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What happened to 5-year outcomes?
I recently returned from Professor Roger Greenhalgh's excellent Charing Cross meeting in London. A plethora of exciting new developments was presented to almost 4,000 attendees from all over the world. As impressive as these presentations may have been, I became acutely aware that most of what was presented consisted of short-term data. Perhaps I am dating myself, but before the advent of endovascular technology, one could hardly get a presentation accepted at a major meeting without long-term, preferably 5-year-data.
Dr. D. Emerick Szilagyi, a pioneer of vascular surgery and former editor of the Journal of Vascular Surgery, having experienced the early failure of homografts, was renowned for stating that a new treatment required a 5-year track record before it could be deemed beneficial. Perhaps 5 years was chosen because that was an average life span for patients undergoing what was then major vascular surgery. Or was it because we knew that, at least in the short term, most vascular procedures worked but needed multiple revisions. Who would have anticipated that after aortic endografts were first inserted, we would soon be dealing with a new "condition," which we now refer to as an endoleak?
Regardless, at recent symposia and in our journals, we seem to receive predominately premature information. It is now commonplace to be presented with 1-year outcomes but more often with 90-, 30-, or even 7-day results. An even shorter interval is described in reports detailing "technical success."
It is as if we have won a victory of sorts when we do something that actually works until the end of the procedure! It appears that the announcement of every new product or treatment is accompanied by a proclamation of a new "breakthrough," a "paradigm shift," or a new major addition to our armamentarium. I wonder if we have succumbed to an embarrassing new malady that I will euphemistically describe as "premature congratulation."
I find these reports particularly common in cardiology and interventional radiology journals. They are also appearing with increasing frequency in our vascular literature and at scientific meetings. In fact, my own presentation at this year?s Charing Cross meeting was only a 4-year comparison of heparin bonded ePTFE vs. standard ePTFE. Perhaps even this could be considered to be too short a follow-up. Furthermore, can we forget how our popular press touted the advent of carotid stents when the original SAPPHIRE paper was presented? Using premature data, the newspaper USA Today announced the demise of carotid endarterectomy. Another example is how ezetimibe became a best-selling drug to treat hypercholesterolemia, and it still has yet to show any clinical benefit (JAMA 2014;311:11279 [doi:10.1001/jama.2014.2896]).
Admittedly, it may be important for new technologies or methods to be announced before they have been proven to be helpful, since these new "advances" may inspire more fruitful modifications to established procedures. On occasion, they may also uncover new avenues of investigation which may lead to new inventions or techniques. The question remains: how should we as vascular physicians respond to short-term data? Should we embrace new devices before they have stood the test of time? Or should we avoid their use, perhaps preventing a patient from receiving a life- or limb-saving procedure simply because we are unsure of its longevity or unforeseeable complication?
This is a quandary that our meeting organizers and journal editors must also face. Should they reject new material until it has been proven to have lasting benefit? I believe that the answer is no, but would interject a cautionary note in the general adoption of new methods until more definitive data are available. I have had personal experience with premature adoption of new technology when I was guilty of publishing excellent 1-year data with a balloon system only to later publish disappointing 2-year results. Of course, there is a benefit to having to retract earlier reports -- you become the author of two peer-reviewed manuscripts. Sarcasm aside, we do need to be kept informed about all new developments in our field. But it may be beneficial for proponents and experts to emphasize the true potential as well as possible drawbacks and complications of the new methods. It is also our responsibility to maintain an open mind.
While we can be cautiously optimistic, it is inadvisable to rush headlong into performing every new modality. Early adopters should be reminded that there is little to celebrate when a procedure?s benefits are brief. To avoid "premature congratulation," follow the slow and steady mantra that has served us well in other areas of life.
I recently returned from Professor Roger Greenhalgh's excellent Charing Cross meeting in London. A plethora of exciting new developments was presented to almost 4,000 attendees from all over the world. As impressive as these presentations may have been, I became acutely aware that most of what was presented consisted of short-term data. Perhaps I am dating myself, but before the advent of endovascular technology, one could hardly get a presentation accepted at a major meeting without long-term, preferably 5-year-data.
Dr. D. Emerick Szilagyi, a pioneer of vascular surgery and former editor of the Journal of Vascular Surgery, having experienced the early failure of homografts, was renowned for stating that a new treatment required a 5-year track record before it could be deemed beneficial. Perhaps 5 years was chosen because that was an average life span for patients undergoing what was then major vascular surgery. Or was it because we knew that, at least in the short term, most vascular procedures worked but needed multiple revisions. Who would have anticipated that after aortic endografts were first inserted, we would soon be dealing with a new "condition," which we now refer to as an endoleak?
Regardless, at recent symposia and in our journals, we seem to receive predominately premature information. It is now commonplace to be presented with 1-year outcomes but more often with 90-, 30-, or even 7-day results. An even shorter interval is described in reports detailing "technical success."
It is as if we have won a victory of sorts when we do something that actually works until the end of the procedure! It appears that the announcement of every new product or treatment is accompanied by a proclamation of a new "breakthrough," a "paradigm shift," or a new major addition to our armamentarium. I wonder if we have succumbed to an embarrassing new malady that I will euphemistically describe as "premature congratulation."
I find these reports particularly common in cardiology and interventional radiology journals. They are also appearing with increasing frequency in our vascular literature and at scientific meetings. In fact, my own presentation at this year?s Charing Cross meeting was only a 4-year comparison of heparin bonded ePTFE vs. standard ePTFE. Perhaps even this could be considered to be too short a follow-up. Furthermore, can we forget how our popular press touted the advent of carotid stents when the original SAPPHIRE paper was presented? Using premature data, the newspaper USA Today announced the demise of carotid endarterectomy. Another example is how ezetimibe became a best-selling drug to treat hypercholesterolemia, and it still has yet to show any clinical benefit (JAMA 2014;311:11279 [doi:10.1001/jama.2014.2896]).
Admittedly, it may be important for new technologies or methods to be announced before they have been proven to be helpful, since these new "advances" may inspire more fruitful modifications to established procedures. On occasion, they may also uncover new avenues of investigation which may lead to new inventions or techniques. The question remains: how should we as vascular physicians respond to short-term data? Should we embrace new devices before they have stood the test of time? Or should we avoid their use, perhaps preventing a patient from receiving a life- or limb-saving procedure simply because we are unsure of its longevity or unforeseeable complication?
This is a quandary that our meeting organizers and journal editors must also face. Should they reject new material until it has been proven to have lasting benefit? I believe that the answer is no, but would interject a cautionary note in the general adoption of new methods until more definitive data are available. I have had personal experience with premature adoption of new technology when I was guilty of publishing excellent 1-year data with a balloon system only to later publish disappointing 2-year results. Of course, there is a benefit to having to retract earlier reports -- you become the author of two peer-reviewed manuscripts. Sarcasm aside, we do need to be kept informed about all new developments in our field. But it may be beneficial for proponents and experts to emphasize the true potential as well as possible drawbacks and complications of the new methods. It is also our responsibility to maintain an open mind.
While we can be cautiously optimistic, it is inadvisable to rush headlong into performing every new modality. Early adopters should be reminded that there is little to celebrate when a procedure?s benefits are brief. To avoid "premature congratulation," follow the slow and steady mantra that has served us well in other areas of life.
I recently returned from Professor Roger Greenhalgh's excellent Charing Cross meeting in London. A plethora of exciting new developments was presented to almost 4,000 attendees from all over the world. As impressive as these presentations may have been, I became acutely aware that most of what was presented consisted of short-term data. Perhaps I am dating myself, but before the advent of endovascular technology, one could hardly get a presentation accepted at a major meeting without long-term, preferably 5-year-data.
Dr. D. Emerick Szilagyi, a pioneer of vascular surgery and former editor of the Journal of Vascular Surgery, having experienced the early failure of homografts, was renowned for stating that a new treatment required a 5-year track record before it could be deemed beneficial. Perhaps 5 years was chosen because that was an average life span for patients undergoing what was then major vascular surgery. Or was it because we knew that, at least in the short term, most vascular procedures worked but needed multiple revisions. Who would have anticipated that after aortic endografts were first inserted, we would soon be dealing with a new "condition," which we now refer to as an endoleak?
Regardless, at recent symposia and in our journals, we seem to receive predominately premature information. It is now commonplace to be presented with 1-year outcomes but more often with 90-, 30-, or even 7-day results. An even shorter interval is described in reports detailing "technical success."
It is as if we have won a victory of sorts when we do something that actually works until the end of the procedure! It appears that the announcement of every new product or treatment is accompanied by a proclamation of a new "breakthrough," a "paradigm shift," or a new major addition to our armamentarium. I wonder if we have succumbed to an embarrassing new malady that I will euphemistically describe as "premature congratulation."
