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Care your way to LOS solutions
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?)
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?)
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?)
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].
Honey
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.
E-mailing patients
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.
I Am Psyched; Are You?
For the past two centuries, disorders of behavior have been held separate and distinct from manifestations of systemic disease that are more easily characterized by the science of the day. In the 19th century, individuals with behavioral disorders were confined to psychiatric hospitals, and in the 20th century, community mental health centers were established and funded under rules that were distinct from those of the evolving system of health care in the United States. The resulting segregation of mental health from primary care has created a crisis that plays out in the national media on a daily basis. Moreover, the continuing economic impact of maintaining this separation has profound implications for the future.
Change is upon us. Seeing the handwriting on the wall isn’t the result of a delusion. It is hard to argue that mental health is not a cornerstone of an individual’s overall well-being and the foundation of health. Behavior has a profound effect on organic pathologies, and pathologies impact behavior. To separate mental health from primary care makes little sense, and it is time to recognize that mental health is an important component of primary care.
Consider the evidence. Any experienced health care practitioner recognizes the immense role that mental health plays in patient care. Simply looking at the waiting area of a community health center (CHC) provides stark evidence. The medical director for one CHC estimated that “at least 85% of the patients seen at my practice have some form of comorbid mental health and physical health chronic disease.”1 Others have suggested that half the individuals in a CHC waiting area are there primarily for some recognized or unrecognized mental health issue.2 There is no doubt that this is also the case in America’s emergency departments and other primary care clinics.
People with mental health disorders have a higher mortality rate and often die prematurely due to well understood and preventable diseases such as diabetes, hypertension, respiratory problems, and infectious disorders. One need look no further than a recent issue of JAMA to understand the impact of mental health comorbidities on diabetes. Diabetic persons with depression are poorly compliant, have poor glycemic control, and experience more diabetic complications and decreased quality of life. Moreover, the economic impact of this comorbidity is staggering when the costs of increased care, unemployment, and work disability are added to the physical toll.3
With arguments as compelling and apparent as these, why then has it been so difficult to achieve meaningful levels of integration? The barriers are many. Reimbursement, legislation, and role identities are familiar reasons that an out-of-date, inefficient system continues to be propagated. But these obstacles are beginning to crumble. Providing primary care without integrating mental health is literally caring for the body and ignoring the mind. Integration of primary and mental health is now the battle cry as systems define the medical homes of the future.
Anticipating the changing environment in health care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has funded a series of studies that review the diversity of approaches to mental health services and attempt to define an optimum future framework that will bring mental health back into the domain of primary care. The results of these studies were recently published as a Rand Corporation Research Report.4
Yet even as vested parties seek to identify the best practices for this integration, it is clear that the biggest challenge relates to the workforce. The logic of integration is unimpeachable and the process already in motion (unlike most changes, this one is rapidly occurring), but the supply of qualified providers is woefully inadequate.
CHCs are the largest health care system in the US and provide the “safety net” for the country’s approximately 25 million uninsured and underinsured individuals. Over the next five years, this number will grow to more than 35 million. About 70% of CHCs presently offer mental health services in some form.1 A recent survey of CHC leaders found that their biggest fear is the tidal wave of mental health problems and their ability to adequately address the needs of these patients because of a severe shortage of properly educated providers.
Psychiatrists are rare in CHCs, and those that exist focus a majority of their time on the most acutely ill. Some centers have formed alliances with community-based mental health services, but too often patient referrals don’t happen or the patient is lost to follow-up. The complex maze of reimbursement, prescribing, and follow-up makes the continued propagation of this inefficient approach unacceptable for the future.
What is needed are clinicians who are properly educated to begin to fill the gap. As such, the workforce challenges of this integration represent a significant opportunity, especially for PAs and NPs. With the exception of physicians, who are in increasingly limited supply, there are no other health care professionals who have the capability to bridge the gap between primary care and mental health. To meet the projected workforce needs, PAs and NPs will have to make a significant commitment to gain the necessary knowledge, skills, and behaviors required to treat mental health problems.
There are a number of excellent entry-level psychiatric nurse practitioner programs that prepare NPs to provide both primary and mental health care. However, most entry-level PA programs don’t have the time to do more than skim the surface of mental health care as they prepare students to begin practice as broadly educated generalist caregivers.
Fortunately, about three years ago, the National Commission on the Certification of Physician Assistants (NCCPA) began to recognize the qualifications and promote the need for PAs with advanced skills in psychiatry and mental health. As of December 2013, almost 100 PAs had successfully received a Certificate of Advanced Qualification (CAQ) in psychiatry from the NCCPA. The nation needs more than 0.1% of all PAs with a credential that recognizes their expertise in mental health. It is time to set an aggressive goal of having 1% of all PAs with a CAQ in psychiatry within the next five years.
Any PA or NP planning their future should give serious consideration to the overwhelming demand for practitioners who can effectively link primary care and mental health. This opportunity for individuals is a current reality. But even greater is the opportunity for the professions to claim a very meaningful and needed position on the health care teams of the future.
I hope you agree. Please share your thoughts with me via [email protected].
For the past two centuries, disorders of behavior have been held separate and distinct from manifestations of systemic disease that are more easily characterized by the science of the day. In the 19th century, individuals with behavioral disorders were confined to psychiatric hospitals, and in the 20th century, community mental health centers were established and funded under rules that were distinct from those of the evolving system of health care in the United States. The resulting segregation of mental health from primary care has created a crisis that plays out in the national media on a daily basis. Moreover, the continuing economic impact of maintaining this separation has profound implications for the future.
Change is upon us. Seeing the handwriting on the wall isn’t the result of a delusion. It is hard to argue that mental health is not a cornerstone of an individual’s overall well-being and the foundation of health. Behavior has a profound effect on organic pathologies, and pathologies impact behavior. To separate mental health from primary care makes little sense, and it is time to recognize that mental health is an important component of primary care.
Consider the evidence. Any experienced health care practitioner recognizes the immense role that mental health plays in patient care. Simply looking at the waiting area of a community health center (CHC) provides stark evidence. The medical director for one CHC estimated that “at least 85% of the patients seen at my practice have some form of comorbid mental health and physical health chronic disease.”1 Others have suggested that half the individuals in a CHC waiting area are there primarily for some recognized or unrecognized mental health issue.2 There is no doubt that this is also the case in America’s emergency departments and other primary care clinics.
People with mental health disorders have a higher mortality rate and often die prematurely due to well understood and preventable diseases such as diabetes, hypertension, respiratory problems, and infectious disorders. One need look no further than a recent issue of JAMA to understand the impact of mental health comorbidities on diabetes. Diabetic persons with depression are poorly compliant, have poor glycemic control, and experience more diabetic complications and decreased quality of life. Moreover, the economic impact of this comorbidity is staggering when the costs of increased care, unemployment, and work disability are added to the physical toll.3
With arguments as compelling and apparent as these, why then has it been so difficult to achieve meaningful levels of integration? The barriers are many. Reimbursement, legislation, and role identities are familiar reasons that an out-of-date, inefficient system continues to be propagated. But these obstacles are beginning to crumble. Providing primary care without integrating mental health is literally caring for the body and ignoring the mind. Integration of primary and mental health is now the battle cry as systems define the medical homes of the future.
Anticipating the changing environment in health care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has funded a series of studies that review the diversity of approaches to mental health services and attempt to define an optimum future framework that will bring mental health back into the domain of primary care. The results of these studies were recently published as a Rand Corporation Research Report.4
Yet even as vested parties seek to identify the best practices for this integration, it is clear that the biggest challenge relates to the workforce. The logic of integration is unimpeachable and the process already in motion (unlike most changes, this one is rapidly occurring), but the supply of qualified providers is woefully inadequate.
CHCs are the largest health care system in the US and provide the “safety net” for the country’s approximately 25 million uninsured and underinsured individuals. Over the next five years, this number will grow to more than 35 million. About 70% of CHCs presently offer mental health services in some form.1 A recent survey of CHC leaders found that their biggest fear is the tidal wave of mental health problems and their ability to adequately address the needs of these patients because of a severe shortage of properly educated providers.
Psychiatrists are rare in CHCs, and those that exist focus a majority of their time on the most acutely ill. Some centers have formed alliances with community-based mental health services, but too often patient referrals don’t happen or the patient is lost to follow-up. The complex maze of reimbursement, prescribing, and follow-up makes the continued propagation of this inefficient approach unacceptable for the future.
What is needed are clinicians who are properly educated to begin to fill the gap. As such, the workforce challenges of this integration represent a significant opportunity, especially for PAs and NPs. With the exception of physicians, who are in increasingly limited supply, there are no other health care professionals who have the capability to bridge the gap between primary care and mental health. To meet the projected workforce needs, PAs and NPs will have to make a significant commitment to gain the necessary knowledge, skills, and behaviors required to treat mental health problems.
