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Gender Disparities in Occupational Health
Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.
Gender differences in occupational asthma were also seen in snow crab processing plant workers. Women were significantly more likely to have occupational asthma than men. However, they found that overall, women had a greater cumulative exposure to crab allergens, which may be a major contributor to this disparity (Howse et al. Environ Res. 2006;101[2]:163).
Although several occupational health studies are beginning to highlight gender disparities, a major confounding factor is that of occupational segregation, meaning the under-representation of one gender in some jobs and over-representation in others. Differences in jobs and tasks even within the same job title between men and women are often major contributors to gender disparities [WHO Dept of Gender, Women and Health, 2006]. Also, several studies suggest that more women should be included in toxicology and occupational cancer studies, since currently, they have included mostly men (Sorrentino et al. Ann Ist Super Sanità. 2016;52[2]:190). Perhaps future studies can improve the overall understanding of these important contributing factors to gender disparities in occupational health.
Krystal Cleven, MD
Fellow-in-Training Member
Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?
Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.
Douglas E. Masini, EdD, FCCP
Steering Committee Member
Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators
Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).
However, after reviewing the public input and data, the FRA and FMCSA recently announced that there was “not enough information available to support moving forward with a rulemaking action,” and, therefore, they are no longer pursuing the regulation that would require SA screening for truck drivers and train engineers (Federal Register August 2017;49 CFR 391,240,242). See CHEST’s press release at www.chestnet.org/News/Press-Releases/2017/08/American-College-of-Chest-Physicians-Responds-to-DOT-Withdrawal-of-Sleep-Apnea-Screening. The FMCSA endorses existing resources,such as the North American Fatigue Management Program (NAFMP) (www.nafmp.org), which is a web-based program designed to reduce driver fatigue and includes information on SA screening and treatment. The medical examiners, however, will have the ultimate responsibility to screen, diagnose, and treat SA based on their medical knowledge and clinical experience.
Vaishnavi Kundel, MD
NetWork Member
Steering Committee Member
Corrections to previous NetWork articles
July 2017
Clinical Research
Mohsin Ijaz’s name was misspelled.
August 2017
Transplant
The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.
The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.
Gender Disparities in Occupational Health
Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.
Gender differences in occupational asthma were also seen in snow crab processing plant workers. Women were significantly more likely to have occupational asthma than men. However, they found that overall, women had a greater cumulative exposure to crab allergens, which may be a major contributor to this disparity (Howse et al. Environ Res. 2006;101[2]:163).
Although several occupational health studies are beginning to highlight gender disparities, a major confounding factor is that of occupational segregation, meaning the under-representation of one gender in some jobs and over-representation in others. Differences in jobs and tasks even within the same job title between men and women are often major contributors to gender disparities [WHO Dept of Gender, Women and Health, 2006]. Also, several studies suggest that more women should be included in toxicology and occupational cancer studies, since currently, they have included mostly men (Sorrentino et al. Ann Ist Super Sanità. 2016;52[2]:190). Perhaps future studies can improve the overall understanding of these important contributing factors to gender disparities in occupational health.
Krystal Cleven, MD
Fellow-in-Training Member
Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?
Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.
Douglas E. Masini, EdD, FCCP
Steering Committee Member
Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators
Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).
However, after reviewing the public input and data, the FRA and FMCSA recently announced that there was “not enough information available to support moving forward with a rulemaking action,” and, therefore, they are no longer pursuing the regulation that would require SA screening for truck drivers and train engineers (Federal Register August 2017;49 CFR 391,240,242). See CHEST’s press release at www.chestnet.org/News/Press-Releases/2017/08/American-College-of-Chest-Physicians-Responds-to-DOT-Withdrawal-of-Sleep-Apnea-Screening. The FMCSA endorses existing resources,such as the North American Fatigue Management Program (NAFMP) (www.nafmp.org), which is a web-based program designed to reduce driver fatigue and includes information on SA screening and treatment. The medical examiners, however, will have the ultimate responsibility to screen, diagnose, and treat SA based on their medical knowledge and clinical experience.
Vaishnavi Kundel, MD
NetWork Member
Steering Committee Member
Corrections to previous NetWork articles
July 2017
Clinical Research
Mohsin Ijaz’s name was misspelled.
August 2017
Transplant
The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.
The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.
Gender Disparities in Occupational Health
Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.
Gender differences in occupational asthma were also seen in snow crab processing plant workers. Women were significantly more likely to have occupational asthma than men. However, they found that overall, women had a greater cumulative exposure to crab allergens, which may be a major contributor to this disparity (Howse et al. Environ Res. 2006;101[2]:163).