I find these reports particularly common in cardiology and interventional radiology journals. They are also appearing with increasing frequency in our vascular literature and at scientific meetings. In fact, my own presentation at this year?s Charing Cross meeting was only a 4-year comparison of heparin bonded ePTFE vs. standard ePTFE. Perhaps even this could be considered to be too short a follow-up. Furthermore, can we forget how our popular press touted the advent of carotid stents when the original SAPPHIRE paper was presented? Using premature data, the newspaper USA Today announced the demise of carotid endarterectomy. Another example is how ezetimibe became a best-selling drug to treat hypercholesterolemia, and it still has yet to show any clinical benefit (JAMA 2014;311:11279 [doi:10.1001/jama.2014.2896]).
Admittedly, it may be important for new technologies or methods to be announced before they have been proven to be helpful, since these new "advances" may inspire more fruitful modifications to established procedures. On occasion, they may also uncover new avenues of investigation which may lead to new inventions or techniques. The question remains: how should we as vascular physicians respond to short-term data? Should we embrace new devices before they have stood the test of time? Or should we avoid their use, perhaps preventing a patient from receiving a life- or limb-saving procedure simply because we are unsure of its longevity or unforeseeable complication?
This is a quandary that our meeting organizers and journal editors must also face. Should they reject new material until it has been proven to have lasting benefit? I believe that the answer is no, but would interject a cautionary note in the general adoption of new methods until more definitive data are available. I have had personal experience with premature adoption of new technology when I was guilty of publishing excellent 1-year data with a balloon system only to later publish disappointing 2-year results. Of course, there is a benefit to having to retract earlier reports -- you become the author of two peer-reviewed manuscripts. Sarcasm aside, we do need to be kept informed about all new developments in our field. But it may be beneficial for proponents and experts to emphasize the true potential as well as possible drawbacks and complications of the new methods. It is also our responsibility to maintain an open mind.
While we can be cautiously optimistic, it is inadvisable to rush headlong into performing every new modality. Early adopters should be reminded that there is little to celebrate when a procedure?s benefits are brief. To avoid "premature congratulation," follow the slow and steady mantra that has served us well in other areas of life.
Potpourri of travel medicine tips and updates
School’s out for the summer soon! Many of your patients may have plans to travel to areas where they may be exposed to infectious diseases and other health risks not routinely encountered in the United States. They will join the 29 million Americans, including almost 3 million children, who traveled to overseas destinations in 2013. The potential for exposures to these risks is dependent on several factors, including the traveler’s age, health and immunization status, destination, accommodations, and duration of travel. Leisure travel, including visiting friends and relatives, accounts for approximately 90% of overseas travel. Some adolescents are traveling to resource-limited areas for adventure travel, educational experiences, and volunteerism. Many times they will reside with host families as part of this experience. There are also children who will have prolonged stays as a result of parental job relocation.
Unfortunately, health precautions often are not considered as many make their travel arrangements. International trips on average are planned at least 105 days in advance; however, many patients wait until the last minute to seek medical advice, if at all. Of 10,032 ill persons who sought post-travel evaluations at participating surveillance facilities (U.S. GeoSentinel sites) between 1997 and 2011, less than half (44%) reported seeking pretravel advice (MMWR 2013;62(SS03):1-15).
Here are some tips that should be useful and easy to implement in your practice for your internationally traveling patients.
• Make sure routine immunizations are up-to-date for age. The exception to this rule is for measles. All children at least 12 months age should receive two doses of MMR prior to departure regardless of their international destination. The second dose of MMR can be administered as early as 4 weeks after the first. Children between 6 and 11 months of age should receive a single dose of MMR prior to departure. If the initial dose is administered at less than 12 months of age, two additional doses will need to be administered to complete the series beginning at 12 months of age.
While measles is no longer endemic in the United States, as of April 25, 2014, there have been 154 cases reported from 14 states. (See measles graphic.) The majority of cases were imported by unvaccinated travelers who became ill after returning home and exposed susceptible individuals. In the last few years, most of the U.S. cases were imported from Western Europe. Currently, there are several countries experiencing record numbers of cases, including Vietnam (3,700) and the Philippines (26,000). This is not to imply that ongoing international outbreaks are limited to these two countries. For additional information, go to cdc.gov/measles.
• Identify someone in your area as a local resource for travel-related information and referrals. Make sure they are willing to see children. Develop a system to send out reminders to families to seek pretravel advice, ideally at least 1 month prior to departure. For children with chronic diseases or compromised immune systems, destination selection may need to be adjusted depending on their medical needs, availability of comparable health care at the overseas destination, and ability to receive pretravel vaccine interventions. Involvement prior to booking the trip would be advisable. Many offices successfully send out reminders for well visits and influenza vaccine. Consider incorporating one for overseas travel.
• The timing of initiation of antimalarial prophylaxis is dependent on the medication. Weekly medications such as chloroquine and mefloquine should begin at least 2 weeks prior to exposure. Atovaquone/proguanil and doxycycline are two drugs that are administered daily, and travelers can begin as late as 2 days prior to entry into a malaria-endemic area. This is a great option for the last-minute traveler.
However, there are contraindications for the use of each drug. Some are age dependent, while others are directly related to the presence of a specific medical condition. Areas where chloroquine-sensitive malaria is present are limited. It is always important to prescribe a prophylactic antimalarial agent, but even more prudent to prescribe the appropriate drug and dosage.
Not sure which drug is most appropriate for your patient? Refer to your local travel medicine expert, or visit cdc.gov/malaria.
• The accompanying table lists vaccines that are traditionally considered to be travel vaccines, but pediatricians and family physicians might not consider all to belong in that group. Most are not required for entry into a specific country, but are recommended based on the risk for potential exposure and disease acquisition. In contrast, yellow fever and meningococcal vaccines are required for entry into certain countries. Yellow fever vaccine can be administered only at authorized sites and should be received at least 10 days prior to arrival at the destination. As with routinely administered vaccines, occasionally there are shortages of travel-related vaccines. Most recently, a shortage of yellow fever vaccine has been resolved.
The majority of vaccines should be administered at least 2 weeks prior to departure, while others, such as rabies and Japanese encephalitis, take at least 28 days to complete the series. These are a few additional reasons it behooves your patients to seek advice early.
Travel updates
Chikungunya virus (CHIK V). Local transmission in the Americas was first reported from St. Martin in December 2013. As of May 5, 2014, a total of 12 Caribbean countries have reported locally acquired cases. The disease is transmitted by Aedes species, which are the same species that transmit dengue fever. Disease is characterized by sudden onset of high fever with severe polyarthralgia. Additional symptoms can include headache, myalgias, rash, nausea, and vomiting. Epidemics have historically occurred in Africa, Asia, and islands in the Indian Ocean. Outbreaks also have occurred in Italy and France.
There is no preventive vaccine or drug available. Treatment is symptomatic care. The disease is best prevented by taking adequate mosquito precautions, especially during the daytime. Application of DEET (N,N-diethyl-m-toluamide) and picaridin-containing agents to the skin or treating clothes with a permethrin-containing agent are just two ways to avoid sustaining a mosquito bite.
While no cases Chikungunya virus have been acquired in the United States, there is a potential risk that the virus will be introduced by an infected traveler or mosquito. The Aedes species that transmits the virus is present in several areas of the United States. For additional information, go to cdc.gov/chikungunya.
Polio. While polio has been eliminated in the United States since 1979, it has never been eradicated in Afghanistan, Nigeria, and Pakistan. For a country to be certified as polio free, there cannot be evidence of circulation of wild polio virus for 3 consecutive years. In spite of a massive global initiative to eliminate this disease, in the last 3 months there have been cases confirmed in the following countries: Cameroon, Ethiopia, Equatorial Guinea, Iraq, Kenya, Somalia, and Syria. While no cases of flaccid paralysis have been confirmed in Israel, wild polio virus has been detected in sewage and isolated from stool of asymptomatic individuals.
Completion of the polio series is recommended for those persons inadequately immunized, and a one-time booster dose is recommended for all adults with travel plans to these countries. This should not be an issue for most pediatric patients, except those who may have deferred immunizations. Booster doses are no longer recommended for travel to countries that border countries with active circulation
African tick bite fever. Frequently overshadowed by the appropriate concern for prevention and acquisition of malaria is a rickettsial disease caused by Rickettsia africae, one of the spotted fever group of rickettsial infections. Its geographic distribution is limited to sub-Saharan Africa, and as its name implies, it is transmitted by a tick. It is the most commonly diagnosed rickettsial disease acquired by travelers (Emerg. Infect. Dis. 2009;15:1791-8). Of 280 individuals diagnosed with rickettsiosis, 231 (82.5%) had spotted fever; almost 87% of the spotted fever rickettsiosis cases were acquired in sub-Saharan Africa, and 69% of these patients reported leisure travel to South Africa. In another review, it was the second-leading cause of systemic febrile illnesses acquired in travelers to sub-Saharan Africa. It was surpassed only by malaria (N. Engl. J. Med. 2006;354:119-30). All age groups are at risk.
