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A diabetic foot infection progresses to amputation
The story
KL was a 56-year-old man with multiple comorbidities, including obesity, coronary artery disease, hypertension, insulin-dependent diabetes, chronic kidney disease, and dyslipidemia. He presented to Hospital A with fever and chills, along with an open wound on the bottom of his left foot. Laboratory studies revealed a WBC 14,000 cells/mL and a serum creatinine of 3.1 mg/dL. KL was admitted by Dr. Hospitalist for cellulitis and an infected diabetic foot ulcer.
KL was started on intravenous vancomycin and piperacillin/tazobactam and blood cultures were drawn. A bone scan was negative for osteomyelitis. Blood cultures did not grow any bacteria, but a wound culture from his foot ulcer grew Klebsiella. Dr. Hospitalist consulted inpatient podiatry for wound debridement, but KL apparently refused in favor of being seen by his own podiatrist as an outpatient. By hospital day 2, KL was afebrile, eating well, and he was discharged on oral ciprofloxacin later that same day.
Two days after discharge, KL followed up with his primary care physician (PCP). KL was again febrile and his foot ulcer looked worse. The PCP recommended hospitalization with intravenous antibiotics, but KL was reluctant to return to the hospital. The PCP arranged for midline placement and KL was referred to a local wound clinic for intravenous vancomycin to begin the next day. KL remained on the oral ciprofloxacin.
Over the next 3 days, KL received daily intravenous vancomycin at the wound clinic. However, the foot ulcer continued to drain purulent material with associated cellulitis and advancing erythema across the forefoot. The wound nurse contacted the PCP who had sent KL to the emergency department of Hospital B. Laboratory studies revealed a WBC 18,300 cells/mL and a serum creatinine of 2.2 mg/dL. KL was informed that he needed wound debridement and was offered the same podiatrist that he refused at Hospital A. Once again, KL deferred in favor of his own podiatrist who apparently was on vacation. Blood and wound cultures were obtained and KL received a dose of intravenous amoxicillin/sulbactam in the ED, but because of his refusal to receive wound debridement and care at Hospital A or B, he was sent home that same afternoon.
KL left Hospital B and drove 2 hours to the ED of Hospital C. He was immediately admitted and intravenous vancomycin and piperacillin/tazobactam were begun. Plain films of the foot were consistent with osteomyelitis. An MRI of the foot demonstrated cellulitis, myositis, and a forefoot abscess. Within 24 hours of admission, KL developed chest pain and was subsequently ruled-in for a non–ST-elevation MI. KL ended up getting a left heart catheterization, and this delayed surgical debridement of his infected foot. Ultimately, KL did have debridement of his foot, but the infection had an advanced to the point that a below-the-knee amputation was required. Surgical pathology cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA).
Complaint
KL was now facing life without his left leg, and he was angry and felt that the medical system had let him down. A complaint was quickly filed and alleged multiple breaches in the standard of care against multiple providers. The complaint included Dr. Hospitalist and asserted that he failed to obtain an MRI of the left foot from the very start, stopped intravenous vancomycin inappropriately, and failed to obtain infectious disease and orthopedic surgery consults.
The complaint further asserted that the PCP and the ED providers at Hospital B were negligent for not readmitting KL and obtaining infectious disease and orthopedic surgery consults. If the providers in this case had continued intravenous vancomycin throughout his case and otherwise obtained appropriate specialty care, KL’s leg would have been saved.
Scientific principles
Diabetic foot infections are associated with substantial morbidity and mortality. Important risk factors for development of diabetic foot infections include neuropathy, peripheral vascular disease, and poor glycemic control. Most diabetic foot infections are polymicrobial, but MRSA is a common pathogen. Although severe diabetic foot infections warrant hospitalization for urgent surgical consultation, antimicrobial administration, and medical stabilization, most mild infections and many moderate infections can be managed in the outpatient setting with close follow-up.
The possibility of osteomyelitis should be considered in diabetic patients with foot wounds associated with signs of infection in the deeper soft tissues and in patients with chronic ulcers. Many patients with confirmed osteomyelitis of the foot benefit from surgical resection.
Complaint rebuttal and discussion
Although Dr. Hospitalist had a negative bone scan result, he should have considered MRSA as a pathogen for KL despite a wound culture growing Klebsiella only. Most experts agreed, however, that it would be pure speculation as to what an MRI would have shown so early in KL’s course and ultimately, Dr. Hospitalist was defensible because KL did have appropriate follow-up just 48 hours after discharge. In fact, more than 21 days from original presentation to his amputation, KL only had 3 days off of intravenous vancomycin.
As a result, defense experts focused on the failure of KL to obtain debridement as the main reason for his injury. Dr. Hospitalist, the PCP and the ED providers at Hospital B, all documented KL’s refusal to allow debridement by a podiatrist other than his own. KL denied this allegation, but the chart was consistent in this regard.
Conclusion
In the era of patient-centered care, patient wishes and preferences are important to integrate into the overall care plan. But when a patient’s wishes and preferences delay or otherwise subvert optimal care, it is vital that the hospitalist document the circumstances in their entirety. Documentation should confirm that the patient has capacity for decision making and that care recommendation benefits, risks for not following said recommendations, and care recommendation alternatives have been fully reviewed.
It is also helpful to have such discussions witnessed by other providers (that is, the nurse) so that the documentation is corroborated. The PCP and Hospital B were dismissed from the case. Hospital A settled with the plaintiff by waiving all hospital charges from his original hospitalization.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
The story
KL was a 56-year-old man with multiple comorbidities, including obesity, coronary artery disease, hypertension, insulin-dependent diabetes, chronic kidney disease, and dyslipidemia. He presented to Hospital A with fever and chills, along with an open wound on the bottom of his left foot. Laboratory studies revealed a WBC 14,000 cells/mL and a serum creatinine of 3.1 mg/dL. KL was admitted by Dr. Hospitalist for cellulitis and an infected diabetic foot ulcer.
KL was started on intravenous vancomycin and piperacillin/tazobactam and blood cultures were drawn. A bone scan was negative for osteomyelitis. Blood cultures did not grow any bacteria, but a wound culture from his foot ulcer grew Klebsiella. Dr. Hospitalist consulted inpatient podiatry for wound debridement, but KL apparently refused in favor of being seen by his own podiatrist as an outpatient. By hospital day 2, KL was afebrile, eating well, and he was discharged on oral ciprofloxacin later that same day.
Two days after discharge, KL followed up with his primary care physician (PCP). KL was again febrile and his foot ulcer looked worse. The PCP recommended hospitalization with intravenous antibiotics, but KL was reluctant to return to the hospital. The PCP arranged for midline placement and KL was referred to a local wound clinic for intravenous vancomycin to begin the next day. KL remained on the oral ciprofloxacin.
Over the next 3 days, KL received daily intravenous vancomycin at the wound clinic. However, the foot ulcer continued to drain purulent material with associated cellulitis and advancing erythema across the forefoot. The wound nurse contacted the PCP who had sent KL to the emergency department of Hospital B. Laboratory studies revealed a WBC 18,300 cells/mL and a serum creatinine of 2.2 mg/dL. KL was informed that he needed wound debridement and was offered the same podiatrist that he refused at Hospital A. Once again, KL deferred in favor of his own podiatrist who apparently was on vacation. Blood and wound cultures were obtained and KL received a dose of intravenous amoxicillin/sulbactam in the ED, but because of his refusal to receive wound debridement and care at Hospital A or B, he was sent home that same afternoon.
KL left Hospital B and drove 2 hours to the ED of Hospital C. He was immediately admitted and intravenous vancomycin and piperacillin/tazobactam were begun. Plain films of the foot were consistent with osteomyelitis. An MRI of the foot demonstrated cellulitis, myositis, and a forefoot abscess. Within 24 hours of admission, KL developed chest pain and was subsequently ruled-in for a non–ST-elevation MI. KL ended up getting a left heart catheterization, and this delayed surgical debridement of his infected foot. Ultimately, KL did have debridement of his foot, but the infection had an advanced to the point that a below-the-knee amputation was required. Surgical pathology cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA).
Complaint
KL was now facing life without his left leg, and he was angry and felt that the medical system had let him down. A complaint was quickly filed and alleged multiple breaches in the standard of care against multiple providers. The complaint included Dr. Hospitalist and asserted that he failed to obtain an MRI of the left foot from the very start, stopped intravenous vancomycin inappropriately, and failed to obtain infectious disease and orthopedic surgery consults.
The complaint further asserted that the PCP and the ED providers at Hospital B were negligent for not readmitting KL and obtaining infectious disease and orthopedic surgery consults. If the providers in this case had continued intravenous vancomycin throughout his case and otherwise obtained appropriate specialty care, KL’s leg would have been saved.
Scientific principles
Diabetic foot infections are associated with substantial morbidity and mortality. Important risk factors for development of diabetic foot infections include neuropathy, peripheral vascular disease, and poor glycemic control. Most diabetic foot infections are polymicrobial, but MRSA is a common pathogen. Although severe diabetic foot infections warrant hospitalization for urgent surgical consultation, antimicrobial administration, and medical stabilization, most mild infections and many moderate infections can be managed in the outpatient setting with close follow-up.
The possibility of osteomyelitis should be considered in diabetic patients with foot wounds associated with signs of infection in the deeper soft tissues and in patients with chronic ulcers. Many patients with confirmed osteomyelitis of the foot benefit from surgical resection.
Complaint rebuttal and discussion
Although Dr. Hospitalist had a negative bone scan result, he should have considered MRSA as a pathogen for KL despite a wound culture growing Klebsiella only. Most experts agreed, however, that it would be pure speculation as to what an MRI would have shown so early in KL’s course and ultimately, Dr. Hospitalist was defensible because KL did have appropriate follow-up just 48 hours after discharge. In fact, more than 21 days from original presentation to his amputation, KL only had 3 days off of intravenous vancomycin.
As a result, defense experts focused on the failure of KL to obtain debridement as the main reason for his injury. Dr. Hospitalist, the PCP and the ED providers at Hospital B, all documented KL’s refusal to allow debridement by a podiatrist other than his own. KL denied this allegation, but the chart was consistent in this regard.
Conclusion
In the era of patient-centered care, patient wishes and preferences are important to integrate into the overall care plan. But when a patient’s wishes and preferences delay or otherwise subvert optimal care, it is vital that the hospitalist document the circumstances in their entirety. Documentation should confirm that the patient has capacity for decision making and that care recommendation benefits, risks for not following said recommendations, and care recommendation alternatives have been fully reviewed.
It is also helpful to have such discussions witnessed by other providers (that is, the nurse) so that the documentation is corroborated. The PCP and Hospital B were dismissed from the case. Hospital A settled with the plaintiff by waiving all hospital charges from his original hospitalization.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
The story
KL was a 56-year-old man with multiple comorbidities, including obesity, coronary artery disease, hypertension, insulin-dependent diabetes, chronic kidney disease, and dyslipidemia. He presented to Hospital A with fever and chills, along with an open wound on the bottom of his left foot. Laboratory studies revealed a WBC 14,000 cells/mL and a serum creatinine of 3.1 mg/dL. KL was admitted by Dr. Hospitalist for cellulitis and an infected diabetic foot ulcer.
KL was started on intravenous vancomycin and piperacillin/tazobactam and blood cultures were drawn. A bone scan was negative for osteomyelitis. Blood cultures did not grow any bacteria, but a wound culture from his foot ulcer grew Klebsiella. Dr. Hospitalist consulted inpatient podiatry for wound debridement, but KL apparently refused in favor of being seen by his own podiatrist as an outpatient. By hospital day 2, KL was afebrile, eating well, and he was discharged on oral ciprofloxacin later that same day.
Two days after discharge, KL followed up with his primary care physician (PCP). KL was again febrile and his foot ulcer looked worse. The PCP recommended hospitalization with intravenous antibiotics, but KL was reluctant to return to the hospital. The PCP arranged for midline placement and KL was referred to a local wound clinic for intravenous vancomycin to begin the next day. KL remained on the oral ciprofloxacin.
Over the next 3 days, KL received daily intravenous vancomycin at the wound clinic. However, the foot ulcer continued to drain purulent material with associated cellulitis and advancing erythema across the forefoot. The wound nurse contacted the PCP who had sent KL to the emergency department of Hospital B. Laboratory studies revealed a WBC 18,300 cells/mL and a serum creatinine of 2.2 mg/dL. KL was informed that he needed wound debridement and was offered the same podiatrist that he refused at Hospital A. Once again, KL deferred in favor of his own podiatrist who apparently was on vacation. Blood and wound cultures were obtained and KL received a dose of intravenous amoxicillin/sulbactam in the ED, but because of his refusal to receive wound debridement and care at Hospital A or B, he was sent home that same afternoon.
KL left Hospital B and drove 2 hours to the ED of Hospital C. He was immediately admitted and intravenous vancomycin and piperacillin/tazobactam were begun. Plain films of the foot were consistent with osteomyelitis. An MRI of the foot demonstrated cellulitis, myositis, and a forefoot abscess. Within 24 hours of admission, KL developed chest pain and was subsequently ruled-in for a non–ST-elevation MI. KL ended up getting a left heart catheterization, and this delayed surgical debridement of his infected foot. Ultimately, KL did have debridement of his foot, but the infection had an advanced to the point that a below-the-knee amputation was required. Surgical pathology cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA).
Complaint
KL was now facing life without his left leg, and he was angry and felt that the medical system had let him down. A complaint was quickly filed and alleged multiple breaches in the standard of care against multiple providers. The complaint included Dr. Hospitalist and asserted that he failed to obtain an MRI of the left foot from the very start, stopped intravenous vancomycin inappropriately, and failed to obtain infectious disease and orthopedic surgery consults.