Although several occupational health studies are beginning to highlight gender disparities, a major confounding factor is that of occupational segregation, meaning the under-representation of one gender in some jobs and over-representation in others. Differences in jobs and tasks even within the same job title between men and women are often major contributors to gender disparities [WHO Dept of Gender, Women and Health, 2006]. Also, several studies suggest that more women should be included in toxicology and occupational cancer studies, since currently, they have included mostly men (Sorrentino et al. Ann Ist Super Sanità. 2016;52[2]:190). Perhaps future studies can improve the overall understanding of these important contributing factors to gender disparities in occupational health.
Krystal Cleven, MD
Fellow-in-Training Member
Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?
Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.
Douglas E. Masini, EdD, FCCP
Steering Committee Member
Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators
Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).
However, after reviewing the public input and data, the FRA and FMCSA recently announced that there was “not enough information available to support moving forward with a rulemaking action,” and, therefore, they are no longer pursuing the regulation that would require SA screening for truck drivers and train engineers (Federal Register August 2017;49 CFR 391,240,242). See CHEST’s press release at www.chestnet.org/News/Press-Releases/2017/08/American-College-of-Chest-Physicians-Responds-to-DOT-Withdrawal-of-Sleep-Apnea-Screening. The FMCSA endorses existing resources,such as the North American Fatigue Management Program (NAFMP) (www.nafmp.org), which is a web-based program designed to reduce driver fatigue and includes information on SA screening and treatment. The medical examiners, however, will have the ultimate responsibility to screen, diagnose, and treat SA based on their medical knowledge and clinical experience.
Vaishnavi Kundel, MD
NetWork Member
Steering Committee Member
Corrections to previous NetWork articles
July 2017
Clinical Research
Mohsin Ijaz’s name was misspelled.
August 2017
Transplant
The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.
The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.
This month in CHEST : Editor’s picks
Giants in Chest Medicine
Jack Hirsh, MD, FCCP.
By Dr. S. Z. Goldhaber.
Original Research
IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia.
By Dr. A. Padmanabhan et al.
The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD:
A Population-Based Cohort Study.
By Dr. A. J. Raymakers et al.
Pathologic Findings and Prognosis in a Large Prospective Cohort of Chronic Hypersensitivity Pneumonitis.
By Dr. P. Wang et al.
Evidence-based Medicine
Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report.
By Dr. A. B. Chang et al, on behalf of the CHEST Expert Cough Panel.
Giants in Chest Medicine
Jack Hirsh, MD, FCCP.
By Dr. S. Z. Goldhaber.
Original Research
IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia.
By Dr. A. Padmanabhan et al.
The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD:
A Population-Based Cohort Study.
By Dr. A. J. Raymakers et al.
Pathologic Findings and Prognosis in a Large Prospective Cohort of Chronic Hypersensitivity Pneumonitis.
By Dr. P. Wang et al.
Evidence-based Medicine
Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report.
By Dr. A. B. Chang et al, on behalf of the CHEST Expert Cough Panel.
Giants in Chest Medicine
Jack Hirsh, MD, FCCP.
By Dr. S. Z. Goldhaber.
Original Research
IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia.
By Dr. A. Padmanabhan et al.
The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD:
A Population-Based Cohort Study.
By Dr. A. J. Raymakers et al.
Pathologic Findings and Prognosis in a Large Prospective Cohort of Chronic Hypersensitivity Pneumonitis.
By Dr. P. Wang et al.
Evidence-based Medicine
Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report.
By Dr. A. B. Chang et al, on behalf of the CHEST Expert Cough Panel.
CHEST 2017 Keynote Speaker
John O’Leary is a father of four, business owner, speaker, writer, and former hospital chaplain—a fortunate guy. But he attributes the best of everything he has to an unfortunate event that happened back in 1987.
At the age of 9, O’Leary was involved in a house fire that left burns on 100% of his body, 87% of which were third degree. Doctors gave O’Leary less than a 1% chance to live, odds that were overwhelming—but not entirely impossible to beat.
Despite what the health-care professionals told his mother, when O’Leary asked her if he was going to die, she responded by asking her son if he wanted to die or if he wanted to live: a question that O’Leary says must have taken lot more courage for a mother to ask than it did for a 9-year-old to answer.
Although he was taken aback, the answer seemed obvious to O’Leary. Of course he wanted to live. And live he did, but only after 5 months in the hospital and the amputation of all of his fingers.
After he returned to school 18 months later with his classmates welcoming him back with a parade, O’Leary didn’t see the necessity in sharing his story. “I always knew my story, I just never truly embraced it.”