Transmission occurs most frequently during the spring and summer months, coinciding with increased tick activity and greater outdoor activities. It is commonly acquired by tourists between November and April in South Africa during a safari or game hunting vacation. Because the incubation period is 5 to 14 days, most travelers may not become symptomatic until after their return. This disease should be suspected in any traveler who presents with fever, headache, and myalgias; has an eschar; and indicates they have recently returned from South Africa. Diagnosis is based on clinical history and serology. Therapy with doxycycline is initiated pending laboratory results.
Disease is controlled by prevention of transmission of the organism by the vector to humans. Use of repellents that contain 20%-30% DEET on exposed skin and wearing clothes treated with permethrin are recommended. Pretreated clothing is also available. Travelers should be encouraged to always check their body after exposure and remove ticks if discovered. Many advocate a bath or shower after coming indoors to facilitate finding any ticks.
Parents should check their children thoroughly for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].
School’s out for the summer soon! Many of your patients may have plans to travel to areas where they may be exposed to infectious diseases and other health risks not routinely encountered in the United States. They will join the 29 million Americans, including almost 3 million children, who traveled to overseas destinations in 2013. The potential for exposures to these risks is dependent on several factors, including the traveler’s age, health and immunization status, destination, accommodations, and duration of travel. Leisure travel, including visiting friends and relatives, accounts for approximately 90% of overseas travel. Some adolescents are traveling to resource-limited areas for adventure travel, educational experiences, and volunteerism. Many times they will reside with host families as part of this experience. There are also children who will have prolonged stays as a result of parental job relocation.
Unfortunately, health precautions often are not considered as many make their travel arrangements. International trips on average are planned at least 105 days in advance; however, many patients wait until the last minute to seek medical advice, if at all. Of 10,032 ill persons who sought post-travel evaluations at participating surveillance facilities (U.S. GeoSentinel sites) between 1997 and 2011, less than half (44%) reported seeking pretravel advice (MMWR 2013;62(SS03):1-15).
Here are some tips that should be useful and easy to implement in your practice for your internationally traveling patients.
• Make sure routine immunizations are up-to-date for age. The exception to this rule is for measles. All children at least 12 months age should receive two doses of MMR prior to departure regardless of their international destination. The second dose of MMR can be administered as early as 4 weeks after the first. Children between 6 and 11 months of age should receive a single dose of MMR prior to departure. If the initial dose is administered at less than 12 months of age, two additional doses will need to be administered to complete the series beginning at 12 months of age.
While measles is no longer endemic in the United States, as of April 25, 2014, there have been 154 cases reported from 14 states. (See measles graphic.) The majority of cases were imported by unvaccinated travelers who became ill after returning home and exposed susceptible individuals. In the last few years, most of the U.S. cases were imported from Western Europe. Currently, there are several countries experiencing record numbers of cases, including Vietnam (3,700) and the Philippines (26,000). This is not to imply that ongoing international outbreaks are limited to these two countries. For additional information, go to cdc.gov/measles.
• Identify someone in your area as a local resource for travel-related information and referrals. Make sure they are willing to see children. Develop a system to send out reminders to families to seek pretravel advice, ideally at least 1 month prior to departure. For children with chronic diseases or compromised immune systems, destination selection may need to be adjusted depending on their medical needs, availability of comparable health care at the overseas destination, and ability to receive pretravel vaccine interventions. Involvement prior to booking the trip would be advisable. Many offices successfully send out reminders for well visits and influenza vaccine. Consider incorporating one for overseas travel.
• The timing of initiation of antimalarial prophylaxis is dependent on the medication. Weekly medications such as chloroquine and mefloquine should begin at least 2 weeks prior to exposure. Atovaquone/proguanil and doxycycline are two drugs that are administered daily, and travelers can begin as late as 2 days prior to entry into a malaria-endemic area. This is a great option for the last-minute traveler.
However, there are contraindications for the use of each drug. Some are age dependent, while others are directly related to the presence of a specific medical condition. Areas where chloroquine-sensitive malaria is present are limited. It is always important to prescribe a prophylactic antimalarial agent, but even more prudent to prescribe the appropriate drug and dosage.
Not sure which drug is most appropriate for your patient? Refer to your local travel medicine expert, or visit cdc.gov/malaria.
• The accompanying table lists vaccines that are traditionally considered to be travel vaccines, but pediatricians and family physicians might not consider all to belong in that group. Most are not required for entry into a specific country, but are recommended based on the risk for potential exposure and disease acquisition. In contrast, yellow fever and meningococcal vaccines are required for entry into certain countries. Yellow fever vaccine can be administered only at authorized sites and should be received at least 10 days prior to arrival at the destination. As with routinely administered vaccines, occasionally there are shortages of travel-related vaccines. Most recently, a shortage of yellow fever vaccine has been resolved.
The majority of vaccines should be administered at least 2 weeks prior to departure, while others, such as rabies and Japanese encephalitis, take at least 28 days to complete the series. These are a few additional reasons it behooves your patients to seek advice early.
Travel updates
Chikungunya virus (CHIK V). Local transmission in the Americas was first reported from St. Martin in December 2013. As of May 5, 2014, a total of 12 Caribbean countries have reported locally acquired cases. The disease is transmitted by Aedes species, which are the same species that transmit dengue fever. Disease is characterized by sudden onset of high fever with severe polyarthralgia. Additional symptoms can include headache, myalgias, rash, nausea, and vomiting. Epidemics have historically occurred in Africa, Asia, and islands in the Indian Ocean. Outbreaks also have occurred in Italy and France.
There is no preventive vaccine or drug available. Treatment is symptomatic care. The disease is best prevented by taking adequate mosquito precautions, especially during the daytime. Application of DEET (N,N-diethyl-m-toluamide) and picaridin-containing agents to the skin or treating clothes with a permethrin-containing agent are just two ways to avoid sustaining a mosquito bite.
While no cases Chikungunya virus have been acquired in the United States, there is a potential risk that the virus will be introduced by an infected traveler or mosquito. The Aedes species that transmits the virus is present in several areas of the United States. For additional information, go to cdc.gov/chikungunya.
Polio. While polio has been eliminated in the United States since 1979, it has never been eradicated in Afghanistan, Nigeria, and Pakistan. For a country to be certified as polio free, there cannot be evidence of circulation of wild polio virus for 3 consecutive years. In spite of a massive global initiative to eliminate this disease, in the last 3 months there have been cases confirmed in the following countries: Cameroon, Ethiopia, Equatorial Guinea, Iraq, Kenya, Somalia, and Syria. While no cases of flaccid paralysis have been confirmed in Israel, wild polio virus has been detected in sewage and isolated from stool of asymptomatic individuals.
Completion of the polio series is recommended for those persons inadequately immunized, and a one-time booster dose is recommended for all adults with travel plans to these countries. This should not be an issue for most pediatric patients, except those who may have deferred immunizations. Booster doses are no longer recommended for travel to countries that border countries with active circulation
African tick bite fever. Frequently overshadowed by the appropriate concern for prevention and acquisition of malaria is a rickettsial disease caused by Rickettsia africae, one of the spotted fever group of rickettsial infections. Its geographic distribution is limited to sub-Saharan Africa, and as its name implies, it is transmitted by a tick. It is the most commonly diagnosed rickettsial disease acquired by travelers (Emerg. Infect. Dis. 2009;15:1791-8). Of 280 individuals diagnosed with rickettsiosis, 231 (82.5%) had spotted fever; almost 87% of the spotted fever rickettsiosis cases were acquired in sub-Saharan Africa, and 69% of these patients reported leisure travel to South Africa. In another review, it was the second-leading cause of systemic febrile illnesses acquired in travelers to sub-Saharan Africa. It was surpassed only by malaria (N. Engl. J. Med. 2006;354:119-30). All age groups are at risk.
Transmission occurs most frequently during the spring and summer months, coinciding with increased tick activity and greater outdoor activities. It is commonly acquired by tourists between November and April in South Africa during a safari or game hunting vacation. Because the incubation period is 5 to 14 days, most travelers may not become symptomatic until after their return. This disease should be suspected in any traveler who presents with fever, headache, and myalgias; has an eschar; and indicates they have recently returned from South Africa. Diagnosis is based on clinical history and serology. Therapy with doxycycline is initiated pending laboratory results.
Disease is controlled by prevention of transmission of the organism by the vector to humans. Use of repellents that contain 20%-30% DEET on exposed skin and wearing clothes treated with permethrin are recommended. Pretreated clothing is also available. Travelers should be encouraged to always check their body after exposure and remove ticks if discovered. Many advocate a bath or shower after coming indoors to facilitate finding any ticks.
Parents should check their children thoroughly for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].