There are a number of excellent entry-level psychiatric nurse practitioner programs that prepare NPs to provide both primary and mental health care. However, most entry-level PA programs don’t have the time to do more than skim the surface of mental health care as they prepare students to begin practice as broadly educated generalist caregivers.
Fortunately, about three years ago, the National Commission on the Certification of Physician Assistants (NCCPA) began to recognize the qualifications and promote the need for PAs with advanced skills in psychiatry and mental health. As of December 2013, almost 100 PAs had successfully received a Certificate of Advanced Qualification (CAQ) in psychiatry from the NCCPA. The nation needs more than 0.1% of all PAs with a credential that recognizes their expertise in mental health. It is time to set an aggressive goal of having 1% of all PAs with a CAQ in psychiatry within the next five years.
Any PA or NP planning their future should give serious consideration to the overwhelming demand for practitioners who can effectively link primary care and mental health. This opportunity for individuals is a current reality. But even greater is the opportunity for the professions to claim a very meaningful and needed position on the health care teams of the future.
I hope you agree. Please share your thoughts with me via [email protected].
For the past two centuries, disorders of behavior have been held separate and distinct from manifestations of systemic disease that are more easily characterized by the science of the day. In the 19th century, individuals with behavioral disorders were confined to psychiatric hospitals, and in the 20th century, community mental health centers were established and funded under rules that were distinct from those of the evolving system of health care in the United States. The resulting segregation of mental health from primary care has created a crisis that plays out in the national media on a daily basis. Moreover, the continuing economic impact of maintaining this separation has profound implications for the future.
Change is upon us. Seeing the handwriting on the wall isn’t the result of a delusion. It is hard to argue that mental health is not a cornerstone of an individual’s overall well-being and the foundation of health. Behavior has a profound effect on organic pathologies, and pathologies impact behavior. To separate mental health from primary care makes little sense, and it is time to recognize that mental health is an important component of primary care.
Consider the evidence. Any experienced health care practitioner recognizes the immense role that mental health plays in patient care. Simply looking at the waiting area of a community health center (CHC) provides stark evidence. The medical director for one CHC estimated that “at least 85% of the patients seen at my practice have some form of comorbid mental health and physical health chronic disease.”1 Others have suggested that half the individuals in a CHC waiting area are there primarily for some recognized or unrecognized mental health issue.2 There is no doubt that this is also the case in America’s emergency departments and other primary care clinics.
People with mental health disorders have a higher mortality rate and often die prematurely due to well understood and preventable diseases such as diabetes, hypertension, respiratory problems, and infectious disorders. One need look no further than a recent issue of JAMA to understand the impact of mental health comorbidities on diabetes. Diabetic persons with depression are poorly compliant, have poor glycemic control, and experience more diabetic complications and decreased quality of life. Moreover, the economic impact of this comorbidity is staggering when the costs of increased care, unemployment, and work disability are added to the physical toll.3
With arguments as compelling and apparent as these, why then has it been so difficult to achieve meaningful levels of integration? The barriers are many. Reimbursement, legislation, and role identities are familiar reasons that an out-of-date, inefficient system continues to be propagated. But these obstacles are beginning to crumble. Providing primary care without integrating mental health is literally caring for the body and ignoring the mind. Integration of primary and mental health is now the battle cry as systems define the medical homes of the future.
Anticipating the changing environment in health care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has funded a series of studies that review the diversity of approaches to mental health services and attempt to define an optimum future framework that will bring mental health back into the domain of primary care. The results of these studies were recently published as a Rand Corporation Research Report.4
Yet even as vested parties seek to identify the best practices for this integration, it is clear that the biggest challenge relates to the workforce. The logic of integration is unimpeachable and the process already in motion (unlike most changes, this one is rapidly occurring), but the supply of qualified providers is woefully inadequate.
CHCs are the largest health care system in the US and provide the “safety net” for the country’s approximately 25 million uninsured and underinsured individuals. Over the next five years, this number will grow to more than 35 million. About 70% of CHCs presently offer mental health services in some form.1 A recent survey of CHC leaders found that their biggest fear is the tidal wave of mental health problems and their ability to adequately address the needs of these patients because of a severe shortage of properly educated providers.
Psychiatrists are rare in CHCs, and those that exist focus a majority of their time on the most acutely ill. Some centers have formed alliances with community-based mental health services, but too often patient referrals don’t happen or the patient is lost to follow-up. The complex maze of reimbursement, prescribing, and follow-up makes the continued propagation of this inefficient approach unacceptable for the future.
What is needed are clinicians who are properly educated to begin to fill the gap. As such, the workforce challenges of this integration represent a significant opportunity, especially for PAs and NPs. With the exception of physicians, who are in increasingly limited supply, there are no other health care professionals who have the capability to bridge the gap between primary care and mental health. To meet the projected workforce needs, PAs and NPs will have to make a significant commitment to gain the necessary knowledge, skills, and behaviors required to treat mental health problems.
There are a number of excellent entry-level psychiatric nurse practitioner programs that prepare NPs to provide both primary and mental health care. However, most entry-level PA programs don’t have the time to do more than skim the surface of mental health care as they prepare students to begin practice as broadly educated generalist caregivers.
Fortunately, about three years ago, the National Commission on the Certification of Physician Assistants (NCCPA) began to recognize the qualifications and promote the need for PAs with advanced skills in psychiatry and mental health. As of December 2013, almost 100 PAs had successfully received a Certificate of Advanced Qualification (CAQ) in psychiatry from the NCCPA. The nation needs more than 0.1% of all PAs with a credential that recognizes their expertise in mental health. It is time to set an aggressive goal of having 1% of all PAs with a CAQ in psychiatry within the next five years.
Any PA or NP planning their future should give serious consideration to the overwhelming demand for practitioners who can effectively link primary care and mental health. This opportunity for individuals is a current reality. But even greater is the opportunity for the professions to claim a very meaningful and needed position on the health care teams of the future.
I hope you agree. Please share your thoughts with me via [email protected].
Managing Your Practice: What is your practice worth?
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.
Monitoring calcium with lithium treatment
I appreciate Dr. McInnis’s article and his recommendation to monitor the comprehensive metabolic profile, including the calcium level, before and during lithium treatment. There is an association among lithium treatment, hypercalcemia, and hyperparathyroidism.1,2 This can occur by lithium reducing parathyroid hormone suppression or stimulating parathyroid glands.3
Surprisingly, many guidelines do not include a recommendation to monitor the calcium level; however, the International Society for Bipolar Disorders and other experts do recommend obtaining a calcium level before initiating lithium therapy and at least annually thereafter.1,4 If hypercalcemia is present, assessing lithium and the parathyroid hormone level is recommended.3
Clinicians can continue lithium and monitor calcium if treatment is beneficial, hypercalcemia is mild, and the patient is asymptomatic.2 For a symptomatic patient or one who has significant hypercalcemia, clinicians should consider discontinuing lithium and monitoring for a normalizing calcium level.2 For patients with significant hypercalcemia who need lithium therapy, consultation with an endocrinologist is advised.3
Jonathan R. Scarff, MD
VA Outpatient Clinic
Spartanburg, South Carolina
Dr. McInnis responds
Generally, calcium is included in the comprehensive biochemistry panel (Table 1). Typically, magnesium or phosphorus is overlooked, and therefore was specifically included in the table of recommendations. There is a complex relationship between lithium and calcium; Dr. Scarff’s points highlight this. It is noteworthy that lithium normalizes the calcium amplitude during action potentials in neurons derived from induced pluripotent stem cells from persons with BD1; this suggests that there might be a direct mode of action in BD involving lithium and calcium. This finding further emphasizes the importance of monitoring calcium, and the wise clinician will verify that it is included in the comprehensive biochemistry panel.
1. McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728.
2. Lehmann SW, Lee J. Lithium-associated hyper-calcemia and hyperparathyroidism in the elderly: what do we know? J Affect Disord. 2013;146(2): 151-157.
3. Broome JT, Solorzano CC. Lithium use and primary hyperparathyroidism. Endocr Pract. 2011; 17(suppl 1):31-35.
4. Ng F, Mammen OK, Wilting I, et al. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Bipolar Disord. 2009; 11(6):559-595.
Reference
1. Chen HM, DeLong CJ, Bame M, et al. Transcripts involved in calcium signaling and telencephalic neuronal fate are altered in induced pluripotent stem cells from bipolar disorder patients. Transl Psychiatry. 2014;4:e375. doi:10.1038/tp.2014.12.
