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How optimistic should we be about family medicine?
While I appreciate Dr. Hickner’s optimism for the future of family medicine (J Fam Pract. 2014;63:127), the reality is that family physicians (FPs) have been—and still are—considered cheap labor by insurers and hospital systems. Some subspecialists earn triple (and even quadruple) what FPs do, and there’s really no reason for this. FPs shoulder the burden for the vast majority of acute and chronic health care in this country. FPs bring in more revenue per provider to hospital systems and are able to provide more efficient, cost-effective care than subspecialists. Despite this, we are still not recognized financially.
However, I do share some of Dr. Hickner’s optimism, although for a different reason. I work for a company that contracts directly with larger, self-insured companies to provide medical care for their employees. Our focus is preventive medicine, wellness, and behavioral change, but we also provide occupational health services and one-on-one health coaching. Our resources go directly to patient care and we can reduce employer health care costs by as much as 30% due to fewer emergency department visits and hospitalizations and less time lost from work. This model offers hope in a broken health care system. I’m once again enjoying practicing cost-effective medicine that is truly patient-centered.
Joseph E. Badolato, DO
Seattle, Wash
I want to thank Dr. Hickner for sharing his reasons for optimism, but feel compelled to refute his comment that “the health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.” Speaking with my colleagues across all specialties, I’ve learned there has been an inexorable decrease of payment for physician services under the guise of controlling costs or stamping out fraud and abuse. The meteoric rise in health care costs has been driven by nonphysician services—especially technology, but also by third-party insurers (including Medicare and Medicaid), government paperwork requirements, and skyrocketing pharmaceutical costs—but blamed on physicians.
In my area, I can care for 20 patients for the cost of one computed tomography scan, or 40 patients for the cost of a magnetic resonance imaging scan. Physician services—not physician extenders, information technology, and the rest—are the best value in medicine today. Our focus needs to be on training and rewarding physicians for their dedication and service with proper reimbursement. I think the Affordable Care Act’s version of medical care has failed and will continue to fail without universal physician support to eliminate it.
James A. Taylor, DO
Jackson, Mich
While I appreciate Dr. Hickner’s optimism for the future of family medicine (J Fam Pract. 2014;63:127), the reality is that family physicians (FPs) have been—and still are—considered cheap labor by insurers and hospital systems. Some subspecialists earn triple (and even quadruple) what FPs do, and there’s really no reason for this. FPs shoulder the burden for the vast majority of acute and chronic health care in this country. FPs bring in more revenue per provider to hospital systems and are able to provide more efficient, cost-effective care than subspecialists. Despite this, we are still not recognized financially.
However, I do share some of Dr. Hickner’s optimism, although for a different reason. I work for a company that contracts directly with larger, self-insured companies to provide medical care for their employees. Our focus is preventive medicine, wellness, and behavioral change, but we also provide occupational health services and one-on-one health coaching. Our resources go directly to patient care and we can reduce employer health care costs by as much as 30% due to fewer emergency department visits and hospitalizations and less time lost from work. This model offers hope in a broken health care system. I’m once again enjoying practicing cost-effective medicine that is truly patient-centered.
Joseph E. Badolato, DO
Seattle, Wash
I want to thank Dr. Hickner for sharing his reasons for optimism, but feel compelled to refute his comment that “the health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.” Speaking with my colleagues across all specialties, I’ve learned there has been an inexorable decrease of payment for physician services under the guise of controlling costs or stamping out fraud and abuse. The meteoric rise in health care costs has been driven by nonphysician services—especially technology, but also by third-party insurers (including Medicare and Medicaid), government paperwork requirements, and skyrocketing pharmaceutical costs—but blamed on physicians.
In my area, I can care for 20 patients for the cost of one computed tomography scan, or 40 patients for the cost of a magnetic resonance imaging scan. Physician services—not physician extenders, information technology, and the rest—are the best value in medicine today. Our focus needs to be on training and rewarding physicians for their dedication and service with proper reimbursement. I think the Affordable Care Act’s version of medical care has failed and will continue to fail without universal physician support to eliminate it.
James A. Taylor, DO
Jackson, Mich
While I appreciate Dr. Hickner’s optimism for the future of family medicine (J Fam Pract. 2014;63:127), the reality is that family physicians (FPs) have been—and still are—considered cheap labor by insurers and hospital systems. Some subspecialists earn triple (and even quadruple) what FPs do, and there’s really no reason for this. FPs shoulder the burden for the vast majority of acute and chronic health care in this country. FPs bring in more revenue per provider to hospital systems and are able to provide more efficient, cost-effective care than subspecialists. Despite this, we are still not recognized financially.
However, I do share some of Dr. Hickner’s optimism, although for a different reason. I work for a company that contracts directly with larger, self-insured companies to provide medical care for their employees. Our focus is preventive medicine, wellness, and behavioral change, but we also provide occupational health services and one-on-one health coaching. Our resources go directly to patient care and we can reduce employer health care costs by as much as 30% due to fewer emergency department visits and hospitalizations and less time lost from work. This model offers hope in a broken health care system. I’m once again enjoying practicing cost-effective medicine that is truly patient-centered.
Joseph E. Badolato, DO
Seattle, Wash
I want to thank Dr. Hickner for sharing his reasons for optimism, but feel compelled to refute his comment that “the health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.” Speaking with my colleagues across all specialties, I’ve learned there has been an inexorable decrease of payment for physician services under the guise of controlling costs or stamping out fraud and abuse. The meteoric rise in health care costs has been driven by nonphysician services—especially technology, but also by third-party insurers (including Medicare and Medicaid), government paperwork requirements, and skyrocketing pharmaceutical costs—but blamed on physicians.
In my area, I can care for 20 patients for the cost of one computed tomography scan, or 40 patients for the cost of a magnetic resonance imaging scan. Physician services—not physician extenders, information technology, and the rest—are the best value in medicine today. Our focus needs to be on training and rewarding physicians for their dedication and service with proper reimbursement. I think the Affordable Care Act’s version of medical care has failed and will continue to fail without universal physician support to eliminate it.
James A. Taylor, DO
Jackson, Mich
Editorial: The 21st-Century Emergency Department
Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.
So, if we are making some of our most potent tools available to the public, how are we repurposing the 21st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.
In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.
Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.
A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.
The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.
In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.
Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.
So, if we are making some of our most potent tools available to the public, how are we repurposing the 21st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.
In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.
Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.
A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.
The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.
In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.
Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.
So, if we are making some of our most potent tools available to the public, how are we repurposing the 21st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.
In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.
Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.
A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.
The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.
In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.
I’ve Been Framed!
Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.
Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!
This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.
Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.
For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.1 The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.
What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.2
Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.3 Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.
On the next page: Categories of diagnostic errors >>
According to Graber et al4, diagnostic errors fall into three categories:
“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.
System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.
Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.4
What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.
Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted.
I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.
Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.5 Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.
On the next page: How to avoid framing bias >>
There are some remedies to avoid framing bias:
• Acknowledge that framing bias may exist, and be on the lookout for it.
• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.
• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.
• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.
• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.6
With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.
I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].
REFERENCES
1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.
2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.
3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.
4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014. 5, 2014.
Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.
Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!
This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.
Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.
For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.1 The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.
What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.2
Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.3 Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.
On the next page: Categories of diagnostic errors >>
According to Graber et al4, diagnostic errors fall into three categories:
“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.
System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.
Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.4
What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.
Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted.
I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.
Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.5 Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.
On the next page: How to avoid framing bias >>
There are some remedies to avoid framing bias:
• Acknowledge that framing bias may exist, and be on the lookout for it.
• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.
• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.
• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.
• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.6
With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.
I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].
REFERENCES
1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.
2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.
3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.
4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014. 5, 2014.
Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.
Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!
This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.
Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.
For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.1 The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.
What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.2
Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.3 Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.
On the next page: Categories of diagnostic errors >>
According to Graber et al4, diagnostic errors fall into three categories:
“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.
System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.
Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.4
What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.
Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted.
I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.
Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.5 Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.
On the next page: How to avoid framing bias >>
There are some remedies to avoid framing bias:
• Acknowledge that framing bias may exist, and be on the lookout for it.
• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.
• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.
• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.
• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.6
With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.
I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].
REFERENCES
1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.
2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.
3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.
4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014. 5, 2014.
iPad app could change how MS is measured, treated
DALLAS – The superior performance of an iPad-based app for the self-administration of the multiple sclerosis performance test, when compared with a technician-administered one, could mean big changes in how data are collected and interpreted for the purposes of clinical trials and disease management, according to an expert.
"There are some important implications of this," said Dr. Richard Rudick, who was director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic until recently accepting a position with Biogen Idec as vice president, development sciences, Value-Based Medicine Group.
Among the considerations implicated by the findings is that unfiltered, accurate patient data could be transferred in real time to the "cloud" where it would be available for immediate viewing, as well as kept for future study. This would give clinicians new ways to "collect, display, aggregate, and analyze neurological performance," Dr. Rudick said at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.
iPad app bested technician performance
The app-based multiple sclerosis performance test (MSPT) was developed by Dr. Rudick and his colleagues to simulate the technician-based one in all aspects and comprises the walking speed test, the manual dexterity test, the low-contrast visual acuity test, and the processing speed test. These approximate the MSPT’s timed 25-foot walk test, the 9-hole peg test, the Sloan low-contrast visual acuity test, and the Symbol Digit Modalities Test.