The complaint further asserted that the PCP and the ED providers at Hospital B were negligent for not readmitting KL and obtaining infectious disease and orthopedic surgery consults. If the providers in this case had continued intravenous vancomycin throughout his case and otherwise obtained appropriate specialty care, KL’s leg would have been saved.
Scientific principles
Diabetic foot infections are associated with substantial morbidity and mortality. Important risk factors for development of diabetic foot infections include neuropathy, peripheral vascular disease, and poor glycemic control. Most diabetic foot infections are polymicrobial, but MRSA is a common pathogen. Although severe diabetic foot infections warrant hospitalization for urgent surgical consultation, antimicrobial administration, and medical stabilization, most mild infections and many moderate infections can be managed in the outpatient setting with close follow-up.
The possibility of osteomyelitis should be considered in diabetic patients with foot wounds associated with signs of infection in the deeper soft tissues and in patients with chronic ulcers. Many patients with confirmed osteomyelitis of the foot benefit from surgical resection.
Complaint rebuttal and discussion
Although Dr. Hospitalist had a negative bone scan result, he should have considered MRSA as a pathogen for KL despite a wound culture growing Klebsiella only. Most experts agreed, however, that it would be pure speculation as to what an MRI would have shown so early in KL’s course and ultimately, Dr. Hospitalist was defensible because KL did have appropriate follow-up just 48 hours after discharge. In fact, more than 21 days from original presentation to his amputation, KL only had 3 days off of intravenous vancomycin.
As a result, defense experts focused on the failure of KL to obtain debridement as the main reason for his injury. Dr. Hospitalist, the PCP and the ED providers at Hospital B, all documented KL’s refusal to allow debridement by a podiatrist other than his own. KL denied this allegation, but the chart was consistent in this regard.
Conclusion
In the era of patient-centered care, patient wishes and preferences are important to integrate into the overall care plan. But when a patient’s wishes and preferences delay or otherwise subvert optimal care, it is vital that the hospitalist document the circumstances in their entirety. Documentation should confirm that the patient has capacity for decision making and that care recommendation benefits, risks for not following said recommendations, and care recommendation alternatives have been fully reviewed.
It is also helpful to have such discussions witnessed by other providers (that is, the nurse) so that the documentation is corroborated. The PCP and Hospital B were dismissed from the case. Hospital A settled with the plaintiff by waiving all hospital charges from his original hospitalization.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
Homesick
I don’t think that my kids appreciate how good they have it when it comes to summer camp. When I was their age, there was just one kind of camp: the kind with a mosquito-clouded lake, flatulent horses, and songs the other campers all seemed to know. No one asked what your interests were; it was assumed you had always dreamed of expressing yourself in the form of a lanyard keychain.
Now my children can choose between DJ camp, computer gaming camp, and, I kid you not, LEGO camp. They literally have camps just for the stuff you had to leave at home when you were at camp. I can’t wait for the letters home: “Today we programmed mosquitoes for our lake in Minecraft. Since I did so well, my counselor said I could join some of the older campers tomorrow and help them figure out how to design virtual horses that pass gas....”
Soap opera
With five kids, two dogs, and a cat, I’ve had to adjust my standards for what constitutes a clean house. Are the dust bunnies hidden behind piles of mismatched socks? Then it’s clean. Are the dirty dishes all within a yard of the sink? Clean. Do the roaches scatter within 2 seconds of the light coming on? We’re good. Three seconds is bad. At least we’re doing our part to fight allergies and asthma, according to a new report, which I’m sure is around here...ah, right under that wet towel!
Dr. Robert Wood, chief of allergy and immunology at Johns Hopkins Children's Center, Baltimore, wondered why studies seemed to show that dirt and bacteria protect rural children from developing allergies when other studies implicate roach droppings and animal dander in promoting allergies in urban settings. How can city dirt be so bad when urban music is so much better than country?
As it turns out, it’s all about the timing. A review of exposures and allergy and asthma symptoms among 467 children in four cities demonstrated that kids exposed to increased levels of mouse and cat dander, cockroach droppings, and house-dust harboring Firmicutes and Bacteriodetes bacteria enjoyed protection from wheezing so long as that exposure occurred in the first year of life. The implications are clear: Either we need to develop a strain of bacteria-encrusted urban cats that harbor mice infested with cockroaches, or I should tour America’s cities giving housekeeping tips.
Too cool
The study that I’ve been waiting for since 7th grade is finally out! We now have scientific proof that being a...what did they used call me...a geek? Nerd? Dork? Weirdo? Dweeb? Wonk? Bookworm? Poindexter? Grind? Hey-you-with-the-glasses? Well, anyway, over the long run we do better than those cool kids with their admittedly impressive vocabulary of insults.
Publishing in Child Behavior, University of Virginia psychologist Joseph Allen evaluated 184 adolescents’ use of “pseudomature behavior” to impress their peers. He questioned kids, their families, and their peers over 10 years, as the subjects matured from age 13 to 23. Early on, those kids who experimented with cigarettes, alcohol, and sex were indeed rated as “cool” by their peers, who also secretly seethed with resentment. (Dr. Allen did not report that last part, but I just know, okay?)
By age 22, however, those same kids were experiencing increased trouble with alcohol, substance abuse, and criminality compared to their peers. Their classmates, in the meantime (at least those who hadn’t managed to get out of that dusty little town and pursue their dreams in the big city), rated the “cool” kids as being less socially competent and less mature. Whether they were also starting to lose some hair and get a little thick around the middle is, again, unreported, but we know, because we may wear glasses, but we can see just fine, thank you.
The whole truth
I just finished reading the scariest article I’ve seen in a while, at least as a parent. Researchers at the Massachusetts Institute of Technology claim to have proven that children as young as age 6 years cannot only tell when an adult is lying to them, but they also can tell when we’re simply not giving them the whole truth. Go ahead and give that a moment to sink in. Yep, it’s bad, real bad.
My only hope comes from the underlying experimental design. The subject of subterfuge was a pyramid-shaped toy with knobs and buttons, not, say, the human reproductive tract. And the uninformative “teacher” was a puppet, not a real person who might convincingly sell, say, the idea that a chubby elf could deliver billions of presents in a single 24-hour period. Of course, if they do reproduce this experiment with valid human liars, then the implications are clear: Only 6-year-olds should be allowed to vote for Congress. I just hope my own kids don’t catch on until after I tell them about camp.
David L. Hill, M.D., FAAP is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.
I don’t think that my kids appreciate how good they have it when it comes to summer camp. When I was their age, there was just one kind of camp: the kind with a mosquito-clouded lake, flatulent horses, and songs the other campers all seemed to know. No one asked what your interests were; it was assumed you had always dreamed of expressing yourself in the form of a lanyard keychain.
Now my children can choose between DJ camp, computer gaming camp, and, I kid you not, LEGO camp. They literally have camps just for the stuff you had to leave at home when you were at camp. I can’t wait for the letters home: “Today we programmed mosquitoes for our lake in Minecraft. Since I did so well, my counselor said I could join some of the older campers tomorrow and help them figure out how to design virtual horses that pass gas....”
Soap opera
With five kids, two dogs, and a cat, I’ve had to adjust my standards for what constitutes a clean house. Are the dust bunnies hidden behind piles of mismatched socks? Then it’s clean. Are the dirty dishes all within a yard of the sink? Clean. Do the roaches scatter within 2 seconds of the light coming on? We’re good. Three seconds is bad. At least we’re doing our part to fight allergies and asthma, according to a new report, which I’m sure is around here...ah, right under that wet towel!
Dr. Robert Wood, chief of allergy and immunology at Johns Hopkins Children's Center, Baltimore, wondered why studies seemed to show that dirt and bacteria protect rural children from developing allergies when other studies implicate roach droppings and animal dander in promoting allergies in urban settings. How can city dirt be so bad when urban music is so much better than country?
As it turns out, it’s all about the timing. A review of exposures and allergy and asthma symptoms among 467 children in four cities demonstrated that kids exposed to increased levels of mouse and cat dander, cockroach droppings, and house-dust harboring Firmicutes and Bacteriodetes bacteria enjoyed protection from wheezing so long as that exposure occurred in the first year of life. The implications are clear: Either we need to develop a strain of bacteria-encrusted urban cats that harbor mice infested with cockroaches, or I should tour America’s cities giving housekeeping tips.
Too cool
The study that I’ve been waiting for since 7th grade is finally out! We now have scientific proof that being a...what did they used call me...a geek? Nerd? Dork? Weirdo? Dweeb? Wonk? Bookworm? Poindexter? Grind? Hey-you-with-the-glasses? Well, anyway, over the long run we do better than those cool kids with their admittedly impressive vocabulary of insults.
Publishing in Child Behavior, University of Virginia psychologist Joseph Allen evaluated 184 adolescents’ use of “pseudomature behavior” to impress their peers. He questioned kids, their families, and their peers over 10 years, as the subjects matured from age 13 to 23. Early on, those kids who experimented with cigarettes, alcohol, and sex were indeed rated as “cool” by their peers, who also secretly seethed with resentment. (Dr. Allen did not report that last part, but I just know, okay?)
By age 22, however, those same kids were experiencing increased trouble with alcohol, substance abuse, and criminality compared to their peers. Their classmates, in the meantime (at least those who hadn’t managed to get out of that dusty little town and pursue their dreams in the big city), rated the “cool” kids as being less socially competent and less mature. Whether they were also starting to lose some hair and get a little thick around the middle is, again, unreported, but we know, because we may wear glasses, but we can see just fine, thank you.
The whole truth
I just finished reading the scariest article I’ve seen in a while, at least as a parent. Researchers at the Massachusetts Institute of Technology claim to have proven that children as young as age 6 years cannot only tell when an adult is lying to them, but they also can tell when we’re simply not giving them the whole truth. Go ahead and give that a moment to sink in. Yep, it’s bad, real bad.
My only hope comes from the underlying experimental design. The subject of subterfuge was a pyramid-shaped toy with knobs and buttons, not, say, the human reproductive tract. And the uninformative “teacher” was a puppet, not a real person who might convincingly sell, say, the idea that a chubby elf could deliver billions of presents in a single 24-hour period. Of course, if they do reproduce this experiment with valid human liars, then the implications are clear: Only 6-year-olds should be allowed to vote for Congress. I just hope my own kids don’t catch on until after I tell them about camp.
David L. Hill, M.D., FAAP is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.
I don’t think that my kids appreciate how good they have it when it comes to summer camp. When I was their age, there was just one kind of camp: the kind with a mosquito-clouded lake, flatulent horses, and songs the other campers all seemed to know. No one asked what your interests were; it was assumed you had always dreamed of expressing yourself in the form of a lanyard keychain.
Now my children can choose between DJ camp, computer gaming camp, and, I kid you not, LEGO camp. They literally have camps just for the stuff you had to leave at home when you were at camp. I can’t wait for the letters home: “Today we programmed mosquitoes for our lake in Minecraft. Since I did so well, my counselor said I could join some of the older campers tomorrow and help them figure out how to design virtual horses that pass gas....”
Soap opera
With five kids, two dogs, and a cat, I’ve had to adjust my standards for what constitutes a clean house. Are the dust bunnies hidden behind piles of mismatched socks? Then it’s clean. Are the dirty dishes all within a yard of the sink? Clean. Do the roaches scatter within 2 seconds of the light coming on? We’re good. Three seconds is bad. At least we’re doing our part to fight allergies and asthma, according to a new report, which I’m sure is around here...ah, right under that wet towel!
Dr. Robert Wood, chief of allergy and immunology at Johns Hopkins Children's Center, Baltimore, wondered why studies seemed to show that dirt and bacteria protect rural children from developing allergies when other studies implicate roach droppings and animal dander in promoting allergies in urban settings. How can city dirt be so bad when urban music is so much better than country?
As it turns out, it’s all about the timing. A review of exposures and allergy and asthma symptoms among 467 children in four cities demonstrated that kids exposed to increased levels of mouse and cat dander, cockroach droppings, and house-dust harboring Firmicutes and Bacteriodetes bacteria enjoyed protection from wheezing so long as that exposure occurred in the first year of life. The implications are clear: Either we need to develop a strain of bacteria-encrusted urban cats that harbor mice infested with cockroaches, or I should tour America’s cities giving housekeeping tips.
Too cool
The study that I’ve been waiting for since 7th grade is finally out! We now have scientific proof that being a...what did they used call me...a geek? Nerd? Dork? Weirdo? Dweeb? Wonk? Bookworm? Poindexter? Grind? Hey-you-with-the-glasses? Well, anyway, over the long run we do better than those cool kids with their admittedly impressive vocabulary of insults.
Publishing in Child Behavior, University of Virginia psychologist Joseph Allen evaluated 184 adolescents’ use of “pseudomature behavior” to impress their peers. He questioned kids, their families, and their peers over 10 years, as the subjects matured from age 13 to 23. Early on, those kids who experimented with cigarettes, alcohol, and sex were indeed rated as “cool” by their peers, who also secretly seethed with resentment. (Dr. Allen did not report that last part, but I just know, okay?)
By age 22, however, those same kids were experiencing increased trouble with alcohol, substance abuse, and criminality compared to their peers. Their classmates, in the meantime (at least those who hadn’t managed to get out of that dusty little town and pursue their dreams in the big city), rated the “cool” kids as being less socially competent and less mature. Whether they were also starting to lose some hair and get a little thick around the middle is, again, unreported, but we know, because we may wear glasses, but we can see just fine, thank you.
The whole truth
I just finished reading the scariest article I’ve seen in a while, at least as a parent. Researchers at the Massachusetts Institute of Technology claim to have proven that children as young as age 6 years cannot only tell when an adult is lying to them, but they also can tell when we’re simply not giving them the whole truth. Go ahead and give that a moment to sink in. Yep, it’s bad, real bad.
