Commentary

The Food and Drug Administration recently approved another weight-loss drug (Contrave), a combination of naltrexone (indicated for opioid dependence) and bupropion (indicated for depression). This is the third weight-loss drug approved in the past 2 years. The FDA previously approved lorcaserin (Belviq) and topiramate/phentermine (Qsymia). This approval activity signals pharmaceutical interest in a multibillion dollar weight loss industry and perhaps, maybe less so, the FDA’s recognition of our public health crisis.

For patients who meet criteria for the use of these medications, they should be offered if they can be afforded. However, these medications may make patients behave differently.

It’s called “license.”

License is the psychological phenomenon in which people who feel they have made progress toward a goal feel liberated to make an incongruent choice. Think of a patient interested in losing weight who now takes a weight-loss pill. Despite not having lost any weight yet and perhaps just after taking the first pill, the patient then makes a choice to consume a high-calorie dessert.

Here are some data that support that this could be happening.

One team of investigators randomized subjects to being informed they were taking a placebo or a weight-loss supplement (which was actually the same placebo tablet as in the other study arm). After receiving the supplement, participants were allowed access to a reward buffet lunch at which their food consumption was recorded. Compared with controls, participants receiving a purported weight-loss supplement ate more food at the reward buffet. This effect seemed to occur through a perceived sense that they were making progress toward their weight-loss goal by taking the pill (Nutrition 2014;30:1007-14).

This is critical for us to think about and incorporate into our clinical teaching when prescribing these medications. Psychological liberation threatens any health gains we can make at a population level with any weight-loss approach. We need to help our patients understand that these medications should be used in combination with sustainable lifestyle changes or they may as well be taking a placebo.

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

The Food and Drug Administration recently approved another weight-loss drug (Contrave), a combination of naltrexone (indicated for opioid dependence) and bupropion (indicated for depression). This is the third weight-loss drug approved in the past 2 years. The FDA previously approved lorcaserin (Belviq) and topiramate/phentermine (Qsymia). This approval activity signals pharmaceutical interest in a multibillion dollar weight loss industry and perhaps, maybe less so, the FDA’s recognition of our public health crisis.

For patients who meet criteria for the use of these medications, they should be offered if they can be afforded. However, these medications may make patients behave differently.

It’s called “license.”

License is the psychological phenomenon in which people who feel they have made progress toward a goal feel liberated to make an incongruent choice. Think of a patient interested in losing weight who now takes a weight-loss pill. Despite not having lost any weight yet and perhaps just after taking the first pill, the patient then makes a choice to consume a high-calorie dessert.

Here are some data that support that this could be happening.

One team of investigators randomized subjects to being informed they were taking a placebo or a weight-loss supplement (which was actually the same placebo tablet as in the other study arm). After receiving the supplement, participants were allowed access to a reward buffet lunch at which their food consumption was recorded. Compared with controls, participants receiving a purported weight-loss supplement ate more food at the reward buffet. This effect seemed to occur through a perceived sense that they were making progress toward their weight-loss goal by taking the pill (Nutrition 2014;30:1007-14).

This is critical for us to think about and incorporate into our clinical teaching when prescribing these medications. Psychological liberation threatens any health gains we can make at a population level with any weight-loss approach. We need to help our patients understand that these medications should be used in combination with sustainable lifestyle changes or they may as well be taking a placebo.

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

The Food and Drug Administration recently approved another weight-loss drug (Contrave), a combination of naltrexone (indicated for opioid dependence) and bupropion (indicated for depression). This is the third weight-loss drug approved in the past 2 years. The FDA previously approved lorcaserin (Belviq) and topiramate/phentermine (Qsymia). This approval activity signals pharmaceutical interest in a multibillion dollar weight loss industry and perhaps, maybe less so, the FDA’s recognition of our public health crisis.

For patients who meet criteria for the use of these medications, they should be offered if they can be afforded. However, these medications may make patients behave differently.

It’s called “license.”

License is the psychological phenomenon in which people who feel they have made progress toward a goal feel liberated to make an incongruent choice. Think of a patient interested in losing weight who now takes a weight-loss pill. Despite not having lost any weight yet and perhaps just after taking the first pill, the patient then makes a choice to consume a high-calorie dessert.

Here are some data that support that this could be happening.

One team of investigators randomized subjects to being informed they were taking a placebo or a weight-loss supplement (which was actually the same placebo tablet as in the other study arm). After receiving the supplement, participants were allowed access to a reward buffet lunch at which their food consumption was recorded. Compared with controls, participants receiving a purported weight-loss supplement ate more food at the reward buffet. This effect seemed to occur through a perceived sense that they were making progress toward their weight-loss goal by taking the pill (Nutrition 2014;30:1007-14).

This is critical for us to think about and incorporate into our clinical teaching when prescribing these medications. Psychological liberation threatens any health gains we can make at a population level with any weight-loss approach. We need to help our patients understand that these medications should be used in combination with sustainable lifestyle changes or they may as well be taking a placebo.

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

 High-quality care, optimal length of stay (LOS), patient satisfaction, cost-effectiveness – all part of the hospitalists’ creed, our raison d’être. But with these exist national, as well as local imperatives, some of which carry penalties and/or rewards. Public and private organizations devote a huge amount of resources into setting higher and higher bars of excellence for physicians. Individual hospitals adapt and tweak the methods of other centers that have outstanding track records in hopes they, too, may enjoy similar success. Yet, at the end of the day, we are the foot soldiers.

Insurers should not mandate the care we provide. Government should not have to tell us what is acceptable practice and what is not. And hospital administrators – God bless them – should not have to stab blindly in the dark for solutions to the problems that plague their individual institutions. After all, we physicians are at the patients’ bedsides. We talk to them and their families, consult effective and efficient specialists, write orders to take care of them, and ultimately discharge them to their next phase in care.

There is a tremendous amount of low-hanging fruit we easily could seize upon to make our hospitals run more smoothly and make our patients much happier (though the processes and procedures that make one institution ineffective may not plague the next).

For instance, many hospitals have a peak time for admissions, as well as for discharges, and these two times frequently do not coincide. As a result, there may be a backlog of patients in the emergency department (ED) awaiting a clean bed. Invariably, meanwhile, there are patients pacing the halls anxiously waiting for the doctor to arrive to discharge them. But if that doctor is busy seeing a new or very sick patient, that discharge may just have to wait, sometimes for several hours. Here, I have learned to try to look for opportunities instead of focusing on obstacles.

If I anticipate that a patient will be discharged the following day, I try prepare the discharge summary and patient instruction sheet, and to write the prescriptions a day in advance (when time permits). That way, on the following day, instead of devoting 45 minutes to reviewing the records of a lengthy hospital stay, I can simply check on the patient to confirm that she has no new problems and that her examination is stable. Within seconds, I can type in a discharge order and move along to the next patient. Even in the midst of a very busy day, I can typically work in this type of visit fairly early.