The industry-sponsored, cross-sectional validation study matched 49 healthy controls with 51 patients according to age, sex, and education. Roughly three-quarters of the study arm had relapsing MS, and a quarter had the progressive form of the disease.
Participants were tested at a single site via each modality, once in the morning and then again in the afternoon. The test/retest results were consistent and correlative, according to Dr. Rudick. "They were highly reliable, whether the technician did it, or the iPad," he said.
The question was whether the two tests were measuring the same thing. Because data for all aspects of each test were comparable, Dr. Rudick concluded that the tests were comparable.
The most important measure was how well the app version separated the two study groups, when compared with the ability of the technician-based test, according to Dr. Rudick. "In virtually every case, except for the visual, the iPad actually does a little bit better than the technician in distinguishing the MS patients from the healthy controls," he said.
For example, in the timed 25-foot walk test administered by the technician, the mean score in the MS group was 7 (P less than .001; standard deviation, 4.28), while the mean score for the walking speed test in the MS group was 7.26 (P less than .001; SD, 4.25). In the healthy controls group, the mean score for the technician-given test was 4.24 (P less than .001). That group’s mean score for the self-given walking speed test was 4.27 (P less than .001; SD, 4.27).
Still need humans
Patient-reported outcomes were also correlative to both forms of the tests. However, in an interview after the presentation, Dr. Rudick said that patient-reported cognitive impairment doesn’t usually correlate with the actual measurements used in neurocognitive testing. "What does seem to correlate with patients reporting cognitive impairment is if they are depressed. Then the depression score matches the patient-reported cognitive impairment better than the actual cognitive test score does," he said.
When Dr. Rudick asked the audience, which included many physician assistants and registered nurses in addition to physicians, whether they would embrace the use of this technology, the majority assented. However, during the discussion following the presentation, Neil Jouvenant, a physician assistant at the University of Nebraska Medical Center in Omaha, said there are some patients for whom this technology would not be appropriate, such as those who walk with difficulty.
In an interview, Mr. Jouvenant said that in addition, "you still need a technician to instruct and encourage patients. If the iPad were to instruct a patient to ‘get up now, strap this to your back, and walk 25 feet,’ they won’t because they don’t really think they can. There is a fine line between someone who can walk a certain distance and someone who can’t." The technician can help in those situations, he said.
More inclusive and comprehensive
Although Dr. Rudick agreed that at least for now, this technology is not appropriate for all patients, the technology does hold promise for those who would have been excluded in the past, such as patients who live in rural areas but would like to participate in clinical trials.
The collection of normative data from healthy adults will also mean that clinical interpretations of MSPT scores will have broader utility in MS patients and groups, and the technology can be adapted to yield additional data such as specific measurements for balance and speed.
Dr. Patricia Coyle, professor of psychiatry and neurology at the State University of New York at Stony Brook, and director of the MS comprehensive care center there, said in an interview that technology such as this has the power to "revolutionize" disease management, particularly if it is collected into a central database accessible to any clinician or researcher.
"There are only so many MS patients, and we don’t have a good idea of their disease activity. They’re not tracked. No one’s trying to pull that data together," she said. But having these data "potentially would mean revolutionizing" the field.
Novartis funded the study on the MSPT app. Dr. Rudick said that he has received consulting fees from Genzyme and Novartis. Dr. Coyle reported she has financial relationships with Biogen Idec, Genentech, and Genzyme, among others.
On Twitter @whitneymcknight
DALLAS – The superior performance of an iPad-based app for the self-administration of the multiple sclerosis performance test, when compared with a technician-administered one, could mean big changes in how data are collected and interpreted for the purposes of clinical trials and disease management, according to an expert.
"There are some important implications of this," said Dr. Richard Rudick, who was director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic until recently accepting a position with Biogen Idec as vice president, development sciences, Value-Based Medicine Group.
Among the considerations implicated by the findings is that unfiltered, accurate patient data could be transferred in real time to the "cloud" where it would be available for immediate viewing, as well as kept for future study. This would give clinicians new ways to "collect, display, aggregate, and analyze neurological performance," Dr. Rudick said at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.
iPad app bested technician performance
The app-based multiple sclerosis performance test (MSPT) was developed by Dr. Rudick and his colleagues to simulate the technician-based one in all aspects and comprises the walking speed test, the manual dexterity test, the low-contrast visual acuity test, and the processing speed test. These approximate the MSPT’s timed 25-foot walk test, the 9-hole peg test, the Sloan low-contrast visual acuity test, and the Symbol Digit Modalities Test.
The industry-sponsored, cross-sectional validation study matched 49 healthy controls with 51 patients according to age, sex, and education. Roughly three-quarters of the study arm had relapsing MS, and a quarter had the progressive form of the disease.
Participants were tested at a single site via each modality, once in the morning and then again in the afternoon. The test/retest results were consistent and correlative, according to Dr. Rudick. "They were highly reliable, whether the technician did it, or the iPad," he said.
The question was whether the two tests were measuring the same thing. Because data for all aspects of each test were comparable, Dr. Rudick concluded that the tests were comparable.
The most important measure was how well the app version separated the two study groups, when compared with the ability of the technician-based test, according to Dr. Rudick. "In virtually every case, except for the visual, the iPad actually does a little bit better than the technician in distinguishing the MS patients from the healthy controls," he said.
For example, in the timed 25-foot walk test administered by the technician, the mean score in the MS group was 7 (P less than .001; standard deviation, 4.28), while the mean score for the walking speed test in the MS group was 7.26 (P less than .001; SD, 4.25). In the healthy controls group, the mean score for the technician-given test was 4.24 (P less than .001). That group’s mean score for the self-given walking speed test was 4.27 (P less than .001; SD, 4.27).
Still need humans
Patient-reported outcomes were also correlative to both forms of the tests. However, in an interview after the presentation, Dr. Rudick said that patient-reported cognitive impairment doesn’t usually correlate with the actual measurements used in neurocognitive testing. "What does seem to correlate with patients reporting cognitive impairment is if they are depressed. Then the depression score matches the patient-reported cognitive impairment better than the actual cognitive test score does," he said.
When Dr. Rudick asked the audience, which included many physician assistants and registered nurses in addition to physicians, whether they would embrace the use of this technology, the majority assented. However, during the discussion following the presentation, Neil Jouvenant, a physician assistant at the University of Nebraska Medical Center in Omaha, said there are some patients for whom this technology would not be appropriate, such as those who walk with difficulty.
In an interview, Mr. Jouvenant said that in addition, "you still need a technician to instruct and encourage patients. If the iPad were to instruct a patient to ‘get up now, strap this to your back, and walk 25 feet,’ they won’t because they don’t really think they can. There is a fine line between someone who can walk a certain distance and someone who can’t." The technician can help in those situations, he said.
More inclusive and comprehensive
Although Dr. Rudick agreed that at least for now, this technology is not appropriate for all patients, the technology does hold promise for those who would have been excluded in the past, such as patients who live in rural areas but would like to participate in clinical trials.
The collection of normative data from healthy adults will also mean that clinical interpretations of MSPT scores will have broader utility in MS patients and groups, and the technology can be adapted to yield additional data such as specific measurements for balance and speed.
Dr. Patricia Coyle, professor of psychiatry and neurology at the State University of New York at Stony Brook, and director of the MS comprehensive care center there, said in an interview that technology such as this has the power to "revolutionize" disease management, particularly if it is collected into a central database accessible to any clinician or researcher.
"There are only so many MS patients, and we don’t have a good idea of their disease activity. They’re not tracked. No one’s trying to pull that data together," she said. But having these data "potentially would mean revolutionizing" the field.
Novartis funded the study on the MSPT app. Dr. Rudick said that he has received consulting fees from Genzyme and Novartis. Dr. Coyle reported she has financial relationships with Biogen Idec, Genentech, and Genzyme, among others.
On Twitter @whitneymcknight
DALLAS – The superior performance of an iPad-based app for the self-administration of the multiple sclerosis performance test, when compared with a technician-administered one, could mean big changes in how data are collected and interpreted for the purposes of clinical trials and disease management, according to an expert.
"There are some important implications of this," said Dr. Richard Rudick, who was director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic until recently accepting a position with Biogen Idec as vice president, development sciences, Value-Based Medicine Group.
Among the considerations implicated by the findings is that unfiltered, accurate patient data could be transferred in real time to the "cloud" where it would be available for immediate viewing, as well as kept for future study. This would give clinicians new ways to "collect, display, aggregate, and analyze neurological performance," Dr. Rudick said at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.
iPad app bested technician performance
The app-based multiple sclerosis performance test (MSPT) was developed by Dr. Rudick and his colleagues to simulate the technician-based one in all aspects and comprises the walking speed test, the manual dexterity test, the low-contrast visual acuity test, and the processing speed test. These approximate the MSPT’s timed 25-foot walk test, the 9-hole peg test, the Sloan low-contrast visual acuity test, and the Symbol Digit Modalities Test.