I appreciate Dr. McInnis’s article and his recommendation to monitor the comprehensive metabolic profile, including the calcium level, before and during lithium treatment. There is an association among lithium treatment, hypercalcemia, and hyperparathyroidism.1,2 This can occur by lithium reducing parathyroid hormone suppression or stimulating parathyroid glands.3
Surprisingly, many guidelines do not include a recommendation to monitor the calcium level; however, the International Society for Bipolar Disorders and other experts do recommend obtaining a calcium level before initiating lithium therapy and at least annually thereafter.1,4 If hypercalcemia is present, assessing lithium and the parathyroid hormone level is recommended.3
Clinicians can continue lithium and monitor calcium if treatment is beneficial, hypercalcemia is mild, and the patient is asymptomatic.2 For a symptomatic patient or one who has significant hypercalcemia, clinicians should consider discontinuing lithium and monitoring for a normalizing calcium level.2 For patients with significant hypercalcemia who need lithium therapy, consultation with an endocrinologist is advised.3
Jonathan R. Scarff, MD
VA Outpatient Clinic
Spartanburg, South Carolina
Dr. McInnis responds
Generally, calcium is included in the comprehensive biochemistry panel (Table 1). Typically, magnesium or phosphorus is overlooked, and therefore was specifically included in the table of recommendations. There is a complex relationship between lithium and calcium; Dr. Scarff’s points highlight this. It is noteworthy that lithium normalizes the calcium amplitude during action potentials in neurons derived from induced pluripotent stem cells from persons with BD1; this suggests that there might be a direct mode of action in BD involving lithium and calcium. This finding further emphasizes the importance of monitoring calcium, and the wise clinician will verify that it is included in the comprehensive biochemistry panel.
I appreciate Dr. McInnis’s article and his recommendation to monitor the comprehensive metabolic profile, including the calcium level, before and during lithium treatment. There is an association among lithium treatment, hypercalcemia, and hyperparathyroidism.1,2 This can occur by lithium reducing parathyroid hormone suppression or stimulating parathyroid glands.3
Surprisingly, many guidelines do not include a recommendation to monitor the calcium level; however, the International Society for Bipolar Disorders and other experts do recommend obtaining a calcium level before initiating lithium therapy and at least annually thereafter.1,4 If hypercalcemia is present, assessing lithium and the parathyroid hormone level is recommended.3
Clinicians can continue lithium and monitor calcium if treatment is beneficial, hypercalcemia is mild, and the patient is asymptomatic.2 For a symptomatic patient or one who has significant hypercalcemia, clinicians should consider discontinuing lithium and monitoring for a normalizing calcium level.2 For patients with significant hypercalcemia who need lithium therapy, consultation with an endocrinologist is advised.3
Jonathan R. Scarff, MD
VA Outpatient Clinic
Spartanburg, South Carolina
Dr. McInnis responds
Generally, calcium is included in the comprehensive biochemistry panel (Table 1). Typically, magnesium or phosphorus is overlooked, and therefore was specifically included in the table of recommendations. There is a complex relationship between lithium and calcium; Dr. Scarff’s points highlight this. It is noteworthy that lithium normalizes the calcium amplitude during action potentials in neurons derived from induced pluripotent stem cells from persons with BD1; this suggests that there might be a direct mode of action in BD involving lithium and calcium. This finding further emphasizes the importance of monitoring calcium, and the wise clinician will verify that it is included in the comprehensive biochemistry panel.
1. McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728.
2. Lehmann SW, Lee J. Lithium-associated hyper-calcemia and hyperparathyroidism in the elderly: what do we know? J Affect Disord. 2013;146(2): 151-157.
3. Broome JT, Solorzano CC. Lithium use and primary hyperparathyroidism. Endocr Pract. 2011; 17(suppl 1):31-35.
4. Ng F, Mammen OK, Wilting I, et al. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Bipolar Disord. 2009; 11(6):559-595.
Reference
1. Chen HM, DeLong CJ, Bame M, et al. Transcripts involved in calcium signaling and telencephalic neuronal fate are altered in induced pluripotent stem cells from bipolar disorder patients. Transl Psychiatry. 2014;4:e375. doi:10.1038/tp.2014.12.
1. McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728.
2. Lehmann SW, Lee J. Lithium-associated hyper-calcemia and hyperparathyroidism in the elderly: what do we know? J Affect Disord. 2013;146(2): 151-157.
3. Broome JT, Solorzano CC. Lithium use and primary hyperparathyroidism. Endocr Pract. 2011; 17(suppl 1):31-35.
4. Ng F, Mammen OK, Wilting I, et al. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Bipolar Disord. 2009; 11(6):559-595.
Reference
1. Chen HM, DeLong CJ, Bame M, et al. Transcripts involved in calcium signaling and telencephalic neuronal fate are altered in induced pluripotent stem cells from bipolar disorder patients. Transl Psychiatry. 2014;4:e375. doi:10.1038/tp.2014.12.
Cautions when prescribing lithium
I was astonished that Dr. Melvin G. McInnis’ article on using lithium to treat bipolar disorder (BD) (Current Psychiatry, June 2014, p. 38-44; [http://bit.ly/1sszAUr]) did not address all the potential hazards of the medication. He discussed side effects, but only how to manage them so that patients will adhere to treatment.
I have used lithium for patients with BD, and often it is efficacious, although hazardous in overdose. Lithium toxicity can cause cardiac arrhythmias, and must be monitored closely. In addition, the effects of hydration and exercise on the lithium level, especially during summer, often are ignored.
Two of my patients, an adolescent and an adult, were well-maintained on lithium, adhered to treatment, and had no concurrent medical problems, but developed significant toxicity for no reason that I could determine. The adult had a lithium level of 2.0 mEq/L in the emergency room; the adolescent had a lithium level of 1.8 mEq/L. Levels this high are considered potentially lethal, and because it happened without warning and without a cause that I could determine, I consider lithium to be one of the riskier mood stabilizers. I still prescribe it, but with great caution.
Dr. McInnis also did not mention the possibility of lithium-induced diabetes insipidus, a condition in which the kidneys are no longer able to concentrate urine and that is marked by excessive urination, concomitant water intake, and low urine specific gravity. It is uncommon, but I have seen it 3 times in 30 years, in a practice that specializes in psychotherapy and does not see a high percentage of patients with BD. I consider it a condition that must be kept in mind as we follow our patients in long-term treatment.
Mary Davis, MD
Lancaster, Pennsylvania
Dr. McInnis responds
Dr. Davis raises the issue of lithium toxicity and provides examples of 2 patients who developed levels of 2.0 mEq/L and 1.8 mEq/L. These levels clearly are well beyond the toxicity threshold of 1.3 mEq/L, and the patients wisely sought urgent care. These scenarios exemplify the need for regular monitoring of the lithium level—in particular, when there is any change in physical or mental health status. Development of significant toxicity generally has some lead-time with emerging short-term side effects (outlined in Table 2 of my article), which underscores the importance of discussing the nature of emerging side effects with your patient.
Dr. Davis is correct in noting that the practitioner must be aware of long-term side effects of lithium. I find it helpful to discuss these effects with the patient in the context of short-term (days or weeks), intermediate (weeks or months), and long-term (months or years) time frames (Table 2). Diabetes insipidus is listed as an intermediate side effect.
I am grateful to Dr. Davis for raising the issue of hydration and summer heat, a concern among parents and coaches when student athletes practice strenuously for extended hours.1 Miller et al2 found that the concentration of lithium was between 1.2- and 4.6-fold in forearm sweat compared with serum levels, with the implication that heat-induced sweating may lower lithium levels. Jefferson et al3 studied 4 athletes after a 20-km race and found that all had become dehydrated but had a decrease in the serum lithium level. This is contrary to the widely held belief that excessive sweating predisposes to lithium toxicity.
BD is among the more lethal psychiatric disorders, and lithium is among the few medications shown to mitigate suicidal behavior.4 As with any medication, lithium is not without risk, and there is a clear need for informed medical management. Any notable change in health status or physical activity in a patient taking lithium is worthy of review, with recommendations based on knowledge of the patient and medical science.
1. Reardon CL, Factor RM. Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40:961-980.
2. Miller EB, Pain RW, Skripal PJ. Sweat lithium in manic-depression. Br J Psychiatry. 1978;133:477-478.
3. Jefferson JW, Greist JH, Clagnaz PJ, et al. Effect of strenuous exercise on serum lithium level in man. Am J Psychiatry. 1982;139(12):1593-1595.
4. Goodwin FK, Fireman B, Simon GE, et al. Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA. 2003;290(11):1467-1473.
I was astonished that Dr. Melvin G. McInnis’ article on using lithium to treat bipolar disorder (BD) (Current Psychiatry, June 2014, p. 38-44; [http://bit.ly/1sszAUr]) did not address all the potential hazards of the medication. He discussed side effects, but only how to manage them so that patients will adhere to treatment.