On the other hand, if the same patient is likely to be discharged the day after I leave the service, the same preparation by me can save my partner a great deal of time the next day. If everything is already done except the official discharge order, she, too, can likely discharge the patient early in the day, instead of late in the evening after she learns the entire service. (Who likes going home in the dark anyway?)

pupunkkop

The patient is happier. The administration is happier to have more beds freed up earlier. The little old lady in the ED with a comminuted hip fracture will get a nice warm bed quicker, and the rounder is less stressed. Everyone wins!

Listening to our patients’ desires, not just their needs can also go a long way in patient satisfaction.

I recently had a patient who was visiting from the other side of the country who, unfortunately, wound up in our ED for cellulitis. She was part of a historical group from California who had traveled to the Washington, D.C., area to attend a national function. The event was to culminate in a banquet that evening – a banquet that she was going to miss. When I saw her, she acknowledged she was getting better on the intravenous vancomycin that was started in the ED the night before, and though the line of demarcation drawn by my partner clearly showed her infection was improving, she still had mild-moderate cellulitis. Her history of methicillin-resistant Staphylococcus aureus (MRSA) made me uncomfortable discharging her on a regimen that would “probably” cover MRSA, and we all know that linezolid (Zyvox) can be incredibly expensive if not on a patient’s formulary. There we were at 5 p.m. on a Saturday. Who would be reachable for a prior authorization?

As I looked down at her sad face and saw the disappointment in her eyes, I had to do something! She was in the area for a great cause; the hospitalization was an unexpected nuisance that threatened to destroy her entire trip. The solution was simple. I called her pharmacist in California and found out that her copay for Zyvox was an affordable $30, so I could safely discharge her in time for her banquet. While that falls far short of an near-miracle that changed a life, my simple effort made a big difference for her.

The point is that when we focus on the patient’s entire needs – not just the disease that brought them to the hospital in the first place – we can create solutions to many of their problems. Sometimes it’s the finishing touches, not just the medical care, that patients remember most.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

 High-quality care, optimal length of stay (LOS), patient satisfaction, cost-effectiveness – all part of the hospitalists’ creed, our raison d’être. But with these exist national, as well as local imperatives, some of which carry penalties and/or rewards. Public and private organizations devote a huge amount of resources into setting higher and higher bars of excellence for physicians. Individual hospitals adapt and tweak the methods of other centers that have outstanding track records in hopes they, too, may enjoy similar success. Yet, at the end of the day, we are the foot soldiers.

Insurers should not mandate the care we provide. Government should not have to tell us what is acceptable practice and what is not. And hospital administrators – God bless them – should not have to stab blindly in the dark for solutions to the problems that plague their individual institutions. After all, we physicians are at the patients’ bedsides. We talk to them and their families, consult effective and efficient specialists, write orders to take care of them, and ultimately discharge them to their next phase in care.

There is a tremendous amount of low-hanging fruit we easily could seize upon to make our hospitals run more smoothly and make our patients much happier (though the processes and procedures that make one institution ineffective may not plague the next).

For instance, many hospitals have a peak time for admissions, as well as for discharges, and these two times frequently do not coincide. As a result, there may be a backlog of patients in the emergency department (ED) awaiting a clean bed. Invariably, meanwhile, there are patients pacing the halls anxiously waiting for the doctor to arrive to discharge them. But if that doctor is busy seeing a new or very sick patient, that discharge may just have to wait, sometimes for several hours. Here, I have learned to try to look for opportunities instead of focusing on obstacles.

If I anticipate that a patient will be discharged the following day, I try prepare the discharge summary and patient instruction sheet, and to write the prescriptions a day in advance (when time permits). That way, on the following day, instead of devoting 45 minutes to reviewing the records of a lengthy hospital stay, I can simply check on the patient to confirm that she has no new problems and that her examination is stable. Within seconds, I can type in a discharge order and move along to the next patient. Even in the midst of a very busy day, I can typically work in this type of visit fairly early.

On the other hand, if the same patient is likely to be discharged the day after I leave the service, the same preparation by me can save my partner a great deal of time the next day. If everything is already done except the official discharge order, she, too, can likely discharge the patient early in the day, instead of late in the evening after she learns the entire service. (Who likes going home in the dark anyway?)

pupunkkop

The patient is happier. The administration is happier to have more beds freed up earlier. The little old lady in the ED with a comminuted hip fracture will get a nice warm bed quicker, and the rounder is less stressed. Everyone wins!

Listening to our patients’ desires, not just their needs can also go a long way in patient satisfaction.

I recently had a patient who was visiting from the other side of the country who, unfortunately, wound up in our ED for cellulitis. She was part of a historical group from California who had traveled to the Washington, D.C., area to attend a national function. The event was to culminate in a banquet that evening – a banquet that she was going to miss. When I saw her, she acknowledged she was getting better on the intravenous vancomycin that was started in the ED the night before, and though the line of demarcation drawn by my partner clearly showed her infection was improving, she still had mild-moderate cellulitis. Her history of methicillin-resistant Staphylococcus aureus (MRSA) made me uncomfortable discharging her on a regimen that would “probably” cover MRSA, and we all know that linezolid (Zyvox) can be incredibly expensive if not on a patient’s formulary. There we were at 5 p.m. on a Saturday. Who would be reachable for a prior authorization?

As I looked down at her sad face and saw the disappointment in her eyes, I had to do something! She was in the area for a great cause; the hospitalization was an unexpected nuisance that threatened to destroy her entire trip. The solution was simple. I called her pharmacist in California and found out that her copay for Zyvox was an affordable $30, so I could safely discharge her in time for her banquet. While that falls far short of an near-miracle that changed a life, my simple effort made a big difference for her.

The point is that when we focus on the patient’s entire needs – not just the disease that brought them to the hospital in the first place – we can create solutions to many of their problems. Sometimes it’s the finishing touches, not just the medical care, that patients remember most.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

 High-quality care, optimal length of stay (LOS), patient satisfaction, cost-effectiveness – all part of the hospitalists’ creed, our raison d’être. But with these exist national, as well as local imperatives, some of which carry penalties and/or rewards. Public and private organizations devote a huge amount of resources into setting higher and higher bars of excellence for physicians. Individual hospitals adapt and tweak the methods of other centers that have outstanding track records in hopes they, too, may enjoy similar success. Yet, at the end of the day, we are the foot soldiers.

Insurers should not mandate the care we provide. Government should not have to tell us what is acceptable practice and what is not. And hospital administrators – God bless them – should not have to stab blindly in the dark for solutions to the problems that plague their individual institutions. After all, we physicians are at the patients’ bedsides. We talk to them and their families, consult effective and efficient specialists, write orders to take care of them, and ultimately discharge them to their next phase in care.

There is a tremendous amount of low-hanging fruit we easily could seize upon to make our hospitals run more smoothly and make our patients much happier (though the processes and procedures that make one institution ineffective may not plague the next).

For instance, many hospitals have a peak time for admissions, as well as for discharges, and these two times frequently do not coincide. As a result, there may be a backlog of patients in the emergency department (ED) awaiting a clean bed. Invariably, meanwhile, there are patients pacing the halls anxiously waiting for the doctor to arrive to discharge them. But if that doctor is busy seeing a new or very sick patient, that discharge may just have to wait, sometimes for several hours. Here, I have learned to try to look for opportunities instead of focusing on obstacles.