School’s out for the summer soon! Many of your patients may have plans to travel to areas where they may be exposed to infectious diseases and other health risks not routinely encountered in the United States. They will join the 29 million Americans, including almost 3 million children, who traveled to overseas destinations in 2013. The potential for exposures to these risks is dependent on several factors, including the traveler’s age, health and immunization status, destination, accommodations, and duration of travel. Leisure travel, including visiting friends and relatives, accounts for approximately 90% of overseas travel. Some adolescents are traveling to resource-limited areas for adventure travel, educational experiences, and volunteerism. Many times they will reside with host families as part of this experience. There are also children who will have prolonged stays as a result of parental job relocation.
Unfortunately, health precautions often are not considered as many make their travel arrangements. International trips on average are planned at least 105 days in advance; however, many patients wait until the last minute to seek medical advice, if at all. Of 10,032 ill persons who sought post-travel evaluations at participating surveillance facilities (U.S. GeoSentinel sites) between 1997 and 2011, less than half (44%) reported seeking pretravel advice (MMWR 2013;62(SS03):1-15).
Here are some tips that should be useful and easy to implement in your practice for your internationally traveling patients.
• Make sure routine immunizations are up-to-date for age. The exception to this rule is for measles. All children at least 12 months age should receive two doses of MMR prior to departure regardless of their international destination. The second dose of MMR can be administered as early as 4 weeks after the first. Children between 6 and 11 months of age should receive a single dose of MMR prior to departure. If the initial dose is administered at less than 12 months of age, two additional doses will need to be administered to complete the series beginning at 12 months of age.
While measles is no longer endemic in the United States, as of April 25, 2014, there have been 154 cases reported from 14 states. (See measles graphic.) The majority of cases were imported by unvaccinated travelers who became ill after returning home and exposed susceptible individuals. In the last few years, most of the U.S. cases were imported from Western Europe. Currently, there are several countries experiencing record numbers of cases, including Vietnam (3,700) and the Philippines (26,000). This is not to imply that ongoing international outbreaks are limited to these two countries. For additional information, go to cdc.gov/measles.
• Identify someone in your area as a local resource for travel-related information and referrals. Make sure they are willing to see children. Develop a system to send out reminders to families to seek pretravel advice, ideally at least 1 month prior to departure. For children with chronic diseases or compromised immune systems, destination selection may need to be adjusted depending on their medical needs, availability of comparable health care at the overseas destination, and ability to receive pretravel vaccine interventions. Involvement prior to booking the trip would be advisable. Many offices successfully send out reminders for well visits and influenza vaccine. Consider incorporating one for overseas travel.
• The timing of initiation of antimalarial prophylaxis is dependent on the medication. Weekly medications such as chloroquine and mefloquine should begin at least 2 weeks prior to exposure. Atovaquone/proguanil and doxycycline are two drugs that are administered daily, and travelers can begin as late as 2 days prior to entry into a malaria-endemic area. This is a great option for the last-minute traveler.
However, there are contraindications for the use of each drug. Some are age dependent, while others are directly related to the presence of a specific medical condition. Areas where chloroquine-sensitive malaria is present are limited. It is always important to prescribe a prophylactic antimalarial agent, but even more prudent to prescribe the appropriate drug and dosage.
Not sure which drug is most appropriate for your patient? Refer to your local travel medicine expert, or visit cdc.gov/malaria.
• The accompanying table lists vaccines that are traditionally considered to be travel vaccines, but pediatricians and family physicians might not consider all to belong in that group. Most are not required for entry into a specific country, but are recommended based on the risk for potential exposure and disease acquisition. In contrast, yellow fever and meningococcal vaccines are required for entry into certain countries. Yellow fever vaccine can be administered only at authorized sites and should be received at least 10 days prior to arrival at the destination. As with routinely administered vaccines, occasionally there are shortages of travel-related vaccines. Most recently, a shortage of yellow fever vaccine has been resolved.
The majority of vaccines should be administered at least 2 weeks prior to departure, while others, such as rabies and Japanese encephalitis, take at least 28 days to complete the series. These are a few additional reasons it behooves your patients to seek advice early.
Travel updates
Chikungunya virus (CHIK V). Local transmission in the Americas was first reported from St. Martin in December 2013. As of May 5, 2014, a total of 12 Caribbean countries have reported locally acquired cases. The disease is transmitted by Aedes species, which are the same species that transmit dengue fever. Disease is characterized by sudden onset of high fever with severe polyarthralgia. Additional symptoms can include headache, myalgias, rash, nausea, and vomiting. Epidemics have historically occurred in Africa, Asia, and islands in the Indian Ocean. Outbreaks also have occurred in Italy and France.
There is no preventive vaccine or drug available. Treatment is symptomatic care. The disease is best prevented by taking adequate mosquito precautions, especially during the daytime. Application of DEET (N,N-diethyl-m-toluamide) and picaridin-containing agents to the skin or treating clothes with a permethrin-containing agent are just two ways to avoid sustaining a mosquito bite.
While no cases Chikungunya virus have been acquired in the United States, there is a potential risk that the virus will be introduced by an infected traveler or mosquito. The Aedes species that transmits the virus is present in several areas of the United States. For additional information, go to cdc.gov/chikungunya.
Polio. While polio has been eliminated in the United States since 1979, it has never been eradicated in Afghanistan, Nigeria, and Pakistan. For a country to be certified as polio free, there cannot be evidence of circulation of wild polio virus for 3 consecutive years. In spite of a massive global initiative to eliminate this disease, in the last 3 months there have been cases confirmed in the following countries: Cameroon, Ethiopia, Equatorial Guinea, Iraq, Kenya, Somalia, and Syria. While no cases of flaccid paralysis have been confirmed in Israel, wild polio virus has been detected in sewage and isolated from stool of asymptomatic individuals.
Completion of the polio series is recommended for those persons inadequately immunized, and a one-time booster dose is recommended for all adults with travel plans to these countries. This should not be an issue for most pediatric patients, except those who may have deferred immunizations. Booster doses are no longer recommended for travel to countries that border countries with active circulation
African tick bite fever. Frequently overshadowed by the appropriate concern for prevention and acquisition of malaria is a rickettsial disease caused by Rickettsia africae, one of the spotted fever group of rickettsial infections. Its geographic distribution is limited to sub-Saharan Africa, and as its name implies, it is transmitted by a tick. It is the most commonly diagnosed rickettsial disease acquired by travelers (Emerg. Infect. Dis. 2009;15:1791-8). Of 280 individuals diagnosed with rickettsiosis, 231 (82.5%) had spotted fever; almost 87% of the spotted fever rickettsiosis cases were acquired in sub-Saharan Africa, and 69% of these patients reported leisure travel to South Africa. In another review, it was the second-leading cause of systemic febrile illnesses acquired in travelers to sub-Saharan Africa. It was surpassed only by malaria (N. Engl. J. Med. 2006;354:119-30). All age groups are at risk.
Transmission occurs most frequently during the spring and summer months, coinciding with increased tick activity and greater outdoor activities. It is commonly acquired by tourists between November and April in South Africa during a safari or game hunting vacation. Because the incubation period is 5 to 14 days, most travelers may not become symptomatic until after their return. This disease should be suspected in any traveler who presents with fever, headache, and myalgias; has an eschar; and indicates they have recently returned from South Africa. Diagnosis is based on clinical history and serology. Therapy with doxycycline is initiated pending laboratory results.
Disease is controlled by prevention of transmission of the organism by the vector to humans. Use of repellents that contain 20%-30% DEET on exposed skin and wearing clothes treated with permethrin are recommended. Pretreated clothing is also available. Travelers should be encouraged to always check their body after exposure and remove ticks if discovered. Many advocate a bath or shower after coming indoors to facilitate finding any ticks.
Parents should check their children thoroughly for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].
Nurturing values: An inevitable part of parenting
If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.
One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.
While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.
With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.
Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.
Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.
Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.
Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].
If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.
One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.
While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.
With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.
Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.
Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.
Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.
Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].
If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.
One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.
While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.
With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.
Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.
Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.
Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.
Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].
The official dermatologist [YOUR NAME HERE]
Who do you call when your windshield’s busted?
Call Giant Glass!
There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.
Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"
If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.
Or why Beth Israel Deaconess is the Red Sox Official Hospital.
You can see where I’m going with this, can’t you?
In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)
I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.
*******************
Marriott Hotels
Dear Mr. or Ms. Marriott:
I salute you as Official Hotel of the Red Sox!
But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?
Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.
Our rates are reasonable. Give us a call!
*******************
Dunkin’ Donuts
Dear Donuts:
It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!
I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?
That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)
*******************
John Hancock Insurance
Dear Mr. Hancock,
Congratulations on being the Official Insurance of the Boston Red Sox.
I just love your building, a real Boston landmark.
Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)
While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.
Let’s do lunch. Do you like Dunkin’ Donuts?
*******************
You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.
Here’s a sample letter:
Toledo Mud Hens
Toledo, Ohio
Dear Mud Hens,
I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.
Let’s all get together and triangulate.
Go Mud Hens!
*******************
OK, colleagues, I’ve given you direction. Now get out there and make it happen!