I have used lithium for patients with BD, and often it is efficacious, although hazardous in overdose. Lithium toxicity can cause cardiac arrhythmias, and must be monitored closely. In addition, the effects of hydration and exercise on the lithium level, especially during summer, often are ignored.
Two of my patients, an adolescent and an adult, were well-maintained on lithium, adhered to treatment, and had no concurrent medical problems, but developed significant toxicity for no reason that I could determine. The adult had a lithium level of 2.0 mEq/L in the emergency room; the adolescent had a lithium level of 1.8 mEq/L. Levels this high are considered potentially lethal, and because it happened without warning and without a cause that I could determine, I consider lithium to be one of the riskier mood stabilizers. I still prescribe it, but with great caution.
Dr. McInnis also did not mention the possibility of lithium-induced diabetes insipidus, a condition in which the kidneys are no longer able to concentrate urine and that is marked by excessive urination, concomitant water intake, and low urine specific gravity. It is uncommon, but I have seen it 3 times in 30 years, in a practice that specializes in psychotherapy and does not see a high percentage of patients with BD. I consider it a condition that must be kept in mind as we follow our patients in long-term treatment.
Mary Davis, MD
Lancaster, Pennsylvania
Dr. McInnis responds
Dr. Davis raises the issue of lithium toxicity and provides examples of 2 patients who developed levels of 2.0 mEq/L and 1.8 mEq/L. These levels clearly are well beyond the toxicity threshold of 1.3 mEq/L, and the patients wisely sought urgent care. These scenarios exemplify the need for regular monitoring of the lithium level—in particular, when there is any change in physical or mental health status. Development of significant toxicity generally has some lead-time with emerging short-term side effects (outlined in Table 2 of my article), which underscores the importance of discussing the nature of emerging side effects with your patient.
Dr. Davis is correct in noting that the practitioner must be aware of long-term side effects of lithium. I find it helpful to discuss these effects with the patient in the context of short-term (days or weeks), intermediate (weeks or months), and long-term (months or years) time frames (Table 2). Diabetes insipidus is listed as an intermediate side effect.
I am grateful to Dr. Davis for raising the issue of hydration and summer heat, a concern among parents and coaches when student athletes practice strenuously for extended hours.1 Miller et al2 found that the concentration of lithium was between 1.2- and 4.6-fold in forearm sweat compared with serum levels, with the implication that heat-induced sweating may lower lithium levels. Jefferson et al3 studied 4 athletes after a 20-km race and found that all had become dehydrated but had a decrease in the serum lithium level. This is contrary to the widely held belief that excessive sweating predisposes to lithium toxicity.
BD is among the more lethal psychiatric disorders, and lithium is among the few medications shown to mitigate suicidal behavior.4 As with any medication, lithium is not without risk, and there is a clear need for informed medical management. Any notable change in health status or physical activity in a patient taking lithium is worthy of review, with recommendations based on knowledge of the patient and medical science.
I was astonished that Dr. Melvin G. McInnis’ article on using lithium to treat bipolar disorder (BD) (Current Psychiatry, June 2014, p. 38-44; [http://bit.ly/1sszAUr]) did not address all the potential hazards of the medication. He discussed side effects, but only how to manage them so that patients will adhere to treatment.
I have used lithium for patients with BD, and often it is efficacious, although hazardous in overdose. Lithium toxicity can cause cardiac arrhythmias, and must be monitored closely. In addition, the effects of hydration and exercise on the lithium level, especially during summer, often are ignored.
Two of my patients, an adolescent and an adult, were well-maintained on lithium, adhered to treatment, and had no concurrent medical problems, but developed significant toxicity for no reason that I could determine. The adult had a lithium level of 2.0 mEq/L in the emergency room; the adolescent had a lithium level of 1.8 mEq/L. Levels this high are considered potentially lethal, and because it happened without warning and without a cause that I could determine, I consider lithium to be one of the riskier mood stabilizers. I still prescribe it, but with great caution.
Dr. McInnis also did not mention the possibility of lithium-induced diabetes insipidus, a condition in which the kidneys are no longer able to concentrate urine and that is marked by excessive urination, concomitant water intake, and low urine specific gravity. It is uncommon, but I have seen it 3 times in 30 years, in a practice that specializes in psychotherapy and does not see a high percentage of patients with BD. I consider it a condition that must be kept in mind as we follow our patients in long-term treatment.
Mary Davis, MD
Lancaster, Pennsylvania
Dr. McInnis responds
Dr. Davis raises the issue of lithium toxicity and provides examples of 2 patients who developed levels of 2.0 mEq/L and 1.8 mEq/L. These levels clearly are well beyond the toxicity threshold of 1.3 mEq/L, and the patients wisely sought urgent care. These scenarios exemplify the need for regular monitoring of the lithium level—in particular, when there is any change in physical or mental health status. Development of significant toxicity generally has some lead-time with emerging short-term side effects (outlined in Table 2 of my article), which underscores the importance of discussing the nature of emerging side effects with your patient.
Dr. Davis is correct in noting that the practitioner must be aware of long-term side effects of lithium. I find it helpful to discuss these effects with the patient in the context of short-term (days or weeks), intermediate (weeks or months), and long-term (months or years) time frames (Table 2). Diabetes insipidus is listed as an intermediate side effect.
I am grateful to Dr. Davis for raising the issue of hydration and summer heat, a concern among parents and coaches when student athletes practice strenuously for extended hours.1 Miller et al2 found that the concentration of lithium was between 1.2- and 4.6-fold in forearm sweat compared with serum levels, with the implication that heat-induced sweating may lower lithium levels. Jefferson et al3 studied 4 athletes after a 20-km race and found that all had become dehydrated but had a decrease in the serum lithium level. This is contrary to the widely held belief that excessive sweating predisposes to lithium toxicity.
BD is among the more lethal psychiatric disorders, and lithium is among the few medications shown to mitigate suicidal behavior.4 As with any medication, lithium is not without risk, and there is a clear need for informed medical management. Any notable change in health status or physical activity in a patient taking lithium is worthy of review, with recommendations based on knowledge of the patient and medical science.
1. Reardon CL, Factor RM. Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40:961-980.
2. Miller EB, Pain RW, Skripal PJ. Sweat lithium in manic-depression. Br J Psychiatry. 1978;133:477-478.
3. Jefferson JW, Greist JH, Clagnaz PJ, et al. Effect of strenuous exercise on serum lithium level in man. Am J Psychiatry. 1982;139(12):1593-1595.
4. Goodwin FK, Fireman B, Simon GE, et al. Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA. 2003;290(11):1467-1473.
1. Reardon CL, Factor RM. Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40:961-980.
2. Miller EB, Pain RW, Skripal PJ. Sweat lithium in manic-depression. Br J Psychiatry. 1978;133:477-478.
3. Jefferson JW, Greist JH, Clagnaz PJ, et al. Effect of strenuous exercise on serum lithium level in man. Am J Psychiatry. 1982;139(12):1593-1595.
4. Goodwin FK, Fireman B, Simon GE, et al. Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA. 2003;290(11):1467-1473.
A new form to fill out
I got my Medicare card 2 years ago (guess how old I am?). At this year’s physical exam (my first exam under new rules that let Medicare pay for routine annual physicals), the clerk asked me to fill out the “Health-Risk Assessment” form my PCP would need for billing.
This form had two pages. Page 1 listed 26 questions, each to be answered by checking off one of the following six choices: Never, Sometimes, Seldom, Often, Always, and Not Applicable.
Right away you see a problem. If this were an SAT test, say, where I actually cared whether or not I passed, I would summon a proctor and demand to know the difference between “Sometimes” and “Seldom,” or whether “Always” includes when I’m asleep, intoxicated, or filling out forms.
I will not burden you with all 26 questions. Instead, I’ll present several (these are the actual questions, folks, word for word), along with the answers I would have given had I not been hamstrung by the Six Categories. Each question is headed, “In the past 4 weeks.”
Q: How much have you felt little interest or pleasure?
A: I have very much felt little interest, and very little felt much interest. On the other hand, I have much interest in the little pleasure I have felt, and much pleasure in the little interest I have had.
Q: Has your physical and emotional health limited your social activities with family, friends, neighbors or groups?
A: No, but lack of money has.
Q: Have you needed help preparing your own meals?
A: Yes, ever since I got married, but that was more than 4 weeks ago. I can still make omelets, though.
Q: Are you having difficulties driving your car?
A: Do you know Boston drivers?
Q: Have you needed help managing your finances?
A: Not since 2008, and then it was my broker who needed the help.
Q: Have you needed help with household chores?
A: Never do ‘em.
Q: Do you have concerns about your memory?