The industry-sponsored, cross-sectional validation study matched 49 healthy controls with 51 patients according to age, sex, and education. Roughly three-quarters of the study arm had relapsing MS, and a quarter had the progressive form of the disease.
Participants were tested at a single site via each modality, once in the morning and then again in the afternoon. The test/retest results were consistent and correlative, according to Dr. Rudick. "They were highly reliable, whether the technician did it, or the iPad," he said.
The question was whether the two tests were measuring the same thing. Because data for all aspects of each test were comparable, Dr. Rudick concluded that the tests were comparable.
The most important measure was how well the app version separated the two study groups, when compared with the ability of the technician-based test, according to Dr. Rudick. "In virtually every case, except for the visual, the iPad actually does a little bit better than the technician in distinguishing the MS patients from the healthy controls," he said.
For example, in the timed 25-foot walk test administered by the technician, the mean score in the MS group was 7 (P less than .001; standard deviation, 4.28), while the mean score for the walking speed test in the MS group was 7.26 (P less than .001; SD, 4.25). In the healthy controls group, the mean score for the technician-given test was 4.24 (P less than .001). That group’s mean score for the self-given walking speed test was 4.27 (P less than .001; SD, 4.27).
Still need humans
Patient-reported outcomes were also correlative to both forms of the tests. However, in an interview after the presentation, Dr. Rudick said that patient-reported cognitive impairment doesn’t usually correlate with the actual measurements used in neurocognitive testing. "What does seem to correlate with patients reporting cognitive impairment is if they are depressed. Then the depression score matches the patient-reported cognitive impairment better than the actual cognitive test score does," he said.
When Dr. Rudick asked the audience, which included many physician assistants and registered nurses in addition to physicians, whether they would embrace the use of this technology, the majority assented. However, during the discussion following the presentation, Neil Jouvenant, a physician assistant at the University of Nebraska Medical Center in Omaha, said there are some patients for whom this technology would not be appropriate, such as those who walk with difficulty.
In an interview, Mr. Jouvenant said that in addition, "you still need a technician to instruct and encourage patients. If the iPad were to instruct a patient to ‘get up now, strap this to your back, and walk 25 feet,’ they won’t because they don’t really think they can. There is a fine line between someone who can walk a certain distance and someone who can’t." The technician can help in those situations, he said.
More inclusive and comprehensive
Although Dr. Rudick agreed that at least for now, this technology is not appropriate for all patients, the technology does hold promise for those who would have been excluded in the past, such as patients who live in rural areas but would like to participate in clinical trials.
The collection of normative data from healthy adults will also mean that clinical interpretations of MSPT scores will have broader utility in MS patients and groups, and the technology can be adapted to yield additional data such as specific measurements for balance and speed.
Dr. Patricia Coyle, professor of psychiatry and neurology at the State University of New York at Stony Brook, and director of the MS comprehensive care center there, said in an interview that technology such as this has the power to "revolutionize" disease management, particularly if it is collected into a central database accessible to any clinician or researcher.
"There are only so many MS patients, and we don’t have a good idea of their disease activity. They’re not tracked. No one’s trying to pull that data together," she said. But having these data "potentially would mean revolutionizing" the field.
Novartis funded the study on the MSPT app. Dr. Rudick said that he has received consulting fees from Genzyme and Novartis. Dr. Coyle reported she has financial relationships with Biogen Idec, Genentech, and Genzyme, among others.
On Twitter @whitneymcknight
EXPERT ANALYSIS AT THE CMSC/ACTRIMS ANNUAL MEETING
In the weeds
You know you have it somewhere in your head: a short list of stuff you’re just too bad at to even attempt, at least not in public. For some of us, it’s dancing. For others, it’s golf (my own congenital incompetence at golf has saved me countless hours and dollars, not to mention the confusion that ensues when someone leaves their clubs at the club so they can go to the clubhouse for a club). Tragically, my list includes gardening. If you ever hear someone say that I have a “green thumb,” get me on IV antibiotics stat, because that’s a nasty infection!
What’s saddest is how much my gardening ambition outstrips my skill. Last year, for example, everyone in the family agreed that our tomato was among the better ones they had ever eaten a small bite of. Worse yet, I now have a neighbor with a back yard dominated by a professionally installed network of raised beds already producing enough organic microgreens to fill a green minivan. I’m hoping to barter with her once our vegetables come in. Perhaps I’ll offer her this year’s tomato.
All over down under
Can we all just agree to stop trying to disprove conspiracy theories? I mean, has your crazy great-uncle ever said, “You know, I watched the Zapruder film one more time, and actually there really was just a lone gunman.” I don’t think so. Likewise, let’s accept that for the next 100 years, vaccine-hesitant parents are going to insist that the link between vaccines and autism just hasn’t been adequately studied, just like climate change, evolution, and why celebrities give their children weird names.
Now that Sydney Medical School Associate Professor Guy Eslick has published the ultimate meta-analysis of vaccines and autism, I vote that we never, ever spend another nickel researching this topic. Eslick’s team of Aussies aggregated data from five cohort studies and five case-control studies, to include a total of more than1.25 million children, comparing autism rates between vaccinated and unvaccinated children. You already know the results, even if you haven’t read the study, because you know that autism spectrum disorders don’t result from postnatal insults: zero correlation between vaccines and autism.
In the words of the Melbourne Herald Sun, this study should have “settled the debate,” especially since Dr. Eslick has no grants from or ties to vaccine manufacturers. But what about the Trilateral Commission? Agenda 21? The Rothschilds? We only know one thing for sure: What you don’t know can hurt you.
Green gobbling
Did you, too, have that grandmother who told you carrots would give you night vision? I remember gorging on the orange vegetables and then stumbling around the yard in the dark, twisting my ankle on mole tunnels. It’s possible that I was also hoping for laser vision: “A B-minus on my spelling test?! Take that, Mrs. Mulherin!”
A new study out of Chicago, however, suggests that not all kids are as gullible as I was which, I suppose, will cut down on the rates of ankle sprains. According to author Dr. Ayelet Fishbach of the University of Chicago's Booth School of Business, the absolute worst way to get kids to eat any food is to tell them it will make them “healthy,” which includes taller, stronger, smarter, or less constipated. Ironically, the same logic works brilliantly to sell young men overpriced plastic barrels of powdered protein.
Among the 270 3- to 5-year-old children studied, the more adults emphasized the health benefits of a given food, the less of it the kids ate. They apparently subscribed to a “zero sum game” theory of food: The positive health properties of any given food must be subtracted proportionately from its taste. The implication for parents is clear: We must immediately band together to convince children that broccoli will give them cavities and gummy worms improve eyesight. Just don’t forget to stock up on Ace bandages.
The young and the restless
What parent of a preschooler hasn’t occasionally wished there was something you could give them to make them behave? Actually, according to a new report from the Centers for Disease Control and Prevention (CDC), there are around 10,000 young children in the US whose parents have stopped wishing. That’s the estimated number of 2- to 3-year-old children who are being prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD). CDC officials and other child behavior experts suggest that the doctors prescribing these meds be put in time out.
Aside from the little issue that stimulant medications have never been tested for safety and efficacy in young children, there’s the problem of diagnosing ADHD in preschoolers. After all, the definition of ADHD can be boiled down to, “has the attention span of a 3-year-old,” a problem that’s nearly universal among 3-year-olds. I’ll come out and say that I think the docs prescribing these meds to young children deserve a rotten tomato, and that’s the one thing I know how to grow.
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.
You know you have it somewhere in your head: a short list of stuff you’re just too bad at to even attempt, at least not in public. For some of us, it’s dancing. For others, it’s golf (my own congenital incompetence at golf has saved me countless hours and dollars, not to mention the confusion that ensues when someone leaves their clubs at the club so they can go to the clubhouse for a club). Tragically, my list includes gardening. If you ever hear someone say that I have a “green thumb,” get me on IV antibiotics stat, because that’s a nasty infection!
What’s saddest is how much my gardening ambition outstrips my skill. Last year, for example, everyone in the family agreed that our tomato was among the better ones they had ever eaten a small bite of. Worse yet, I now have a neighbor with a back yard dominated by a professionally installed network of raised beds already producing enough organic microgreens to fill a green minivan. I’m hoping to barter with her once our vegetables come in. Perhaps I’ll offer her this year’s tomato.
All over down under
Can we all just agree to stop trying to disprove conspiracy theories? I mean, has your crazy great-uncle ever said, “You know, I watched the Zapruder film one more time, and actually there really was just a lone gunman.” I don’t think so. Likewise, let’s accept that for the next 100 years, vaccine-hesitant parents are going to insist that the link between vaccines and autism just hasn’t been adequately studied, just like climate change, evolution, and why celebrities give their children weird names.
Now that Sydney Medical School Associate Professor Guy Eslick has published the ultimate meta-analysis of vaccines and autism, I vote that we never, ever spend another nickel researching this topic. Eslick’s team of Aussies aggregated data from five cohort studies and five case-control studies, to include a total of more than1.25 million children, comparing autism rates between vaccinated and unvaccinated children. You already know the results, even if you haven’t read the study, because you know that autism spectrum disorders don’t result from postnatal insults: zero correlation between vaccines and autism.