My only hope comes from the underlying experimental design. The subject of subterfuge was a pyramid-shaped toy with knobs and buttons, not, say, the human reproductive tract. And the uninformative “teacher” was a puppet, not a real person who might convincingly sell, say, the idea that a chubby elf could deliver billions of presents in a single 24-hour period. Of course, if they do reproduce this experiment with valid human liars, then the implications are clear: Only 6-year-olds should be allowed to vote for Congress. I just hope my own kids don’t catch on until after I tell them about camp.
David L. Hill, M.D., FAAP is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.
Passing stones with PDE5 inhibitors
Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.
Tamsulosin works, and prednisolone may also be helpful. Anything else?
Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).
In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.
The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.
The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.
In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).
Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.
Dr. Ebbert is a professor of medicine and 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. He reports no disclosures.
Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.
Tamsulosin works, and prednisolone may also be helpful. Anything else?
Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).
In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.
The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.
The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.
In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).
Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.
Dr. Ebbert is a professor of medicine and 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. He reports no disclosures.
Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.
Tamsulosin works, and prednisolone may also be helpful. Anything else?
Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).
In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.
The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.
The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.
In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).
Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.
Dr. Ebbert is a professor of medicine and 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. He reports no disclosures.
Just do it?
The typical American world view has always extolled the virtues of positive thinking. From the pilgrim fathers to the Western settlers, we pursued goals that were considered insurmountable. In the modern era, Ronald Reagan inspired us by stating that "Nothing is impossible," while President Obama informed us that "We can," and the sports company Nike tells us to "Just do it."
This optimistic and entrepreneurial spirit has also been adopted by vascular surgeons worldwide. It resulted in pioneering developments that have given us a whole new armamentarium that would never have been deemed possible 30 years ago. Without the benefit of the "We can" mentality, would we have been able to endograft aortic aneurysms or laser through blocked arteries? Who would have thought you could take out a saphenous vein, turn it upside down, and make it into a new artery?
However, this positive attitude, which has been absorbed into the communal psyche of vascular specialists, may have a dark side. I fear that vascular surgeons and other vascular interventionalists have developed an "I can" mantra that allows us to perform multiple hopeless procedures. We may stretch the indications for use of a new endograft, because it just might work. Like a football quarterback down by 4 points with 1 second left on the clock, we will perform a "Hail Mary" procedure, expecting to salvage a dying limb without concern that the attempt might raise the level of a subsequent amputation.
I know the famed mountaineer George Mallory tried to summit Mount Everest "Because it’s there," but why will cardiologists sometimes stent an intra-abdominal lesion just because they see it on their way to the coronaries? And why will they laser an occluded popliteal and stent a tibial, because they "can" – even though a tibial bypass would have achieved a better outcome? Is it then surprising that the "We can" and "Just do it" mentality has paved the road of good intentions with dismembered limbs and departed souls?
Of course, I do believe that a heroic attempt may be justified when faced with the alternative of loss of life or limb. But should we intervene on non–lifestyle limiting claudication just because we can? Should we stent, restent, and restent and reoperate ad infinitum until our patient begs us to stop?
Years ago, the comic newspaper The Onion published a macabre parody of an obituary, writing about a young man who "died following a brief, cowardly battle with stomach cancer. But is it cowardly to give up when things are inevitable? Is it justified to keep doing the impossible, knowing full well it will not work just because one has the self-delusion of invincibility? When should we not even try? When is enough enough?
We are not the only ones responsible for overzealous interventions. This positive attitude has caused many of our patients to have unrealistic expectations about what we are capable of achieving with our procedures.
I am sure we have all been implored by the children of a decrepit, elderly, and terminally ill patient to "Do everything. We know you can pull him through, save his leg, stop his stroke, bring him back to life, and make him young again!" How many times have such demands made us, against our better judgment, attempt the impossible?
But, lest I be accused of being overly pessimistic in this optimistic environment, let me say how proud I am to be part of the generation of vascular surgeons who have pioneered and embraced new procedures. However, I appeal to my colleagues, and especially to those who may not be vascular surgeons but who "treat" vascular patients, to sometimes say, "We won’t" even though "We can."
Dr. Samson is the medical editor of Vascular Specialist. He is a physician in the practice of Samson, Showalter, Lepore, and Nair, and a clinical professor of surgery, Florida State University.
The typical American world view has always extolled the virtues of positive thinking. From the pilgrim fathers to the Western settlers, we pursued goals that were considered insurmountable. In the modern era, Ronald Reagan inspired us by stating that "Nothing is impossible," while President Obama informed us that "We can," and the sports company Nike tells us to "Just do it."
This optimistic and entrepreneurial spirit has also been adopted by vascular surgeons worldwide. It resulted in pioneering developments that have given us a whole new armamentarium that would never have been deemed possible 30 years ago. Without the benefit of the "We can" mentality, would we have been able to endograft aortic aneurysms or laser through blocked arteries? Who would have thought you could take out a saphenous vein, turn it upside down, and make it into a new artery?
However, this positive attitude, which has been absorbed into the communal psyche of vascular specialists, may have a dark side. I fear that vascular surgeons and other vascular interventionalists have developed an "I can" mantra that allows us to perform multiple hopeless procedures. We may stretch the indications for use of a new endograft, because it just might work. Like a football quarterback down by 4 points with 1 second left on the clock, we will perform a "Hail Mary" procedure, expecting to salvage a dying limb without concern that the attempt might raise the level of a subsequent amputation.
I know the famed mountaineer George Mallory tried to summit Mount Everest "Because it’s there," but why will cardiologists sometimes stent an intra-abdominal lesion just because they see it on their way to the coronaries? And why will they laser an occluded popliteal and stent a tibial, because they "can" – even though a tibial bypass would have achieved a better outcome? Is it then surprising that the "We can" and "Just do it" mentality has paved the road of good intentions with dismembered limbs and departed souls?
Of course, I do believe that a heroic attempt may be justified when faced with the alternative of loss of life or limb. But should we intervene on non–lifestyle limiting claudication just because we can? Should we stent, restent, and restent and reoperate ad infinitum until our patient begs us to stop?
Years ago, the comic newspaper The Onion published a macabre parody of an obituary, writing about a young man who "died following a brief, cowardly battle with stomach cancer. But is it cowardly to give up when things are inevitable? Is it justified to keep doing the impossible, knowing full well it will not work just because one has the self-delusion of invincibility? When should we not even try? When is enough enough?
We are not the only ones responsible for overzealous interventions. This positive attitude has caused many of our patients to have unrealistic expectations about what we are capable of achieving with our procedures.
I am sure we have all been implored by the children of a decrepit, elderly, and terminally ill patient to "Do everything. We know you can pull him through, save his leg, stop his stroke, bring him back to life, and make him young again!" How many times have such demands made us, against our better judgment, attempt the impossible?
But, lest I be accused of being overly pessimistic in this optimistic environment, let me say how proud I am to be part of the generation of vascular surgeons who have pioneered and embraced new procedures. However, I appeal to my colleagues, and especially to those who may not be vascular surgeons but who "treat" vascular patients, to sometimes say, "We won’t" even though "We can."
Dr. Samson is the medical editor of Vascular Specialist. He is a physician in the practice of Samson, Showalter, Lepore, and Nair, and a clinical professor of surgery, Florida State University.
The typical American world view has always extolled the virtues of positive thinking. From the pilgrim fathers to the Western settlers, we pursued goals that were considered insurmountable. In the modern era, Ronald Reagan inspired us by stating that "Nothing is impossible," while President Obama informed us that "We can," and the sports company Nike tells us to "Just do it."
This optimistic and entrepreneurial spirit has also been adopted by vascular surgeons worldwide. It resulted in pioneering developments that have given us a whole new armamentarium that would never have been deemed possible 30 years ago. Without the benefit of the "We can" mentality, would we have been able to endograft aortic aneurysms or laser through blocked arteries? Who would have thought you could take out a saphenous vein, turn it upside down, and make it into a new artery?
However, this positive attitude, which has been absorbed into the communal psyche of vascular specialists, may have a dark side. I fear that vascular surgeons and other vascular interventionalists have developed an "I can" mantra that allows us to perform multiple hopeless procedures. We may stretch the indications for use of a new endograft, because it just might work. Like a football quarterback down by 4 points with 1 second left on the clock, we will perform a "Hail Mary" procedure, expecting to salvage a dying limb without concern that the attempt might raise the level of a subsequent amputation.
I know the famed mountaineer George Mallory tried to summit Mount Everest "Because it’s there," but why will cardiologists sometimes stent an intra-abdominal lesion just because they see it on their way to the coronaries? And why will they laser an occluded popliteal and stent a tibial, because they "can" – even though a tibial bypass would have achieved a better outcome? Is it then surprising that the "We can" and "Just do it" mentality has paved the road of good intentions with dismembered limbs and departed souls?
Of course, I do believe that a heroic attempt may be justified when faced with the alternative of loss of life or limb. But should we intervene on non–lifestyle limiting claudication just because we can? Should we stent, restent, and restent and reoperate ad infinitum until our patient begs us to stop?
Years ago, the comic newspaper The Onion published a macabre parody of an obituary, writing about a young man who "died following a brief, cowardly battle with stomach cancer. But is it cowardly to give up when things are inevitable? Is it justified to keep doing the impossible, knowing full well it will not work just because one has the self-delusion of invincibility? When should we not even try? When is enough enough?
We are not the only ones responsible for overzealous interventions. This positive attitude has caused many of our patients to have unrealistic expectations about what we are capable of achieving with our procedures.
I am sure we have all been implored by the children of a decrepit, elderly, and terminally ill patient to "Do everything. We know you can pull him through, save his leg, stop his stroke, bring him back to life, and make him young again!" How many times have such demands made us, against our better judgment, attempt the impossible?
But, lest I be accused of being overly pessimistic in this optimistic environment, let me say how proud I am to be part of the generation of vascular surgeons who have pioneered and embraced new procedures. However, I appeal to my colleagues, and especially to those who may not be vascular surgeons but who "treat" vascular patients, to sometimes say, "We won’t" even though "We can."
Dr. Samson is the medical editor of Vascular Specialist. He is a physician in the practice of Samson, Showalter, Lepore, and Nair, and a clinical professor of surgery, Florida State University.
Law & Medicine: Antitrust issues in health care, part 3
Question: Which of the following is likely to run afoul of antitrust laws?
A. A medical center in a big city buys the practices of several retiring doctors.
B. The only two hospitals in a rural area agree to merge to integrate better delivery of health care at lower cost.
C. A medical association’s president advises members of the drawbacks of a new managed care health plan.
D. All of the above.
E. None of the above.
Answer: B. Choice B constitutes illegal monopolization, whereas A is not likely to wield market power and C, without more, does not amount to a boycott. This article, the last in the series on health care antitrust, will showcase several cases illustrative of recurring themes such as the "state action doctrine," exclusive dealings, and mergers.
One broad category of cases concerns the so-called "state action doctrine," which confers antitrust immunity to all state governmental agencies.
For doctors, the most dramatic example is probably Patrick v. Burget (108 S. Ct. 1658 [1988]), an adverse peer review action against a physician who challenged it as nothing less than an anticompetitive ploy. In 1973, Dr. Timothy Patrick, a surgeon, chose to leave the Astoria Clinic in Oregon to establish an independent practice in general and vascular surgery. He continued to have staff privileges at Columbia Memorial Hospital, Astoria, but experienced refusal of professional dealings by former colleagues who were still at the clinic. One of them lodged a complaint that Dr. Patrick had left a patient unattended following surgery. In due course, the hospital medical staff voted to revoke his privileges because of substandard care.
Dr. Patrick’s lawsuit alleged that the staff’s true purpose was to eliminate him as a competitor, rather than to improve quality. The U.S. Court of Appeals for the Ninth Circuit found that the state of Oregon had articulated a policy in favor of peer review and had supervised the process. It therefore held that the "state action doctrine" exemption protected the hospital staff from antitrust liability even if the peer review proceedings were abused to disadvantage a competitor.
However, in a unanimous decision, the U.S. Supreme Court reversed, finding that the "active supervision" requirement was not satisfied, because that required Oregon to exercise ultimate control over the conduct of peer review, not simply some state involvement or monitoring. The state’s agencies were the Oregon Board of Medical Examiners and the Health Division, neither of which had the authority to expressly supervise the peer review process.
In a recent merger case, Federal Trade Commission v. Phoebe Putney Health System Inc. (133 S. Ct. 1003 [2013]) the U.S. Supreme Court again refuted the use of the "state action doctrine" defense.
The state of Georgia had claimed immunity when county-owned Phoebe Putney Memorial Hospital, Albany, Ga., made a bid to purchase Palmyra Park Hospital, also in Albany, its chief competitor. The Eleventh Circuit acknowledged that the challenged transaction would substantially lessen competition. However, the court reasoned that the transaction was exempted from the antitrust laws because the legislature, under the Georgia Hospital Authorities Law, had given hospital authorities the power to acquire or lease out hospitals despite potential anticompetitive effects.
However, the U.S. Supreme Court disagreed and reversed, holding the doctrine inapplicable because the general grant of power to the hospital authority did not clearly articulate the state’s intent to restrict competition.
Another remarkable example of the "state action doctrine" at play is North Carolina State Board of Dental Examiners v. Federal Trade Commission (719 F.3d 359 [4th Cir. 2013]). The case, currently under appeal, deals with the North Carolina State Board of Dental Examiners’ (NCSBDE) actions to forbid nondentists from providing teeth-whitening services to the public at spas, salons, and various retail outlets. NCSBDE also urged mall owners not to lease space to such providers. The FTC argued that most of the board members were practicing dentists rather than state employees; so, for purposes of the antitrust laws, the NCSBDE should be deemed a private person rather than part of a state government. Because North Carolina did not actively supervise its actions, the NCSBDE could not hide behind the protection of the "state action doctrine."