If I anticipate that a patient will be discharged the following day, I try prepare the discharge summary and patient instruction sheet, and to write the prescriptions a day in advance (when time permits). That way, on the following day, instead of devoting 45 minutes to reviewing the records of a lengthy hospital stay, I can simply check on the patient to confirm that she has no new problems and that her examination is stable. Within seconds, I can type in a discharge order and move along to the next patient. Even in the midst of a very busy day, I can typically work in this type of visit fairly early.

On the other hand, if the same patient is likely to be discharged the day after I leave the service, the same preparation by me can save my partner a great deal of time the next day. If everything is already done except the official discharge order, she, too, can likely discharge the patient early in the day, instead of late in the evening after she learns the entire service. (Who likes going home in the dark anyway?)

pupunkkop

The patient is happier. The administration is happier to have more beds freed up earlier. The little old lady in the ED with a comminuted hip fracture will get a nice warm bed quicker, and the rounder is less stressed. Everyone wins!

Listening to our patients’ desires, not just their needs can also go a long way in patient satisfaction.

I recently had a patient who was visiting from the other side of the country who, unfortunately, wound up in our ED for cellulitis. She was part of a historical group from California who had traveled to the Washington, D.C., area to attend a national function. The event was to culminate in a banquet that evening – a banquet that she was going to miss. When I saw her, she acknowledged she was getting better on the intravenous vancomycin that was started in the ED the night before, and though the line of demarcation drawn by my partner clearly showed her infection was improving, she still had mild-moderate cellulitis. Her history of methicillin-resistant Staphylococcus aureus (MRSA) made me uncomfortable discharging her on a regimen that would “probably” cover MRSA, and we all know that linezolid (Zyvox) can be incredibly expensive if not on a patient’s formulary. There we were at 5 p.m. on a Saturday. Who would be reachable for a prior authorization?

As I looked down at her sad face and saw the disappointment in her eyes, I had to do something! She was in the area for a great cause; the hospitalization was an unexpected nuisance that threatened to destroy her entire trip. The solution was simple. I called her pharmacist in California and found out that her copay for Zyvox was an affordable $30, so I could safely discharge her in time for her banquet. While that falls far short of an near-miracle that changed a life, my simple effort made a big difference for her.

The point is that when we focus on the patient’s entire needs – not just the disease that brought them to the hospital in the first place – we can create solutions to many of their problems. Sometimes it’s the finishing touches, not just the medical care, that patients remember most.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

Honeybees (Apis mellifera, A. cerana, A. dorsata, A. floria, A. andreniformis, A. koschevnikov, and A. laborisa) play a key role in propagating numerous plants, flower nectar, and flower pollen as well as in pollinating approximately one-third of common agricultural crops, including fruits, vegetables, nuts, and seeds (Time magazine; Proc. Biol. Sci. 2007;274[1608]:303-13). Indeed, the honeybee is the lone insect that produces food regularly consumed by human beings (Am. J. Ther. 2014;21:304-23). Honey, which contains more than 180 compounds, is produced by honeybees from flower nectar. This sweet food product is supersaturated in sugar, and also contains phenolic acids, flavonoids, ascorbic acid, alpha-tocopherol, carotenoids, the enzymes glucose oxidase and catalase, organic and amino acids, and proteins (J. Food Sci. 2008;73:R117-24). Honey has been used since ancient times in Ayurvedic medicine to treat diabetes and has long been used to treat infected wounds (Ayu 2012;33:178-82; Clin. Infect. Dis. 2009;49:1541-9). Currently, honey is used in Ayurvedic medicine to treat acne, and it is incorporated in various cosmetic formulations such as facial washes, skin moisturizers, and hair conditioners (Ayu 2012;33:178-82).

History

For at least 2,700 years, traditional medical practice has included the use of topically applied honey for various conditions, with many modern researchers retrospectively attributing this usage to the antibacterial activity of honey (Am. J. Ther. 2014;21:304-23; Clin. Infect. Dis. 2008;46:1677-82). Honey served as a potent anti-inflammatory and antibacterial agent in folk remedies in ancient Egypt, Greece, and Rome, with written references to the medical application of bee products dating back to ancientEgypt, India, and China (Am. J. Ther. 2014;21:304-23; Cancer Res. 1993;53:1255-61; Evid. Based Complement. Alternat. Med. 2013;2013:697390)). For more than 4,000 years, honey has been used in Ayurvedic medicine, and its use has been traced to the Xin dynasty in China (Am. J. Ther. 2014;21:304-23). The antibacterial characteristics of honey were first reported in 1892 (IUBMB Life 2012;64:48-55). Russia and Germany used honey for wound treatment through World War I. The traditional medical application of honey began to subside with the advent of antibiotics in the 1940s(Burns 2013; 39:1514-25; Int. J. Clin. Pract. 2007;61:1705-7).

Chemistry

Myriad biological functions are associated with honey (antibacterial, antioxidant, antitumor, anti-inflammatory, antibrowning, and antiviral) and ascribed mainly to its constituent phenolic compounds, such as flavonoids, including chrysin (J. Food Sci. 2008;73:R117-24). Indeed, medical grade honeys such as manuka honey (a monofloral honey derived from Leptospermum scoparium, a member of the Myrtaceae family, native to New Zealand) and Medihoney® (a standardized mix of Australian and New Zealand honeys) are rich in flavonoids (Int. J. Clin. Pract. 2007;61:1705-7;J. Int. Acad. Periodontol. 2004;6:63-7; Evid. Based Complement. Alternat. Med. 2009;6:165-73;J. Agric. Food Chem. 2012;60:7229-37). Honey has a pH ranging from 3.2 to 4.5 and an acidity level that stymies the growth of many microorganisms (Burns 2013;39:1514-25; J. Clin. Nurs. 2008;17:2604-23; Nurs. Times. 2006;102:40-2; Br. J. Community Nurs. 2004;Suppl:S21-7 ).

Antibacterial activity

In 2008, Kwakman et al. found that within 24 hours, 10%-40% (vol/vol) medical grade honey (Revamil) destroyed antibiotic-susceptible and antibiotic-resistant isolates of Staphylococcus aureus,S. epidermidis, Enterococcus faecium, Escherichia coli, Pseudomonas aeruginosa, Enterobacter cloacae, and Klebsiella oxytoca. After 2 days of honey application, they also observed a 100-fold decrease in forearm skin colonization in healthy volunteers, with the number of positive skin cultures declining by 76%. The researchers concluded that Revamil exhibits significant potential to prevent or treat infections, including those spawned by multidrug-resistant bacteria (Clin. Infect. Dis. 2008;46:1677-82). Honey has been demonstrated to be clinically effective in treating several kinds of wound infections, reducing skin colonization of multiple bacteria, including methicillin-resistant S. aureus (Clin. Infect. Dis. 2008;46:1677-82) and enhancing wound healing, without provoking adverse effects ( Clin. Infect. Dis. 2009;49:1541-9). Manuka honey and Medihoney are the main forms of medical grade honey used in clinical practice. Nonmedical grade honey may contain viable bacterial spores (including clostridia), and manifest less predictable antibacterial properties (Clin. Infect. Dis. 2009;49:1541-9).

