadership activities?

• If yes, do you feel it is a fair payment when compared with what you make seeing patients?

• What training have you had in physician leadership?

• Assuming I were to accept this position, how often would you and I meet?

• How would you like me to communicate with you if I have a question or concern?

• How would you communicate back with me and in what time frame?

• What happens if you and I were ever to disagree about a decision/project/action step ... what would we do then and how would we resolve our disagreement?

• What do you feel is the most stressful part of your job when you are serving as a physician leader?

• What is currently the biggest challenge to this group?

• What do you see as the biggest challenge to the group in the next 5 years?

Now it’s your turn

If you have an interview coming up ... make your list and take it with you.

If you are in a position now and not looking to change, I still suggest you answer these questions about your current group just to make sure you recognize these potential seeds of future discontent early. In my work as an executive coach with hundreds of overstressed doctors, it is not uncommon for them to quit a job and realize these issues only in hindsight.

Don’t let that happen to you.

Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention MATRIX Free Report with over 117 different ways physicians and organizations can lower stress and prevent burnout. He provides stress management, burnout prevention, and physician wellness and engagement coaching and consulting through his website, The Happy MD.

You must ask these questions if you are going to avoid the top three reasons employed physicians quit down the road. Let me give you a big list of queries and a method you can use in your interview to make a quality decision about your contract.

(Note: If you are not searching for a job at the moment ... This is a very interesting set of questions to ask about your current job. The answers may surprise you and give you some ideas on how to improve the quality of your work day.)

Let’s set the stage

I assume you have avoided the physician job search No. 1 mistake and have actually created an Ideal Job Description ... Yes? You will dramatically increase the odds of finding a great position when you compare your Ideal Job Description to any offers you get.

In your interview, I am sure you will ask the usual questions ... things like:

• How do I get paid?

• What is the call schedule?

• What are my benefits, and how much time off do I get?

These questions are important, and they give you no idea of what your day-to-day work experience will be with this group, in this facility, in this larger organization. Remember that the top three reasons employed physicians quit are culture, the way the group makes decisions, and the quality of your immediate supervisor.

This question list is designed to help you understand these important issues.

How to ask your interview questions

1) Take the questions below as a written list.

Yep, take a clipboard and this list so you make sure to ask all the questions. There is a piece of you that is hesitant to do this and will want to memorize the questions. But you are working too hard and that is just a piece of your physician programming. Honest. Take the list with you and take notes about the answers.

2) Channel Columbo.

The people interviewing you will have never heard questions like this. They might say something like, “Wow, never heard that question before.” It helps to have a way to ask these questions in a very nonthreatening manner. The key is to channel Columbo.

You remember the detective in the TV series with the baggy coat and half-chewed cigar? When you channel Columbo ... you start your questions with ...

• I’m curious .....

• I’m confused here, maybe you can help me out ...

Be “curious” and “confused.” Ask them to help you understand. You will be surprised at the candor of their answers when you adopt this attitude.

© iStock / ThinkStockPhotos.com

The questions

These questions are intended to give you specific information about the three main reasons you might eventually quit this position ... up front where you need it the most. I suggest you use these questions as raw materials to craft specific questions you would be comfortable asking in your interview. Then put them on a written list, take them with you to the interview, and channel your best Columbo.

1) Group culture:

• How long has this group existed?

• Please tell me a little about its history.

• Is there a group mission statement?

• If so, do the doctors and staff and the quality of their lives appear in it?

• How would you describe the culture of this group?

• If there were one thing you could change about the group’s culture, what would that be?

• How well do you feel the group members like each other?

• Do group members hang out together when not in the office?

• How much do you feel your partners “have your back”?

• Please tell me about the compensation formula.

• What physician behaviors is this compensation formula intended to motivate?

•If I worked here and wanted to maximize my compensation ... what is the simplest way for me to do that?

• Which do you feel the group values more as a whole ... making money or the quality of the care you provide?

• How much does the group believe that having a balanced life outside of your medical practice is important?

• What is the process you use to bring a new physician on board? What training, mentoring, and coaching would I receive, from whom and for how long?

• Who are the physicians in the group currently in this onboarding process? May I speak with one of them?

2) How the group makes decisions:

• How does this group make decisions?