In the words of the Melbourne Herald Sun, this study should have “settled the debate,” especially since Dr. Eslick has no grants from or ties to vaccine manufacturers. But what about the Trilateral Commission? Agenda 21? The Rothschilds? We only know one thing for sure: What you don’t know can hurt you.
Green gobbling
Did you, too, have that grandmother who told you carrots would give you night vision? I remember gorging on the orange vegetables and then stumbling around the yard in the dark, twisting my ankle on mole tunnels. It’s possible that I was also hoping for laser vision: “A B-minus on my spelling test?! Take that, Mrs. Mulherin!”
A new study out of Chicago, however, suggests that not all kids are as gullible as I was which, I suppose, will cut down on the rates of ankle sprains. According to author Dr. Ayelet Fishbach of the University of Chicago's Booth School of Business, the absolute worst way to get kids to eat any food is to tell them it will make them “healthy,” which includes taller, stronger, smarter, or less constipated. Ironically, the same logic works brilliantly to sell young men overpriced plastic barrels of powdered protein.
Among the 270 3- to 5-year-old children studied, the more adults emphasized the health benefits of a given food, the less of it the kids ate. They apparently subscribed to a “zero sum game” theory of food: The positive health properties of any given food must be subtracted proportionately from its taste. The implication for parents is clear: We must immediately band together to convince children that broccoli will give them cavities and gummy worms improve eyesight. Just don’t forget to stock up on Ace bandages.
The young and the restless
What parent of a preschooler hasn’t occasionally wished there was something you could give them to make them behave? Actually, according to a new report from the Centers for Disease Control and Prevention (CDC), there are around 10,000 young children in the US whose parents have stopped wishing. That’s the estimated number of 2- to 3-year-old children who are being prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD). CDC officials and other child behavior experts suggest that the doctors prescribing these meds be put in time out.
Aside from the little issue that stimulant medications have never been tested for safety and efficacy in young children, there’s the problem of diagnosing ADHD in preschoolers. After all, the definition of ADHD can be boiled down to, “has the attention span of a 3-year-old,” a problem that’s nearly universal among 3-year-olds. I’ll come out and say that I think the docs prescribing these meds to young children deserve a rotten tomato, and that’s the one thing I know how to grow.
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.
You know you have it somewhere in your head: a short list of stuff you’re just too bad at to even attempt, at least not in public. For some of us, it’s dancing. For others, it’s golf (my own congenital incompetence at golf has saved me countless hours and dollars, not to mention the confusion that ensues when someone leaves their clubs at the club so they can go to the clubhouse for a club). Tragically, my list includes gardening. If you ever hear someone say that I have a “green thumb,” get me on IV antibiotics stat, because that’s a nasty infection!
What’s saddest is how much my gardening ambition outstrips my skill. Last year, for example, everyone in the family agreed that our tomato was among the better ones they had ever eaten a small bite of. Worse yet, I now have a neighbor with a back yard dominated by a professionally installed network of raised beds already producing enough organic microgreens to fill a green minivan. I’m hoping to barter with her once our vegetables come in. Perhaps I’ll offer her this year’s tomato.
All over down under
Can we all just agree to stop trying to disprove conspiracy theories? I mean, has your crazy great-uncle ever said, “You know, I watched the Zapruder film one more time, and actually there really was just a lone gunman.” I don’t think so. Likewise, let’s accept that for the next 100 years, vaccine-hesitant parents are going to insist that the link between vaccines and autism just hasn’t been adequately studied, just like climate change, evolution, and why celebrities give their children weird names.
Now that Sydney Medical School Associate Professor Guy Eslick has published the ultimate meta-analysis of vaccines and autism, I vote that we never, ever spend another nickel researching this topic. Eslick’s team of Aussies aggregated data from five cohort studies and five case-control studies, to include a total of more than1.25 million children, comparing autism rates between vaccinated and unvaccinated children. You already know the results, even if you haven’t read the study, because you know that autism spectrum disorders don’t result from postnatal insults: zero correlation between vaccines and autism.
In the words of the Melbourne Herald Sun, this study should have “settled the debate,” especially since Dr. Eslick has no grants from or ties to vaccine manufacturers. But what about the Trilateral Commission? Agenda 21? The Rothschilds? We only know one thing for sure: What you don’t know can hurt you.
Green gobbling
Did you, too, have that grandmother who told you carrots would give you night vision? I remember gorging on the orange vegetables and then stumbling around the yard in the dark, twisting my ankle on mole tunnels. It’s possible that I was also hoping for laser vision: “A B-minus on my spelling test?! Take that, Mrs. Mulherin!”
A new study out of Chicago, however, suggests that not all kids are as gullible as I was which, I suppose, will cut down on the rates of ankle sprains. According to author Dr. Ayelet Fishbach of the University of Chicago's Booth School of Business, the absolute worst way to get kids to eat any food is to tell them it will make them “healthy,” which includes taller, stronger, smarter, or less constipated. Ironically, the same logic works brilliantly to sell young men overpriced plastic barrels of powdered protein.
Among the 270 3- to 5-year-old children studied, the more adults emphasized the health benefits of a given food, the less of it the kids ate. They apparently subscribed to a “zero sum game” theory of food: The positive health properties of any given food must be subtracted proportionately from its taste. The implication for parents is clear: We must immediately band together to convince children that broccoli will give them cavities and gummy worms improve eyesight. Just don’t forget to stock up on Ace bandages.
The young and the restless
What parent of a preschooler hasn’t occasionally wished there was something you could give them to make them behave? Actually, according to a new report from the Centers for Disease Control and Prevention (CDC), there are around 10,000 young children in the US whose parents have stopped wishing. That’s the estimated number of 2- to 3-year-old children who are being prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD). CDC officials and other child behavior experts suggest that the doctors prescribing these meds be put in time out.
Aside from the little issue that stimulant medications have never been tested for safety and efficacy in young children, there’s the problem of diagnosing ADHD in preschoolers. After all, the definition of ADHD can be boiled down to, “has the attention span of a 3-year-old,” a problem that’s nearly universal among 3-year-olds. I’ll come out and say that I think the docs prescribing these meds to young children deserve a rotten tomato, and that’s the one thing I know how to grow.
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.
BPD and the broader landscape of neuropsychiatric illness
Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.
In recent papers1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.
There also is electrophysiological (including evoked potential) evidence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.
Particularly when BPD is diagnosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humiliation or cruelty, or head injury, what else is there, if not genetically predisposed alterations in the frontolimbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar disorders, especially bipolar II disorder, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?
Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York
----------------------------------------------------------------------------------------------------------
As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual processing disorders have gone undiagnosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.
An example: For 12 years, I have been treating a patient who has auditory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frustrated her parents, who, in their frustration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her problem was, I changed my technique.
When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.
Over time, she has improved and is more functional. After several years of disability, she returned to work, although she still struggles interpersonally.
With many of such patients, I have had to modify traditional techniques of psychotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychological development, the more I can help my patients.
Howard Wishnie, MD
Cambridge, Massachusetts
Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concurrence with my thinking about BPD. It would have been appropriate to include discussion of neurophysiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.
Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
1. Stone MH. The spectrum of borderline personality disorder: a neurophysiological view. Neuropsychiatric Electrophysiology. In press.
2. Stone MH. A new look at borderline personality disorder and related disorders: hyper-activity in the limbic system and lower centers. Psychodyn Psychiatry. 2013;41(3):437-466.
Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.
In recent papers1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.
There also is electrophysiological (including evoked potential) evidence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.
Particularly when BPD is diagnosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humiliation or cruelty, or head injury, what else is there, if not genetically predisposed alterations in the frontolimbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar disorders, especially bipolar II disorder, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?
Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York
----------------------------------------------------------------------------------------------------------
As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual processing disorders have gone undiagnosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.
An example: For 12 years, I have been treating a patient who has auditory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frustrated her parents, who, in their frustration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her problem was, I changed my technique.
When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.
Over time, she has improved and is more functional. After several years of disability, she returned to work, although she still struggles interpersonally.
With many of such patients, I have had to modify traditional techniques of psychotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychological development, the more I can help my patients.
Howard Wishnie, MD
Cambridge, Massachusetts
Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concurrence with my thinking about BPD. It would have been appropriate to include discussion of neurophysiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.
Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
Dr. Henry A. Nasrallah’s recent Editorial on borderline personality disorder (BPD) (Current Psychiatry, From the Editor, April 2014, p. 19-20, 32 [http://bit.ly/1e8yAwE]) describes BPD as a heritable brain disease. I have been arguing this point for many years, often finding support from my colleague, Hagop Akiskal, MD, and opposition from my psychoanalytic colleagues.
In recent papers1,2 on brain changes in BPD and the connection between BPD and bipolar disorders, I wrote that there often is a heritable aspect to the condition. There are exceptions to such heritability, as in the setting of a horrific environment (eg, father-daughter incest, parental brutality), where the same symptoms seen in BPD develop primarily from post-natal influences. Dr. Akiskal and I were discussing this a long time back, before MRI. Now I feel vindicated, with generous help from someone of Dr. Nasrallah’s prestige and influence.