The United States Court of Appeals for the Fourth Circuit sided with the FTC, holding that NCSBDE could not restrain competition through means such as the use of cease and desist letters. The U.S. Supreme Court has agreed to hear the case, which has major implications for the regulatory authority of professional licensing boards.
A different recurring antitrust issue concerns the exclusion of doctors from a provider network. In Little Rock Cardiology Clinic v. Baptist Health (591 F.3d 591 [8th Cir. 2009]), the Little Rock (Ark.) Cardiology Clinic sued Baptist Health for entering into an exclusive contract with Blue Cross/Blue Shield of Arkansas in order to monopolize the market for cardiac care services. However, the trial court as well as the U.S. Court of Appeals for the Eighth Circuit held that the complaint failed to identify the relevant geographic area, product, or service market, without which it was impossible to reach a finding of monopolization.
Can a professional organization advise its members of pitfalls or drawbacks of health care plans? In International Healthcare Management v. Hawaii Coalition for Health (332 F.3d 600 [9th Cir. 2003]), the Hawaii Medical Association (HMA), the state’s medical organization, was sued for allegedly organizing a boycott of two managed care organizations when it advised its doctor members of certain problems with the proposed provider contracts. HMA argued that it neither forged an agreement to act in concert nor encouraged its members to participate in any boycott. It won a summary judgment in the U.S. District Court dismissing the suit, which the U.S. Court of Appeals for the Ninth Circuit affirmed.
Finally, antitrust prosecutions may be expected to increase under Obamacare, which advocates the efficient integration and consolidation of quality health services to achieve health cost savings. Any action taken, however, must still pass antitrust scrutiny.
One scenario is the trend toward hospital acquisitions of physician practices. The case of Idaho’s St. Luke Health Systems, a nonprofit, six-hospital system based in Boise and the largest in the state, is a prime example.
In a recent decision, a federal judge sided with the FTC in blocking St. Luke’s Health System from acquiring the 40-doctor Saltzer Medical Group – an acquisition made in the name of better "integrated health care." The FTC had alleged that the merger would give St. Luke a nearly 60% share of the primary-care market, resulting in diminished competition among primary care physicians. Idaho’s attorney general, as well as two other competitor health systems in Boise, also joined in the suit.
The federal court ruled against St. Luke’s, claiming that there was a legal and less anticompetitive way to achieve its goal of improving health care delivery in the area. The acquisition had in fact taken place more than a year ago, and St. Luke’s is now left with the task of dismantling the acquisition.
Antitrust law is complex and difficult, some issues and results may appear surprising and counterintuitive, and penalties can be severe (such as treble damages). All business transactions including those that touch on health care should therefore proactively examine whether they illegally affect free market competition.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].
Question: Which of the following is likely to run afoul of antitrust laws?
A. A medical center in a big city buys the practices of several retiring doctors.
B. The only two hospitals in a rural area agree to merge to integrate better delivery of health care at lower cost.
C. A medical association’s president advises members of the drawbacks of a new managed care health plan.
D. All of the above.
E. None of the above.
Answer: B. Choice B constitutes illegal monopolization, whereas A is not likely to wield market power and C, without more, does not amount to a boycott. This article, the last in the series on health care antitrust, will showcase several cases illustrative of recurring themes such as the "state action doctrine," exclusive dealings, and mergers.
One broad category of cases concerns the so-called "state action doctrine," which confers antitrust immunity to all state governmental agencies.
For doctors, the most dramatic example is probably Patrick v. Burget (108 S. Ct. 1658 [1988]), an adverse peer review action against a physician who challenged it as nothing less than an anticompetitive ploy. In 1973, Dr. Timothy Patrick, a surgeon, chose to leave the Astoria Clinic in Oregon to establish an independent practice in general and vascular surgery. He continued to have staff privileges at Columbia Memorial Hospital, Astoria, but experienced refusal of professional dealings by former colleagues who were still at the clinic. One of them lodged a complaint that Dr. Patrick had left a patient unattended following surgery. In due course, the hospital medical staff voted to revoke his privileges because of substandard care.
Dr. Patrick’s lawsuit alleged that the staff’s true purpose was to eliminate him as a competitor, rather than to improve quality. The U.S. Court of Appeals for the Ninth Circuit found that the state of Oregon had articulated a policy in favor of peer review and had supervised the process. It therefore held that the "state action doctrine" exemption protected the hospital staff from antitrust liability even if the peer review proceedings were abused to disadvantage a competitor.
However, in a unanimous decision, the U.S. Supreme Court reversed, finding that the "active supervision" requirement was not satisfied, because that required Oregon to exercise ultimate control over the conduct of peer review, not simply some state involvement or monitoring. The state’s agencies were the Oregon Board of Medical Examiners and the Health Division, neither of which had the authority to expressly supervise the peer review process.
In a recent merger case, Federal Trade Commission v. Phoebe Putney Health System Inc. (133 S. Ct. 1003 [2013]) the U.S. Supreme Court again refuted the use of the "state action doctrine" defense.
The state of Georgia had claimed immunity when county-owned Phoebe Putney Memorial Hospital, Albany, Ga., made a bid to purchase Palmyra Park Hospital, also in Albany, its chief competitor. The Eleventh Circuit acknowledged that the challenged transaction would substantially lessen competition. However, the court reasoned that the transaction was exempted from the antitrust laws because the legislature, under the Georgia Hospital Authorities Law, had given hospital authorities the power to acquire or lease out hospitals despite potential anticompetitive effects.
However, the U.S. Supreme Court disagreed and reversed, holding the doctrine inapplicable because the general grant of power to the hospital authority did not clearly articulate the state’s intent to restrict competition.
Another remarkable example of the "state action doctrine" at play is North Carolina State Board of Dental Examiners v. Federal Trade Commission (719 F.3d 359 [4th Cir. 2013]). The case, currently under appeal, deals with the North Carolina State Board of Dental Examiners’ (NCSBDE) actions to forbid nondentists from providing teeth-whitening services to the public at spas, salons, and various retail outlets. NCSBDE also urged mall owners not to lease space to such providers. The FTC argued that most of the board members were practicing dentists rather than state employees; so, for purposes of the antitrust laws, the NCSBDE should be deemed a private person rather than part of a state government. Because North Carolina did not actively supervise its actions, the NCSBDE could not hide behind the protection of the "state action doctrine."
The United States Court of Appeals for the Fourth Circuit sided with the FTC, holding that NCSBDE could not restrain competition through means such as the use of cease and desist letters. The U.S. Supreme Court has agreed to hear the case, which has major implications for the regulatory authority of professional licensing boards.
A different recurring antitrust issue concerns the exclusion of doctors from a provider network. In Little Rock Cardiology Clinic v. Baptist Health (591 F.3d 591 [8th Cir. 2009]), the Little Rock (Ark.) Cardiology Clinic sued Baptist Health for entering into an exclusive contract with Blue Cross/Blue Shield of Arkansas in order to monopolize the market for cardiac care services. However, the trial court as well as the U.S. Court of Appeals for the Eighth Circuit held that the complaint failed to identify the relevant geographic area, product, or service market, without which it was impossible to reach a finding of monopolization.
Can a professional organization advise its members of pitfalls or drawbacks of health care plans? In International Healthcare Management v. Hawaii Coalition for Health (332 F.3d 600 [9th Cir. 2003]), the Hawaii Medical Association (HMA), the state’s medical organization, was sued for allegedly organizing a boycott of two managed care organizations when it advised its doctor members of certain problems with the proposed provider contracts. HMA argued that it neither forged an agreement to act in concert nor encouraged its members to participate in any boycott. It won a summary judgment in the U.S. District Court dismissing the suit, which the U.S. Court of Appeals for the Ninth Circuit affirmed.
Finally, antitrust prosecutions may be expected to increase under Obamacare, which advocates the efficient integration and consolidation of quality health services to achieve health cost savings. Any action taken, however, must still pass antitrust scrutiny.
One scenario is the trend toward hospital acquisitions of physician practices. The case of Idaho’s St. Luke Health Systems, a nonprofit, six-hospital system based in Boise and the largest in the state, is a prime example.
In a recent decision, a federal judge sided with the FTC in blocking St. Luke’s Health System from acquiring the 40-doctor Saltzer Medical Group – an acquisition made in the name of better "integrated health care." The FTC had alleged that the merger would give St. Luke a nearly 60% share of the primary-care market, resulting in diminished competition among primary care physicians. Idaho’s attorney general, as well as two other competitor health systems in Boise, also joined in the suit.
The federal court ruled against St. Luke’s, claiming that there was a legal and less anticompetitive way to achieve its goal of improving health care delivery in the area. The acquisition had in fact taken place more than a year ago, and St. Luke’s is now left with the task of dismantling the acquisition.
Antitrust law is complex and difficult, some issues and results may appear surprising and counterintuitive, and penalties can be severe (such as treble damages). All business transactions including those that touch on health care should therefore proactively examine whether they illegally affect free market competition.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].
Question: Which of the following is likely to run afoul of antitrust laws?
A. A medical center in a big city buys the practices of several retiring doctors.
B. The only two hospitals in a rural area agree to merge to integrate better delivery of health care at lower cost.
C. A medical association’s president advises members of the drawbacks of a new managed care health plan.
D. All of the above.
E. None of the above.
Answer: B. Choice B constitutes illegal monopolization, whereas A is not likely to wield market power and C, without more, does not amount to a boycott. This article, the last in the series on health care antitrust, will showcase several cases illustrative of recurring themes such as the "state action doctrine," exclusive dealings, and mergers.
One broad category of cases concerns the so-called "state action doctrine," which confers antitrust immunity to all state governmental agencies.
For doctors, the most dramatic example is probably Patrick v. Burget (108 S. Ct. 1658 [1988]), an adverse peer review action against a physician who challenged it as nothing less than an anticompetitive ploy. In 1973, Dr. Timothy Patrick, a surgeon, chose to leave the Astoria Clinic in Oregon to establish an independent practice in general and vascular surgery. He continued to have staff privileges at Columbia Memorial Hospital, Astoria, but experienced refusal of professional dealings by former colleagues who were still at the clinic. One of them lodged a complaint that Dr. Patrick had left a patient unattended following surgery. In due course, the hospital medical staff voted to revoke his privileges because of substandard care.
Dr. Patrick’s lawsuit alleged that the staff’s true purpose was to eliminate him as a competitor, rather than to improve quality. The U.S. Court of Appeals for the Ninth Circuit found that the state of Oregon had articulated a policy in favor of peer review and had supervised the process. It therefore held that the "state action doctrine" exemption protected the hospital staff from antitrust liability even if the peer review proceedings were abused to disadvantage a competitor.
However, in a unanimous decision, the U.S. Supreme Court reversed, finding that the "active supervision" requirement was not satisfied, because that required Oregon to exercise ultimate control over the conduct of peer review, not simply some state involvement or monitoring. The state’s agencies were the Oregon Board of Medical Examiners and the Health Division, neither of which had the authority to expressly supervise the peer review process.
In a recent merger case, Federal Trade Commission v. Phoebe Putney Health System Inc. (133 S. Ct. 1003 [2013]) the U.S. Supreme Court again refuted the use of the "state action doctrine" defense.
The state of Georgia had claimed immunity when county-owned Phoebe Putney Memorial Hospital, Albany, Ga., made a bid to purchase Palmyra Park Hospital, also in Albany, its chief competitor. The Eleventh Circuit acknowledged that the challenged transaction would substantially lessen competition. However, the court reasoned that the transaction was exempted from the antitrust laws because the legislature, under the Georgia Hospital Authorities Law, had given hospital authorities the power to acquire or lease out hospitals despite potential anticompetitive effects.
However, the U.S. Supreme Court disagreed and reversed, holding the doctrine inapplicable because the general grant of power to the hospital authority did not clearly articulate the state’s intent to restrict competition.
Another remarkable example of the "state action doctrine" at play is North Carolina State Board of Dental Examiners v. Federal Trade Commission (719 F.3d 359 [4th Cir. 2013]). The case, currently under appeal, deals with the North Carolina State Board of Dental Examiners’ (NCSBDE) actions to forbid nondentists from providing teeth-whitening services to the public at spas, salons, and various retail outlets. NCSBDE also urged mall owners not to lease space to such providers. The FTC argued that most of the board members were practicing dentists rather than state employees; so, for purposes of the antitrust laws, the NCSBDE should be deemed a private person rather than part of a state government. Because North Carolina did not actively supervise its actions, the NCSBDE could not hide behind the protection of the "state action doctrine."
The United States Court of Appeals for the Fourth Circuit sided with the FTC, holding that NCSBDE could not restrain competition through means such as the use of cease and desist letters. The U.S. Supreme Court has agreed to hear the case, which has major implications for the regulatory authority of professional licensing boards.
A different recurring antitrust issue concerns the exclusion of doctors from a provider network. In Little Rock Cardiology Clinic v. Baptist Health (591 F.3d 591 [8th Cir. 2009]), the Little Rock (Ark.) Cardiology Clinic sued Baptist Health for entering into an exclusive contract with Blue Cross/Blue Shield of Arkansas in order to monopolize the market for cardiac care services. However, the trial court as well as the U.S. Court of Appeals for the Eighth Circuit held that the complaint failed to identify the relevant geographic area, product, or service market, without which it was impossible to reach a finding of monopolization.