• How often does the group meet to discuss the practice and the systems used to deliver care?

• Has the group ever had a strategic planning retreat?

• If so, how long ago was the last one?

• Who are the leaders of the group and how are they selected/elected?

• What were the last three significant decisions the group made?

• What happens if one or more physicians disagree with a decision the group has made?

• What is the relationship between the physicians and the administration?

• What happens if the physicians have made a decision and the administration (CEO, board of directors, executive committee) disagrees?

• Who were the last three physicians to leave the group and why did they leave?

• May I have their contact information so I can ask them a few questions?

3) Your immediate supervisor:

• Who would be my immediate supervisor or “boss” or the person in this group / organization that I report directly to? May I speak with him or her, too?

• Are you a physician?

• Do you still see patients?

• How long have you been in this position?

• How would you describe your leadership style?

• Does the group pay you for your leadership activities?

• If yes, do you feel it is a fair payment when compared with what you make seeing patients?

• What training have you had in physician leadership?

• Assuming I were to accept this position, how often would you and I meet?

• How would you like me to communicate with you if I have a question or concern?

• How would you communicate back with me and in what time frame?

• What happens if you and I were ever to disagree about a decision/project/action step ... what would we do then and how would we resolve our disagreement?

• What do you feel is the most stressful part of your job when you are serving as a physician leader?

• What is currently the biggest challenge to this group?

• What do you see as the biggest challenge to the group in the next 5 years?

Now it’s your turn

If you have an interview coming up ... make your list and take it with you.

If you are in a position now and not looking to change, I still suggest you answer these questions about your current group just to make sure you recognize these potential seeds of future discontent early. In my work as an executive coach with hundreds of overstressed doctors, it is not uncommon for them to quit a job and realize these issues only in hindsight.

Don’t let that happen to you.

Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention MATRIX Free Report with over 117 different ways physicians and organizations can lower stress and prevent burnout. He provides stress management, burnout prevention, and physician wellness and engagement coaching and consulting through his website, The Happy MD.

You must ask these questions if you are going to avoid the top three reasons employed physicians quit down the road. Let me give you a big list of queries and a method you can use in your interview to make a quality decision about your contract.

(Note: If you are not searching for a job at the moment ... This is a very interesting set of questions to ask about your current job. The answers may surprise you and give you some ideas on how to improve the quality of your work day.)

Let’s set the stage

I assume you have avoided the physician job search No. 1 mistake and have actually created an Ideal Job Description ... Yes? You will dramatically increase the odds of finding a great position when you compare your Ideal Job Description to any offers you get.

In your interview, I am sure you will ask the usual questions ... things like:

• How do I get paid?

• What is the call schedule?

• What are my benefits, and how much time off do I get?

These questions are important, and they give you no idea of what your day-to-day work experience will be with this group, in this facility, in this larger organization. Remember that the top three reasons employed physicians quit are culture, the way the group makes decisions, and the quality of your immediate supervisor.

This question list is designed to help you understand these important issues.

How to ask your interview questions

1) Take the questions below as a written list.

Yep, take a clipboard and this list so you make sure to ask all the questions. There is a piece of you that is hesitant to do this and will want to memorize the questions. But you are working too hard and that is just a piece of your physician programming. Honest. Take the list with you and take notes about the answers.

2) Channel Columbo.

The people interviewing you will have never heard questions like this. They might say something like, “Wow, never heard that question before.” It helps to have a way to ask these questions in a very nonthreatening manner. The key is to channel Columbo.

You remember the detective in the TV series with the baggy coat and half-chewed cigar? When you channel Columbo ... you start your questions with ...

• I’m curious .....

• I’m confused here, maybe you can help me out ...

Be “curious” and “confused.” Ask them to help you understand. You will be surprised at the candor of their answers when you adopt this attitude.

© iStock / ThinkStockPhotos.com

The questions

These questions are intended to give you specific information about the three main reasons you might eventually quit this position ... up front where you need it the most. I suggest you use these questions as raw materials to craft specific questions you would be comfortable asking in your interview. Then put them on a written list, take them with you to the interview, and channel your best Columbo.

1) Group culture:

• How long has this group existed?

• Please tell me a little about its history.

• Is there a group mission statement?