Honey is used in over-the-counter products as a moisturizing agent and in hair-conditioning products based on its strong humectant properties. It is also used in home remedies to treat burns, wounds, eczema, and dermatitis, especially in Asia (Ayu 2012;33:178-8).

Seborrheic dermatitis/dandruff

In 2001, Al-Waili assessed the potential of topically applied crude honey (90% honey diluted in warm water) to treat chronic seborrheic dermatitis of the scalp, face, and chest in 30 patients (20 males and 10 females, aged 15-60 years). Over the initial 4 weeks of treatment, honey was gently rubbed onto lesions every other day for 2-3 minutes at a time, with the ointment left on for 3 hours before gentle warm-water rinsing. Then, in a 6-month prophylactic phase, the participants were divided into a once-weekly treatment group and a control group. Skin lesions healed completely within 2 weeks in the treatment group, after significant reductions in itching and scaling in just the first week. Subjective improvements in hair loss were also reported. Relapse was observed in 12 of the 15 subjects in the control group within 2-4 months of therapy cessation and none in the treatment group. The author concluded that weekly use of crude honey significantly improves seborrheic dermatitis symptoms and related hair loss (Eur. J. Med. Res. 2001;6:306-8).

Wound healing

In February 2013, Jull published a review of 25 randomized and quasirandomized trials evaluating honey in the treatment of acute or chronic wounds, finding that honey might delay healing in partial- and full-thickness burns, compared with early excision and grafting, but it does not significantly enhance healing of chronic venous leg ulcers. They suggested that while honey may prove to be more effective than some conventional dressings for such ulcers, evidence is currently insufficient to support this claim ( Cochrane Database Syst. Rev. 2013;2:CD005083). Later that year, Vandamme et al. identified 55 studies in a literature review suggesting that honey stimulates healing of burns, ulcers, and other wounds. They also found, despite some methodologic concerns, that honey exerts antibacterial activity in burn treatment and deodorizing, debridement, anti-inflammatory, and analgesic activity ( Burns 2013;39:1514-25).

Conclusion

Honey has a long history of traditional medicinal use and has been found to display significant biologic activity, including antibacterial, antioxidant, antitumor, anti-inflammatory, antibrowning, and antiviral. The antibacterial properties of honey are particularly compelling. While more research, in the form of randomized, controlled trials, is needed prior to incorporating bee products into the dermatologic armamentarium as first-line therapies, the potential of honey usage for skin care is promising.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, April 2002), and a book for consumers, “The Skin Type Solution” (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.

Honeybees (Apis mellifera, A. cerana, A. dorsata, A. floria, A. andreniformis, A. koschevnikov, and A. laborisa) play a key role in propagating numerous plants, flower nectar, and flower pollen as well as in pollinating approximately one-third of common agricultural crops, including fruits, vegetables, nuts, and seeds (Time magazine; Proc. Biol. Sci. 2007;274[1608]:303-13). Indeed, the honeybee is the lone insect that produces food regularly consumed by human beings (Am. J. Ther. 2014;21:304-23). Honey, which contains more than 180 compounds, is produced by honeybees from flower nectar. This sweet food product is supersaturated in sugar, and also contains phenolic acids, flavonoids, ascorbic acid, alpha-tocopherol, carotenoids, the enzymes glucose oxidase and catalase, organic and amino acids, and proteins (J. Food Sci. 2008;73:R117-24). Honey has been used since ancient times in Ayurvedic medicine to treat diabetes and has long been used to treat infected wounds (Ayu 2012;33:178-82; Clin. Infect. Dis. 2009;49:1541-9). Currently, honey is used in Ayurvedic medicine to treat acne, and it is incorporated in various cosmetic formulations such as facial washes, skin moisturizers, and hair conditioners (Ayu 2012;33:178-82).

History

For at least 2,700 years, traditional medical practice has included the use of topically applied honey for various conditions, with many modern researchers retrospectively attributing this usage to the antibacterial activity of honey (Am. J. Ther. 2014;21:304-23; Clin. Infect. Dis. 2008;46:1677-82). Honey served as a potent anti-inflammatory and antibacterial agent in folk remedies in ancient Egypt, Greece, and Rome, with written references to the medical application of bee products dating back to ancientEgypt, India, and China (Am. J. Ther. 2014;21:304-23; Cancer Res. 1993;53:1255-61; Evid. Based Complement. Alternat. Med. 2013;2013:697390)). For more than 4,000 years, honey has been used in Ayurvedic medicine, and its use has been traced to the Xin dynasty in China (Am. J. Ther. 2014;21:304-23). The antibacterial characteristics of honey were first reported in 1892 (IUBMB Life 2012;64:48-55). Russia and Germany used honey for wound treatment through World War I. The traditional medical application of honey began to subside with the advent of antibiotics in the 1940s(Burns 2013; 39:1514-25; Int. J. Clin. Pract. 2007;61:1705-7).

Chemistry

Myriad biological functions are associated with honey (antibacterial, antioxidant, antitumor, anti-inflammatory, antibrowning, and antiviral) and ascribed mainly to its constituent phenolic compounds, such as flavonoids, including chrysin (J. Food Sci. 2008;73:R117-24). Indeed, medical grade honeys such as manuka honey (a monofloral honey derived from Leptospermum scoparium, a member of the Myrtaceae family, native to New Zealand) and Medihoney® (a standardized mix of Australian and New Zealand honeys) are rich in flavonoids (Int. J. Clin. Pract. 2007;61:1705-7;J. Int. Acad. Periodontol. 2004;6:63-7; Evid. Based Complement. Alternat. Med. 2009;6:165-73;J. Agric. Food Chem. 2012;60:7229-37). Honey has a pH ranging from 3.2 to 4.5 and an acidity level that stymies the growth of many microorganisms (Burns 2013;39:1514-25; J. Clin. Nurs. 2008;17:2604-23; Nurs. Times. 2006;102:40-2; Br. J. Community Nurs. 2004;Suppl:S21-7 ).

Antibacterial activity

In 2008, Kwakman et al. found that within 24 hours, 10%-40% (vol/vol) medical grade honey (Revamil) destroyed antibiotic-susceptible and antibiotic-resistant isolates of Staphylococcus aureus,S. epidermidis, Enterococcus faecium, Escherichia coli, Pseudomonas aeruginosa, Enterobacter cloacae, and Klebsiella oxytoca. After 2 days of honey application, they also observed a 100-fold decrease in forearm skin colonization in healthy volunteers, with the number of positive skin cultures declining by 76%. The researchers concluded that Revamil exhibits significant potential to prevent or treat infections, including those spawned by multidrug-resistant bacteria (Clin. Infect. Dis. 2008;46:1677-82). Honey has been demonstrated to be clinically effective in treating several kinds of wound infections, reducing skin colonization of multiple bacteria, including methicillin-resistant S. aureus (Clin. Infect. Dis. 2008;46:1677-82) and enhancing wound healing, without provoking adverse effects ( Clin. Infect. Dis. 2009;49:1541-9). Manuka honey and Medihoney are the main forms of medical grade honey used in clinical practice. Nonmedical grade honey may contain viable bacterial spores (including clostridia), and manifest less predictable antibacterial properties (Clin. Infect. Dis. 2009;49:1541-9).