O’Leary’s father told him that he wanted to thank the community members who truly helped their family through the tough times and that he planned to do so by writing a book. With the help of O’Leary’s mother, 100 copies of Overwhelming Odds were originally printed and given to members of the community. Today, over 70,000 copies of their book have been sold.
When some Girl Scouts approached O’Leary and asked him to share his story with their troop and their parents, his life changed. O’Leary says that he now tries to say yes to each person/organization that asks him to share. As a result, he has said yes over 1,500 times and has even made a life of it.
“We confuse being out of bed with being awake, being at work with being fully engaged, or being with a patient with being actively present for and with that patient,” O’Leary says of accidental living. “That’s not really awake; that’s not alive. It’s more of sleepwalking through life.”
O’Leary believes that too often we give away the freedom of life to things that are out of our control and that he feels it is his job to remind his listeners that there are a lot of things in our control on which we should be fully living. “We want people to realize they have the ability to be actively present in every engagement and every decision, every thought, and every word, and ultimately, every result in their lives.”
CHEST Annual Meeting 2017 is one of the events that O’Leary has recently said “yes” to, and he is very excited about it. “As things continue to change…we can forget why we got into what we got into,” O’Leary says. “I am excited to remind everyone at CHEST about the profoundly beautiful nature of their work and how it has the ability to affect both the staff and patients.”
Members of O’Leary’s medical team, as well as other hospital staff members, were crucial to his survival and improved health. One of his doctors was not only a respected physician and surgeon but also a powerful leader who was capable of reminding every member of the hospital of their purpose and necessity to a patient’s life, something that O’Leary hopes can be common in every health-care team.
“When you have the chance to influence men and women who serve patients and teams and impact lives and do it generationally—I think we forget that it is a generational ripple effect; my kids are where and who they are today because doctors, nurses, practitioners, and janitors showed up 30 years ago.”
John O’Leary is a father of four, business owner, speaker, writer, and former hospital chaplain—a fortunate guy. But he attributes the best of everything he has to an unfortunate event that happened back in 1987.
At the age of 9, O’Leary was involved in a house fire that left burns on 100% of his body, 87% of which were third degree. Doctors gave O’Leary less than a 1% chance to live, odds that were overwhelming—but not entirely impossible to beat.
Despite what the health-care professionals told his mother, when O’Leary asked her if he was going to die, she responded by asking her son if he wanted to die or if he wanted to live: a question that O’Leary says must have taken lot more courage for a mother to ask than it did for a 9-year-old to answer.
Although he was taken aback, the answer seemed obvious to O’Leary. Of course he wanted to live. And live he did, but only after 5 months in the hospital and the amputation of all of his fingers.
After he returned to school 18 months later with his classmates welcoming him back with a parade, O’Leary didn’t see the necessity in sharing his story. “I always knew my story, I just never truly embraced it.”
O’Leary’s father told him that he wanted to thank the community members who truly helped their family through the tough times and that he planned to do so by writing a book. With the help of O’Leary’s mother, 100 copies of Overwhelming Odds were originally printed and given to members of the community. Today, over 70,000 copies of their book have been sold.
When some Girl Scouts approached O’Leary and asked him to share his story with their troop and their parents, his life changed. O’Leary says that he now tries to say yes to each person/organization that asks him to share. As a result, he has said yes over 1,500 times and has even made a life of it.
“We confuse being out of bed with being awake, being at work with being fully engaged, or being with a patient with being actively present for and with that patient,” O’Leary says of accidental living. “That’s not really awake; that’s not alive. It’s more of sleepwalking through life.”
O’Leary believes that too often we give away the freedom of life to things that are out of our control and that he feels it is his job to remind his listeners that there are a lot of things in our control on which we should be fully living. “We want people to realize they have the ability to be actively present in every engagement and every decision, every thought, and every word, and ultimately, every result in their lives.”
CHEST Annual Meeting 2017 is one of the events that O’Leary has recently said “yes” to, and he is very excited about it. “As things continue to change…we can forget why we got into what we got into,” O’Leary says. “I am excited to remind everyone at CHEST about the profoundly beautiful nature of their work and how it has the ability to affect both the staff and patients.”
Members of O’Leary’s medical team, as well as other hospital staff members, were crucial to his survival and improved health. One of his doctors was not only a respected physician and surgeon but also a powerful leader who was capable of reminding every member of the hospital of their purpose and necessity to a patient’s life, something that O’Leary hopes can be common in every health-care team.