• If so, do the doctors and staff and the quality of their lives appear in it?

• How would you describe the culture of this group?

• If there were one thing you could change about the group’s culture, what would that be?

• How well do you feel the group members like each other?

• Do group members hang out together when not in the office?

• How much do you feel your partners “have your back”?

• Please tell me about the compensation formula.

• What physician behaviors is this compensation formula intended to motivate?

•If I worked here and wanted to maximize my compensation ... what is the simplest way for me to do that?

• Which do you feel the group values more as a whole ... making money or the quality of the care you provide?

• How much does the group believe that having a balanced life outside of your medical practice is important?

• What is the process you use to bring a new physician on board? What training, mentoring, and coaching would I receive, from whom and for how long?

• Who are the physicians in the group currently in this onboarding process? May I speak with one of them?

2) How the group makes decisions:

• How does this group make decisions?

• How often does the group meet to discuss the practice and the systems used to deliver care?

• Has the group ever had a strategic planning retreat?

• If so, how long ago was the last one?

• Who are the leaders of the group and how are they selected/elected?

• What were the last three significant decisions the group made?

• What happens if one or more physicians disagree with a decision the group has made?

• What is the relationship between the physicians and the administration?

• What happens if the physicians have made a decision and the administration (CEO, board of directors, executive committee) disagrees?

• Who were the last three physicians to leave the group and why did they leave?

• May I have their contact information so I can ask them a few questions?

3) Your immediate supervisor:

• Who would be my immediate supervisor or “boss” or the person in this group / organization that I report directly to? May I speak with him or her, too?

• Are you a physician?

• Do you still see patients?

• How long have you been in this position?

• How would you describe your leadership style?

• Does the group pay you for your leadership activities?

• If yes, do you feel it is a fair payment when compared with what you make seeing patients?

• What training have you had in physician leadership?

• Assuming I were to accept this position, how often would you and I meet?

• How would you like me to communicate with you if I have a question or concern?

• How would you communicate back with me and in what time frame?

• What happens if you and I were ever to disagree about a decision/project/action step ... what would we do then and how would we resolve our disagreement?

• What do you feel is the most stressful part of your job when you are serving as a physician leader?

• What is currently the biggest challenge to this group?

• What do you see as the biggest challenge to the group in the next 5 years?

Now it’s your turn

If you have an interview coming up ... make your list and take it with you.

If you are in a position now and not looking to change, I still suggest you answer these questions about your current group just to make sure you recognize these potential seeds of future discontent early. In my work as an executive coach with hundreds of overstressed doctors, it is not uncommon for them to quit a job and realize these issues only in hindsight.

Don’t let that happen to you.

Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention MATRIX Free Report with over 117 different ways physicians and organizations can lower stress and prevent burnout. He provides stress management, burnout prevention, and physician wellness and engagement coaching and consulting through his website, The Happy MD.

The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.

Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.

Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.

It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.

Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.

We are privileged to practice a specialty that can provide patients with dramatic improvements in health and quality of life. We give back in so many ways, such as volunteering to help underserved populations overseas or at home. We have raised public awareness of the threat of melanoma. The Canadian Dermatology Association turned Niagara Falls orange on Melanoma Monday this year to raise skin cancer awareness; well done! Every one of us who helps support our patient advocacy efforts or the continued success of Camp Discovery (http://www.aad.org/dermatology-a-to-z/for-kids/camp-discovery) enhances the image of our specialty. Each time you see a hospital consultation, volunteer in the community, or squeeze in a patient who cannot pay at the end of a long day, you do more than help an individual; you help ensure the very future of our specialty.

To face the challenges ahead, we must stick together and project a unified voice. Stay informed! If you do not regularly read Dermatology World and the AAD’s member-to-member alerts, you are missing a lot. Our future depends on each one of us working together for our patients and our specialty.

The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.

Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.

Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.

It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.

Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.

We are privileged to practice a specialty that can provide patients with dramatic improvements in health and quality of life. We give back in so many ways, such as volunteering to help underserved populations overseas or at home. We have raised public awareness of the threat of melanoma. The Canadian Dermatology Association turned Niagara Falls orange on Melanoma Monday this year to raise skin cancer awareness; well done! Every one of us who helps support our patient advocacy efforts or the continued success of Camp Discovery (http://www.aad.org/dermatology-a-to-z/for-kids/camp-discovery) enhances the image of our specialty. Each time you see a hospital consultation, volunteer in the community, or squeeze in a patient who cannot pay at the end of a long day, you do more than help an individual; you help ensure the very future of our specialty.