A: What?
Q: DO YOU HAVE CONCERNS ABOUT YOUR MEMORY?
A: Not so much about what I can’t remember, mostly about what I can.
Q: Do any of your friends/family have concerns about your memory?
A: No, other than whether I’ll remember them in my will.
Q: Have you had sexual problems?
A: Too much. Too little. I forget. But that’s just the last 4 weeks. Six weeks ago was amazing.
Q: Have problems using a telephone?
A: Damn right. Cellular connectivity around here stinks.
Q: Do you exercise for about 20 minutes, 3 or more days a week?
A: I always exercise sometimes. I sometimes exercise always. Could you repeat the question?
Q: Does your home have throw rugs?
A: It has rugs, but nobody throws them.
Q: Does your home have poor lighting?
A: Ever since they outlawed incandescents. When I flip the switch, they’re fully lit by the time I finish breakfast, but by then it’s time to turn them off and go to work.
Q: During the past 4 weeks, how have things been going for you?
A: The Red Sox are doing lousy. Did you have to ask?
The form ends with thanks for taking the time to fill out the form and concludes with this cheery note: “Your responses will help you receive the best health and health care possible.”
When my physical was done, my doctor found the form in my paper pile. “I see you filled it out,” she said.
“By the way,” I asked her. ‘”What do you do with these forms?”
“Absolutely nothing,” she said.
“You don’t have to submit them for tabulation or something?”
“No,” she said.
If you’re not on Medicare yet, this is what you have to look forward to. Always.
Sometimes.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
I got my Medicare card 2 years ago (guess how old I am?). At this year’s physical exam (my first exam under new rules that let Medicare pay for routine annual physicals), the clerk asked me to fill out the “Health-Risk Assessment” form my PCP would need for billing.
This form had two pages. Page 1 listed 26 questions, each to be answered by checking off one of the following six choices: Never, Sometimes, Seldom, Often, Always, and Not Applicable.
Right away you see a problem. If this were an SAT test, say, where I actually cared whether or not I passed, I would summon a proctor and demand to know the difference between “Sometimes” and “Seldom,” or whether “Always” includes when I’m asleep, intoxicated, or filling out forms.
I will not burden you with all 26 questions. Instead, I’ll present several (these are the actual questions, folks, word for word), along with the answers I would have given had I not been hamstrung by the Six Categories. Each question is headed, “In the past 4 weeks.”
Q: How much have you felt little interest or pleasure?
A: I have very much felt little interest, and very little felt much interest. On the other hand, I have much interest in the little pleasure I have felt, and much pleasure in the little interest I have had.
Q: Has your physical and emotional health limited your social activities with family, friends, neighbors or groups?
A: No, but lack of money has.
Q: Have you needed help preparing your own meals?
A: Yes, ever since I got married, but that was more than 4 weeks ago. I can still make omelets, though.
Q: Are you having difficulties driving your car?
A: Do you know Boston drivers?
Q: Have you needed help managing your finances?
A: Not since 2008, and then it was my broker who needed the help.
Q: Have you needed help with household chores?
A: Never do ‘em.
Q: Do you have concerns about your memory?
A: What?
Q: DO YOU HAVE CONCERNS ABOUT YOUR MEMORY?
A: Not so much about what I can’t remember, mostly about what I can.
Q: Do any of your friends/family have concerns about your memory?
A: No, other than whether I’ll remember them in my will.
Q: Have you had sexual problems?
A: Too much. Too little. I forget. But that’s just the last 4 weeks. Six weeks ago was amazing.
Q: Have problems using a telephone?
A: Damn right. Cellular connectivity around here stinks.
Q: Do you exercise for about 20 minutes, 3 or more days a week?
A: I always exercise sometimes. I sometimes exercise always. Could you repeat the question?
Q: Does your home have throw rugs?
A: It has rugs, but nobody throws them.
Q: Does your home have poor lighting?
A: Ever since they outlawed incandescents. When I flip the switch, they’re fully lit by the time I finish breakfast, but by then it’s time to turn them off and go to work.
Q: During the past 4 weeks, how have things been going for you?
A: The Red Sox are doing lousy. Did you have to ask?
The form ends with thanks for taking the time to fill out the form and concludes with this cheery note: “Your responses will help you receive the best health and health care possible.”
When my physical was done, my doctor found the form in my paper pile. “I see you filled it out,” she said.
“By the way,” I asked her. ‘”What do you do with these forms?”
“Absolutely nothing,” she said.
“You don’t have to submit them for tabulation or something?”
“No,” she said.
If you’re not on Medicare yet, this is what you have to look forward to. Always.
Sometimes.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
I got my Medicare card 2 years ago (guess how old I am?). At this year’s physical exam (my first exam under new rules that let Medicare pay for routine annual physicals), the clerk asked me to fill out the “Health-Risk Assessment” form my PCP would need for billing.
This form had two pages. Page 1 listed 26 questions, each to be answered by checking off one of the following six choices: Never, Sometimes, Seldom, Often, Always, and Not Applicable.
Right away you see a problem. If this were an SAT test, say, where I actually cared whether or not I passed, I would summon a proctor and demand to know the difference between “Sometimes” and “Seldom,” or whether “Always” includes when I’m asleep, intoxicated, or filling out forms.
I will not burden you with all 26 questions. Instead, I’ll present several (these are the actual questions, folks, word for word), along with the answers I would have given had I not been hamstrung by the Six Categories. Each question is headed, “In the past 4 weeks.”
Q: How much have you felt little interest or pleasure?
A: I have very much felt little interest, and very little felt much interest. On the other hand, I have much interest in the little pleasure I have felt, and much pleasure in the little interest I have had.
Q: Has your physical and emotional health limited your social activities with family, friends, neighbors or groups?
A: No, but lack of money has.
Q: Have you needed help preparing your own meals?
A: Yes, ever since I got married, but that was more than 4 weeks ago. I can still make omelets, though.
Q: Are you having difficulties driving your car?
A: Do you know Boston drivers?
Q: Have you needed help managing your finances?
A: Not since 2008, and then it was my broker who needed the help.
Q: Have you needed help with household chores?
A: Never do ‘em.
Q: Do you have concerns about your memory?
A: What?
Q: DO YOU HAVE CONCERNS ABOUT YOUR MEMORY?
A: Not so much about what I can’t remember, mostly about what I can.
Q: Do any of your friends/family have concerns about your memory?
A: No, other than whether I’ll remember them in my will.
Q: Have you had sexual problems?
A: Too much. Too little. I forget. But that’s just the last 4 weeks. Six weeks ago was amazing.
Q: Have problems using a telephone?
A: Damn right. Cellular connectivity around here stinks.
Q: Do you exercise for about 20 minutes, 3 or more days a week?
A: I always exercise sometimes. I sometimes exercise always. Could you repeat the question?
Q: Does your home have throw rugs?
A: It has rugs, but nobody throws them.
Q: Does your home have poor lighting?
A: Ever since they outlawed incandescents. When I flip the switch, they’re fully lit by the time I finish breakfast, but by then it’s time to turn them off and go to work.
Q: During the past 4 weeks, how have things been going for you?
A: The Red Sox are doing lousy. Did you have to ask?
The form ends with thanks for taking the time to fill out the form and concludes with this cheery note: “Your responses will help you receive the best health and health care possible.”
When my physical was done, my doctor found the form in my paper pile. “I see you filled it out,” she said.
“By the way,” I asked her. ‘”What do you do with these forms?”
“Absolutely nothing,” she said.
“You don’t have to submit them for tabulation or something?”
“No,” she said.
If you’re not on Medicare yet, this is what you have to look forward to. Always.
Sometimes.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Probiotics for IBS
Irritable bowel syndrome affects up to 15% of the U.S. adult population, which may be an underestimate. When patients are managing themselves well, their clinical course can be routine. When their self-management is poor, IBS can make life exceedingly challenging for both patients and their clinicians. Many of us may be stepping up our game in patients with known IBS experiencing symptoms, first by recommending a diet low in FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols), which have been shown to reduce IBS symptoms.
My experience is that patients who have been struggling for years with IBS have a high degree of health literacy. And they are usually receptive to trying new things that might make their lives better. The exceptions are the occasional patients who are convinced that they do not have IBS and that their clinicians are just too poorly informed to figure out what the real cause is.
Anything else we can recommend?
Jun Sik Yoon and colleagues have published a clinical trial evaluating the effectiveness of multispecies probiotics on IBS symptoms and changes in the gut microbiota. In this randomized, placebo-controlled trial, 49 subjects (25 probiotics, 24 placebo) with clinically-diagnosed IBS received tablets twice a day for 4 weeks. The primary outcome was the proportion of individuals whose IBS symptoms were substantially relieved at 4 weeks.