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.
Who do you call when your windshield’s busted?
Call Giant Glass!
There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.
Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"
If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.
Or why Beth Israel Deaconess is the Red Sox Official Hospital.
You can see where I’m going with this, can’t you?
In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)
I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.
*******************
Marriott Hotels
Dear Mr. or Ms. Marriott:
I salute you as Official Hotel of the Red Sox!
But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?
Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.
Our rates are reasonable. Give us a call!
*******************
Dunkin’ Donuts
Dear Donuts:
It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!
I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?
That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)
*******************
John Hancock Insurance
Dear Mr. Hancock,
Congratulations on being the Official Insurance of the Boston Red Sox.
I just love your building, a real Boston landmark.
Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)
While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.
Let’s do lunch. Do you like Dunkin’ Donuts?
*******************
You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.
Here’s a sample letter:
Toledo Mud Hens
Toledo, Ohio
Dear Mud Hens,
I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.
Let’s all get together and triangulate.
Go Mud Hens!
*******************
OK, colleagues, I’ve given you direction. Now get out there and make it happen!
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.
Who do you call when your windshield’s busted?
Call Giant Glass!
There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.
Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"
If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.
Or why Beth Israel Deaconess is the Red Sox Official Hospital.
You can see where I’m going with this, can’t you?
In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)
I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.
*******************
Marriott Hotels
Dear Mr. or Ms. Marriott:
I salute you as Official Hotel of the Red Sox!
But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?
Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.
Our rates are reasonable. Give us a call!
*******************
Dunkin’ Donuts
Dear Donuts:
It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!
I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?
That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)
*******************
John Hancock Insurance
Dear Mr. Hancock,
Congratulations on being the Official Insurance of the Boston Red Sox.
I just love your building, a real Boston landmark.
Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)
While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.
Let’s do lunch. Do you like Dunkin’ Donuts?
*******************
You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.
Here’s a sample letter:
Toledo Mud Hens
Toledo, Ohio
Dear Mud Hens,
I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.
Let’s all get together and triangulate.
Go Mud Hens!
*******************
OK, colleagues, I’ve given you direction. Now get out there and make it happen!
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.
What we know that ain’t so
Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.
Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.
I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.
My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H2 receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.
So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.
My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.
The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).
I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.
The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.
Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].
Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.
Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.
I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.
My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H2 receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.
So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.
My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.
The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).
I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.
The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.
Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].
Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.
Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.
I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.
My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H2 receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.
So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.
My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.
The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).
I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.
The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.
Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].
The ICU: From bed to bedside
I recently came to the realization that one doesn’t usually end up in an ICU unless the odds of making it out are not in one’s favor.
Now, I want to make it clear from the very first that my wife and I survived life-threatening medical experiences as a result of the superb care provided to both of us. Nevertheless, the experience made me aware of how ICU and hospital care has changed in the last 50 years. I have spent most of my life in ICUs from the "invention" of the Coronary Care Unit in the mid-1960s to its current iteration of an intensely monitored hospital room where emergency surgery could be performed if need be. Much of that change is a result of the variety of medical specialists who are players in the ICU drama. The other major changes have been the time restraints of house staff rotation to meet certification criteria and rotation of the senior staff in order to provide continuing on-site coverage of the ICU. As the acuteness of hospital admissions has increased, the ICU and its management have assumed a larger role in the care and the finances of major hospitals.
Some years ago, we hosted a distinguished European physician who spent 2 months with us as a visiting professor. It was at a time when we felt a need to begin to develop subspecialties in angiography, electrophysiology, and echocardiography in order to provide a research and training atmosphere for our fellowship program. Later, he wrote an editorial in his local medical journal criticizing cardiac care in the United States because of the lack of continuity. He was of the tradition that mandated that he would see the patient in the clinic, perform a cardiac catheterization himself, and follow his patient through surgery and manage their postoperative care, as was standard practice in the mid-20th century. He believed that the concept of delegating diagnostic and care responsibilities to specialty trained colleagues that he observed here was a major disaster. He should see the system now. Nevertheless, his plea for continuity in care resonates in my mind.
That need for continuity came back to me as I experienced the dizzying rotation of house staff and senior staff that takes place in the ICU today. Any semblance of continuity of care was lacking at a time when there was a need to provide information to anxious patients and their families. In the environment of medical uncertainty, when you would like to find a familiar physician to ask "How are we doing," the attending physician or medical resident in charge was either on another rotation or being covered by a colleague. No training or adherence to "sign-off" rounds can replace the need for that professional continuity. As competent and well meaning the covering doctor was, answers to questions seemed shallow. It was difficult even to express gratitude to "a" physician who had tipped the scales in my favor. One had to direct it to an amorphous team of doctors, nurses, and technicians who had participated in care. That is a reality that describes the methodology of ICU and its success. It is a reality that to a similar degree characterizes the current management of inpatient care.
It seemed that in the setting of a life-threatening experience, the link between the treating physicians and the patients or family has almost disappeared in the ICU. The challenge to us as we play our role in the ICU, and the CCU, is to establish and maintain a personal relationship with the patients and their family.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
I recently came to the realization that one doesn’t usually end up in an ICU unless the odds of making it out are not in one’s favor.
Now, I want to make it clear from the very first that my wife and I survived life-threatening medical experiences as a result of the superb care provided to both of us. Nevertheless, the experience made me aware of how ICU and hospital care has changed in the last 50 years. I have spent most of my life in ICUs from the "invention" of the Coronary Care Unit in the mid-1960s to its current iteration of an intensely monitored hospital room where emergency surgery could be performed if need be. Much of that change is a result of the variety of medical specialists who are players in the ICU drama. The other major changes have been the time restraints of house staff rotation to meet certification criteria and rotation of the senior staff in order to provide continuing on-site coverage of the ICU. As the acuteness of hospital admissions has increased, the ICU and its management have assumed a larger role in the care and the finances of major hospitals.
Some years ago, we hosted a distinguished European physician who spent 2 months with us as a visiting professor. It was at a time when we felt a need to begin to develop subspecialties in angiography, electrophysiology, and echocardiography in order to provide a research and training atmosphere for our fellowship program. Later, he wrote an editorial in his local medical journal criticizing cardiac care in the United States because of the lack of continuity. He was of the tradition that mandated that he would see the patient in the clinic, perform a cardiac catheterization himself, and follow his patient through surgery and manage their postoperative care, as was standard practice in the mid-20th century. He believed that the concept of delegating diagnostic and care responsibilities to specialty trained colleagues that he observed here was a major disaster. He should see the system now. Nevertheless, his plea for continuity in care resonates in my mind.
That need for continuity came back to me as I experienced the dizzying rotation of house staff and senior staff that takes place in the ICU today. Any semblance of continuity of care was lacking at a time when there was a need to provide information to anxious patients and their families. In the environment of medical uncertainty, when you would like to find a familiar physician to ask "How are we doing," the attending physician or medical resident in charge was either on another rotation or being covered by a colleague. No training or adherence to "sign-off" rounds can replace the need for that professional continuity. As competent and well meaning the covering doctor was, answers to questions seemed shallow. It was difficult even to express gratitude to "a" physician who had tipped the scales in my favor. One had to direct it to an amorphous team of doctors, nurses, and technicians who had participated in care. That is a reality that describes the methodology of ICU and its success. It is a reality that to a similar degree characterizes the current management of inpatient care.
It seemed that in the setting of a life-threatening experience, the link between the treating physicians and the patients or family has almost disappeared in the ICU. The challenge to us as we play our role in the ICU, and the CCU, is to establish and maintain a personal relationship with the patients and their family.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
I recently came to the realization that one doesn’t usually end up in an ICU unless the odds of making it out are not in one’s favor.
Now, I want to make it clear from the very first that my wife and I survived life-threatening medical experiences as a result of the superb care provided to both of us. Nevertheless, the experience made me aware of how ICU and hospital care has changed in the last 50 years. I have spent most of my life in ICUs from the "invention" of the Coronary Care Unit in the mid-1960s to its current iteration of an intensely monitored hospital room where emergency surgery could be performed if need be. Much of that change is a result of the variety of medical specialists who are players in the ICU drama. The other major changes have been the time restraints of house staff rotation to meet certification criteria and rotation of the senior staff in order to provide continuing on-site coverage of the ICU. As the acuteness of hospital admissions has increased, the ICU and its management have assumed a larger role in the care and the finances of major hospitals.
Some years ago, we hosted a distinguished European physician who spent 2 months with us as a visiting professor. It was at a time when we felt a need to begin to develop subspecialties in angiography, electrophysiology, and echocardiography in order to provide a research and training atmosphere for our fellowship program. Later, he wrote an editorial in his local medical journal criticizing cardiac care in the United States because of the lack of continuity. He was of the tradition that mandated that he would see the patient in the clinic, perform a cardiac catheterization himself, and follow his patient through surgery and manage their postoperative care, as was standard practice in the mid-20th century. He believed that the concept of delegating diagnostic and care responsibilities to specialty trained colleagues that he observed here was a major disaster. He should see the system now. Nevertheless, his plea for continuity in care resonates in my mind.