To face the challenges ahead, we must stick together and project a unified voice. Stay informed! If you do not regularly read Dermatology World and the AAD’s member-to-member alerts, you are missing a lot. Our future depends on each one of us working together for our patients and our specialty.

The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.

Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.

Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.

It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.

Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.

We are privileged to practice a specialty that can provide patients with dramatic improvements in health and quality of life. We give back in so many ways, such as volunteering to help underserved populations overseas or at home. We have raised public awareness of the threat of melanoma. The Canadian Dermatology Association turned Niagara Falls orange on Melanoma Monday this year to raise skin cancer awareness; well done! Every one of us who helps support our patient advocacy efforts or the continued success of Camp Discovery (http://www.aad.org/dermatology-a-to-z/for-kids/camp-discovery) enhances the image of our specialty. Each time you see a hospital consultation, volunteer in the community, or squeeze in a patient who cannot pay at the end of a long day, you do more than help an individual; you help ensure the very future of our specialty.

To face the challenges ahead, we must stick together and project a unified voice. Stay informed! If you do not regularly read Dermatology World and the AAD’s member-to-member alerts, you are missing a lot. Our future depends on each one of us working together for our patients and our specialty.

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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

In last month’s column, we began our discussion of Stage 2 of meaningful use. As a reminder, we noted that clinicians must meet or exceed the thresholds for the 17 core objectives and three of six menu objectives, as well as report on defined Clinical Quality Measures. We reviewed in detail the rationale for the program, as well as details of the core and menu measures.

For Stage 2 of meaningful use, the menu items and quality measures are aimed at enhancing actionable decision support to improve the quality of medical care and enable population management for patients who come into our office (and even for those who don’t). Stage 2 is also meant to facilitate physician-patient communication.

As a point of reminder and clarification, on August 29th the U.S. Department of Health and Human Services published a final rule allowing certain eligible providers the flexibility to continue using the Stage 1 criteria for the 2014 attestation year, even if they were due to start Stage 2. Unfortunately, this only applies to those who have been unable to obtain the 2014-certified software in time because of vendor delays. The reprieve does not extend to those who can’t meet Stage 2 due to measure difficulty or procrastination in purchasing software or adopting new work flow. As always, we recommend speaking with a meaningful use expert or consultant before attempting to take advantage of this flexibility. Either way, you’ll need to proceed with the 2014 Clinical Quality Measures, as these new definitions are now required by both the Stage 1 and Stage 2 goals. In this month’s EHR Report, we will highlight the most noteworthy 2014 Clinical Quality Measures.

Clinical Quality Measures are meant to measure and track the quality of health care services that are provided by the practitioner. Clinical Quality Measures are constructed to measure these aspects of care:

• Health outcomes

• Cinical processes

• Patient safety 

• Efficient use of health care resources 

• Care coordination

• Patient engagements

• Population and public health

• Adherence to clinical guidelines

Beginning in 2014, practitioners must select and report on 9 out of a list of 64 approved Clinical Quality Measures for the EHR Incentive Programs.

Clinical Quality Measures may be reported electronically through the EHR if this function is available through your EHR software. It can also be done through CMS’s Physician Quality Reporting System Portal. In order for a practice to report through the portal, the practice needs to sign up through CMS, which can be done through the CMS website. In addition, reporting can be done through a number of group reporting options if a practice is part of a large group of practices or an ACO, or via attestation as before. While the details go of how to report go beyond what we can cover in this column, your IT support person or consultant should be well acquainted with the process.

The Clinical Quality Measures are divided into six different domains of care, and providers must report on Clinical Quality Measures from at least three different domains (Table 1).

CMS encourages reporting on nine recommended core sets of Clinical Quality Measures, as long as those measures are relevant to a practitioner’s patient population. The recommended core measures focus on aspects of medical care that are felt to have the most significant effect on morbidity and mortality of Medicare and Medicaid beneficiaries.