Probiotics were associated with a significantly higher proportion of patients with reductions in IBS symptoms (68% vs. 37.5%; P < .05). Probiotics also improved abdominal pain/discomfort and bloating. Fecal analysis revealed increases in the microbiota obtained with the probiotics (J. Gastroenterol. Hepatol. 2014;29:52-9).
So probiotics may help our patients with IBS if a low FODMAP diet does not. But what probiotic (i.e., containing which species) should we select? Species may have different effects on gut motility. Importantly, taking probiotics with certain species does not mean that those species will set up permanent residence in the colon. In the current study, only three of the six species contained in the probiotics were still in the stool after 4 weeks. The author concluded that the alleviation in bowel symptoms was attributable to Bifidobacterium lactis, Lactobacillus rhamnosus, and Streptococcus thermophiles. So let’s tell patients to look for probiotics with these species.
Probiotics are generally safe with the only possible contraindication being their use in patients with a severely immunocompromised state, but this is debatable. But now we have another evidence-based tool for our patients struggling with symptom recrudescence.
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.
Irritable bowel syndrome affects up to 15% of the U.S. adult population, which may be an underestimate. When patients are managing themselves well, their clinical course can be routine. When their self-management is poor, IBS can make life exceedingly challenging for both patients and their clinicians. Many of us may be stepping up our game in patients with known IBS experiencing symptoms, first by recommending a diet low in FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols), which have been shown to reduce IBS symptoms.
My experience is that patients who have been struggling for years with IBS have a high degree of health literacy. And they are usually receptive to trying new things that might make their lives better. The exceptions are the occasional patients who are convinced that they do not have IBS and that their clinicians are just too poorly informed to figure out what the real cause is.
Anything else we can recommend?
Jun Sik Yoon and colleagues have published a clinical trial evaluating the effectiveness of multispecies probiotics on IBS symptoms and changes in the gut microbiota. In this randomized, placebo-controlled trial, 49 subjects (25 probiotics, 24 placebo) with clinically-diagnosed IBS received tablets twice a day for 4 weeks. The primary outcome was the proportion of individuals whose IBS symptoms were substantially relieved at 4 weeks.
Probiotics were associated with a significantly higher proportion of patients with reductions in IBS symptoms (68% vs. 37.5%; P < .05). Probiotics also improved abdominal pain/discomfort and bloating. Fecal analysis revealed increases in the microbiota obtained with the probiotics (J. Gastroenterol. Hepatol. 2014;29:52-9).
So probiotics may help our patients with IBS if a low FODMAP diet does not. But what probiotic (i.e., containing which species) should we select? Species may have different effects on gut motility. Importantly, taking probiotics with certain species does not mean that those species will set up permanent residence in the colon. In the current study, only three of the six species contained in the probiotics were still in the stool after 4 weeks. The author concluded that the alleviation in bowel symptoms was attributable to Bifidobacterium lactis, Lactobacillus rhamnosus, and Streptococcus thermophiles. So let’s tell patients to look for probiotics with these species.
Probiotics are generally safe with the only possible contraindication being their use in patients with a severely immunocompromised state, but this is debatable. But now we have another evidence-based tool for our patients struggling with symptom recrudescence.
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.
Irritable bowel syndrome affects up to 15% of the U.S. adult population, which may be an underestimate. When patients are managing themselves well, their clinical course can be routine. When their self-management is poor, IBS can make life exceedingly challenging for both patients and their clinicians. Many of us may be stepping up our game in patients with known IBS experiencing symptoms, first by recommending a diet low in FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols), which have been shown to reduce IBS symptoms.
My experience is that patients who have been struggling for years with IBS have a high degree of health literacy. And they are usually receptive to trying new things that might make their lives better. The exceptions are the occasional patients who are convinced that they do not have IBS and that their clinicians are just too poorly informed to figure out what the real cause is.
Anything else we can recommend?
Jun Sik Yoon and colleagues have published a clinical trial evaluating the effectiveness of multispecies probiotics on IBS symptoms and changes in the gut microbiota. In this randomized, placebo-controlled trial, 49 subjects (25 probiotics, 24 placebo) with clinically-diagnosed IBS received tablets twice a day for 4 weeks. The primary outcome was the proportion of individuals whose IBS symptoms were substantially relieved at 4 weeks.
Probiotics were associated with a significantly higher proportion of patients with reductions in IBS symptoms (68% vs. 37.5%; P < .05). Probiotics also improved abdominal pain/discomfort and bloating. Fecal analysis revealed increases in the microbiota obtained with the probiotics (J. Gastroenterol. Hepatol. 2014;29:52-9).
So probiotics may help our patients with IBS if a low FODMAP diet does not. But what probiotic (i.e., containing which species) should we select? Species may have different effects on gut motility. Importantly, taking probiotics with certain species does not mean that those species will set up permanent residence in the colon. In the current study, only three of the six species contained in the probiotics were still in the stool after 4 weeks. The author concluded that the alleviation in bowel symptoms was attributable to Bifidobacterium lactis, Lactobacillus rhamnosus, and Streptococcus thermophiles. So let’s tell patients to look for probiotics with these species.
Probiotics are generally safe with the only possible contraindication being their use in patients with a severely immunocompromised state, but this is debatable. But now we have another evidence-based tool for our patients struggling with symptom recrudescence.
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.
A Call to Action: Intensive Lifestyle Intervention Against Diabesity
The U.S. health care system is being overwhelmed by an epidemic of obesity and type 2 diabetes, sometimes referred to as “diabesity.” This metabolic problem is not limited to hyperglycemia (high blood sugar), but in most cases includes lipid abnormalities (high cholesterol and triglycerides) and high blood pressure (BP). The major long-term complications of obesity-induced type 2 diabetes are renal failure; retinopathy, causing blindness; neuropathy, leading to chronic pain and foot problems that can require amputation; atherosclerosis (large vessel disease), causing myocardial infarction, heart failure, strokes; and peripheral vascular insufficiency (also a cause of amputations).
Treating these complications costs billions of dollars annually. In 2012, the American Diabetes Association (ADA) estimated the total annual U.S. cost of type 2 diabetes and its complications at $245 billion or about $671 million a day. Numerous clinical research studies have shown that intensive treatment to lower blood sugar, reduce BP, and decrease low-density lipoprotein cholesterol and triglycerides are powerfully effective in reducing the incidence of these devastating complications.
However, there are simply not enough endocrinologists to see and treat all the patients with this syndrome, let alone provide preventive care to patients who do not yet have diabetes but are at high risk. Wait times for new patients to see an endocrine-metabolism specialist in the private sector are often 40 days or more. The increasing numbers of new patients with diabesity are also overwhelming primary care providers. The current VA guidelines mandate new patients wait < 30 days for a medical subspecialty consultation appointment. Unfortunately, this is already impossible to meet, given the increasing numbers of diabetic patients and the limited capacity of the system.
The Diabesity Problem
Over the past 20 years, we have developed a whole new armamentarium of medications that either increase insulin secretion, increase sensitivity to insulin, or delay digestion and absorption of carbohydrates with the most recent addition being agents that promote urinary excretion of glucose. New long-acting and rapid-acting insulins allow us to simulate islet cell function with multiple daily injections or pump therapy. Nevertheless, good control of blood glucose still eludes far too many patients. Likewise, lipid-lowering drugs and combinations of antihypertensive agents with different modes of actions can reduce cholesterol and triglycerides and lower BP.
However, many patients are either unable or unwilling, as evidenced by the high rates of poor adherence. Moreover, many of the antidiabetic medications, including insulin, lead to weight gain, producing a vicious cycle requiring higher doses and additional therapies as time goes on. The medical model of treatment of diabesity is just not working or not working well enough.
Diabesity is not only a medical problem. It is also a lifestyle problem. The primary treatment recommended by the ADA and other national medical organizations for type 2 diabetes and patients at high risk for type 2 diabetes is a lifestyle intervention: Mainly weight loss by improved nutrition and a regimen of regular exercise. Despite clear evidence that these interventions, when implemented appropriately, are remarkably effective and knowledgeable medical care providers consistently recommend them to obese patients with diabetes, success in implementing them has been limited. As a result, we continue to attempt to control diabesity using the medical model of drug treatment.
Perhaps it is time to do something different. We know that exercise and weight loss are effective. What we have not figured out is how to get patients to exercise, eat healthful diets, and lose weight. We can estimate the costs of complications from our failure to treat diabesity successfully, and even the costs for treating the minority of patients who obtain some level of success by meeting goals for hemoglobin A1c, lipid levels, and BP. These costs remain staggering.
What we have not examined are the comparative costs of large-scale, innovative programs to get patients to adhere to regimens of diet and exercise that will result in weight loss. Are such programs beyond our reach? I suggest they are not.