Can a professional organization advise its members of pitfalls or drawbacks of health care plans? In International Healthcare Management v. Hawaii Coalition for Health (332 F.3d 600 [9th Cir. 2003]), the Hawaii Medical Association (HMA), the state’s medical organization, was sued for allegedly organizing a boycott of two managed care organizations when it advised its doctor members of certain problems with the proposed provider contracts. HMA argued that it neither forged an agreement to act in concert nor encouraged its members to participate in any boycott. It won a summary judgment in the U.S. District Court dismissing the suit, which the U.S. Court of Appeals for the Ninth Circuit affirmed.
Finally, antitrust prosecutions may be expected to increase under Obamacare, which advocates the efficient integration and consolidation of quality health services to achieve health cost savings. Any action taken, however, must still pass antitrust scrutiny.
One scenario is the trend toward hospital acquisitions of physician practices. The case of Idaho’s St. Luke Health Systems, a nonprofit, six-hospital system based in Boise and the largest in the state, is a prime example.
In a recent decision, a federal judge sided with the FTC in blocking St. Luke’s Health System from acquiring the 40-doctor Saltzer Medical Group – an acquisition made in the name of better "integrated health care." The FTC had alleged that the merger would give St. Luke a nearly 60% share of the primary-care market, resulting in diminished competition among primary care physicians. Idaho’s attorney general, as well as two other competitor health systems in Boise, also joined in the suit.
The federal court ruled against St. Luke’s, claiming that there was a legal and less anticompetitive way to achieve its goal of improving health care delivery in the area. The acquisition had in fact taken place more than a year ago, and St. Luke’s is now left with the task of dismantling the acquisition.
Antitrust law is complex and difficult, some issues and results may appear surprising and counterintuitive, and penalties can be severe (such as treble damages). All business transactions including those that touch on health care should therefore proactively examine whether they illegally affect free market competition.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].
Advance medical directive
Question: R, a woman with diabetes and Parkinson’s disease, executed an advance medical directive (AMD) when she was aged 70 years. Her AMD stipulated that no extraordinary measures be taken should she become terminally ill or permanently comatose, and she named her sister as her agent with durable power of attorney (DPA). Ten years later, at age 80 years, R sustained a stroke, which left her with hemiparesis and loss of cognitive function. She remained comatose for a week and was dependent on a feeding tube. Her sister decided to honor the AMD and stop all medical treatment including artificial nutrition and hydration. Given the above scenario, which of the following is most accurate?
A. R’s AMD sprang into effect when she became decisionally incapacitated.
B. An AMD can direct only the forgoing of life-sustaining treatment, not the continuation of treatment measures.
C. AMD’s are mandatory under the 1990 Federal Patient Self-Determination Act, and those without an AMD are required to make one upon admission to a hospital.
D. Those with DPA for health-care decisions are obligated to carry out the patient’s instructions but can also override them.
E. In the absence of an AMD or DPA, the attending doctor makes the final decision in the best interest of the patient.
Answer: A. An advance medical directive (AMD), sometimes called a living will, is a legally binding document executed by a competent person that provides instructions for future health-care decisions if and when that person loses decisional capacity. One can elect to forgo some or all life-sustaining measures, or to continue receiving all treatments. In 1990, Congress enacted the Federal Patient Self Determination Act, which allows patients to stipulate in advance the nature of their healthcare should they become incapacitated. Additionally, they can appoint an agent or proxy, said to have durable power of attorney (DPA) for health-care decisions, to speak for them. Agents are required to carry out, not override, the patient’s wishes. The Federal Act requires all hospitals to inquire into whether a patient has an AMD and to provide information on the subject, but the Act does not mandate that everyone should execute one. All 50 states, beginning with California in 1976, have enacted legislation on AMDs. In the absence of an AMD and DPA, a surrogate decision maker, sometimes court appointed, directs the care. The attending doctor provides the prognosis, but does not make the final decision to forgo or continue treatment.
Physicians are obligated by law to respect wishes regarding whether to forgo or continue therapy, and, if contrary to their conscience, transfer the patient to a willing health-care provider. In some jurisdictions, a patient’s wish to discontinue artificial nutrition and hydration, for example, via nasogastric or G-tube, requires a specific opt-in or opt-out choice. AMD instructions become relevant when the patient is terminally ill, but many jurisdictions allow their applicability in nonterminal conditions such as irreversible unconscious states or where the likely risks and burdens of treatment would outweigh the expected benefits (Hawaii is such a state under HRS 327E-16).
A recent review of 3,746 patients who had died between 2000 and 2006 showed that those with AMDs were more likely to want limited care or comfort care rather than all possible care, with the vast majority receiving treatment compatible with their wishes. Those who had assigned a durable power of attorney were less likely to die in the hospital or receive all care possible. The authors concluded that patients who have prepared AMDs received care that was strongly associated with their preferences. Other observers are less sanguine, noting that in only two-thirds of the time were decisions consistent, and one-third of patients changed their preferences in the face of actual illness, usually in favor of treatments rejected in advance. Surrogate agreement was only 58%, and surrogates tended to overestimate their loved one’s desire for treatment.
AMDs direct future end-of-life treatment in a hospital setting, and do not typically address emergency measures taken by ambulance personnel. The National POLST (Physician Orders for Life-Sustaining Treatment) Paradigm grew out of the need to address outpatient emergency treatment especially for seriously ill and frail patients. POLST, now available in many states across the country, is in actuality a medical order signed by the patient’s doctor directing what is and is not to be done, for example, intubation, defibrillation, etc. It does not replace the AMD but is complementary in ensuring respect for a patient’s medical wishes.
Unsurprisingly, there has been litigation over AMDs. Some of the earlier cases tended to favor the health-care institution’s refusal to cease life-sustaining treatment. In Bartling v. Glendale Adventist Medical Center, 184 Cal App 3d 961 (1986), a needle biopsy caused a patient’s lung to collapse. The patient had to be placed in restraints as he tried to remove the ventilator tubes. He had earlier executed a living will and a durable power of attorney for health care, and the family, agreeing to release the hospital and doctors from any civil liability, asked that the ventilator be removed. Instead, the hospital merely tried to "wean" him, and planned to resuscitate him in the event of a cardiopulmonary arrest. Unfortunately, no other facility was willing to accept him in transfer. However, in a defense verdict, the court held that although case law was evolving toward a greater recognition of patients’ rights, it could not be said that a common legal standard existed to guide the medical community.
The case of Osgood v. Genesys St. Joseph Hospital (No. 94-26731-NH, Mich 1996) gave a different result. The patient had a long history of seizures, and the doctors warned that a massive one could leave her in a persistent vegetative state. The patient named her mom as having durable power of attorney. One month later, the patient suffered a massive seizure but was kept alive on a ventilator with full medical support consisting of tube feeding, dialysis, blood transfusions, and medications. Although asked to have these measures removed, the hospital allegedly said they were not life support, but were "comfort care." After 2 months, the patient awoke and was able to be discharged home. However, she remained bedridden and spent most of her time "rhythmically screaming and thrashing" for hours on end, saying, "bury me". The family won a jury award of $16.5 million, which was reduced to $1.4 million on appeal.
A third case, Noonkester v. Kline, was a 1996 defense verdict for a doctor who instituted aggressive treatment despite his patient’s rejection of extraordinary measures evident in his living will. The patient, Mr. Noonkester, had Lou Gehrig’s disease and had instructed the doctor to write a DNR order. He gave his ex-wife power of attorney, and even made arrangements to be taken to a hospice in an emergency, where he planned to die peacefully. When Mr. Noonkester developed breathing problems from pneumonia, the ambulance took him to the hospital instead, and the doctor ordered a ventilator. The patient gave a "thumbs up" when told of the treatment plan, and 3 months later wrote a letter thanking Dr. Kline of the Scripps Clinic for saving his life. Although he had refused to have the ventilator removed, deeming it to be a suicidal act that he opposed, he subsequently sued Dr. Kline for interfering with his preplanned death and continuing costs of living. The jury took all of 45 minutes to return a unanimous verdict for Dr. Kline.
The contents of an AMD may be subject to differing interpretations, as was the case in Wright v. Johns Hopkins Health Systems Corp., 728 A.2d 166 (Md. 1999). A patient with AIDS arrested following a blood transfusion and was resuscitated but left in a comatose state for 10 days before dying. The family alleged that the aggressive treatment violated the patient’s living will instructions, but their lawsuit against the hospital was unsuccessful. Maryland’s Court of Appeals agreed with the hospital and the lower court that the living will could not take effect since no doctor had certified that he was in a terminal state and that his death was imminent.
The late Daniel Callahan, a prominent philosopher-ethicist, eloquently stated that dying in America has over the centuries "evolved from the sacred to the secular, private to institutional, and natural to artifactual." AMDs are a modern attempt to address the many dilemmas and emotions surrounding death. Patient autonomy and palliative care have rightly taken center stage. This may in part be the result of a seminal paper in 1995, which reported on a multicenter study of critically ill patients and their wishes regarding DNR and other end-of-life issues. The authors found that the wishes of many of the patients were ignored, and that 50% were in moderate or severe pain. Incredibly, physician treatment failed to change despite nurse intervention with prognostic information and patient preference.
142 USC 1395cc(f), 1396a(w) (1994).
2 Silveira MJ et al., Advance Directives and Outcomes of Surrogate Decision Making Before Death. (N. Engl. J. Med. 2010; 362:1211-8).
3 Lee et al., Do Patients’ Treatment Decisions Match Advance Statements of Their Preference? (J. Clin. Ethics 1998; 9:258-62).
4 See www.polst.org
5 A controlled trial to improve care for seriously ill hospitalized patients.1995 "SUPPORT" trial. (JAMA 1995; 274:1591-8).
Question: R, a woman with diabetes and Parkinson’s disease, executed an advance medical directive (AMD) when she was aged 70 years. Her AMD stipulated that no extraordinary measures be taken should she become terminally ill or permanently comatose, and she named her sister as her agent with durable power of attorney (DPA). Ten years later, at age 80 years, R sustained a stroke, which left her with hemiparesis and loss of cognitive function. She remained comatose for a week and was dependent on a feeding tube. Her sister decided to honor the AMD and stop all medical treatment including artificial nutrition and hydration. Given the above scenario, which of the following is most accurate?
A. R’s AMD sprang into effect when she became decisionally incapacitated.
B. An AMD can direct only the forgoing of life-sustaining treatment, not the continuation of treatment measures.
C. AMD’s are mandatory under the 1990 Federal Patient Self-Determination Act, and those without an AMD are required to make one upon admission to a hospital.
D. Those with DPA for health-care decisions are obligated to carry out the patient’s instructions but can also override them.
E. In the absence of an AMD or DPA, the attending doctor makes the final decision in the best interest of the patient.
Answer: A. An advance medical directive (AMD), sometimes called a living will, is a legally binding document executed by a competent person that provides instructions for future health-care decisions if and when that person loses decisional capacity. One can elect to forgo some or all life-sustaining measures, or to continue receiving all treatments. In 1990, Congress enacted the Federal Patient Self Determination Act, which allows patients to stipulate in advance the nature of their healthcare should they become incapacitated. Additionally, they can appoint an agent or proxy, said to have durable power of attorney (DPA) for health-care decisions, to speak for them. Agents are required to carry out, not override, the patient’s wishes. The Federal Act requires all hospitals to inquire into whether a patient has an AMD and to provide information on the subject, but the Act does not mandate that everyone should execute one. All 50 states, beginning with California in 1976, have enacted legislation on AMDs. In the absence of an AMD and DPA, a surrogate decision maker, sometimes court appointed, directs the care. The attending doctor provides the prognosis, but does not make the final decision to forgo or continue treatment.
Physicians are obligated by law to respect wishes regarding whether to forgo or continue therapy, and, if contrary to their conscience, transfer the patient to a willing health-care provider. In some jurisdictions, a patient’s wish to discontinue artificial nutrition and hydration, for example, via nasogastric or G-tube, requires a specific opt-in or opt-out choice. AMD instructions become relevant when the patient is terminally ill, but many jurisdictions allow their applicability in nonterminal conditions such as irreversible unconscious states or where the likely risks and burdens of treatment would outweigh the expected benefits (Hawaii is such a state under HRS 327E-16).
A recent review of 3,746 patients who had died between 2000 and 2006 showed that those with AMDs were more likely to want limited care or comfort care rather than all possible care, with the vast majority receiving treatment compatible with their wishes. Those who had assigned a durable power of attorney were less likely to die in the hospital or receive all care possible. The authors concluded that patients who have prepared AMDs received care that was strongly associated with their preferences. Other observers are less sanguine, noting that in only two-thirds of the time were decisions consistent, and one-third of patients changed their preferences in the face of actual illness, usually in favor of treatments rejected in advance. Surrogate agreement was only 58%, and surrogates tended to overestimate their loved one’s desire for treatment.
AMDs direct future end-of-life treatment in a hospital setting, and do not typically address emergency measures taken by ambulance personnel. The National POLST (Physician Orders for Life-Sustaining Treatment) Paradigm grew out of the need to address outpatient emergency treatment especially for seriously ill and frail patients. POLST, now available in many states across the country, is in actuality a medical order signed by the patient’s doctor directing what is and is not to be done, for example, intubation, defibrillation, etc. It does not replace the AMD but is complementary in ensuring respect for a patient’s medical wishes.
Unsurprisingly, there has been litigation over AMDs. Some of the earlier cases tended to favor the health-care institution’s refusal to cease life-sustaining treatment. In Bartling v. Glendale Adventist Medical Center, 184 Cal App 3d 961 (1986), a needle biopsy caused a patient’s lung to collapse. The patient had to be placed in restraints as he tried to remove the ventilator tubes. He had earlier executed a living will and a durable power of attorney for health care, and the family, agreeing to release the hospital and doctors from any civil liability, asked that the ventilator be removed. Instead, the hospital merely tried to "wean" him, and planned to resuscitate him in the event of a cardiopulmonary arrest. Unfortunately, no other facility was willing to accept him in transfer. However, in a defense verdict, the court held that although case law was evolving toward a greater recognition of patients’ rights, it could not be said that a common legal standard existed to guide the medical community.