Honey is used in over-the-counter products as a moisturizing agent and in hair-conditioning products based on its strong humectant properties. It is also used in home remedies to treat burns, wounds, eczema, and dermatitis, especially in Asia (Ayu 2012;33:178-8).

Seborrheic dermatitis/dandruff

In 2001, Al-Waili assessed the potential of topically applied crude honey (90% honey diluted in warm water) to treat chronic seborrheic dermatitis of the scalp, face, and chest in 30 patients (20 males and 10 females, aged 15-60 years). Over the initial 4 weeks of treatment, honey was gently rubbed onto lesions every other day for 2-3 minutes at a time, with the ointment left on for 3 hours before gentle warm-water rinsing. Then, in a 6-month prophylactic phase, the participants were divided into a once-weekly treatment group and a control group. Skin lesions healed completely within 2 weeks in the treatment group, after significant reductions in itching and scaling in just the first week. Subjective improvements in hair loss were also reported. Relapse was observed in 12 of the 15 subjects in the control group within 2-4 months of therapy cessation and none in the treatment group. The author concluded that weekly use of crude honey significantly improves seborrheic dermatitis symptoms and related hair loss (Eur. J. Med. Res. 2001;6:306-8).

Wound healing

In February 2013, Jull published a review of 25 randomized and quasirandomized trials evaluating honey in the treatment of acute or chronic wounds, finding that honey might delay healing in partial- and full-thickness burns, compared with early excision and grafting, but it does not significantly enhance healing of chronic venous leg ulcers. They suggested that while honey may prove to be more effective than some conventional dressings for such ulcers, evidence is currently insufficient to support this claim ( Cochrane Database Syst. Rev. 2013;2:CD005083). Later that year, Vandamme et al. identified 55 studies in a literature review suggesting that honey stimulates healing of burns, ulcers, and other wounds. They also found, despite some methodologic concerns, that honey exerts antibacterial activity in burn treatment and deodorizing, debridement, anti-inflammatory, and analgesic activity ( Burns 2013;39:1514-25).

Conclusion

Honey has a long history of traditional medicinal use and has been found to display significant biologic activity, including antibacterial, antioxidant, antitumor, anti-inflammatory, antibrowning, and antiviral. The antibacterial properties of honey are particularly compelling. While more research, in the form of randomized, controlled trials, is needed prior to incorporating bee products into the dermatologic armamentarium as first-line therapies, the potential of honey usage for skin care is promising.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, April 2002), and a book for consumers, “The Skin Type Solution” (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.

Honeybees (Apis mellifera, A. cerana, A. dorsata, A. floria, A. andreniformis, A. koschevnikov, and A. laborisa) play a key role in propagating numerous plants, flower nectar, and flower pollen as well as in pollinating approximately one-third of common agricultural crops, including fruits, vegetables, nuts, and seeds (Time magazine; Proc. Biol. Sci. 2007;274[1608]:303-13). Indeed, the honeybee is the lone insect that produces food regularly consumed by human beings (Am. J. Ther. 2014;21:304-23). Honey, which contains more than 180 compounds, is produced by honeybees from flower nectar. This sweet food product is supersaturated in sugar, and also contains phenolic acids, flavonoids, ascorbic acid, alpha-tocopherol, carotenoids, the enzymes glucose oxidase and catalase, organic and amino acids, and proteins (J. Food Sci. 2008;73:R117-24). Honey has been used since ancient times in Ayurvedic medicine to treat diabetes and has long been used to treat infected wounds (Ayu 2012;33:178-82; Clin. Infect. Dis. 2009;49:1541-9). Currently, honey is used in Ayurvedic medicine to treat acne, and it is incorporated in various cosmetic formulations such as facial washes, skin moisturizers, and hair conditioners (Ayu 2012;33:178-82).

History

For at least 2,700 years, traditional medical practice has included the use of topically applied honey for various conditions, with many modern researchers retrospectively attributing this usage to the antibacterial activity of honey (Am. J. Ther. 2014;21:304-23; Clin. Infect. Dis. 2008;46:1677-82). Honey served as a potent anti-inflammatory and antibacterial agent in folk remedies in ancient Egypt, Greece, and Rome, with written references to the medical application of bee products dating back to ancientEgypt, India, and China (Am. J. Ther. 2014;21:304-23; Cancer Res. 1993;53:1255-61; Evid. Based Complement. Alternat. Med. 2013;2013:697390)). For more than 4,000 years, honey has been used in Ayurvedic medicine, and its use has been traced to the Xin dynasty in China (Am. J. Ther. 2014;21:304-23). The antibacterial characteristics of honey were first reported in 1892 (IUBMB Life 2012;64:48-55). Russia and Germany used honey for wound treatment through World War I. The traditional medical application of honey began to subside with the advent of antibiotics in the 1940s(Burns 2013; 39:1514-25; Int. J. Clin. Pract. 2007;61:1705-7).

Chemistry

Myriad biological functions are associated with honey (antibacterial, antioxidant, antitumor, anti-inflammatory, antibrowning, and antiviral) and ascribed mainly to its constituent phenolic compounds, such as flavonoids, including chrysin (J. Food Sci. 2008;73:R117-24). Indeed, medical grade honeys such as manuka honey (a monofloral honey derived from Leptospermum scoparium, a member of the Myrtaceae family, native to New Zealand) and Medihoney® (a standardized mix of Australian and New Zealand honeys) are rich in flavonoids (Int. J. Clin. Pract. 2007;61:1705-7;J. Int. Acad. Periodontol. 2004;6:63-7; Evid. Based Complement. Alternat. Med. 2009;6:165-73;J. Agric. Food Chem. 2012;60:7229-37). Honey has a pH ranging from 3.2 to 4.5 and an acidity level that stymies the growth of many microorganisms (Burns 2013;39:1514-25; J. Clin. Nurs. 2008;17:2604-23; Nurs. Times. 2006;102:40-2; Br. J. Community Nurs. 2004;Suppl:S21-7 ).