That need for continuity came back to me as I experienced the dizzying rotation of house staff and senior staff that takes place in the ICU today. Any semblance of continuity of care was lacking at a time when there was a need to provide information to anxious patients and their families. In the environment of medical uncertainty, when you would like to find a familiar physician to ask "How are we doing," the attending physician or medical resident in charge was either on another rotation or being covered by a colleague. No training or adherence to "sign-off" rounds can replace the need for that professional continuity. As competent and well meaning the covering doctor was, answers to questions seemed shallow. It was difficult even to express gratitude to "a" physician who had tipped the scales in my favor. One had to direct it to an amorphous team of doctors, nurses, and technicians who had participated in care. That is a reality that describes the methodology of ICU and its success. It is a reality that to a similar degree characterizes the current management of inpatient care.
It seemed that in the setting of a life-threatening experience, the link between the treating physicians and the patients or family has almost disappeared in the ICU. The challenge to us as we play our role in the ICU, and the CCU, is to establish and maintain a personal relationship with the patients and their family.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
A day in the life of a rheumatologist
7:00 a.m. When they called me for this consult on this young female with known lupus presenting with pleuritic chest pain, they didn’t tell me that (a) she has a history of pleural effusions, and (b) her creatinine is 4.9 mg/dL.
8:00 a.m. Waiting for my patient to be roomed. We’re implementing a new electronic health record, so I have to wait for the medical assistant (MA) to finish her tasks: input the patient’s medications, take his vital signs, and ask for his chief complaint.
8:20 a.m. Patient is still not ready for me. Who thought it would be a good idea for the MA to take the patient’s medications? It’d be so much more efficient if I did it myself.
9:00 a.m. Finally finished with the first patient. It was a follow-up visit that was scheduled as 15 minutes. I am now 45 minutes behind schedule. Thankfully, the MA managed to use the 45 minutes to room the 8:15 patient.
12:30 p.m. Whew, I just finished my morning. I start again in 30 minutes. I am never going to finish these 12 charts in 30 minutes. Also, I am hungry. If I don’t eat now, I am going to have my MA for lunch.
12:45 p.m. Speaking to Dr. Winchester from Blue Cross to get approval for a contrast MRI of the right foot. (This call may be recorded. What did your x-rays show? Have you failed conservative treatment? Will it change management? Here’s your approval number.)
1:00 p.m. The new patient is here. She is the proud owner of a very long med list. It’ll probably take the MA 30 minutes to get through all that. Let me call dermatology in the meantime; I need a full-thickness skin biopsy on Mrs. Rodrigues. (One week later, biopsy shows polyarteritis nodosa.)
3:15 p.m. I just finished a visit with Silvi. Her rheumatoid arthritis is quiescent, but she is in tears. Not only did her mother die unexpectedly from a ruptured aneurysm 2 months ago, she has just received a new diagnosis of breast cancer, and her husband lost his job. I can’t make this stuff up. That was an emotionally draining visit. I need a drink. Oh wait, there are no drinks to be had at a doctor’s office. Maybe the drug rep brought some ice cream.
3:20 p.m. Some ice cream regret going on here.
4:40 p.m. Just got done with a new-patient consultation for a "positive" antinuclear antibody test of 1:40 and a positive systems review. I’m exhausted.
6:15 p.m. Returning phone calls. Mrs. Greggerson is regaling me with details of her ablutions.
6:35 p.m. Filling out prior authorization forms for a biologic. Among the questions: A1c, T score, growth velocity, Mini-Mental State Exam, free and total testosterone, hepatitis C viral load and genotype. I would like to officially nominate this form for Most Number of Irrelevant Questions Ever.
7:00 p.m. Finally, last prior-authorization form for the day. Wait ... it’s for methotrexate? Since when have I needed to get prior authorization for methotrexate? I didn’t think it was even possible for me to get any angrier after the Mini-Mental State question.
8:00 p.m. Finally home. I’m too beat to go to the gym. My good decision–making reserves are exhausted. I would rather have a glass of red. The resveratrol will do me more good than a workout.
Dr. Chan practices rheumatology in Pawtucket, R.I.
7:00 a.m. When they called me for this consult on this young female with known lupus presenting with pleuritic chest pain, they didn’t tell me that (a) she has a history of pleural effusions, and (b) her creatinine is 4.9 mg/dL.
8:00 a.m. Waiting for my patient to be roomed. We’re implementing a new electronic health record, so I have to wait for the medical assistant (MA) to finish her tasks: input the patient’s medications, take his vital signs, and ask for his chief complaint.
8:20 a.m. Patient is still not ready for me. Who thought it would be a good idea for the MA to take the patient’s medications? It’d be so much more efficient if I did it myself.
9:00 a.m. Finally finished with the first patient. It was a follow-up visit that was scheduled as 15 minutes. I am now 45 minutes behind schedule. Thankfully, the MA managed to use the 45 minutes to room the 8:15 patient.
12:30 p.m. Whew, I just finished my morning. I start again in 30 minutes. I am never going to finish these 12 charts in 30 minutes. Also, I am hungry. If I don’t eat now, I am going to have my MA for lunch.
12:45 p.m. Speaking to Dr. Winchester from Blue Cross to get approval for a contrast MRI of the right foot. (This call may be recorded. What did your x-rays show? Have you failed conservative treatment? Will it change management? Here’s your approval number.)
1:00 p.m. The new patient is here. She is the proud owner of a very long med list. It’ll probably take the MA 30 minutes to get through all that. Let me call dermatology in the meantime; I need a full-thickness skin biopsy on Mrs. Rodrigues. (One week later, biopsy shows polyarteritis nodosa.)
3:15 p.m. I just finished a visit with Silvi. Her rheumatoid arthritis is quiescent, but she is in tears. Not only did her mother die unexpectedly from a ruptured aneurysm 2 months ago, she has just received a new diagnosis of breast cancer, and her husband lost his job. I can’t make this stuff up. That was an emotionally draining visit. I need a drink. Oh wait, there are no drinks to be had at a doctor’s office. Maybe the drug rep brought some ice cream.
3:20 p.m. Some ice cream regret going on here.
4:40 p.m. Just got done with a new-patient consultation for a "positive" antinuclear antibody test of 1:40 and a positive systems review. I’m exhausted.
6:15 p.m. Returning phone calls. Mrs. Greggerson is regaling me with details of her ablutions.
6:35 p.m. Filling out prior authorization forms for a biologic. Among the questions: A1c, T score, growth velocity, Mini-Mental State Exam, free and total testosterone, hepatitis C viral load and genotype. I would like to officially nominate this form for Most Number of Irrelevant Questions Ever.
7:00 p.m. Finally, last prior-authorization form for the day. Wait ... it’s for methotrexate? Since when have I needed to get prior authorization for methotrexate? I didn’t think it was even possible for me to get any angrier after the Mini-Mental State question.
8:00 p.m. Finally home. I’m too beat to go to the gym. My good decision–making reserves are exhausted. I would rather have a glass of red. The resveratrol will do me more good than a workout.
Dr. Chan practices rheumatology in Pawtucket, R.I.
7:00 a.m. When they called me for this consult on this young female with known lupus presenting with pleuritic chest pain, they didn’t tell me that (a) she has a history of pleural effusions, and (b) her creatinine is 4.9 mg/dL.
8:00 a.m. Waiting for my patient to be roomed. We’re implementing a new electronic health record, so I have to wait for the medical assistant (MA) to finish her tasks: input the patient’s medications, take his vital signs, and ask for his chief complaint.
8:20 a.m. Patient is still not ready for me. Who thought it would be a good idea for the MA to take the patient’s medications? It’d be so much more efficient if I did it myself.
9:00 a.m. Finally finished with the first patient. It was a follow-up visit that was scheduled as 15 minutes. I am now 45 minutes behind schedule. Thankfully, the MA managed to use the 45 minutes to room the 8:15 patient.
12:30 p.m. Whew, I just finished my morning. I start again in 30 minutes. I am never going to finish these 12 charts in 30 minutes. Also, I am hungry. If I don’t eat now, I am going to have my MA for lunch.
12:45 p.m. Speaking to Dr. Winchester from Blue Cross to get approval for a contrast MRI of the right foot. (This call may be recorded. What did your x-rays show? Have you failed conservative treatment? Will it change management? Here’s your approval number.)
1:00 p.m. The new patient is here. She is the proud owner of a very long med list. It’ll probably take the MA 30 minutes to get through all that. Let me call dermatology in the meantime; I need a full-thickness skin biopsy on Mrs. Rodrigues. (One week later, biopsy shows polyarteritis nodosa.)