The case of Osgood v. Genesys St. Joseph Hospital (No. 94-26731-NH, Mich 1996) gave a different result. The patient had a long history of seizures, and the doctors warned that a massive one could leave her in a persistent vegetative state. The patient named her mom as having durable power of attorney. One month later, the patient suffered a massive seizure but was kept alive on a ventilator with full medical support consisting of tube feeding, dialysis, blood transfusions, and medications. Although asked to have these measures removed, the hospital allegedly said they were not life support, but were "comfort care." After 2 months, the patient awoke and was able to be discharged home. However, she remained bedridden and spent most of her time "rhythmically screaming and thrashing" for hours on end, saying, "bury me". The family won a jury award of $16.5 million, which was reduced to $1.4 million on appeal.
A third case, Noonkester v. Kline, was a 1996 defense verdict for a doctor who instituted aggressive treatment despite his patient’s rejection of extraordinary measures evident in his living will. The patient, Mr. Noonkester, had Lou Gehrig’s disease and had instructed the doctor to write a DNR order. He gave his ex-wife power of attorney, and even made arrangements to be taken to a hospice in an emergency, where he planned to die peacefully. When Mr. Noonkester developed breathing problems from pneumonia, the ambulance took him to the hospital instead, and the doctor ordered a ventilator. The patient gave a "thumbs up" when told of the treatment plan, and 3 months later wrote a letter thanking Dr. Kline of the Scripps Clinic for saving his life. Although he had refused to have the ventilator removed, deeming it to be a suicidal act that he opposed, he subsequently sued Dr. Kline for interfering with his preplanned death and continuing costs of living. The jury took all of 45 minutes to return a unanimous verdict for Dr. Kline.
The contents of an AMD may be subject to differing interpretations, as was the case in Wright v. Johns Hopkins Health Systems Corp., 728 A.2d 166 (Md. 1999). A patient with AIDS arrested following a blood transfusion and was resuscitated but left in a comatose state for 10 days before dying. The family alleged that the aggressive treatment violated the patient’s living will instructions, but their lawsuit against the hospital was unsuccessful. Maryland’s Court of Appeals agreed with the hospital and the lower court that the living will could not take effect since no doctor had certified that he was in a terminal state and that his death was imminent.
The late Daniel Callahan, a prominent philosopher-ethicist, eloquently stated that dying in America has over the centuries "evolved from the sacred to the secular, private to institutional, and natural to artifactual." AMDs are a modern attempt to address the many dilemmas and emotions surrounding death. Patient autonomy and palliative care have rightly taken center stage. This may in part be the result of a seminal paper in 1995, which reported on a multicenter study of critically ill patients and their wishes regarding DNR and other end-of-life issues. The authors found that the wishes of many of the patients were ignored, and that 50% were in moderate or severe pain. Incredibly, physician treatment failed to change despite nurse intervention with prognostic information and patient preference.
142 USC 1395cc(f), 1396a(w) (1994).
2 Silveira MJ et al., Advance Directives and Outcomes of Surrogate Decision Making Before Death. (N. Engl. J. Med. 2010; 362:1211-8).
3 Lee et al., Do Patients’ Treatment Decisions Match Advance Statements of Their Preference? (J. Clin. Ethics 1998; 9:258-62).
4 See www.polst.org
5 A controlled trial to improve care for seriously ill hospitalized patients.1995 "SUPPORT" trial. (JAMA 1995; 274:1591-8).
Question: R, a woman with diabetes and Parkinson’s disease, executed an advance medical directive (AMD) when she was aged 70 years. Her AMD stipulated that no extraordinary measures be taken should she become terminally ill or permanently comatose, and she named her sister as her agent with durable power of attorney (DPA). Ten years later, at age 80 years, R sustained a stroke, which left her with hemiparesis and loss of cognitive function. She remained comatose for a week and was dependent on a feeding tube. Her sister decided to honor the AMD and stop all medical treatment including artificial nutrition and hydration. Given the above scenario, which of the following is most accurate?
A. R’s AMD sprang into effect when she became decisionally incapacitated.
B. An AMD can direct only the forgoing of life-sustaining treatment, not the continuation of treatment measures.
C. AMD’s are mandatory under the 1990 Federal Patient Self-Determination Act, and those without an AMD are required to make one upon admission to a hospital.
D. Those with DPA for health-care decisions are obligated to carry out the patient’s instructions but can also override them.
E. In the absence of an AMD or DPA, the attending doctor makes the final decision in the best interest of the patient.
Answer: A. An advance medical directive (AMD), sometimes called a living will, is a legally binding document executed by a competent person that provides instructions for future health-care decisions if and when that person loses decisional capacity. One can elect to forgo some or all life-sustaining measures, or to continue receiving all treatments. In 1990, Congress enacted the Federal Patient Self Determination Act, which allows patients to stipulate in advance the nature of their healthcare should they become incapacitated. Additionally, they can appoint an agent or proxy, said to have durable power of attorney (DPA) for health-care decisions, to speak for them. Agents are required to carry out, not override, the patient’s wishes. The Federal Act requires all hospitals to inquire into whether a patient has an AMD and to provide information on the subject, but the Act does not mandate that everyone should execute one. All 50 states, beginning with California in 1976, have enacted legislation on AMDs. In the absence of an AMD and DPA, a surrogate decision maker, sometimes court appointed, directs the care. The attending doctor provides the prognosis, but does not make the final decision to forgo or continue treatment.
Physicians are obligated by law to respect wishes regarding whether to forgo or continue therapy, and, if contrary to their conscience, transfer the patient to a willing health-care provider. In some jurisdictions, a patient’s wish to discontinue artificial nutrition and hydration, for example, via nasogastric or G-tube, requires a specific opt-in or opt-out choice. AMD instructions become relevant when the patient is terminally ill, but many jurisdictions allow their applicability in nonterminal conditions such as irreversible unconscious states or where the likely risks and burdens of treatment would outweigh the expected benefits (Hawaii is such a state under HRS 327E-16).
A recent review of 3,746 patients who had died between 2000 and 2006 showed that those with AMDs were more likely to want limited care or comfort care rather than all possible care, with the vast majority receiving treatment compatible with their wishes. Those who had assigned a durable power of attorney were less likely to die in the hospital or receive all care possible. The authors concluded that patients who have prepared AMDs received care that was strongly associated with their preferences. Other observers are less sanguine, noting that in only two-thirds of the time were decisions consistent, and one-third of patients changed their preferences in the face of actual illness, usually in favor of treatments rejected in advance. Surrogate agreement was only 58%, and surrogates tended to overestimate their loved one’s desire for treatment.
AMDs direct future end-of-life treatment in a hospital setting, and do not typically address emergency measures taken by ambulance personnel. The National POLST (Physician Orders for Life-Sustaining Treatment) Paradigm grew out of the need to address outpatient emergency treatment especially for seriously ill and frail patients. POLST, now available in many states across the country, is in actuality a medical order signed by the patient’s doctor directing what is and is not to be done, for example, intubation, defibrillation, etc. It does not replace the AMD but is complementary in ensuring respect for a patient’s medical wishes.
Unsurprisingly, there has been litigation over AMDs. Some of the earlier cases tended to favor the health-care institution’s refusal to cease life-sustaining treatment. In Bartling v. Glendale Adventist Medical Center, 184 Cal App 3d 961 (1986), a needle biopsy caused a patient’s lung to collapse. The patient had to be placed in restraints as he tried to remove the ventilator tubes. He had earlier executed a living will and a durable power of attorney for health care, and the family, agreeing to release the hospital and doctors from any civil liability, asked that the ventilator be removed. Instead, the hospital merely tried to "wean" him, and planned to resuscitate him in the event of a cardiopulmonary arrest. Unfortunately, no other facility was willing to accept him in transfer. However, in a defense verdict, the court held that although case law was evolving toward a greater recognition of patients’ rights, it could not be said that a common legal standard existed to guide the medical community.
The case of Osgood v. Genesys St. Joseph Hospital (No. 94-26731-NH, Mich 1996) gave a different result. The patient had a long history of seizures, and the doctors warned that a massive one could leave her in a persistent vegetative state. The patient named her mom as having durable power of attorney. One month later, the patient suffered a massive seizure but was kept alive on a ventilator with full medical support consisting of tube feeding, dialysis, blood transfusions, and medications. Although asked to have these measures removed, the hospital allegedly said they were not life support, but were "comfort care." After 2 months, the patient awoke and was able to be discharged home. However, she remained bedridden and spent most of her time "rhythmically screaming and thrashing" for hours on end, saying, "bury me". The family won a jury award of $16.5 million, which was reduced to $1.4 million on appeal.
A third case, Noonkester v. Kline, was a 1996 defense verdict for a doctor who instituted aggressive treatment despite his patient’s rejection of extraordinary measures evident in his living will. The patient, Mr. Noonkester, had Lou Gehrig’s disease and had instructed the doctor to write a DNR order. He gave his ex-wife power of attorney, and even made arrangements to be taken to a hospice in an emergency, where he planned to die peacefully. When Mr. Noonkester developed breathing problems from pneumonia, the ambulance took him to the hospital instead, and the doctor ordered a ventilator. The patient gave a "thumbs up" when told of the treatment plan, and 3 months later wrote a letter thanking Dr. Kline of the Scripps Clinic for saving his life. Although he had refused to have the ventilator removed, deeming it to be a suicidal act that he opposed, he subsequently sued Dr. Kline for interfering with his preplanned death and continuing costs of living. The jury took all of 45 minutes to return a unanimous verdict for Dr. Kline.
The contents of an AMD may be subject to differing interpretations, as was the case in Wright v. Johns Hopkins Health Systems Corp., 728 A.2d 166 (Md. 1999). A patient with AIDS arrested following a blood transfusion and was resuscitated but left in a comatose state for 10 days before dying. The family alleged that the aggressive treatment violated the patient’s living will instructions, but their lawsuit against the hospital was unsuccessful. Maryland’s Court of Appeals agreed with the hospital and the lower court that the living will could not take effect since no doctor had certified that he was in a terminal state and that his death was imminent.
The late Daniel Callahan, a prominent philosopher-ethicist, eloquently stated that dying in America has over the centuries "evolved from the sacred to the secular, private to institutional, and natural to artifactual." AMDs are a modern attempt to address the many dilemmas and emotions surrounding death. Patient autonomy and palliative care have rightly taken center stage. This may in part be the result of a seminal paper in 1995, which reported on a multicenter study of critically ill patients and their wishes regarding DNR and other end-of-life issues. The authors found that the wishes of many of the patients were ignored, and that 50% were in moderate or severe pain. Incredibly, physician treatment failed to change despite nurse intervention with prognostic information and patient preference.
142 USC 1395cc(f), 1396a(w) (1994).
2 Silveira MJ et al., Advance Directives and Outcomes of Surrogate Decision Making Before Death. (N. Engl. J. Med. 2010; 362:1211-8).
3 Lee et al., Do Patients’ Treatment Decisions Match Advance Statements of Their Preference? (J. Clin. Ethics 1998; 9:258-62).
4 See www.polst.org
5 A controlled trial to improve care for seriously ill hospitalized patients.1995 "SUPPORT" trial. (JAMA 1995; 274:1591-8).
Saying ‘I’m sorry’ can still be problematic
"I’m sorry."
I say that a lot – probably a few times an hour. I say it if I’m 2 minutes late taking a patient back, when a patient complains that the MRI was too loud, that a medication didn’t help, that I poked too hard with the pin while testing sensation, when a patient is unhappy that we don’t take American Express, or pretty much anything.
It’s a common phrase, meant to express care and concern and to smooth out the fabric of human social relationships.
A total of 37 states have some form of a medical malpractice "apology law" that allows physicians to apologize after something goes wrong without the apology being used against them in court. Thirteen states do not have an apology law (Alabama, Alaska, Arkansas, Illinois, Kansas, Kentucky, Minnesota, Mississippi, Nevada, New Mexico, New York, Rhode Island, and Wisconsin).
When a case goes bad we all feel awful about it, regardless of whether or not it’s our fault. These include the patient with symptomatic carotid stenosis we referred for surgery who then had a stroke on the operating table, the multiple sclerosis patient with a downhill course regardless of what medication we use, and the young person with speech problems who turns out to have a glioma.
We’ve all seen similar outcomes and feel bad for the patients. We do our best, but things beyond our control happen. Unfortunately, this is part of medicine. At the end of the day, we can only hope to have had more good outcomes than bad, but the bad ones are still unavoidable. Luck, chance, biology, aging, and human fallibility all work against us sometimes.
When things go wrong, it’s normal to say "I’m sorry," because we are concerned and do care and wish it had happened otherwise for the sake of someone who came to us seeking help.
To me, it seems wrong that expressing such feelings can be seen as an admission of guilt. It sounds more like part of the Miranda rights: "Anything you say can and will be used against you in a court of law."
Being afraid to apologize can make a bad situation even worse. Not expressing condolences makes a doctor appear aloof, uncaring, and arrogant.
Communication between a doctor, the patient, and his or her family under difficult circumstances is never easy, and having a simple apology subject to legal action only makes it worse. The medical relationship works best when it is open and honest – the way it should be everywhere.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
"I’m sorry."
I say that a lot – probably a few times an hour. I say it if I’m 2 minutes late taking a patient back, when a patient complains that the MRI was too loud, that a medication didn’t help, that I poked too hard with the pin while testing sensation, when a patient is unhappy that we don’t take American Express, or pretty much anything.