The private sector has voluntary pay-as-you-go programs, such as Weight Watchers, which achieve significant weight loss in a high percentage of participants. These programs work by a combination of motivational psychology and providing a user-friendly set of tools that enable clients to plan their nutritional programs and monitor the results, thus providing feedback that encourages success. Similarly, the Silver Sneakers program has had considerable success in getting older people to exercise regularly. A feature of these programs is group dynamics, in which people active in the program interact and encourage one another.
It is likely that a large-scale program that successfully gets patients to lose weight and exercise would be far less costly than treating diabesity and its complications. For private insurance companies, which largely avoid paying for long-term adverse outcomes for their current clients, such programs may fail the test of cost-benefit analysis. For the VA, where our patients tend to remain our patients “till death do us part,” programs of effective long-term prevention make perfect sense.
The ILIAD
The program can be called ILIAD: Intensive Lifestyle Intervention Against Diabesity. Homer’s Iliad tells the story of the Trojan War, a long, frustrating campaign that the Greeks finally won thanks to a successful and highly imaginative innovation (the Trojan horse).
What then would be the key characteristics of ILIAD? First, it would have to be provided at no additional cost to the patient. Simply telling VA patients to join a gym and buy better quality food is never going to work, even if we educate them regarding the long-term benefits. This is not to say that patient education should not be a component of ILIAD—it certainly should be. Second, it would have to provide rewards for the patients. Human beings do what they are rewarded for doing. A mechanism should be created so patients could receive cash payments or earn reward coupons for services and goods. Third, ILIAD should probably include an element of group dynamics, moderated by a knowledgeable group leader. Fourth, it would have to include a system of regular, frequent monitoring to provide feedback to both the health care providers and the patient. Such a monitoring system should make use of the most up-to-date, user-friendly digital technology and be available as a smartphone application. Finally, it would have to be designed so that it could be implemented across the whole spectrum of VA facilities.
The VA should create a working group to design and test ILIAD. While dedicated VA programs and facilities could be developed, it might be more cost-effective to provide membership for eligible patients in existing private-sector nutrition and exercise programs at existing neighborhood locations. These programs would have to be overseen and, perhaps, the details adjusted in collaboration with the private-sector partners to be more suitable for the VA patient population.
One advantage that VA has for implementing ILIAD is the CPRS. Another potential advantage is that all our patients have military experience. They have been through basic training. At some level, most know the benefits of discipline and regular exercise. In addition, there are veterans who were themselves trainers, ex-drill sergeants with experience in shaping up recruits and keeping troops fit. Perhaps this experience can be used in design and execution of ILIAD programs, even stressing a back-to-basics theme.
The VA currently employs the MOVE! program to encourage patients to improve their diets and engage in regular exercise. It has had notable success at some VA centers and has languished at others. The critical factor for a successful MOVE! program would appear to be the presence of a committed local “champion” and allocation of sufficient resources (personnel, space, dollars), which varies from center to center. ILIAD could be implemented as an “upgrade” (MOVE! 2.0), or as an alternative that would replace it. Unlike MOVE!, ILIAD would subsidize use of community resources, provide specialized trainers, and include a system of incentives and rewards for participation and success.
Without ILIAD, or something like it, the VA is inevitably going to be overwhelmed by the diabesity epidemic. There are simply not enough available medical providers or enough money in the federal budget to effectively treat all the patients using the medical model. If we do not innovate and think out of the box, we are doomed to fail, with enormous costs in terms of money to the system and, more important, in morbidity and mortality for our patients.
Let’s get moving. The time to act is now!
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 complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
The U.S. health care system is being overwhelmed by an epidemic of obesity and type 2 diabetes, sometimes referred to as “diabesity.” This metabolic problem is not limited to hyperglycemia (high blood sugar), but in most cases includes lipid abnormalities (high cholesterol and triglycerides) and high blood pressure (BP). The major long-term complications of obesity-induced type 2 diabetes are renal failure; retinopathy, causing blindness; neuropathy, leading to chronic pain and foot problems that can require amputation; atherosclerosis (large vessel disease), causing myocardial infarction, heart failure, strokes; and peripheral vascular insufficiency (also a cause of amputations).
Treating these complications costs billions of dollars annually. In 2012, the American Diabetes Association (ADA) estimated the total annual U.S. cost of type 2 diabetes and its complications at $245 billion or about $671 million a day. Numerous clinical research studies have shown that intensive treatment to lower blood sugar, reduce BP, and decrease low-density lipoprotein cholesterol and triglycerides are powerfully effective in reducing the incidence of these devastating complications.
However, there are simply not enough endocrinologists to see and treat all the patients with this syndrome, let alone provide preventive care to patients who do not yet have diabetes but are at high risk. Wait times for new patients to see an endocrine-metabolism specialist in the private sector are often 40 days or more. The increasing numbers of new patients with diabesity are also overwhelming primary care providers. The current VA guidelines mandate new patients wait < 30 days for a medical subspecialty consultation appointment. Unfortunately, this is already impossible to meet, given the increasing numbers of diabetic patients and the limited capacity of the system.
The Diabesity Problem
Over the past 20 years, we have developed a whole new armamentarium of medications that either increase insulin secretion, increase sensitivity to insulin, or delay digestion and absorption of carbohydrates with the most recent addition being agents that promote urinary excretion of glucose. New long-acting and rapid-acting insulins allow us to simulate islet cell function with multiple daily injections or pump therapy. Nevertheless, good control of blood glucose still eludes far too many patients. Likewise, lipid-lowering drugs and combinations of antihypertensive agents with different modes of actions can reduce cholesterol and triglycerides and lower BP.
However, many patients are either unable or unwilling, as evidenced by the high rates of poor adherence. Moreover, many of the antidiabetic medications, including insulin, lead to weight gain, producing a vicious cycle requiring higher doses and additional therapies as time goes on. The medical model of treatment of diabesity is just not working or not working well enough.
Diabesity is not only a medical problem. It is also a lifestyle problem. The primary treatment recommended by the ADA and other national medical organizations for type 2 diabetes and patients at high risk for type 2 diabetes is a lifestyle intervention: Mainly weight loss by improved nutrition and a regimen of regular exercise. Despite clear evidence that these interventions, when implemented appropriately, are remarkably effective and knowledgeable medical care providers consistently recommend them to obese patients with diabetes, success in implementing them has been limited. As a result, we continue to attempt to control diabesity using the medical model of drug treatment.
Perhaps it is time to do something different. We know that exercise and weight loss are effective. What we have not figured out is how to get patients to exercise, eat healthful diets, and lose weight. We can estimate the costs of complications from our failure to treat diabesity successfully, and even the costs for treating the minority of patients who obtain some level of success by meeting goals for hemoglobin A1c, lipid levels, and BP. These costs remain staggering.
What we have not examined are the comparative costs of large-scale, innovative programs to get patients to adhere to regimens of diet and exercise that will result in weight loss. Are such programs beyond our reach? I suggest they are not.
The private sector has voluntary pay-as-you-go programs, such as Weight Watchers, which achieve significant weight loss in a high percentage of participants. These programs work by a combination of motivational psychology and providing a user-friendly set of tools that enable clients to plan their nutritional programs and monitor the results, thus providing feedback that encourages success. Similarly, the Silver Sneakers program has had considerable success in getting older people to exercise regularly. A feature of these programs is group dynamics, in which people active in the program interact and encourage one another.
It is likely that a large-scale program that successfully gets patients to lose weight and exercise would be far less costly than treating diabesity and its complications. For private insurance companies, which largely avoid paying for long-term adverse outcomes for their current clients, such programs may fail the test of cost-benefit analysis. For the VA, where our patients tend to remain our patients “till death do us part,” programs of effective long-term prevention make perfect sense.
The ILIAD
The program can be called ILIAD: Intensive Lifestyle Intervention Against Diabesity. Homer’s Iliad tells the story of the Trojan War, a long, frustrating campaign that the Greeks finally won thanks to a successful and highly imaginative innovation (the Trojan horse).
What then would be the key characteristics of ILIAD? First, it would have to be provided at no additional cost to the patient. Simply telling VA patients to join a gym and buy better quality food is never going to work, even if we educate them regarding the long-term benefits. This is not to say that patient education should not be a component of ILIAD—it certainly should be. Second, it would have to provide rewards for the patients. Human beings do what they are rewarded for doing. A mechanism should be created so patients could receive cash payments or earn reward coupons for services and goods. Third, ILIAD should probably include an element of group dynamics, moderated by a knowledgeable group leader. Fourth, it would have to include a system of regular, frequent monitoring to provide feedback to both the health care providers and the patient. Such a monitoring system should make use of the most up-to-date, user-friendly digital technology and be available as a smartphone application. Finally, it would have to be designed so that it could be implemented across the whole spectrum of VA facilities.