3:15 p.m. I just finished a visit with Silvi. Her rheumatoid arthritis is quiescent, but she is in tears. Not only did her mother die unexpectedly from a ruptured aneurysm 2 months ago, she has just received a new diagnosis of breast cancer, and her husband lost his job. I can’t make this stuff up. That was an emotionally draining visit. I need a drink. Oh wait, there are no drinks to be had at a doctor’s office. Maybe the drug rep brought some ice cream.
3:20 p.m. Some ice cream regret going on here.
4:40 p.m. Just got done with a new-patient consultation for a "positive" antinuclear antibody test of 1:40 and a positive systems review. I’m exhausted.
6:15 p.m. Returning phone calls. Mrs. Greggerson is regaling me with details of her ablutions.
6:35 p.m. Filling out prior authorization forms for a biologic. Among the questions: A1c, T score, growth velocity, Mini-Mental State Exam, free and total testosterone, hepatitis C viral load and genotype. I would like to officially nominate this form for Most Number of Irrelevant Questions Ever.
7:00 p.m. Finally, last prior-authorization form for the day. Wait ... it’s for methotrexate? Since when have I needed to get prior authorization for methotrexate? I didn’t think it was even possible for me to get any angrier after the Mini-Mental State question.
8:00 p.m. Finally home. I’m too beat to go to the gym. My good decision–making reserves are exhausted. I would rather have a glass of red. The resveratrol will do me more good than a workout.
Dr. Chan practices rheumatology in Pawtucket, R.I.
Medicare payment data: a no-win situation for doctors
Recently, Medicare released its 2012 payment data, showing that they paid $77 billion to doctors that year.
So, like many doctors, I got curious and ran my own numbers. If I’m doing the math correctly (which is always questionable), my share of it was $59,622. This is considerably less than the overall average of $87,500 that the 880,000 Medicare-accepting doctors received, and certainly nowhere near the $21 million that the nation’s No. 1 Medicare money recipient, Dr. Salomon Melgan (ophthalmology) of Florida raked in from Uncle Sam.
Now, unlike the popular press, I’m not going to knock Dr. Melgan. From what I’ve read, he uses a lot of Lucentis in his practice for macular degeneration. At roughly $2,000 (doctor’s cost) per dose, I’m sure his overhead is pretty high. I’ll leave those questions to the lawyers.
But it leaves me staring at my number and wondering if I’m doing something wrong. Granted, Medicare isn’t the only insurance I take, but still ... For comparison, that $59,662 doesn’t even cover the salaries of my two awesome, hard-working, staff members.
The trouble is that, like many other doctors, I work a pretty full schedule. Roughly 60-70 hours a week. Unlike the physicians of yore, I don’t take Wednesday afternoon off to go golfing (actually, I’ve never golfed on a real course in my life). I don’t double-book my appointment schedule. I don’t do frivolous procedures just for the billing (though I’m sure what I consider frivolous more successful doctors call necessary). I don’t charge level-5 visits for simple stuff. And I run a relatively low overhead. So why are most doctors today, including me, barely breaking even for trying to run an honest, ethical, practice?
Of course, venting this kind of thing in public is a no-win situation for doctors. We’re seen as either greedy or whiny. People in most other professions aren’t paying $30,000-$300,000 in malpractice insurance or coming out of school $200,000 in debt. Doctors who are actually charging for visits so they can pay their bills and support their families are terrible people because caring should be free.
Medicine is, in many respects, an intangible science. People may be horrified by what they’re charged for a 15-minute visit, but don’t see the 8-15 years (or more) of training behind them. And when they’re feeling better, we’re often forgotten or vilified for daring to charge them a copay.
The bottom line is that the money paid out by Medicare isn’t a fair assessment of our efforts. It’s a raw number, that doesn’t take into account the cost of drugs we have to purchase ($1,050 for a single bottle of Botox), the equipment we need to buy ($16,000 for a basic electromyogram/nerve conduction velocity machine), rent ($2,700 per month for me), malpractice insurance, staff salaries, billing services, office supplies, licensing fees. ... The list goes on, including a measure that you can’t put a price on: lives saved and improved.
Taken in this context, the $77 billion dollars is simply a tool that politicians and media pundits will twist to support whatever argument they want it to. Because, after all, most doctors are too busy helping others to defend themselves.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Recently, Medicare released its 2012 payment data, showing that they paid $77 billion to doctors that year.
So, like many doctors, I got curious and ran my own numbers. If I’m doing the math correctly (which is always questionable), my share of it was $59,622. This is considerably less than the overall average of $87,500 that the 880,000 Medicare-accepting doctors received, and certainly nowhere near the $21 million that the nation’s No. 1 Medicare money recipient, Dr. Salomon Melgan (ophthalmology) of Florida raked in from Uncle Sam.
Now, unlike the popular press, I’m not going to knock Dr. Melgan. From what I’ve read, he uses a lot of Lucentis in his practice for macular degeneration. At roughly $2,000 (doctor’s cost) per dose, I’m sure his overhead is pretty high. I’ll leave those questions to the lawyers.
But it leaves me staring at my number and wondering if I’m doing something wrong. Granted, Medicare isn’t the only insurance I take, but still ... For comparison, that $59,662 doesn’t even cover the salaries of my two awesome, hard-working, staff members.
The trouble is that, like many other doctors, I work a pretty full schedule. Roughly 60-70 hours a week. Unlike the physicians of yore, I don’t take Wednesday afternoon off to go golfing (actually, I’ve never golfed on a real course in my life). I don’t double-book my appointment schedule. I don’t do frivolous procedures just for the billing (though I’m sure what I consider frivolous more successful doctors call necessary). I don’t charge level-5 visits for simple stuff. And I run a relatively low overhead. So why are most doctors today, including me, barely breaking even for trying to run an honest, ethical, practice?
Of course, venting this kind of thing in public is a no-win situation for doctors. We’re seen as either greedy or whiny. People in most other professions aren’t paying $30,000-$300,000 in malpractice insurance or coming out of school $200,000 in debt. Doctors who are actually charging for visits so they can pay their bills and support their families are terrible people because caring should be free.
Medicine is, in many respects, an intangible science. People may be horrified by what they’re charged for a 15-minute visit, but don’t see the 8-15 years (or more) of training behind them. And when they’re feeling better, we’re often forgotten or vilified for daring to charge them a copay.
The bottom line is that the money paid out by Medicare isn’t a fair assessment of our efforts. It’s a raw number, that doesn’t take into account the cost of drugs we have to purchase ($1,050 for a single bottle of Botox), the equipment we need to buy ($16,000 for a basic electromyogram/nerve conduction velocity machine), rent ($2,700 per month for me), malpractice insurance, staff salaries, billing services, office supplies, licensing fees. ... The list goes on, including a measure that you can’t put a price on: lives saved and improved.
Taken in this context, the $77 billion dollars is simply a tool that politicians and media pundits will twist to support whatever argument they want it to. Because, after all, most doctors are too busy helping others to defend themselves.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Recently, Medicare released its 2012 payment data, showing that they paid $77 billion to doctors that year.
So, like many doctors, I got curious and ran my own numbers. If I’m doing the math correctly (which is always questionable), my share of it was $59,622. This is considerably less than the overall average of $87,500 that the 880,000 Medicare-accepting doctors received, and certainly nowhere near the $21 million that the nation’s No. 1 Medicare money recipient, Dr. Salomon Melgan (ophthalmology) of Florida raked in from Uncle Sam.
Now, unlike the popular press, I’m not going to knock Dr. Melgan. From what I’ve read, he uses a lot of Lucentis in his practice for macular degeneration. At roughly $2,000 (doctor’s cost) per dose, I’m sure his overhead is pretty high. I’ll leave those questions to the lawyers.
But it leaves me staring at my number and wondering if I’m doing something wrong. Granted, Medicare isn’t the only insurance I take, but still ... For comparison, that $59,662 doesn’t even cover the salaries of my two awesome, hard-working, staff members.
The trouble is that, like many other doctors, I work a pretty full schedule. Roughly 60-70 hours a week. Unlike the physicians of yore, I don’t take Wednesday afternoon off to go golfing (actually, I’ve never golfed on a real course in my life). I don’t double-book my appointment schedule. I don’t do frivolous procedures just for the billing (though I’m sure what I consider frivolous more successful doctors call necessary). I don’t charge level-5 visits for simple stuff. And I run a relatively low overhead. So why are most doctors today, including me, barely breaking even for trying to run an honest, ethical, practice?
Of course, venting this kind of thing in public is a no-win situation for doctors. We’re seen as either greedy or whiny. People in most other professions aren’t paying $30,000-$300,000 in malpractice insurance or coming out of school $200,000 in debt. Doctors who are actually charging for visits so they can pay their bills and support their families are terrible people because caring should be free.
Medicine is, in many respects, an intangible science. People may be horrified by what they’re charged for a 15-minute visit, but don’t see the 8-15 years (or more) of training behind them. And when they’re feeling better, we’re often forgotten or vilified for daring to charge them a copay.