There also is electrophysiological (including evoked potential) evidence for neural pathology in BPD, as well as data derived from single photon emission CT scanning. The burgeoning literature on MRI and functional MRI studies of BPD is in good agreement about the brain changes most relevant to BPD and that are found with regularity in this condition.
Particularly when BPD is diagnosed in people (usually women) who do not have a history of neglect, sexual molestation, parental humiliation or cruelty, or head injury, what else is there, if not genetically predisposed alterations in the frontolimbic structures (and maybe the periaqueductal gray) that underlie the so-called “personality disorder,” and, not surprisingly, bipolar disorders, especially bipolar II disorder, which often is the other side of the coin as BPD, and amenable to the same combination of medication and psychotherapy?
Michael H. Stone, MD
Professor of Clinical Psychiatry Columbia College of Physicians and Surgeons
New York, New York
----------------------------------------------------------------------------------------------------------
As a psychiatrist/psychoanalyst who works with BPD patients, I read Dr. Nasrallah’s April 2014 Editorial with great interest and enthusiasm. Over the past 10 years, I have been impressed with the number of patients with BPD whose nonverbal learning disorders and auditory and visual processing disorders have gone undiagnosed. Recently, I lectured on this topic to the staff of a school for children with a range of neuropsychiatric disorders; the staff found my observations about such comorbidity consistent with their observations. These dysfunctions, or neurological variations—unknown to the parent and the child—interfere with early object-relation formation, attachment capacity, and learning. Neuropsychiatry and psychological development are, in fact, part of the same system.
An example: For 12 years, I have been treating a patient who has auditory processing and working memory problems, meaning that she could not process the connections among different ideas. This difficulty frustrated her parents, who, in their frustration, criticized her for not paying attention. She was labeled “bad” and assumed the role of the “black sheep” in her family. Although she was intelligent, she was often wrong in her judgments and choices, and easily frustrated. In therapy, as I realized what part of her problem was, I changed my technique.
When my patient asked me to tell her the sequence of understandings that we had just put together, I invited her to take my pad and write down her sense of it. As she described each part of that sequence to me, we would discuss it and I would remind her of lost fragments. Gradually, she learned to put ideas together; however, I also watched her struggle to hold these ideas in working memory and to use them.
Over time, she has improved and is more functional. After several years of disability, she returned to work, although she still struggles interpersonally.
With many of such patients, I have had to modify traditional techniques of psychotherapy. I am fascinated by, and enjoy, such intensive psychotherapy. I am also amazed to see the impact of previously unknown neuropathologic variations on development. The more I learn about the impact of neuropsychiatry on psychological development, the more I can help my patients.
Howard Wishnie, MD
Cambridge, Massachusetts
Dr. Nasrallah responds
I appreciate Dr. Stone’s kind words and concurrence with my thinking about BPD. It would have been appropriate to include discussion of neurophysiological findings in my Editorial, but I opted to use my limited space to focus on structural and functional neuroimaging and genetics.
Henry A. Nasrallah, MD
Professor and Chairman Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
1. Stone MH. The spectrum of borderline personality disorder: a neurophysiological view. Neuropsychiatric Electrophysiology. In press.
2. Stone MH. A new look at borderline personality disorder and related disorders: hyper-activity in the limbic system and lower centers. Psychodyn Psychiatry. 2013;41(3):437-466.
1. Stone MH. The spectrum of borderline personality disorder: a neurophysiological view. Neuropsychiatric Electrophysiology. In press.
2. Stone MH. A new look at borderline personality disorder and related disorders: hyper-activity in the limbic system and lower centers. Psychodyn Psychiatry. 2013;41(3):437-466.
A Conversation With AAOS President Frederick M. Azar, MD
For the past 8 years, I have interviewed the president of the American Academy of Orthopaedic Surgeons (AAOS) to better understand the role the Academy plays in our professional lives in general and the contributions of the AAOS president in particular.
At the 2014 AAOS Annual Meeting this past March in New Orleans, Frederick M. Azar, MD, assumed leadership of the AAOS as its 82nd president. He brings a wide range of orthopedic experience to this role. He has been an Academy volunteer for the last 20 years, and is Chief of Staff at the Campbell Clinic as well as Professor of Orthopedic Surgery and Director of the Sports Medicine Fellowship at the University of Tennessee-Campbell Clinic. He is team physician for the NBA (National Basketball Association) Memphis Grizzlies (see Dr. Azar’s article in this issue of AJO, pages 267-271) and team physician for the University of Memphis and Christian Brothers University sports teams.
This year the Board of Directors of the Academy completed a revision of the AAOS Strategic Plan, last updated in 2010, under the leadership of David Teuscher, MD. The plan, dubbed “Vision 20/20,” includes the following essential elements:
◾ AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.
◾ AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.
◾ Core Values: Excellence, Professionalism, Leadership, Collegiality, Lifelong Learning
◾ Strategic Domains: Advocacy, Education, Membership, Organizational Excellence, Quality and Patient Value
Fred explained that a fundamental aspect of this revised Strategic Plan is that the AAOS takes ownership of all aspects of musculoskeletal tear, not simply surgical management. (For further reading, please visit: www.aaos.org/about/strategicplan.asp.)
Dr. Azar views his role as president of the AAOS as a temporary steward furthering the goals of the organization and not as a proponent of a particular personal agenda. To that end, Fred hopes to focus on 2 areas during his tenure as captain of the orthopedic ship of state: education and communication.
Paradigm shifts are occurring in health care with the passage of the Affordable Care Act, access to medical information via the Internet, and changes in practice management with the near-universal implementation of electronic medical records. In an effort to address the educational needs of its members, the AAOS will expand its electronic media platform and develop mobile apps, ebooks, webinars, and webcasts. In addition, the new AAOS headquarters in Rosemont, Illinois, will house a state-of-the-art Orthopaedic Learning Center. These improvements in education will contribute to the Academy’s core value of lifelong learning.
Regarding communication, Dr. Azar believes that it is extremely important that we, orthopedic surgeons, share with our patients just how much orthopedic care contributes to their quality of life, thereby showcasing the great value orthopedic surgeons bring to millions of patients. Finally, communication with regulators and policymakers in Washington, DC, is equally important as is membership support
for the Orthopaedic Political Action Committee.
We are indeed fortunate to have someone of Dr. Azar’s caliber lead our organization. His extensive experience as an administrator, Academy volunteer, educator, and clinician makes him ideally suited to lead the AAOS during these
challenging times in health care. ◾
For the past 8 years, I have interviewed the president of the American Academy of Orthopaedic Surgeons (AAOS) to better understand the role the Academy plays in our professional lives in general and the contributions of the AAOS president in particular.
At the 2014 AAOS Annual Meeting this past March in New Orleans, Frederick M. Azar, MD, assumed leadership of the AAOS as its 82nd president. He brings a wide range of orthopedic experience to this role. He has been an Academy volunteer for the last 20 years, and is Chief of Staff at the Campbell Clinic as well as Professor of Orthopedic Surgery and Director of the Sports Medicine Fellowship at the University of Tennessee-Campbell Clinic. He is team physician for the NBA (National Basketball Association) Memphis Grizzlies (see Dr. Azar’s article in this issue of AJO, pages 267-271) and team physician for the University of Memphis and Christian Brothers University sports teams.
This year the Board of Directors of the Academy completed a revision of the AAOS Strategic Plan, last updated in 2010, under the leadership of David Teuscher, MD. The plan, dubbed “Vision 20/20,” includes the following essential elements:
◾ AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.
◾ AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.
◾ Core Values: Excellence, Professionalism, Leadership, Collegiality, Lifelong Learning
◾ Strategic Domains: Advocacy, Education, Membership, Organizational Excellence, Quality and Patient Value
Fred explained that a fundamental aspect of this revised Strategic Plan is that the AAOS takes ownership of all aspects of musculoskeletal tear, not simply surgical management. (For further reading, please visit: www.aaos.org/about/strategicplan.asp.)
Dr. Azar views his role as president of the AAOS as a temporary steward furthering the goals of the organization and not as a proponent of a particular personal agenda. To that end, Fred hopes to focus on 2 areas during his tenure as captain of the orthopedic ship of state: education and communication.
Paradigm shifts are occurring in health care with the passage of the Affordable Care Act, access to medical information via the Internet, and changes in practice management with the near-universal implementation of electronic medical records. In an effort to address the educational needs of its members, the AAOS will expand its electronic media platform and develop mobile apps, ebooks, webinars, and webcasts. In addition, the new AAOS headquarters in Rosemont, Illinois, will house a state-of-the-art Orthopaedic Learning Center. These improvements in education will contribute to the Academy’s core value of lifelong learning.
Regarding communication, Dr. Azar believes that it is extremely important that we, orthopedic surgeons, share with our patients just how much orthopedic care contributes to their quality of life, thereby showcasing the great value orthopedic surgeons bring to millions of patients. Finally, communication with regulators and policymakers in Washington, DC, is equally important as is membership support
for the Orthopaedic Political Action Committee.