It’s a common phrase, meant to express care and concern and to smooth out the fabric of human social relationships.
A total of 37 states have some form of a medical malpractice "apology law" that allows physicians to apologize after something goes wrong without the apology being used against them in court. Thirteen states do not have an apology law (Alabama, Alaska, Arkansas, Illinois, Kansas, Kentucky, Minnesota, Mississippi, Nevada, New Mexico, New York, Rhode Island, and Wisconsin).
When a case goes bad we all feel awful about it, regardless of whether or not it’s our fault. These include the patient with symptomatic carotid stenosis we referred for surgery who then had a stroke on the operating table, the multiple sclerosis patient with a downhill course regardless of what medication we use, and the young person with speech problems who turns out to have a glioma.
We’ve all seen similar outcomes and feel bad for the patients. We do our best, but things beyond our control happen. Unfortunately, this is part of medicine. At the end of the day, we can only hope to have had more good outcomes than bad, but the bad ones are still unavoidable. Luck, chance, biology, aging, and human fallibility all work against us sometimes.
When things go wrong, it’s normal to say "I’m sorry," because we are concerned and do care and wish it had happened otherwise for the sake of someone who came to us seeking help.
To me, it seems wrong that expressing such feelings can be seen as an admission of guilt. It sounds more like part of the Miranda rights: "Anything you say can and will be used against you in a court of law."
Being afraid to apologize can make a bad situation even worse. Not expressing condolences makes a doctor appear aloof, uncaring, and arrogant.
Communication between a doctor, the patient, and his or her family under difficult circumstances is never easy, and having a simple apology subject to legal action only makes it worse. The medical relationship works best when it is open and honest – the way it should be everywhere.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
"I’m sorry."
I say that a lot – probably a few times an hour. I say it if I’m 2 minutes late taking a patient back, when a patient complains that the MRI was too loud, that a medication didn’t help, that I poked too hard with the pin while testing sensation, when a patient is unhappy that we don’t take American Express, or pretty much anything.
It’s a common phrase, meant to express care and concern and to smooth out the fabric of human social relationships.
A total of 37 states have some form of a medical malpractice "apology law" that allows physicians to apologize after something goes wrong without the apology being used against them in court. Thirteen states do not have an apology law (Alabama, Alaska, Arkansas, Illinois, Kansas, Kentucky, Minnesota, Mississippi, Nevada, New Mexico, New York, Rhode Island, and Wisconsin).
When a case goes bad we all feel awful about it, regardless of whether or not it’s our fault. These include the patient with symptomatic carotid stenosis we referred for surgery who then had a stroke on the operating table, the multiple sclerosis patient with a downhill course regardless of what medication we use, and the young person with speech problems who turns out to have a glioma.
We’ve all seen similar outcomes and feel bad for the patients. We do our best, but things beyond our control happen. Unfortunately, this is part of medicine. At the end of the day, we can only hope to have had more good outcomes than bad, but the bad ones are still unavoidable. Luck, chance, biology, aging, and human fallibility all work against us sometimes.
When things go wrong, it’s normal to say "I’m sorry," because we are concerned and do care and wish it had happened otherwise for the sake of someone who came to us seeking help.
To me, it seems wrong that expressing such feelings can be seen as an admission of guilt. It sounds more like part of the Miranda rights: "Anything you say can and will be used against you in a court of law."
Being afraid to apologize can make a bad situation even worse. Not expressing condolences makes a doctor appear aloof, uncaring, and arrogant.
Communication between a doctor, the patient, and his or her family under difficult circumstances is never easy, and having a simple apology subject to legal action only makes it worse. The medical relationship works best when it is open and honest – the way it should be everywhere.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Limited English proficiency patients and the hospitalist
America! America! God shed His grace on thee
And crown Thy good with brotherhood
From sea to shining sea!
I fondly remember singing "America the Beautiful" with my classmates when I was a little girl. America has grown by leaps and bounds since my childhood – the pulse of the nation as well as its makeup. One of my fondest memories as a child was traveling to New York. We had a layover in Washington and the airport was filled with people of various skin tones speaking all sorts of languages I had never been exposed to before. It was very exciting! It was my first truly multicultural experience.
Funny, I ultimately relocated to the D.C. area, and my neighbors are literally from all over the world: India, Thailand, Jamaica, Africa, China – and it doesn’t stop there. Naturally, the patient population I serve also reflects this great diversity. As the country becomes more diverse each and every day, we, as practitioners, must be able to communicate effectively with our entire patient base, not just the ones who speak English fluently.
This is quite a challenge. Yes, most hospitals have a language line or an on-call interpreter to help out, but I believe we also need to take some responsibility for improving our ability to communicate as well. While I am not advocating trying to master a new language, or two or three, we can all learn a few basic terms of the foreign languages we encounter most.
Consider that language lines do malfunction. Family members are sometimes not present. And interpreters may not always be available at the drop of a hat. Technology, though, is ever burgeoning. It’s easy to download a smartphone app, such as Medical Spanish: Healthcare Phrasebook with Audio. Google Translate can be helpful for scores of languages, though I would use this site with caution when it comes to patient care.
There is a slew of reputable patient information written in different languages available on the Internet as well.
The Agency for Healthcare Research and Quality offers a guide tool: Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The guide notes that approximately 57 million people speak a language other than English at home and 25 million are defined as limited-English-proficient (LEP). LEP patients were noted to have longer lengths of stay in the hospital and were at greater risk for line infections, surgical infections, falls, and pressure ulcers. They are more likely to be readmitted, as well.
Although it is always best to have a qualified interpreter to help us care for LEP patients, there may be times when one is simply unavailable in an acceptable period of time. Friends and family members can help fill some of the gaps in those instances, but it never hurts for the clinician to know a few vital words as well, such as pain or shortness of breath.
America’s culture is ever evolving, and we must evolve with it. Being able to provide high-quality care to all of our patients is our goal. Standards are important, but sometimes thinking out of the box can be effective as well.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
America! America! God shed His grace on thee
And crown Thy good with brotherhood
From sea to shining sea!
I fondly remember singing "America the Beautiful" with my classmates when I was a little girl. America has grown by leaps and bounds since my childhood – the pulse of the nation as well as its makeup. One of my fondest memories as a child was traveling to New York. We had a layover in Washington and the airport was filled with people of various skin tones speaking all sorts of languages I had never been exposed to before. It was very exciting! It was my first truly multicultural experience.
Funny, I ultimately relocated to the D.C. area, and my neighbors are literally from all over the world: India, Thailand, Jamaica, Africa, China – and it doesn’t stop there. Naturally, the patient population I serve also reflects this great diversity. As the country becomes more diverse each and every day, we, as practitioners, must be able to communicate effectively with our entire patient base, not just the ones who speak English fluently.
This is quite a challenge. Yes, most hospitals have a language line or an on-call interpreter to help out, but I believe we also need to take some responsibility for improving our ability to communicate as well. While I am not advocating trying to master a new language, or two or three, we can all learn a few basic terms of the foreign languages we encounter most.
Consider that language lines do malfunction. Family members are sometimes not present. And interpreters may not always be available at the drop of a hat. Technology, though, is ever burgeoning. It’s easy to download a smartphone app, such as Medical Spanish: Healthcare Phrasebook with Audio. Google Translate can be helpful for scores of languages, though I would use this site with caution when it comes to patient care.
There is a slew of reputable patient information written in different languages available on the Internet as well.
The Agency for Healthcare Research and Quality offers a guide tool: Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The guide notes that approximately 57 million people speak a language other than English at home and 25 million are defined as limited-English-proficient (LEP). LEP patients were noted to have longer lengths of stay in the hospital and were at greater risk for line infections, surgical infections, falls, and pressure ulcers. They are more likely to be readmitted, as well.
Although it is always best to have a qualified interpreter to help us care for LEP patients, there may be times when one is simply unavailable in an acceptable period of time. Friends and family members can help fill some of the gaps in those instances, but it never hurts for the clinician to know a few vital words as well, such as pain or shortness of breath.
America’s culture is ever evolving, and we must evolve with it. Being able to provide high-quality care to all of our patients is our goal. Standards are important, but sometimes thinking out of the box can be effective as well.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
America! America! God shed His grace on thee
And crown Thy good with brotherhood
From sea to shining sea!
I fondly remember singing "America the Beautiful" with my classmates when I was a little girl. America has grown by leaps and bounds since my childhood – the pulse of the nation as well as its makeup. One of my fondest memories as a child was traveling to New York. We had a layover in Washington and the airport was filled with people of various skin tones speaking all sorts of languages I had never been exposed to before. It was very exciting! It was my first truly multicultural experience.
Funny, I ultimately relocated to the D.C. area, and my neighbors are literally from all over the world: India, Thailand, Jamaica, Africa, China – and it doesn’t stop there. Naturally, the patient population I serve also reflects this great diversity. As the country becomes more diverse each and every day, we, as practitioners, must be able to communicate effectively with our entire patient base, not just the ones who speak English fluently.
This is quite a challenge. Yes, most hospitals have a language line or an on-call interpreter to help out, but I believe we also need to take some responsibility for improving our ability to communicate as well. While I am not advocating trying to master a new language, or two or three, we can all learn a few basic terms of the foreign languages we encounter most.
Consider that language lines do malfunction. Family members are sometimes not present. And interpreters may not always be available at the drop of a hat. Technology, though, is ever burgeoning. It’s easy to download a smartphone app, such as Medical Spanish: Healthcare Phrasebook with Audio. Google Translate can be helpful for scores of languages, though I would use this site with caution when it comes to patient care.
There is a slew of reputable patient information written in different languages available on the Internet as well.
The Agency for Healthcare Research and Quality offers a guide tool: Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The guide notes that approximately 57 million people speak a language other than English at home and 25 million are defined as limited-English-proficient (LEP). LEP patients were noted to have longer lengths of stay in the hospital and were at greater risk for line infections, surgical infections, falls, and pressure ulcers. They are more likely to be readmitted, as well.
Although it is always best to have a qualified interpreter to help us care for LEP patients, there may be times when one is simply unavailable in an acceptable period of time. Friends and family members can help fill some of the gaps in those instances, but it never hurts for the clinician to know a few vital words as well, such as pain or shortness of breath.
America’s culture is ever evolving, and we must evolve with it. Being able to provide high-quality care to all of our patients is our goal. Standards are important, but sometimes thinking out of the box can be effective as well.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Cryolipolysis
Cryolipolysis has emerged as a popular noninvasive treatment option for reducing localized areas of fat. The technology was developed on the premise that cold temperatures can selectively damage subcutaneous fat while leaving the overlying skin unharmed, as demonstrated by popsicle panniculitis. In this process, when subcutaneous fat is cooled below body temperature but above freezing, the fat undergoes cell death followed by a local inflammatory response, a localized panniculitis, that gradually results in a reduction of fat in that area.
Dr. Dieter Manstein and Dr. R. Rox Anderson pioneered the concept of cryolipolysis in 2008. The technology was approved by the Food and Drug Administration in 2010 in the form of the Zeltiq device. The device has different-sized hand pieces with a vacuum connection that, after it is applied to the skin, cools the subcutaneous fat without damaging the top layers of skin. Each area is treated for 1 hour, and 20%-30% of the fat cells are expected to be reduced with a single treatment. Typical responses after treatment include numbness, but some patients may also experience bruising and discomfort, all of which typically last no longer than 2-3 weeks.
If discomfort occurs in my patients, I find they report it more often in the lower abdomen than the love handles. Paradoxical adipose hyperplasia was recently reported for the first time in a male patient in his 40s (in the lower abdomen) (JAMA Dermatol. 2014;150:317-9).
In my experience, there is no difference in efficacy or adverse events seen in patients of different ethnicities. One study found no difference in efficacy or adverse events of cryolipolysis in Chinese patients (Lasers Surg. Med. 2012;44:125-30), but no other study of cryolipolysis in ethnic patients has been published.
I was involved in the clinical trials for this device prior to FDA approval where one love handle was treated on a patient and the other side was used as a control. Based on this experience and my experience using the device in practice, it is not a replacement for abdominoplasty or liposuction, but it is a useful technology in the right candidate. The patients who seem to do the best are those who are 10-15 pounds from their goal weight, are not obese (body mass index less than 30 kg/m2), and have a discrete bulge (typically love handles or abdomen) that they can’t get rid of with good diet and exercise alone. Massage for a few minutes after treatment seems to increase efficacy (Lasers Surg. Med. 2014;46:20-6).
Some patients may require more than one treatment to achieve their desired results, but I recommend waiting at least 2-3 months before opting for additional treatment. Choosing the right candidates and providing patients with realistic expectations seem to be the most helpful in this process.
Dr. Wesley practices dermatology in Beverly Hills, Calif.
Cryolipolysis has emerged as a popular noninvasive treatment option for reducing localized areas of fat. The technology was developed on the premise that cold temperatures can selectively damage subcutaneous fat while leaving the overlying skin unharmed, as demonstrated by popsicle panniculitis. In this process, when subcutaneous fat is cooled below body temperature but above freezing, the fat undergoes cell death followed by a local inflammatory response, a localized panniculitis, that gradually results in a reduction of fat in that area.
Dr. Dieter Manstein and Dr. R. Rox Anderson pioneered the concept of cryolipolysis in 2008. The technology was approved by the Food and Drug Administration in 2010 in the form of the Zeltiq device. The device has different-sized hand pieces with a vacuum connection that, after it is applied to the skin, cools the subcutaneous fat without damaging the top layers of skin. Each area is treated for 1 hour, and 20%-30% of the fat cells are expected to be reduced with a single treatment. Typical responses after treatment include numbness, but some patients may also experience bruising and discomfort, all of which typically last no longer than 2-3 weeks.