The bottom line is that the money paid out by Medicare isn’t a fair assessment of our efforts. It’s a raw number, that doesn’t take into account the cost of drugs we have to purchase ($1,050 for a single bottle of Botox), the equipment we need to buy ($16,000 for a basic electromyogram/nerve conduction velocity machine), rent ($2,700 per month for me), malpractice insurance, staff salaries, billing services, office supplies, licensing fees. ... The list goes on, including a measure that you can’t put a price on: lives saved and improved.
Taken in this context, the $77 billion dollars is simply a tool that politicians and media pundits will twist to support whatever argument they want it to. Because, after all, most doctors are too busy helping others to defend themselves.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Making sure patients never walk alone
We are all painfully aware that falls are not uncommon in hospitalized patients, but I was shocked and appalled to learn that there are approximately 11,000 falls that are ultimately fatal in U.S. hospitals each year, according to the Joint Commission Center for Transforming Healthcare.
Fortunately, there appear to be some very viable solutions at hand.
Hospitals that use the center’s new measuring systems and solution have been able to slash the number of patients who fall by 35%, as well cutting the percentage of patients injured when they fall by 62%. Extrapolating these results to an average 200-bed hospital, an estimated $1 million could be saved each year through fall prevention efforts.
Hospitals participating in this study ranged from small community-based hospitals with fewer than 200 beds to large medical centers with more than 1,700 beds. All used a data-driven, Lean Six Sigma–inspired "Robust Process Improvement" methodology to determine the causes of falls and create solutions to prevent them. One solution was simply providing hourly rounding which included proactive toileting. When you think about it, this makes perfect sense. Patients with an immediate need may not be able to hold it until it is "their turn" for the nurse to assist them. In their haste to avoid soiling their clothes, a mechanical fall is very understandable, especially if they are impaired due to weakness or medication.
Other solutions included teaching patients how to actively participate in their own safety, engaging patients and family members in their fall safety program, using a validated fall risk assessment tool, and increasing awareness and participation among staff so that patients did not walk alone.
Most of us have received that dreaded call from the nurse about a patient who was injured from a fall. I once had a patient who slipped and fell, breaking a hip while in the hospital for a relatively minor issue. If she had been more stable on her feet, she probably could have caught herself prior to hitting the hard floor. Had a close relative not witnessed the incident, it would have been very difficult (and embarrassing) to explain to the family why their loved one experienced such a traumatic event while in a seemingly protected environment. Her son was very understanding, though the event was very disconcerting all the same.
Based on their staffing, resources, and creativity, different hospitals may develop different innovative solutions to prevent falls. There is room for a wide variety of options. Yes, early ambulation is crucial to help prevent unnecessary complications, such as pneumonia and blood clots, but we should be mindful of the individual patient’s circumstances. A simple order requesting the nurse to ambulate a patient in the room or down the hall two or three times a day may be adequate for some, while in other cases a formal physical therapy consultation may clearly be in order. If there are any concerns over the patient’s ability to ambulate safely and I am not sure if a physical therapy consult is really needed, I sometimes call the nurse into the room and the two of us walk with the patient. That way, I can get an immediate sense of the likelihood of falls, the need for dedicated strengthening exercises, and, on occasion, the impact that medications are having on gait. And for those difficult, unmotivated patients, family members can frequently provide invaluable encouragement, as well as the emotional, and sometimes physical safety net many patients desire.
With safety interventions and highly engaged care teams in place, even steady patients never walk truly alone.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected]
We are all painfully aware that falls are not uncommon in hospitalized patients, but I was shocked and appalled to learn that there are approximately 11,000 falls that are ultimately fatal in U.S. hospitals each year, according to the Joint Commission Center for Transforming Healthcare.
Fortunately, there appear to be some very viable solutions at hand.
Hospitals that use the center’s new measuring systems and solution have been able to slash the number of patients who fall by 35%, as well cutting the percentage of patients injured when they fall by 62%. Extrapolating these results to an average 200-bed hospital, an estimated $1 million could be saved each year through fall prevention efforts.
Hospitals participating in this study ranged from small community-based hospitals with fewer than 200 beds to large medical centers with more than 1,700 beds. All used a data-driven, Lean Six Sigma–inspired "Robust Process Improvement" methodology to determine the causes of falls and create solutions to prevent them. One solution was simply providing hourly rounding which included proactive toileting. When you think about it, this makes perfect sense. Patients with an immediate need may not be able to hold it until it is "their turn" for the nurse to assist them. In their haste to avoid soiling their clothes, a mechanical fall is very understandable, especially if they are impaired due to weakness or medication.
Other solutions included teaching patients how to actively participate in their own safety, engaging patients and family members in their fall safety program, using a validated fall risk assessment tool, and increasing awareness and participation among staff so that patients did not walk alone.
Most of us have received that dreaded call from the nurse about a patient who was injured from a fall. I once had a patient who slipped and fell, breaking a hip while in the hospital for a relatively minor issue. If she had been more stable on her feet, she probably could have caught herself prior to hitting the hard floor. Had a close relative not witnessed the incident, it would have been very difficult (and embarrassing) to explain to the family why their loved one experienced such a traumatic event while in a seemingly protected environment. Her son was very understanding, though the event was very disconcerting all the same.
Based on their staffing, resources, and creativity, different hospitals may develop different innovative solutions to prevent falls. There is room for a wide variety of options. Yes, early ambulation is crucial to help prevent unnecessary complications, such as pneumonia and blood clots, but we should be mindful of the individual patient’s circumstances. A simple order requesting the nurse to ambulate a patient in the room or down the hall two or three times a day may be adequate for some, while in other cases a formal physical therapy consultation may clearly be in order. If there are any concerns over the patient’s ability to ambulate safely and I am not sure if a physical therapy consult is really needed, I sometimes call the nurse into the room and the two of us walk with the patient. That way, I can get an immediate sense of the likelihood of falls, the need for dedicated strengthening exercises, and, on occasion, the impact that medications are having on gait. And for those difficult, unmotivated patients, family members can frequently provide invaluable encouragement, as well as the emotional, and sometimes physical safety net many patients desire.
With safety interventions and highly engaged care teams in place, even steady patients never walk truly alone.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected]
We are all painfully aware that falls are not uncommon in hospitalized patients, but I was shocked and appalled to learn that there are approximately 11,000 falls that are ultimately fatal in U.S. hospitals each year, according to the Joint Commission Center for Transforming Healthcare.
Fortunately, there appear to be some very viable solutions at hand.
Hospitals that use the center’s new measuring systems and solution have been able to slash the number of patients who fall by 35%, as well cutting the percentage of patients injured when they fall by 62%. Extrapolating these results to an average 200-bed hospital, an estimated $1 million could be saved each year through fall prevention efforts.
Hospitals participating in this study ranged from small community-based hospitals with fewer than 200 beds to large medical centers with more than 1,700 beds. All used a data-driven, Lean Six Sigma–inspired "Robust Process Improvement" methodology to determine the causes of falls and create solutions to prevent them. One solution was simply providing hourly rounding which included proactive toileting. When you think about it, this makes perfect sense. Patients with an immediate need may not be able to hold it until it is "their turn" for the nurse to assist them. In their haste to avoid soiling their clothes, a mechanical fall is very understandable, especially if they are impaired due to weakness or medication.
Other solutions included teaching patients how to actively participate in their own safety, engaging patients and family members in their fall safety program, using a validated fall risk assessment tool, and increasing awareness and participation among staff so that patients did not walk alone.
Most of us have received that dreaded call from the nurse about a patient who was injured from a fall. I once had a patient who slipped and fell, breaking a hip while in the hospital for a relatively minor issue. If she had been more stable on her feet, she probably could have caught herself prior to hitting the hard floor. Had a close relative not witnessed the incident, it would have been very difficult (and embarrassing) to explain to the family why their loved one experienced such a traumatic event while in a seemingly protected environment. Her son was very understanding, though the event was very disconcerting all the same.
Based on their staffing, resources, and creativity, different hospitals may develop different innovative solutions to prevent falls. There is room for a wide variety of options. Yes, early ambulation is crucial to help prevent unnecessary complications, such as pneumonia and blood clots, but we should be mindful of the individual patient’s circumstances. A simple order requesting the nurse to ambulate a patient in the room or down the hall two or three times a day may be adequate for some, while in other cases a formal physical therapy consultation may clearly be in order. If there are any concerns over the patient’s ability to ambulate safely and I am not sure if a physical therapy consult is really needed, I sometimes call the nurse into the room and the two of us walk with the patient. That way, I can get an immediate sense of the likelihood of falls, the need for dedicated strengthening exercises, and, on occasion, the impact that medications are having on gait. And for those difficult, unmotivated patients, family members can frequently provide invaluable encouragement, as well as the emotional, and sometimes physical safety net many patients desire.
With safety interventions and highly engaged care teams in place, even steady patients never walk truly alone.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected]