We are indeed fortunate to have someone of Dr. Azar’s caliber lead our organization. His extensive experience as an administrator, Academy volunteer, educator, and clinician makes him ideally suited to lead the AAOS during these
challenging times in health care. ◾
For the past 8 years, I have interviewed the president of the American Academy of Orthopaedic Surgeons (AAOS) to better understand the role the Academy plays in our professional lives in general and the contributions of the AAOS president in particular.
At the 2014 AAOS Annual Meeting this past March in New Orleans, Frederick M. Azar, MD, assumed leadership of the AAOS as its 82nd president. He brings a wide range of orthopedic experience to this role. He has been an Academy volunteer for the last 20 years, and is Chief of Staff at the Campbell Clinic as well as Professor of Orthopedic Surgery and Director of the Sports Medicine Fellowship at the University of Tennessee-Campbell Clinic. He is team physician for the NBA (National Basketball Association) Memphis Grizzlies (see Dr. Azar’s article in this issue of AJO, pages 267-271) and team physician for the University of Memphis and Christian Brothers University sports teams.
This year the Board of Directors of the Academy completed a revision of the AAOS Strategic Plan, last updated in 2010, under the leadership of David Teuscher, MD. The plan, dubbed “Vision 20/20,” includes the following essential elements:
◾ AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.
◾ AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.
◾ Core Values: Excellence, Professionalism, Leadership, Collegiality, Lifelong Learning
◾ Strategic Domains: Advocacy, Education, Membership, Organizational Excellence, Quality and Patient Value
Fred explained that a fundamental aspect of this revised Strategic Plan is that the AAOS takes ownership of all aspects of musculoskeletal tear, not simply surgical management. (For further reading, please visit: www.aaos.org/about/strategicplan.asp.)
Dr. Azar views his role as president of the AAOS as a temporary steward furthering the goals of the organization and not as a proponent of a particular personal agenda. To that end, Fred hopes to focus on 2 areas during his tenure as captain of the orthopedic ship of state: education and communication.
Paradigm shifts are occurring in health care with the passage of the Affordable Care Act, access to medical information via the Internet, and changes in practice management with the near-universal implementation of electronic medical records. In an effort to address the educational needs of its members, the AAOS will expand its electronic media platform and develop mobile apps, ebooks, webinars, and webcasts. In addition, the new AAOS headquarters in Rosemont, Illinois, will house a state-of-the-art Orthopaedic Learning Center. These improvements in education will contribute to the Academy’s core value of lifelong learning.
Regarding communication, Dr. Azar believes that it is extremely important that we, orthopedic surgeons, share with our patients just how much orthopedic care contributes to their quality of life, thereby showcasing the great value orthopedic surgeons bring to millions of patients. Finally, communication with regulators and policymakers in Washington, DC, is equally important as is membership support
for the Orthopaedic Political Action Committee.
We are indeed fortunate to have someone of Dr. Azar’s caliber lead our organization. His extensive experience as an administrator, Academy volunteer, educator, and clinician makes him ideally suited to lead the AAOS during these
challenging times in health care. ◾
Low-dose aspirin and preeclampsia prevention: Ready for prime time, but as a “re-run” or as a “new series”?
In November 2013, The American College of Obstetricians and Gynecologists (ACOG) published the results of its Task Force on Hypertension in Pregnancy.1 The Task Force aimed to help clinicians become familiar with the state of research in hypertension during pregnancy as well as to assist us in standardizing management approaches to such patients.
The Task Force reported that, worldwide, hypertensive disorders complicate approximately 10% of pregnancies. In addition, in the United States, the past 20 years have brought a 25% increase in the incidence of preeclampsia. According to past ACOG President James N. Martin, Jr, MD, in the last 10 years, the pathophysiology of preeclampsia has become better understood, but the etiology remains unclear and evidence that has emerged to guide therapy has not translated into clinical practice.1
Related articles:
The latest guidance from ACOG on hypertension in pregnancy. Jaimey E. Pauli, MD (Audiocast, January 2014)
Update on Obstetrics. Jaimey E. Pauli, MD, and John T. Repke, MD (January 2014)
The Task Force document contained 60 recommendations for the prevention, prediction, and management of hypertensive disorders of pregnancy, including preeclampsia, gestational hypertension, chronic hypertension, HELLP syndrome, and preeclampsia superimposed on an underlying hypertensive disorder (see box below). One recommendation was that women at high risk for preeclampsia, particularly those with a history of preeclampsia that required delivery before 34 weeks, could possibly benefit from taking aspirin (60–81 mg) daily starting at the end of the first trimester. They further noted that this benefit could include prevention of recurrent severe preeclampsia, or at least a reduction in recurrence risk.
The ACOG Task Force made its recommendation based on results of a meta-analysis of low-dose aspirin trials, involving more than 30,000 patients,2 suggesting a small decrease in the risk of preeclampsia and associated morbidity. More precise risk reduction estimates were difficult to make due to the heterogeneity of the studies reviewed. And the Task Force further stated that this (low-dose aspirin) approach had no demonstrable acute adverse fetal effects, although long-term adverse effects could not be entirely excluded based on the current data.
Unfortunately, according to the ACOG document, the strength of the evidence supporting their recommendation was “moderate” and the strength of the recommendation was “qualified” so, not exactly a resounding endorsement of this approach, but a recommendation nonetheless.
OBSTETRIC PRACTICE CHANGERS 2014
Hypertension and pregnancy and preventing the first cesarean delivery
John T. Repke, MD, author of this Guest Editorial, recently sat down with Errol R. Norwitz, MD, PhD, fellow OBG Management Board of Editors Member and author of this month’s "Update on Operative Vaginal Delivery." Their discussion focused on individual takeaways from ACOG’s Hypertension in Pregnancy guidelines and the recent joint ACOG−Society of Maternal-Fetal Medicine report on emerging clinical and scientific advances in safe prevention of the primary cesarean delivery.
From their conversation:
Dr. Repke: About 60 recommendations came out of ACOG’s Hypertension in Pregnancy document; only six had high-quality supporting evidence, and I think most practitioners already did them. Many really were based on either moderate- or low-quality evidence, with qualified recommendations. I think this has led to confusion.
Dr. Norwitz, how do you answer when a clinician asks you, “Is this gestational hypertension or is this preeclampsia?”
Click here to access the audiocast with full transcript.
Data suggest aspirin for high-risk women could be reasonable
A recent study by Henderson and colleagues presented a systematic review for the US Preventive Services Task Force (USPSTF) on the potential for low-dose aspirin to prevent morbidity and mortality from preeclampsia.3 The design was a meta-analysis of 28 studies: two large, multisite, randomized clinical trials (RCTs); 13 smaller RCTs of high-risk women, of which eight were deemed “good quality”; and six RCTs and two observational studies of average-risk women, of which seven were deemed to be good quality.
The results essentially supported the notion that low-dose aspirin had a beneficial effect with respect to prevention of preeclampsia and perinatal morbidity in women at high risk for preeclampsia. Additionally, no harmful effects were identified, although the authors acknowledged potential rare or long-term harm could not be excluded.
Questions remain
While somewhat gratifying, the results of the USPSTF systematic review still leave many questions. First, the dose of aspirin used in the studies analyzed ranged from 50 mg/d to 150 mg/d. In the United States, “low-dose” aspirin is usually prescribed at 81 mg/d, so the applicability of this review’s findings to US clinical practice is not exact. Second, the authors acknowledged that the putative positive effects observed could be secondary to so-called “small study effects,” and that when only the larger studies were analyzed the effects were less impressive.
Related article: A stepwise approach to managing eclampsia and other hypertensive emergencies. Baha M. Sibai (October 2013)
In my opinion, both the USPSTF study and the recommendations from the ACOG Task Force provide some reassurance for clinicians that the use of daily, low-dose aspirin by women at high risk for preeclampsia probably does afford some benefit, and seems to be a safe approach—as we have known from the initial Maternal-Fetal Medicine Units (MFMU) trial published in 1993 on low-risk women4 and the follow-up MFMU study on high-risk women.5
The need for additional studies is clear, however. The idea that preeclampsia is the same in every patient would seem to make no more sense than thinking all cancer is the same, with the same risk factors, the same epidemiology and pathophysiology, and the same response to similar treatments. Fundamentally, we need to further explore the different pathways through which preeclampsia develops in women and then apply the strategy best suited to treating (or preventing) their form of the disease—a personalized medicine approach.
In the meantime, most patients who have delivered at 34 weeks or less because of preeclampsia and who are contemplating another pregnancy are really not interested in hearing us tell them that we cannot do anything to prevent recurrent preeclampsia because we are awaiting further studies. At least the ACOG recommendations and the results of the USPSTF’s systematic review provide us with a reasonable, although perhaps not yet optimal, therapeutic option.
Related article: 10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia. Baha M. Sibai (November 2011)
The bottom line
In my own practice, I discuss the option of initiating low-dose aspirin (81 mg/d) as early as 12 weeks’ gestation for patients who had either prior early-onset preeclampsia requiring delivery before 34 weeks’ gestation or preeclampsia during more than one pregnancy.
QUICK POLL
Do you offer low-dose aspirin for preeclampsia prevention?
When faced with a patient with prior preeclampsia in more than one pregnancy or with preeclampsia that resulted in delivery prior to 34 weeks, do you offer low-dose aspirin as an option for preventing preeclampsia?