If discomfort occurs in my patients, I find they report it more often in the lower abdomen than the love handles. Paradoxical adipose hyperplasia was recently reported for the first time in a male patient in his 40s (in the lower abdomen) (JAMA Dermatol. 2014;150:317-9).
In my experience, there is no difference in efficacy or adverse events seen in patients of different ethnicities. One study found no difference in efficacy or adverse events of cryolipolysis in Chinese patients (Lasers Surg. Med. 2012;44:125-30), but no other study of cryolipolysis in ethnic patients has been published.
I was involved in the clinical trials for this device prior to FDA approval where one love handle was treated on a patient and the other side was used as a control. Based on this experience and my experience using the device in practice, it is not a replacement for abdominoplasty or liposuction, but it is a useful technology in the right candidate. The patients who seem to do the best are those who are 10-15 pounds from their goal weight, are not obese (body mass index less than 30 kg/m2), and have a discrete bulge (typically love handles or abdomen) that they can’t get rid of with good diet and exercise alone. Massage for a few minutes after treatment seems to increase efficacy (Lasers Surg. Med. 2014;46:20-6).
Some patients may require more than one treatment to achieve their desired results, but I recommend waiting at least 2-3 months before opting for additional treatment. Choosing the right candidates and providing patients with realistic expectations seem to be the most helpful in this process.
Dr. Wesley practices dermatology in Beverly Hills, Calif.
Cryolipolysis has emerged as a popular noninvasive treatment option for reducing localized areas of fat. The technology was developed on the premise that cold temperatures can selectively damage subcutaneous fat while leaving the overlying skin unharmed, as demonstrated by popsicle panniculitis. In this process, when subcutaneous fat is cooled below body temperature but above freezing, the fat undergoes cell death followed by a local inflammatory response, a localized panniculitis, that gradually results in a reduction of fat in that area.
Dr. Dieter Manstein and Dr. R. Rox Anderson pioneered the concept of cryolipolysis in 2008. The technology was approved by the Food and Drug Administration in 2010 in the form of the Zeltiq device. The device has different-sized hand pieces with a vacuum connection that, after it is applied to the skin, cools the subcutaneous fat without damaging the top layers of skin. Each area is treated for 1 hour, and 20%-30% of the fat cells are expected to be reduced with a single treatment. Typical responses after treatment include numbness, but some patients may also experience bruising and discomfort, all of which typically last no longer than 2-3 weeks.
If discomfort occurs in my patients, I find they report it more often in the lower abdomen than the love handles. Paradoxical adipose hyperplasia was recently reported for the first time in a male patient in his 40s (in the lower abdomen) (JAMA Dermatol. 2014;150:317-9).
In my experience, there is no difference in efficacy or adverse events seen in patients of different ethnicities. One study found no difference in efficacy or adverse events of cryolipolysis in Chinese patients (Lasers Surg. Med. 2012;44:125-30), but no other study of cryolipolysis in ethnic patients has been published.
I was involved in the clinical trials for this device prior to FDA approval where one love handle was treated on a patient and the other side was used as a control. Based on this experience and my experience using the device in practice, it is not a replacement for abdominoplasty or liposuction, but it is a useful technology in the right candidate. The patients who seem to do the best are those who are 10-15 pounds from their goal weight, are not obese (body mass index less than 30 kg/m2), and have a discrete bulge (typically love handles or abdomen) that they can’t get rid of with good diet and exercise alone. Massage for a few minutes after treatment seems to increase efficacy (Lasers Surg. Med. 2014;46:20-6).
Some patients may require more than one treatment to achieve their desired results, but I recommend waiting at least 2-3 months before opting for additional treatment. Choosing the right candidates and providing patients with realistic expectations seem to be the most helpful in this process.
Dr. Wesley practices dermatology in Beverly Hills, Calif.
To MU or not to MU, that is the question
If you are still on the fence on meaningful use – our government’s motivational strategy for popularizing electronic health records – the point of no return is rapidly approaching: If you want to qualify for at least a portion of the incentive money, plus avoid a 1% penalty (eventually rising to 5%) on your Medicare Part B reimbursements, this year is your final opportunity to join the party. And, unfortunately, it is not simply a matter of adopting an electronic record system.
Each year, you must attest to demonstrating "meaningful use" (MU) of that system. To do that, you must continually monitor your progress toward meeting the necessary percentage benchmarks, making course corrections as you go. If the numbers are not there when your practice is ready to attest, it will have all been for naught, and a major waste of time and resources.
That being the case, private practitioners who have not yet taken the plunge – and those who have, but are undecided on progressing to stage 2 – must ask themselves whether the significant temporal and monetary investment is worth the trouble.
Many, apparently, have decided that it is not. While a substantial percentage of eligible practitioners signed up for stage 1, approximately 20% of them stopped participating in 2013. And according to the Centers for Medicare & Medicaid Services’ own data, only 4 hospitals and 50 individual practitioners in the entire country had attested to stage 2 through March of 2014.
The American Medical Association has little faith in the program, at least in its current form. In an open letter to the CMS in May 2014, they predicted significantly higher dropout rates unless major modifications are made. Specifically, they singled out the requirement that providers meet all requirements at each stage. Rather than "all or nothing," they proposed a 75% achievement level to receive incentive payments, and a 50% minimum to avoid financial penalties. The AMA also recommended eliminating all benchmarks beyond physicians’ control, such as the stage 2 goal of 5% patient participation on the practice’s electronic health record (EHR) portal.
Another problem that falls outside the control of physicians is maintenance of EHR software. Nearly one EHR-equipped office in five, according to the CMS, is running software that does not meet stage 2 standards. The unfortunate owners of systems that cannot be upgraded before the stage 2 deadline will – through no fault of their own – be faced with a Morton’s fork of replacing their EHR on short notice or abandoning their quest for stage 2 attestation.
While the CMS has not yet indicated whether it has any inclination to address these issues or ease any of the requirements, one official did announce that the agency will be more flexible with its hardship exemptions on a case-by-case basis. Currently, such exemptions are available to new providers, those recovering from natural disasters, and others, such as pathologists, who do not interact face-to-face with patients.
So the question remains: Is the investment of time and resources needed to capture all of the data necessary for successful MU attestation worth making? Is it justified by the promise of MU incentive dollars and the benefits to your practice and your patients? And what exactly are those purported benefits, anyway?
Proponents maintain that integrated EHR will lead to improved documentation, which in turn should lead to improvements in patient care. Errors would be more easily identified because entries from generalists, specialists, labs, and others would be available to all at any time. All involved providers, theoretically, would be on the same page with every individual patient. The downside, of course, is that the real world seldom reflects the ideal situation envisioned by bureaucrats.
Ultimately, the choice is yours: Each private practitioner must decide whether starting (or continuing) meaningful use is worth the financial and time burden in his or her particular situation. If you are still undecided, time is almost up: You must begin your 90-day stage 1 reporting period in July 2014 in order to attest by the final deadline of October 1. The last calendar quarter to begin stage 2 reporting starts on October 1 as well. Detailed instructions for meeting stage 1 and stage 2 deadlines are available from many sources, including the American Academy of Dermatology website.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.
If you are still on the fence on meaningful use – our government’s motivational strategy for popularizing electronic health records – the point of no return is rapidly approaching: If you want to qualify for at least a portion of the incentive money, plus avoid a 1% penalty (eventually rising to 5%) on your Medicare Part B reimbursements, this year is your final opportunity to join the party. And, unfortunately, it is not simply a matter of adopting an electronic record system.
Each year, you must attest to demonstrating "meaningful use" (MU) of that system. To do that, you must continually monitor your progress toward meeting the necessary percentage benchmarks, making course corrections as you go. If the numbers are not there when your practice is ready to attest, it will have all been for naught, and a major waste of time and resources.
That being the case, private practitioners who have not yet taken the plunge – and those who have, but are undecided on progressing to stage 2 – must ask themselves whether the significant temporal and monetary investment is worth the trouble.
Many, apparently, have decided that it is not. While a substantial percentage of eligible practitioners signed up for stage 1, approximately 20% of them stopped participating in 2013. And according to the Centers for Medicare & Medicaid Services’ own data, only 4 hospitals and 50 individual practitioners in the entire country had attested to stage 2 through March of 2014.
The American Medical Association has little faith in the program, at least in its current form. In an open letter to the CMS in May 2014, they predicted significantly higher dropout rates unless major modifications are made. Specifically, they singled out the requirement that providers meet all requirements at each stage. Rather than "all or nothing," they proposed a 75% achievement level to receive incentive payments, and a 50% minimum to avoid financial penalties. The AMA also recommended eliminating all benchmarks beyond physicians’ control, such as the stage 2 goal of 5% patient participation on the practice’s electronic health record (EHR) portal.
Another problem that falls outside the control of physicians is maintenance of EHR software. Nearly one EHR-equipped office in five, according to the CMS, is running software that does not meet stage 2 standards. The unfortunate owners of systems that cannot be upgraded before the stage 2 deadline will – through no fault of their own – be faced with a Morton’s fork of replacing their EHR on short notice or abandoning their quest for stage 2 attestation.
While the CMS has not yet indicated whether it has any inclination to address these issues or ease any of the requirements, one official did announce that the agency will be more flexible with its hardship exemptions on a case-by-case basis. Currently, such exemptions are available to new providers, those recovering from natural disasters, and others, such as pathologists, who do not interact face-to-face with patients.
So the question remains: Is the investment of time and resources needed to capture all of the data necessary for successful MU attestation worth making? Is it justified by the promise of MU incentive dollars and the benefits to your practice and your patients? And what exactly are those purported benefits, anyway?
Proponents maintain that integrated EHR will lead to improved documentation, which in turn should lead to improvements in patient care. Errors would be more easily identified because entries from generalists, specialists, labs, and others would be available to all at any time. All involved providers, theoretically, would be on the same page with every individual patient. The downside, of course, is that the real world seldom reflects the ideal situation envisioned by bureaucrats.
Ultimately, the choice is yours: Each private practitioner must decide whether starting (or continuing) meaningful use is worth the financial and time burden in his or her particular situation. If you are still undecided, time is almost up: You must begin your 90-day stage 1 reporting period in July 2014 in order to attest by the final deadline of October 1. The last calendar quarter to begin stage 2 reporting starts on October 1 as well. Detailed instructions for meeting stage 1 and stage 2 deadlines are available from many sources, including the American Academy of Dermatology website.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.
If you are still on the fence on meaningful use – our government’s motivational strategy for popularizing electronic health records – the point of no return is rapidly approaching: If you want to qualify for at least a portion of the incentive money, plus avoid a 1% penalty (eventually rising to 5%) on your Medicare Part B reimbursements, this year is your final opportunity to join the party. And, unfortunately, it is not simply a matter of adopting an electronic record system.
Each year, you must attest to demonstrating "meaningful use" (MU) of that system. To do that, you must continually monitor your progress toward meeting the necessary percentage benchmarks, making course corrections as you go. If the numbers are not there when your practice is ready to attest, it will have all been for naught, and a major waste of time and resources.
That being the case, private practitioners who have not yet taken the plunge – and those who have, but are undecided on progressing to stage 2 – must ask themselves whether the significant temporal and monetary investment is worth the trouble.
Many, apparently, have decided that it is not. While a substantial percentage of eligible practitioners signed up for stage 1, approximately 20% of them stopped participating in 2013. And according to the Centers for Medicare & Medicaid Services’ own data, only 4 hospitals and 50 individual practitioners in the entire country had attested to stage 2 through March of 2014.
The American Medical Association has little faith in the program, at least in its current form. In an open letter to the CMS in May 2014, they predicted significantly higher dropout rates unless major modifications are made. Specifically, they singled out the requirement that providers meet all requirements at each stage. Rather than "all or nothing," they proposed a 75% achievement level to receive incentive payments, and a 50% minimum to avoid financial penalties. The AMA also recommended eliminating all benchmarks beyond physicians’ control, such as the stage 2 goal of 5% patient participation on the practice’s electronic health record (EHR) portal.
Another problem that falls outside the control of physicians is maintenance of EHR software. Nearly one EHR-equipped office in five, according to the CMS, is running software that does not meet stage 2 standards. The unfortunate owners of systems that cannot be upgraded before the stage 2 deadline will – through no fault of their own – be faced with a Morton’s fork of replacing their EHR on short notice or abandoning their quest for stage 2 attestation.
While the CMS has not yet indicated whether it has any inclination to address these issues or ease any of the requirements, one official did announce that the agency will be more flexible with its hardship exemptions on a case-by-case basis. Currently, such exemptions are available to new providers, those recovering from natural disasters, and others, such as pathologists, who do not interact face-to-face with patients.
So the question remains: Is the investment of time and resources needed to capture all of the data necessary for successful MU attestation worth making? Is it justified by the promise of MU incentive dollars and the benefits to your practice and your patients? And what exactly are those purported benefits, anyway?
Proponents maintain that integrated EHR will lead to improved documentation, which in turn should lead to improvements in patient care. Errors would be more easily identified because entries from generalists, specialists, labs, and others would be available to all at any time. All involved providers, theoretically, would be on the same page with every individual patient. The downside, of course, is that the real world seldom reflects the ideal situation envisioned by bureaucrats.
Ultimately, the choice is yours: Each private practitioner must decide whether starting (or continuing) meaningful use is worth the financial and time burden in his or her particular situation. If you are still undecided, time is almost up: You must begin your 90-day stage 1 reporting period in July 2014 in order to attest by the final deadline of October 1. The last calendar quarter to begin stage 2 reporting starts on October 1 as well. Detailed instructions for meeting stage 1 and stage 2 deadlines are available from many sources, including the American Academy of Dermatology website.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.