Antibacterial activity

In 2008, Kwakman et al. found that within 24 hours, 10%-40% (vol/vol) medical grade honey (Revamil) destroyed antibiotic-susceptible and antibiotic-resistant isolates of Staphylococcus aureus,S. epidermidis, Enterococcus faecium, Escherichia coli, Pseudomonas aeruginosa, Enterobacter cloacae, and Klebsiella oxytoca. After 2 days of honey application, they also observed a 100-fold decrease in forearm skin colonization in healthy volunteers, with the number of positive skin cultures declining by 76%. The researchers concluded that Revamil exhibits significant potential to prevent or treat infections, including those spawned by multidrug-resistant bacteria (Clin. Infect. Dis. 2008;46:1677-82). Honey has been demonstrated to be clinically effective in treating several kinds of wound infections, reducing skin colonization of multiple bacteria, including methicillin-resistant S. aureus (Clin. Infect. Dis. 2008;46:1677-82) and enhancing wound healing, without provoking adverse effects ( Clin. Infect. Dis. 2009;49:1541-9). Manuka honey and Medihoney are the main forms of medical grade honey used in clinical practice. Nonmedical grade honey may contain viable bacterial spores (including clostridia), and manifest less predictable antibacterial properties (Clin. Infect. Dis. 2009;49:1541-9).

Honey is used in over-the-counter products as a moisturizing agent and in hair-conditioning products based on its strong humectant properties. It is also used in home remedies to treat burns, wounds, eczema, and dermatitis, especially in Asia (Ayu 2012;33:178-8).

Seborrheic dermatitis/dandruff

In 2001, Al-Waili assessed the potential of topically applied crude honey (90% honey diluted in warm water) to treat chronic seborrheic dermatitis of the scalp, face, and chest in 30 patients (20 males and 10 females, aged 15-60 years). Over the initial 4 weeks of treatment, honey was gently rubbed onto lesions every other day for 2-3 minutes at a time, with the ointment left on for 3 hours before gentle warm-water rinsing. Then, in a 6-month prophylactic phase, the participants were divided into a once-weekly treatment group and a control group. Skin lesions healed completely within 2 weeks in the treatment group, after significant reductions in itching and scaling in just the first week. Subjective improvements in hair loss were also reported. Relapse was observed in 12 of the 15 subjects in the control group within 2-4 months of therapy cessation and none in the treatment group. The author concluded that weekly use of crude honey significantly improves seborrheic dermatitis symptoms and related hair loss (Eur. J. Med. Res. 2001;6:306-8).

Wound healing

In February 2013, Jull published a review of 25 randomized and quasirandomized trials evaluating honey in the treatment of acute or chronic wounds, finding that honey might delay healing in partial- and full-thickness burns, compared with early excision and grafting, but it does not significantly enhance healing of chronic venous leg ulcers. They suggested that while honey may prove to be more effective than some conventional dressings for such ulcers, evidence is currently insufficient to support this claim ( Cochrane Database Syst. Rev. 2013;2:CD005083). Later that year, Vandamme et al. identified 55 studies in a literature review suggesting that honey stimulates healing of burns, ulcers, and other wounds. They also found, despite some methodologic concerns, that honey exerts antibacterial activity in burn treatment and deodorizing, debridement, anti-inflammatory, and analgesic activity ( Burns 2013;39:1514-25).

Conclusion

Honey has a long history of traditional medicinal use and has been found to display significant biologic activity, including antibacterial, antioxidant, antitumor, anti-inflammatory, antibrowning, and antiviral. The antibacterial properties of honey are particularly compelling. While more research, in the form of randomized, controlled trials, is needed prior to incorporating bee products into the dermatologic armamentarium as first-line therapies, the potential of honey usage for skin care is promising.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, April 2002), and a book for consumers, “The Skin Type Solution” (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.

I’ve never lived in a world without e-mail. No, I’m not one of those millennial kids; e-mail has been around for a long time. Sending messages between computers dates to the 1960s, but most people consider 1971 to be the birth of e-mail. That’s when Ray Tomlinson added the @ symbol to separate users’ names from their e-mail addresses.

Today, e-mail is ubiquitous. You can e-mail your mother, your colleagues, or your cable company. You can even e-mail the president of the United States. Other than the pope and most physicians, there aren’t many people you cannot e-mail. (Although, interestingly, you can reach His Holiness on Twitter @Pontifex.)

We physicians have historically had a few good reasons to avoid e-mailing patients, but many of those objections are unwarranted. As part the meaningful use EHR incentive program from the Centers for Medicare & Medicaid Services, secure messaging will now be required to be eligible for rewards. Although many physicians cite security as a concern, most electronic medical record systems now have patient portals that allow for secure, safe messaging. Encroachment into private time, however, is still a concern for many physicians.

At Kaiser Permanente (KP), we’ve been using secure e-mails with our patients for more than 5 years. When we started, I had some of the same concerns as most doctors: When am I going to have time to do this? What types of questions will patients send? As it turns out, the system has been wildly popular for patients. In 2013 alone, we replied to more than 14 million patient messages. We encourage our patients to use e-mail to stay connected with us, because it leads to improved patient experiences and improved outcomes.

Managing e-mail in-boxes is difficult work, and we KP physicians constantly try to find ways to be more efficient. E-mail does sometimes encroach on my personal time, but I’ve discovered that’s okay. As it turns out, e-mail encroaches on my entrepreneurial brother’s personal time, my financial planner’s personal time, and my plumber’s personal time. Being always connected is a modern luxury and a curse. It’s also part of being a professional.

Here are some steps I’ve taken to manage my patient e-mails. First, I always remember that this electronic message is connected to a real person with real worry. Second, I remember how appreciative patients are to get a message from their doctor. E-mail a patient after 8 p.m., and they will never forget you. Third, clearly delineate time to take care of business. It never feels burdensome in part because I am in control. I choose to e-mail patients not because I have to but because I’m that doctor and it makes me feel good.

This weekend, for example, I did patient messages in a Jackson Hole, Wyo., coffee shop while on vacation. Just as I opened my computer, I noticed a young guy in a fleece jacket next to me checking his e-mail while his wife and two kids enjoyed muffins and hot cocoa. While I was waiting for my wife, Susan, to order our lattes, I overheard him make a call to his office: “Yes, I’m out, but why don’t you e-mail me that and I’ll get right back to you.”

I’m right with you, buddy, I think. I use my token and the wifi there in Wyoming to access my patient e-mails. There are only five. The messages are like most I receive: “I have a new spot,” or “The cream you gave me isn’t working,” or “My acne is better, so should I reduce the spironolactone?” I hammer replies out in 10 minutes.

My wife returns with lattes and opens the local paper while I review 14 biopsy results from 2 days ago. For most of them, I use a template and the secure e-mail to send patients their results. I then send a few notes to some patients, advising them to follow up with me for excisional surgeries.

The work I was doing was not additive; the questions my patients sent would have had to be addressed at some time. In fact, if they had called, then they would have left a message with a nurse who would have sent a message to me, which I would have had to reply to, and then send the message back to the nurse who would have to reply to the patient.

Despite our love/hate relationship with it, e-mail has been one of the great innovations of the 20th century, and it is the primary form of communication in the business world. According to one study, more than 100 billion business e-mails were sent and received every day in 2013. Yet, fewer than one-third of physicians use e-mail to communicate with their patients.Personally, I have found patients to be generally understanding, courteous, and appreciative of e-mail. Of course, there are a few who don’t follow good etiquette. (One of my primary care colleagues relates a story of a patient who e-mailed her every time she had a bowel movement. Gastroenteritis can significantly add to e-mail burden, apparently.)