Visit the Quick Poll on the right column of the OBGManagement.com home page to register your answer and see how your colleagues voted.
WE WANT TO HEAR FROM YOU!
Share your thoughts on this article. Send your Letter to the Editor to: [email protected]
- ACOG Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.
- Duley L, Henderson-Smart DJ, Heher S, King JF. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database Syst Rev. 2007;(2):CD004659.
- Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force [published online ahead of print April 8, 2014]. Ann Intern Med. doi:10.7326/M13-2844.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1993;329(17):1213–1218.
- Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338(11):701–705.
John T. Repke, MD, is University Professor and Chairman of Obstetrics and Gynecology at Penn State University College of Medicine. He is also Obstetrician-Gynecologist-in-Chief at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Dr. Repke serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
John T. Repke, MD, is University Professor and Chairman of Obstetrics and Gynecology at Penn State University College of Medicine. He is also Obstetrician-Gynecologist-in-Chief at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Dr. Repke serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
John T. Repke, MD, is University Professor and Chairman of Obstetrics and Gynecology at Penn State University College of Medicine. He is also Obstetrician-Gynecologist-in-Chief at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Dr. Repke serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
In November 2013, The American College of Obstetricians and Gynecologists (ACOG) published the results of its Task Force on Hypertension in Pregnancy.1 The Task Force aimed to help clinicians become familiar with the state of research in hypertension during pregnancy as well as to assist us in standardizing management approaches to such patients.
The Task Force reported that, worldwide, hypertensive disorders complicate approximately 10% of pregnancies. In addition, in the United States, the past 20 years have brought a 25% increase in the incidence of preeclampsia. According to past ACOG President James N. Martin, Jr, MD, in the last 10 years, the pathophysiology of preeclampsia has become better understood, but the etiology remains unclear and evidence that has emerged to guide therapy has not translated into clinical practice.1
Related articles:
The latest guidance from ACOG on hypertension in pregnancy. Jaimey E. Pauli, MD (Audiocast, January 2014)
Update on Obstetrics. Jaimey E. Pauli, MD, and John T. Repke, MD (January 2014)
The Task Force document contained 60 recommendations for the prevention, prediction, and management of hypertensive disorders of pregnancy, including preeclampsia, gestational hypertension, chronic hypertension, HELLP syndrome, and preeclampsia superimposed on an underlying hypertensive disorder (see box below). One recommendation was that women at high risk for preeclampsia, particularly those with a history of preeclampsia that required delivery before 34 weeks, could possibly benefit from taking aspirin (60–81 mg) daily starting at the end of the first trimester. They further noted that this benefit could include prevention of recurrent severe preeclampsia, or at least a reduction in recurrence risk.
The ACOG Task Force made its recommendation based on results of a meta-analysis of low-dose aspirin trials, involving more than 30,000 patients,2 suggesting a small decrease in the risk of preeclampsia and associated morbidity. More precise risk reduction estimates were difficult to make due to the heterogeneity of the studies reviewed. And the Task Force further stated that this (low-dose aspirin) approach had no demonstrable acute adverse fetal effects, although long-term adverse effects could not be entirely excluded based on the current data.
Unfortunately, according to the ACOG document, the strength of the evidence supporting their recommendation was “moderate” and the strength of the recommendation was “qualified” so, not exactly a resounding endorsement of this approach, but a recommendation nonetheless.
OBSTETRIC PRACTICE CHANGERS 2014
Hypertension and pregnancy and preventing the first cesarean delivery
John T. Repke, MD, author of this Guest Editorial, recently sat down with Errol R. Norwitz, MD, PhD, fellow OBG Management Board of Editors Member and author of this month’s "Update on Operative Vaginal Delivery." Their discussion focused on individual takeaways from ACOG’s Hypertension in Pregnancy guidelines and the recent joint ACOG−Society of Maternal-Fetal Medicine report on emerging clinical and scientific advances in safe prevention of the primary cesarean delivery.
From their conversation:
Dr. Repke: About 60 recommendations came out of ACOG’s Hypertension in Pregnancy document; only six had high-quality supporting evidence, and I think most practitioners already did them. Many really were based on either moderate- or low-quality evidence, with qualified recommendations. I think this has led to confusion.
Dr. Norwitz, how do you answer when a clinician asks you, “Is this gestational hypertension or is this preeclampsia?”
Click here to access the audiocast with full transcript.
Data suggest aspirin for high-risk women could be reasonable
A recent study by Henderson and colleagues presented a systematic review for the US Preventive Services Task Force (USPSTF) on the potential for low-dose aspirin to prevent morbidity and mortality from preeclampsia.3 The design was a meta-analysis of 28 studies: two large, multisite, randomized clinical trials (RCTs); 13 smaller RCTs of high-risk women, of which eight were deemed “good quality”; and six RCTs and two observational studies of average-risk women, of which seven were deemed to be good quality.
The results essentially supported the notion that low-dose aspirin had a beneficial effect with respect to prevention of preeclampsia and perinatal morbidity in women at high risk for preeclampsia. Additionally, no harmful effects were identified, although the authors acknowledged potential rare or long-term harm could not be excluded.
Questions remain
While somewhat gratifying, the results of the USPSTF systematic review still leave many questions. First, the dose of aspirin used in the studies analyzed ranged from 50 mg/d to 150 mg/d. In the United States, “low-dose” aspirin is usually prescribed at 81 mg/d, so the applicability of this review’s findings to US clinical practice is not exact. Second, the authors acknowledged that the putative positive effects observed could be secondary to so-called “small study effects,” and that when only the larger studies were analyzed the effects were less impressive.
Related article: A stepwise approach to managing eclampsia and other hypertensive emergencies. Baha M. Sibai (October 2013)
In my opinion, both the USPSTF study and the recommendations from the ACOG Task Force provide some reassurance for clinicians that the use of daily, low-dose aspirin by women at high risk for preeclampsia probably does afford some benefit, and seems to be a safe approach—as we have known from the initial Maternal-Fetal Medicine Units (MFMU) trial published in 1993 on low-risk women4 and the follow-up MFMU study on high-risk women.5
The need for additional studies is clear, however. The idea that preeclampsia is the same in every patient would seem to make no more sense than thinking all cancer is the same, with the same risk factors, the same epidemiology and pathophysiology, and the same response to similar treatments. Fundamentally, we need to further explore the different pathways through which preeclampsia develops in women and then apply the strategy best suited to treating (or preventing) their form of the disease—a personalized medicine approach.
In the meantime, most patients who have delivered at 34 weeks or less because of preeclampsia and who are contemplating another pregnancy are really not interested in hearing us tell them that we cannot do anything to prevent recurrent preeclampsia because we are awaiting further studies. At least the ACOG recommendations and the results of the USPSTF’s systematic review provide us with a reasonable, although perhaps not yet optimal, therapeutic option.
Related article: 10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia. Baha M. Sibai (November 2011)
The bottom line
In my own practice, I discuss the option of initiating low-dose aspirin (81 mg/d) as early as 12 weeks’ gestation for patients who had either prior early-onset preeclampsia requiring delivery before 34 weeks’ gestation or preeclampsia during more than one pregnancy.
QUICK POLL
Do you offer low-dose aspirin for preeclampsia prevention?
When faced with a patient with prior preeclampsia in more than one pregnancy or with preeclampsia that resulted in delivery prior to 34 weeks, do you offer low-dose aspirin as an option for preventing preeclampsia?
Visit the Quick Poll on the right column of the OBGManagement.com home page to register your answer and see how your colleagues voted.
WE WANT TO HEAR FROM YOU!
Share your thoughts on this article. Send your Letter to the Editor to: [email protected]
In November 2013, The American College of Obstetricians and Gynecologists (ACOG) published the results of its Task Force on Hypertension in Pregnancy.1 The Task Force aimed to help clinicians become familiar with the state of research in hypertension during pregnancy as well as to assist us in standardizing management approaches to such patients.
The Task Force reported that, worldwide, hypertensive disorders complicate approximately 10% of pregnancies. In addition, in the United States, the past 20 years have brought a 25% increase in the incidence of preeclampsia. According to past ACOG President James N. Martin, Jr, MD, in the last 10 years, the pathophysiology of preeclampsia has become better understood, but the etiology remains unclear and evidence that has emerged to guide therapy has not translated into clinical practice.1
Related articles:
The latest guidance from ACOG on hypertension in pregnancy. Jaimey E. Pauli, MD (Audiocast, January 2014)
Update on Obstetrics. Jaimey E. Pauli, MD, and John T. Repke, MD (January 2014)
The Task Force document contained 60 recommendations for the prevention, prediction, and management of hypertensive disorders of pregnancy, including preeclampsia, gestational hypertension, chronic hypertension, HELLP syndrome, and preeclampsia superimposed on an underlying hypertensive disorder (see box below). One recommendation was that women at high risk for preeclampsia, particularly those with a history of preeclampsia that required delivery before 34 weeks, could possibly benefit from taking aspirin (60–81 mg) daily starting at the end of the first trimester. They further noted that this benefit could include prevention of recurrent severe preeclampsia, or at least a reduction in recurrence risk.