They also focus on aspects of medical care that are consistent with national public health priorities or that particularly increase healthcare costs. The nine measures recommended by CMS for adult and pediatric populations are listed in Tables 2 and 3.

Between Core Objectives, Menu Objectives, and CQMs, the requirements for Stage 2 meaningful use have gotten more complicated and perhaps more confusing to track and implement than before. We recommend that every practice has an identified individual who will become a resource to help others both understand and implement Stage 2 meaningful use. We anticipate a range of opinion about the challenges of Stage 2 and are interested in your thoughts. Please email us, and we will try to publish some of the comments in upcoming columns.

References:

1. An Introduction to EHR Incentive Programs 2014 Clincial Quality Measure (CQM) Electronic Reporting Guide for Eligible Professionals.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM2014_GuideEP.pdf.

2. Eligible Professionals Guide to Stage 2 of the EHR Incentive Programs http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_Guide_EPs_9_23_13.pdf.

3. For a comprehensive list of the CQMs, see the 2014 CQMs for eligible professionals PDF (available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf).

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

In last month’s column, we began our discussion of Stage 2 of meaningful use. As a reminder, we noted that clinicians must meet or exceed the thresholds for the 17 core objectives and three of six menu objectives, as well as report on defined Clinical Quality Measures. We reviewed in detail the rationale for the program, as well as details of the core and menu measures.

For Stage 2 of meaningful use, the menu items and quality measures are aimed at enhancing actionable decision support to improve the quality of medical care and enable population management for patients who come into our office (and even for those who don’t). Stage 2 is also meant to facilitate physician-patient communication.

As a point of reminder and clarification, on August 29th the U.S. Department of Health and Human Services published a final rule allowing certain eligible providers the flexibility to continue using the Stage 1 criteria for the 2014 attestation year, even if they were due to start Stage 2. Unfortunately, this only applies to those who have been unable to obtain the 2014-certified software in time because of vendor delays. The reprieve does not extend to those who can’t meet Stage 2 due to measure difficulty or procrastination in purchasing software or adopting new work flow. As always, we recommend speaking with a meaningful use expert or consultant before attempting to take advantage of this flexibility. Either way, you’ll need to proceed with the 2014 Clinical Quality Measures, as these new definitions are now required by both the Stage 1 and Stage 2 goals. In this month’s EHR Report, we will highlight the most noteworthy 2014 Clinical Quality Measures.

Clinical Quality Measures are meant to measure and track the quality of health care services that are provided by the practitioner. Clinical Quality Measures are constructed to measure these aspects of care:

• Health outcomes

• Cinical processes

• Patient safety 

• Efficient use of health care resources 

• Care coordination

• Patient engagements

• Population and public health

• Adherence to clinical guidelines

Beginning in 2014, practitioners must select and report on 9 out of a list of 64 approved Clinical Quality Measures for the EHR Incentive Programs.

Clinical Quality Measures may be reported electronically through the EHR if this function is available through your EHR software. It can also be done through CMS’s Physician Quality Reporting System Portal. In order for a practice to report through the portal, the practice needs to sign up through CMS, which can be done through the CMS website. In addition, reporting can be done through a number of group reporting options if a practice is part of a large group of practices or an ACO, or via attestation as before. While the details go of how to report go beyond what we can cover in this column, your IT support person or consultant should be well acquainted with the process.

The Clinical Quality Measures are divided into six different domains of care, and providers must report on Clinical Quality Measures from at least three different domains (Table 1).

CMS encourages reporting on nine recommended core sets of Clinical Quality Measures, as long as those measures are relevant to a practitioner’s patient population. The recommended core measures focus on aspects of medical care that are felt to have the most significant effect on morbidity and mortality of Medicare and Medicaid beneficiaries.

They also focus on aspects of medical care that are consistent with national public health priorities or that particularly increase healthcare costs. The nine measures recommended by CMS for adult and pediatric populations are listed in Tables 2 and 3.

Between Core Objectives, Menu Objectives, and CQMs, the requirements for Stage 2 meaningful use have gotten more complicated and perhaps more confusing to track and implement than before. We recommend that every practice has an identified individual who will become a resource to help others both understand and implement Stage 2 meaningful use. We anticipate a range of opinion about the challenges of Stage 2 and are interested in your thoughts. Please email us, and we will try to publish some of the comments in upcoming columns.