The VA should create a working group to design and test ILIAD. While dedicated VA programs and facilities could be developed, it might be more cost-effective to provide membership for eligible patients in existing private-sector nutrition and exercise programs at existing neighborhood locations. These programs would have to be overseen and, perhaps, the details adjusted in collaboration with the private-sector partners to be more suitable for the VA patient population.
One advantage that VA has for implementing ILIAD is the CPRS. Another potential advantage is that all our patients have military experience. They have been through basic training. At some level, most know the benefits of discipline and regular exercise. In addition, there are veterans who were themselves trainers, ex-drill sergeants with experience in shaping up recruits and keeping troops fit. Perhaps this experience can be used in design and execution of ILIAD programs, even stressing a back-to-basics theme.
The VA currently employs the MOVE! program to encourage patients to improve their diets and engage in regular exercise. It has had notable success at some VA centers and has languished at others. The critical factor for a successful MOVE! program would appear to be the presence of a committed local “champion” and allocation of sufficient resources (personnel, space, dollars), which varies from center to center. ILIAD could be implemented as an “upgrade” (MOVE! 2.0), or as an alternative that would replace it. Unlike MOVE!, ILIAD would subsidize use of community resources, provide specialized trainers, and include a system of incentives and rewards for participation and success.
Without ILIAD, or something like it, the VA is inevitably going to be overwhelmed by the diabesity epidemic. There are simply not enough available medical providers or enough money in the federal budget to effectively treat all the patients using the medical model. If we do not innovate and think out of the box, we are doomed to fail, with enormous costs in terms of money to the system and, more important, in morbidity and mortality for our patients.
Let’s get moving. The time to act is now!
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 complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
The U.S. health care system is being overwhelmed by an epidemic of obesity and type 2 diabetes, sometimes referred to as “diabesity.” This metabolic problem is not limited to hyperglycemia (high blood sugar), but in most cases includes lipid abnormalities (high cholesterol and triglycerides) and high blood pressure (BP). The major long-term complications of obesity-induced type 2 diabetes are renal failure; retinopathy, causing blindness; neuropathy, leading to chronic pain and foot problems that can require amputation; atherosclerosis (large vessel disease), causing myocardial infarction, heart failure, strokes; and peripheral vascular insufficiency (also a cause of amputations).
Treating these complications costs billions of dollars annually. In 2012, the American Diabetes Association (ADA) estimated the total annual U.S. cost of type 2 diabetes and its complications at $245 billion or about $671 million a day. Numerous clinical research studies have shown that intensive treatment to lower blood sugar, reduce BP, and decrease low-density lipoprotein cholesterol and triglycerides are powerfully effective in reducing the incidence of these devastating complications.
However, there are simply not enough endocrinologists to see and treat all the patients with this syndrome, let alone provide preventive care to patients who do not yet have diabetes but are at high risk. Wait times for new patients to see an endocrine-metabolism specialist in the private sector are often 40 days or more. The increasing numbers of new patients with diabesity are also overwhelming primary care providers. The current VA guidelines mandate new patients wait < 30 days for a medical subspecialty consultation appointment. Unfortunately, this is already impossible to meet, given the increasing numbers of diabetic patients and the limited capacity of the system.
The Diabesity Problem
Over the past 20 years, we have developed a whole new armamentarium of medications that either increase insulin secretion, increase sensitivity to insulin, or delay digestion and absorption of carbohydrates with the most recent addition being agents that promote urinary excretion of glucose. New long-acting and rapid-acting insulins allow us to simulate islet cell function with multiple daily injections or pump therapy. Nevertheless, good control of blood glucose still eludes far too many patients. Likewise, lipid-lowering drugs and combinations of antihypertensive agents with different modes of actions can reduce cholesterol and triglycerides and lower BP.
However, many patients are either unable or unwilling, as evidenced by the high rates of poor adherence. Moreover, many of the antidiabetic medications, including insulin, lead to weight gain, producing a vicious cycle requiring higher doses and additional therapies as time goes on. The medical model of treatment of diabesity is just not working or not working well enough.
Diabesity is not only a medical problem. It is also a lifestyle problem. The primary treatment recommended by the ADA and other national medical organizations for type 2 diabetes and patients at high risk for type 2 diabetes is a lifestyle intervention: Mainly weight loss by improved nutrition and a regimen of regular exercise. Despite clear evidence that these interventions, when implemented appropriately, are remarkably effective and knowledgeable medical care providers consistently recommend them to obese patients with diabetes, success in implementing them has been limited. As a result, we continue to attempt to control diabesity using the medical model of drug treatment.
Perhaps it is time to do something different. We know that exercise and weight loss are effective. What we have not figured out is how to get patients to exercise, eat healthful diets, and lose weight. We can estimate the costs of complications from our failure to treat diabesity successfully, and even the costs for treating the minority of patients who obtain some level of success by meeting goals for hemoglobin A1c, lipid levels, and BP. These costs remain staggering.
What we have not examined are the comparative costs of large-scale, innovative programs to get patients to adhere to regimens of diet and exercise that will result in weight loss. Are such programs beyond our reach? I suggest they are not.
The private sector has voluntary pay-as-you-go programs, such as Weight Watchers, which achieve significant weight loss in a high percentage of participants. These programs work by a combination of motivational psychology and providing a user-friendly set of tools that enable clients to plan their nutritional programs and monitor the results, thus providing feedback that encourages success. Similarly, the Silver Sneakers program has had considerable success in getting older people to exercise regularly. A feature of these programs is group dynamics, in which people active in the program interact and encourage one another.
It is likely that a large-scale program that successfully gets patients to lose weight and exercise would be far less costly than treating diabesity and its complications. For private insurance companies, which largely avoid paying for long-term adverse outcomes for their current clients, such programs may fail the test of cost-benefit analysis. For the VA, where our patients tend to remain our patients “till death do us part,” programs of effective long-term prevention make perfect sense.
The ILIAD
The program can be called ILIAD: Intensive Lifestyle Intervention Against Diabesity. Homer’s Iliad tells the story of the Trojan War, a long, frustrating campaign that the Greeks finally won thanks to a successful and highly imaginative innovation (the Trojan horse).
What then would be the key characteristics of ILIAD? First, it would have to be provided at no additional cost to the patient. Simply telling VA patients to join a gym and buy better quality food is never going to work, even if we educate them regarding the long-term benefits. This is not to say that patient education should not be a component of ILIAD—it certainly should be. Second, it would have to provide rewards for the patients. Human beings do what they are rewarded for doing. A mechanism should be created so patients could receive cash payments or earn reward coupons for services and goods. Third, ILIAD should probably include an element of group dynamics, moderated by a knowledgeable group leader. Fourth, it would have to include a system of regular, frequent monitoring to provide feedback to both the health care providers and the patient. Such a monitoring system should make use of the most up-to-date, user-friendly digital technology and be available as a smartphone application. Finally, it would have to be designed so that it could be implemented across the whole spectrum of VA facilities.
The VA should create a working group to design and test ILIAD. While dedicated VA programs and facilities could be developed, it might be more cost-effective to provide membership for eligible patients in existing private-sector nutrition and exercise programs at existing neighborhood locations. These programs would have to be overseen and, perhaps, the details adjusted in collaboration with the private-sector partners to be more suitable for the VA patient population.
One advantage that VA has for implementing ILIAD is the CPRS. Another potential advantage is that all our patients have military experience. They have been through basic training. At some level, most know the benefits of discipline and regular exercise. In addition, there are veterans who were themselves trainers, ex-drill sergeants with experience in shaping up recruits and keeping troops fit. Perhaps this experience can be used in design and execution of ILIAD programs, even stressing a back-to-basics theme.
The VA currently employs the MOVE! program to encourage patients to improve their diets and engage in regular exercise. It has had notable success at some VA centers and has languished at others. The critical factor for a successful MOVE! program would appear to be the presence of a committed local “champion” and allocation of sufficient resources (personnel, space, dollars), which varies from center to center. ILIAD could be implemented as an “upgrade” (MOVE! 2.0), or as an alternative that would replace it. Unlike MOVE!, ILIAD would subsidize use of community resources, provide specialized trainers, and include a system of incentives and rewards for participation and success.
Without ILIAD, or something like it, the VA is inevitably going to be overwhelmed by the diabesity epidemic. There are simply not enough available medical providers or enough money in the federal budget to effectively treat all the patients using the medical model. If we do not innovate and think out of the box, we are doomed to fail, with enormous costs in terms of money to the system and, more important, in morbidity and mortality for our patients.
Let’s get moving. The time to act is now!
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 complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.