The ACOG Task Force made its recommendation based on results of a meta-analysis of low-dose aspirin trials, involving more than 30,000 patients,2 suggesting a small decrease in the risk of preeclampsia and associated morbidity. More precise risk reduction estimates were difficult to make due to the heterogeneity of the studies reviewed. And the Task Force further stated that this (low-dose aspirin) approach had no demonstrable acute adverse fetal effects, although long-term adverse effects could not be entirely excluded based on the current data.
Unfortunately, according to the ACOG document, the strength of the evidence supporting their recommendation was “moderate” and the strength of the recommendation was “qualified” so, not exactly a resounding endorsement of this approach, but a recommendation nonetheless.
OBSTETRIC PRACTICE CHANGERS 2014
Hypertension and pregnancy and preventing the first cesarean delivery
John T. Repke, MD, author of this Guest Editorial, recently sat down with Errol R. Norwitz, MD, PhD, fellow OBG Management Board of Editors Member and author of this month’s "Update on Operative Vaginal Delivery." Their discussion focused on individual takeaways from ACOG’s Hypertension in Pregnancy guidelines and the recent joint ACOG−Society of Maternal-Fetal Medicine report on emerging clinical and scientific advances in safe prevention of the primary cesarean delivery.
From their conversation:
Dr. Repke: About 60 recommendations came out of ACOG’s Hypertension in Pregnancy document; only six had high-quality supporting evidence, and I think most practitioners already did them. Many really were based on either moderate- or low-quality evidence, with qualified recommendations. I think this has led to confusion.
Dr. Norwitz, how do you answer when a clinician asks you, “Is this gestational hypertension or is this preeclampsia?”
Click here to access the audiocast with full transcript.
Data suggest aspirin for high-risk women could be reasonable
A recent study by Henderson and colleagues presented a systematic review for the US Preventive Services Task Force (USPSTF) on the potential for low-dose aspirin to prevent morbidity and mortality from preeclampsia.3 The design was a meta-analysis of 28 studies: two large, multisite, randomized clinical trials (RCTs); 13 smaller RCTs of high-risk women, of which eight were deemed “good quality”; and six RCTs and two observational studies of average-risk women, of which seven were deemed to be good quality.
The results essentially supported the notion that low-dose aspirin had a beneficial effect with respect to prevention of preeclampsia and perinatal morbidity in women at high risk for preeclampsia. Additionally, no harmful effects were identified, although the authors acknowledged potential rare or long-term harm could not be excluded.
Questions remain
While somewhat gratifying, the results of the USPSTF systematic review still leave many questions. First, the dose of aspirin used in the studies analyzed ranged from 50 mg/d to 150 mg/d. In the United States, “low-dose” aspirin is usually prescribed at 81 mg/d, so the applicability of this review’s findings to US clinical practice is not exact. Second, the authors acknowledged that the putative positive effects observed could be secondary to so-called “small study effects,” and that when only the larger studies were analyzed the effects were less impressive.
Related article: A stepwise approach to managing eclampsia and other hypertensive emergencies. Baha M. Sibai (October 2013)
In my opinion, both the USPSTF study and the recommendations from the ACOG Task Force provide some reassurance for clinicians that the use of daily, low-dose aspirin by women at high risk for preeclampsia probably does afford some benefit, and seems to be a safe approach—as we have known from the initial Maternal-Fetal Medicine Units (MFMU) trial published in 1993 on low-risk women4 and the follow-up MFMU study on high-risk women.5
The need for additional studies is clear, however. The idea that preeclampsia is the same in every patient would seem to make no more sense than thinking all cancer is the same, with the same risk factors, the same epidemiology and pathophysiology, and the same response to similar treatments. Fundamentally, we need to further explore the different pathways through which preeclampsia develops in women and then apply the strategy best suited to treating (or preventing) their form of the disease—a personalized medicine approach.
In the meantime, most patients who have delivered at 34 weeks or less because of preeclampsia and who are contemplating another pregnancy are really not interested in hearing us tell them that we cannot do anything to prevent recurrent preeclampsia because we are awaiting further studies. At least the ACOG recommendations and the results of the USPSTF’s systematic review provide us with a reasonable, although perhaps not yet optimal, therapeutic option.
Related article: 10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia. Baha M. Sibai (November 2011)
The bottom line
In my own practice, I discuss the option of initiating low-dose aspirin (81 mg/d) as early as 12 weeks’ gestation for patients who had either prior early-onset preeclampsia requiring delivery before 34 weeks’ gestation or preeclampsia during more than one pregnancy.
QUICK POLL
Do you offer low-dose aspirin for preeclampsia prevention?
When faced with a patient with prior preeclampsia in more than one pregnancy or with preeclampsia that resulted in delivery prior to 34 weeks, do you offer low-dose aspirin as an option for preventing preeclampsia?
Visit the Quick Poll on the right column of the OBGManagement.com home page to register your answer and see how your colleagues voted.
WE WANT TO HEAR FROM YOU!
Share your thoughts on this article. Send your Letter to the Editor to: [email protected]
- ACOG Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.
- Duley L, Henderson-Smart DJ, Heher S, King JF. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database Syst Rev. 2007;(2):CD004659.
- Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force [published online ahead of print April 8, 2014]. Ann Intern Med. doi:10.7326/M13-2844.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1993;329(17):1213–1218.
- Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338(11):701–705.
- ACOG Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.
- Duley L, Henderson-Smart DJ, Heher S, King JF. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database Syst Rev. 2007;(2):CD004659.
- Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force [published online ahead of print April 8, 2014]. Ann Intern Med. doi:10.7326/M13-2844.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1993;329(17):1213–1218.
- Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338(11):701–705.
Have you read Dr. Errol R. Norwitz's Update on Operative Vaginal Delivery? Click here to access.
I perform extracorporeal morcellation; Better vaginal surgery training needed; A patient's perspective
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
I did not anticipate that, in addition to the normal fears and anxieties of upcoming surgery, I would also have to wonder if I will receive a phone call from the medical center telling me I cannot have surgery because morcellation has been prohibited.
I am relatively young, I have no family history of cancer, and I have 7 years’ worth of MRIs and ultrasounds to show that it is extremely unlikely that I have uterine cancer. I am well aware of the risks, and as an informed adult, I feel it is unconscionable for anybody to tell me that I cannot have the surgery of my choice simply because a very small number of women could be at risk. A greater number of women would be more at risk from having open surgery (blood loss, infection, thromboembolism, urinary and bowel incontinence, greater pain, longer recovery, etc.). Nearly every woman older than age 50 in my family has had an abdominal hysterectomy, with a long and painful recovery. I don’t want that.
I am so lucky to live in a time when surgery has advanced and there are less invasive options. This issue is about choice. Women are constantly having choices infringed upon by the government and its agencies. It’s time to return this operative choice to us.
A patient
Los Angeles, California
WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about this or other current articles: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
I did not anticipate that, in addition to the normal fears and anxieties of upcoming surgery, I would also have to wonder if I will receive a phone call from the medical center telling me I cannot have surgery because morcellation has been prohibited.
I am relatively young, I have no family history of cancer, and I have 7 years’ worth of MRIs and ultrasounds to show that it is extremely unlikely that I have uterine cancer. I am well aware of the risks, and as an informed adult, I feel it is unconscionable for anybody to tell me that I cannot have the surgery of my choice simply because a very small number of women could be at risk. A greater number of women would be more at risk from having open surgery (blood loss, infection, thromboembolism, urinary and bowel incontinence, greater pain, longer recovery, etc.). Nearly every woman older than age 50 in my family has had an abdominal hysterectomy, with a long and painful recovery. I don’t want that.
I am so lucky to live in a time when surgery has advanced and there are less invasive options. This issue is about choice. Women are constantly having choices infringed upon by the government and its agencies. It’s time to return this operative choice to us.
A patient
Los Angeles, California
WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about this or other current articles: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
I did not anticipate that, in addition to the normal fears and anxieties of upcoming surgery, I would also have to wonder if I will receive a phone call from the medical center telling me I cannot have surgery because morcellation has been prohibited.
I am relatively young, I have no family history of cancer, and I have 7 years’ worth of MRIs and ultrasounds to show that it is extremely unlikely that I have uterine cancer. I am well aware of the risks, and as an informed adult, I feel it is unconscionable for anybody to tell me that I cannot have the surgery of my choice simply because a very small number of women could be at risk. A greater number of women would be more at risk from having open surgery (blood loss, infection, thromboembolism, urinary and bowel incontinence, greater pain, longer recovery, etc.). Nearly every woman older than age 50 in my family has had an abdominal hysterectomy, with a long and painful recovery. I don’t want that.
I am so lucky to live in a time when surgery has advanced and there are less invasive options. This issue is about choice. Women are constantly having choices infringed upon by the government and its agencies. It’s time to return this operative choice to us.
A patient
Los Angeles, California
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Duplicating tests when urgency is not an issue
I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.
When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.
The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.
So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.
I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.
This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.
It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.
The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.
When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.
The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.
So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.
I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.
This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.
It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.
The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.
When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.
The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.
So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.
I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.
This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.
It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.
The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