References:

1. An Introduction to EHR Incentive Programs 2014 Clincial Quality Measure (CQM) Electronic Reporting Guide for Eligible Professionals.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM2014_GuideEP.pdf.

2. Eligible Professionals Guide to Stage 2 of the EHR Incentive Programs http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_Guide_EPs_9_23_13.pdf.

3. For a comprehensive list of the CQMs, see the 2014 CQMs for eligible professionals PDF (available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf).

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

In last month’s column, we began our discussion of Stage 2 of meaningful use. As a reminder, we noted that clinicians must meet or exceed the thresholds for the 17 core objectives and three of six menu objectives, as well as report on defined Clinical Quality Measures. We reviewed in detail the rationale for the program, as well as details of the core and menu measures.

For Stage 2 of meaningful use, the menu items and quality measures are aimed at enhancing actionable decision support to improve the quality of medical care and enable population management for patients who come into our office (and even for those who don’t). Stage 2 is also meant to facilitate physician-patient communication.

As a point of reminder and clarification, on August 29th the U.S. Department of Health and Human Services published a final rule allowing certain eligible providers the flexibility to continue using the Stage 1 criteria for the 2014 attestation year, even if they were due to start Stage 2. Unfortunately, this only applies to those who have been unable to obtain the 2014-certified software in time because of vendor delays. The reprieve does not extend to those who can’t meet Stage 2 due to measure difficulty or procrastination in purchasing software or adopting new work flow. As always, we recommend speaking with a meaningful use expert or consultant before attempting to take advantage of this flexibility. Either way, you’ll need to proceed with the 2014 Clinical Quality Measures, as these new definitions are now required by both the Stage 1 and Stage 2 goals. In this month’s EHR Report, we will highlight the most noteworthy 2014 Clinical Quality Measures.

Clinical Quality Measures are meant to measure and track the quality of health care services that are provided by the practitioner. Clinical Quality Measures are constructed to measure these aspects of care:

• Health outcomes

• Cinical processes

• Patient safety 

• Efficient use of health care resources 

• Care coordination

• Patient engagements

• Population and public health

• Adherence to clinical guidelines

Beginning in 2014, practitioners must select and report on 9 out of a list of 64 approved Clinical Quality Measures for the EHR Incentive Programs.

Clinical Quality Measures may be reported electronically through the EHR if this function is available through your EHR software. It can also be done through CMS’s Physician Quality Reporting System Portal. In order for a practice to report through the portal, the practice needs to sign up through CMS, which can be done through the CMS website. In addition, reporting can be done through a number of group reporting options if a practice is part of a large group of practices or an ACO, or via attestation as before. While the details go of how to report go beyond what we can cover in this column, your IT support person or consultant should be well acquainted with the process.

The Clinical Quality Measures are divided into six different domains of care, and providers must report on Clinical Quality Measures from at least three different domains (Table 1).

CMS encourages reporting on nine recommended core sets of Clinical Quality Measures, as long as those measures are relevant to a practitioner’s patient population. The recommended core measures focus on aspects of medical care that are felt to have the most significant effect on morbidity and mortality of Medicare and Medicaid beneficiaries.

They also focus on aspects of medical care that are consistent with national public health priorities or that particularly increase healthcare costs. The nine measures recommended by CMS for adult and pediatric populations are listed in Tables 2 and 3.

Between Core Objectives, Menu Objectives, and CQMs, the requirements for Stage 2 meaningful use have gotten more complicated and perhaps more confusing to track and implement than before. We recommend that every practice has an identified individual who will become a resource to help others both understand and implement Stage 2 meaningful use. We anticipate a range of opinion about the challenges of Stage 2 and are interested in your thoughts. Please email us, and we will try to publish some of the comments in upcoming columns.

References:

1. An Introduction to EHR Incentive Programs 2014 Clincial Quality Measure (CQM) Electronic Reporting Guide for Eligible Professionals.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM2014_GuideEP.pdf.

2. Eligible Professionals Guide to Stage 2 of the EHR Incentive Programs http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_Guide_EPs_9_23_13.pdf.

3. For a comprehensive list of the CQMs, see the 2014 CQMs for eligible professionals PDF (available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf).

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