There’s no doubt that e-mail will soon become the primary way to communicate with patients. Based on our experience at KP, this will ultimately be to the benefit of both doctors and patients. A June 2014 survey by Catalyst Healthcare Research showed that 93% of patients preferred to see a physician who offers e-mail communication with his or her patients. More than one-quarter of those respondents said they’d be willing to pay a $25 charge for such communication. It’s not surprising; as with all businesses, not just medicine, that patients want more channels of communication, not fewer. Fortunately for them, many of today’s medical residents are being trained to use electronic communication with patients. For instance, a 2013 study published in the Postgraduate Medical Journal found that 57% of residents used e-mail to communicate with patients.

My wife finished reading the Jackson Hole Daily newspaper and outlined our hike to Taggart Lake. And I finished answering my messages. The guy sitting next to me is still tapping away at his keyboard. I make eye contact and say, “Almost done?” “Yup,” he replies, “Better for me to just knock it out now, because I’ll just have to deal with it on Monday.” I agree.

Susan and I pack up and head for the trail, which is thankfully connection free. Let’s just hope we don’t run into any bears.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I’ve never lived in a world without e-mail. No, I’m not one of those millennial kids; e-mail has been around for a long time. Sending messages between computers dates to the 1960s, but most people consider 1971 to be the birth of e-mail. That’s when Ray Tomlinson added the @ symbol to separate users’ names from their e-mail addresses.

Today, e-mail is ubiquitous. You can e-mail your mother, your colleagues, or your cable company. You can even e-mail the president of the United States. Other than the pope and most physicians, there aren’t many people you cannot e-mail. (Although, interestingly, you can reach His Holiness on Twitter @Pontifex.)

We physicians have historically had a few good reasons to avoid e-mailing patients, but many of those objections are unwarranted. As part the meaningful use EHR incentive program from the Centers for Medicare & Medicaid Services, secure messaging will now be required to be eligible for rewards. Although many physicians cite security as a concern, most electronic medical record systems now have patient portals that allow for secure, safe messaging. Encroachment into private time, however, is still a concern for many physicians.

At Kaiser Permanente (KP), we’ve been using secure e-mails with our patients for more than 5 years. When we started, I had some of the same concerns as most doctors: When am I going to have time to do this? What types of questions will patients send? As it turns out, the system has been wildly popular for patients. In 2013 alone, we replied to more than 14 million patient messages. We encourage our patients to use e-mail to stay connected with us, because it leads to improved patient experiences and improved outcomes.

Managing e-mail in-boxes is difficult work, and we KP physicians constantly try to find ways to be more efficient. E-mail does sometimes encroach on my personal time, but I’ve discovered that’s okay. As it turns out, e-mail encroaches on my entrepreneurial brother’s personal time, my financial planner’s personal time, and my plumber’s personal time. Being always connected is a modern luxury and a curse. It’s also part of being a professional.

Here are some steps I’ve taken to manage my patient e-mails. First, I always remember that this electronic message is connected to a real person with real worry. Second, I remember how appreciative patients are to get a message from their doctor. E-mail a patient after 8 p.m., and they will never forget you. Third, clearly delineate time to take care of business. It never feels burdensome in part because I am in control. I choose to e-mail patients not because I have to but because I’m that doctor and it makes me feel good.

This weekend, for example, I did patient messages in a Jackson Hole, Wyo., coffee shop while on vacation. Just as I opened my computer, I noticed a young guy in a fleece jacket next to me checking his e-mail while his wife and two kids enjoyed muffins and hot cocoa. While I was waiting for my wife, Susan, to order our lattes, I overheard him make a call to his office: “Yes, I’m out, but why don’t you e-mail me that and I’ll get right back to you.”

I’m right with you, buddy, I think. I use my token and the wifi there in Wyoming to access my patient e-mails. There are only five. The messages are like most I receive: “I have a new spot,” or “The cream you gave me isn’t working,” or “My acne is better, so should I reduce the spironolactone?” I hammer replies out in 10 minutes.

My wife returns with lattes and opens the local paper while I review 14 biopsy results from 2 days ago. For most of them, I use a template and the secure e-mail to send patients their results. I then send a few notes to some patients, advising them to follow up with me for excisional surgeries.

The work I was doing was not additive; the questions my patients sent would have had to be addressed at some time. In fact, if they had called, then they would have left a message with a nurse who would have sent a message to me, which I would have had to reply to, and then send the message back to the nurse who would have to reply to the patient.

Despite our love/hate relationship with it, e-mail has been one of the great innovations of the 20th century, and it is the primary form of communication in the business world. According to one study, more than 100 billion business e-mails were sent and received every day in 2013. Yet, fewer than one-third of physicians use e-mail to communicate with their patients.Personally, I have found patients to be generally understanding, courteous, and appreciative of e-mail. Of course, there are a few who don’t follow good etiquette. (One of my primary care colleagues relates a story of a patient who e-mailed her every time she had a bowel movement. Gastroenteritis can significantly add to e-mail burden, apparently.)

There’s no doubt that e-mail will soon become the primary way to communicate with patients. Based on our experience at KP, this will ultimately be to the benefit of both doctors and patients. A June 2014 survey by Catalyst Healthcare Research showed that 93% of patients preferred to see a physician who offers e-mail communication with his or her patients. More than one-quarter of those respondents said they’d be willing to pay a $25 charge for such communication. It’s not surprising; as with all businesses, not just medicine, that patients want more channels of communication, not fewer. Fortunately for them, many of today’s medical residents are being trained to use electronic communication with patients. For instance, a 2013 study published in the Postgraduate Medical Journal found that 57% of residents used e-mail to communicate with patients.

My wife finished reading the Jackson Hole Daily newspaper and outlined our hike to Taggart Lake. And I finished answering my messages. The guy sitting next to me is still tapping away at his keyboard. I make eye contact and say, “Almost done?” “Yup,” he replies, “Better for me to just knock it out now, because I’ll just have to deal with it on Monday.” I agree.

Susan and I pack up and head for the trail, which is thankfully connection free. Let’s just hope we don’t run into any bears.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I’ve never lived in a world without e-mail. No, I’m not one of those millennial kids; e-mail has been around for a long time. Sending messages between computers dates to the 1960s, but most people consider 1971 to be the birth of e-mail. That’s when Ray Tomlinson added the @ symbol to separate users’ names from their e-mail addresses.

Today, e-mail is ubiquitous. You can e-mail your mother, your colleagues, or your cable company. You can even e-mail the president of the United States. Other than the pope and most physicians, there aren’t many people you cannot e-mail. (Although, interestingly, you can reach His Holiness on Twitter @Pontifex.)

We physicians have historically had a few good reasons to avoid e-mailing patients, but many of those objections are unwarranted. As part the meaningful use EHR incentive program from the Centers for Medicare & Medicaid Services, secure messaging will now be required to be eligible for rewards. Although many physicians cite security as a concern, most electronic medical record systems now have patient portals that allow for secure, safe messaging. Encroachment into private time, however, is still a concern for many physicians.

At Kaiser Permanente (KP), we’ve been using secure e-mails with our patients for more than 5 years. When we started, I had some of the same concerns as most doctors: When am I going to have time to do this? What types of questions will patients send? As it turns out, the system has been wildly popular for patients. In 2013 alone, we replied to more than 14 million patient messages. We encourage our patients to use e-mail to stay connected with us, because it leads to improved patient experiences and improved outcomes.

Managing e-mail in-boxes is difficult work, and we KP physicians constantly try to find ways to be more efficient. E-mail does sometimes encroach on my personal time, but I’ve discovered that’s okay. As it turns out, e-mail encroaches on my entrepreneurial brother’s personal time, my financial planner’s personal time, and my plumber’s personal time. Being always connected is a modern luxury and a curse. It’s also part of being a professional.

Here are some steps I’ve taken to manage my patient e-mails. First, I always remember that this electronic message is connected to a real person with real worry. Second, I remember how appreciative patients are to get a message from their doctor. E-mail a patient after 8 p.m., and they will never forget you. Third, clearly delineate time to take care of business. It never feels burdensome in part because I am in control. I choose to e-mail patients not because I have to but because I’m that doctor and it makes me feel good.

This weekend, for example, I did patient messages in a Jackson Hole, Wyo., coffee shop while on vacation. Just as I opened my computer, I noticed a young guy in a fleece jacket next to me checking his e-mail while his wife and two kids enjoyed muffins and hot cocoa. While I was waiting for my wife, Susan, to order our lattes, I overheard him make a call to his office: “Yes, I’m out, but why don’t you e-mail me that and I’ll get right back to you.”

I’m right with you, buddy, I think. I use my token and the wifi there in Wyoming to access my patient e-mails. There are only five. The messages are like most I receive: “I have a new spot,” or “The cream you gave me isn’t working,” or “My acne is better, so should I reduce the spironolactone?” I hammer replies out in 10 minutes.

My wife returns with lattes and opens the local paper while I review 14 biopsy results from 2 days ago. For most of them, I use a template and the secure e-mail to send patients their results. I then send a few notes to some patients, advising them to follow up with me for excisional surgeries.

The work I was doing was not additive; the questions my patients sent would have had to be addressed at some time. In fact, if they had called, then they would have left a message with a nurse who would have sent a message to me, which I would have had to reply to, and then send the message back to the nurse who would have to reply to the patient.

Despite our love/hate relationship with it, e-mail has been one of the great innovations of the 20th century, and it is the primary form of communication in the business world. According to one study, more than 100 billion business e-mails were sent and received every day in 2013. Yet, fewer than one-third of physicians use e-mail to communicate with their patients.Personally, I have found patients to be generally understanding, courteous, and appreciative of e-mail. Of course, there are a few who don’t follow good etiquette. (One of my primary care colleagues relates a story of a patient who e-mailed her every time she had a bowel movement. Gastroenteritis can significantly add to e-mail burden, apparently.)

There’s no doubt that e-mail will soon become the primary way to communicate with patients. Based on our experience at KP, this will ultimately be to the benefit of both doctors and patients. A June 2014 survey by Catalyst Healthcare Research showed that 93% of patients preferred to see a physician who offers e-mail communication with his or her patients. More than one-quarter of those respondents said they’d be willing to pay a $25 charge for such communication. It’s not surprising; as with all businesses, not just medicine, that patients want more channels of communication, not fewer. Fortunately for them, many of today’s medical residents are being trained to use electronic communication with patients. For instance, a 2013 study published in the Postgraduate Medical Journal found that 57% of residents used e-mail to communicate with patients.

My wife finished reading the Jackson Hole Daily newspaper and outlined our hike to Taggart Lake. And I finished answering my messages. The guy sitting next to me is still tapping away at his keyboard. I make eye contact and say, “Almost done?” “Yup,” he replies, “Better for me to just knock it out now, because I’ll just have to deal with it on Monday.” I agree.

Susan and I pack up and head for the trail, which is thankfully connection free. Let’s just hope we don’t run into any bears.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

At least once during your career, you probably will have to put a value on your practice. The need arises more often than you might think – if you sell it, of course (more on that next month); but also for estate planning, preparation of financial statements, or divorce negotiations; or when an associate joins or leaves your office; or if you have occasion to combine or partner your practice with one or more others, as I will discuss in detail in a future issue.

As you might guess, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in a few hundred words, but three basic yardsticks are essential for a practice appraisal:

Tangible assets: equipment, cash, accounts receivable, and other property owned by the practice.

Liabilities: accounts payable, outstanding loans, and anything else owed to others.

Intangible assets: sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the “equity,” or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons patients come back (if they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferrable. For example, unique skills with a laser, neurotoxins, or filler substances (or extraordinary personal charisma) may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash flow analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider to provide a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings are (and thus its overall value).

Asset-based valuation is the most popular, but by no means the only, method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not the income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll talk about sales and mergers over the next several columns.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Skin & Allergy News.

At least once during your career, you probably will have to put a value on your practice. The need arises more often than you might think – if you sell it, of course (more on that next month); but also for estate planning, preparation of financial statements, or divorce negotiations; or when an associate joins or leaves your office; or if you have occasion to combine or partner your practice with one or more others, as I will discuss in detail in a future issue.

As you might guess, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in a few hundred words, but three basic yardsticks are essential for a practice appraisal:

Tangible assets: equipment, cash, accounts receivable, and other property owned by the practice.

Liabilities: accounts payable, outstanding loans, and anything else owed to others.

Intangible assets: sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the “equity,” or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons patients come back (if they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferrable. For example, unique skills with a laser, neurotoxins, or filler substances (or extraordinary personal charisma) may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash flow analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider to provide a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings are (and thus its overall value).

Asset-based valuation is the most popular, but by no means the only, method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not the income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll talk about sales and mergers over the next several columns.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Skin & Allergy News.

At least once during your career, you probably will have to put a value on your practice. The need arises more often than you might think – if you sell it, of course (more on that next month); but also for estate planning, preparation of financial statements, or divorce negotiations; or when an associate joins or leaves your office; or if you have occasion to combine or partner your practice with one or more others, as I will discuss in detail in a future issue.

As you might guess, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in a few hundred words, but three basic yardsticks are essential for a practice appraisal:

Tangible assets: equipment, cash, accounts receivable, and other property owned by the practice.

Liabilities: accounts payable, outstanding loans, and anything else owed to others.

Intangible assets: sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the “equity,” or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons patients come back (if they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferrable. For example, unique skills with a laser, neurotoxins, or filler substances (or extraordinary personal charisma) may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash flow analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider to provide a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings are (and thus its overall value).

Asset-based valuation is the most popular, but by no means the only, method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not the income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll talk about sales and mergers over the next several columns.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Skin & Allergy News.