“When you have the chance to influence men and women who serve patients and teams and impact lives and do it generationally—I think we forget that it is a generational ripple effect; my kids are where and who they are today because doctors, nurses, practitioners, and janitors showed up 30 years ago.”
John O’Leary is a father of four, business owner, speaker, writer, and former hospital chaplain—a fortunate guy. But he attributes the best of everything he has to an unfortunate event that happened back in 1987.
At the age of 9, O’Leary was involved in a house fire that left burns on 100% of his body, 87% of which were third degree. Doctors gave O’Leary less than a 1% chance to live, odds that were overwhelming—but not entirely impossible to beat.
Despite what the health-care professionals told his mother, when O’Leary asked her if he was going to die, she responded by asking her son if he wanted to die or if he wanted to live: a question that O’Leary says must have taken lot more courage for a mother to ask than it did for a 9-year-old to answer.
Although he was taken aback, the answer seemed obvious to O’Leary. Of course he wanted to live. And live he did, but only after 5 months in the hospital and the amputation of all of his fingers.
After he returned to school 18 months later with his classmates welcoming him back with a parade, O’Leary didn’t see the necessity in sharing his story. “I always knew my story, I just never truly embraced it.”
O’Leary’s father told him that he wanted to thank the community members who truly helped their family through the tough times and that he planned to do so by writing a book. With the help of O’Leary’s mother, 100 copies of Overwhelming Odds were originally printed and given to members of the community. Today, over 70,000 copies of their book have been sold.
When some Girl Scouts approached O’Leary and asked him to share his story with their troop and their parents, his life changed. O’Leary says that he now tries to say yes to each person/organization that asks him to share. As a result, he has said yes over 1,500 times and has even made a life of it.
“We confuse being out of bed with being awake, being at work with being fully engaged, or being with a patient with being actively present for and with that patient,” O’Leary says of accidental living. “That’s not really awake; that’s not alive. It’s more of sleepwalking through life.”
O’Leary believes that too often we give away the freedom of life to things that are out of our control and that he feels it is his job to remind his listeners that there are a lot of things in our control on which we should be fully living. “We want people to realize they have the ability to be actively present in every engagement and every decision, every thought, and every word, and ultimately, every result in their lives.”
CHEST Annual Meeting 2017 is one of the events that O’Leary has recently said “yes” to, and he is very excited about it. “As things continue to change…we can forget why we got into what we got into,” O’Leary says. “I am excited to remind everyone at CHEST about the profoundly beautiful nature of their work and how it has the ability to affect both the staff and patients.”
Members of O’Leary’s medical team, as well as other hospital staff members, were crucial to his survival and improved health. One of his doctors was not only a respected physician and surgeon but also a powerful leader who was capable of reminding every member of the hospital of their purpose and necessity to a patient’s life, something that O’Leary hopes can be common in every health-care team.
“When you have the chance to influence men and women who serve patients and teams and impact lives and do it generationally—I think we forget that it is a generational ripple effect; my kids are where and who they are today because doctors, nurses, practitioners, and janitors showed up 30 years ago.”
NAMDRC Update
The old adage of not wanting to see how laws or sausage is made holds true today, perhaps more so than ever. But certain clinical realities within pulmonary medicine virtually ensure that legislation is actually part of any reasonable solution.
NAMDRC has initiated an outreach to all the key medical, allied health, and patient societies that focus on pulmonary medicine to determine if consensus can be reached on a focused laundry list of issues that, for varying reasons, lean toward Congress for legislative solutions.
Here is a list of some of the issues under discussion:
• Home mechanical ventilation. Under current law, “ventilators” are covered items under the durable medical equipment benefit. In the 1990s, in order to circumvent statutory requirements that ventilators be paid under a “frequent and substantial servicing” payment methodology, HCFA (now CMS) created a new category – respiratory assist devices and declared that these devices, despite classification by FDA as ventilators, are not ventilators in reality, and the payment methodology, therefore, does not apply.
Over the past several years, the pulmonary medicine community tried its best to convince CMS that its rules were problematic, archaic, and costing the Medicare program tens of millions of dollars in unnecessary expenditures. A formal submission to CMS, a request for a National Coverage Determination reconsideration, was denied with a phrase now echoed throughout health care, “it’s complicated.” The only effective solution is a legislative one.
• High flow oxygen therapy for ILD patients. Oxygen remains the largest single component of the durable medical equipment benefit and, largely due to competitive bidding, has seen payment drop dramatically since the implementation of competitive bidding.
One can easily argue that competitive pricing is self-inflicted by the DME industry as the rates are set through a complicated formula based on bids from suppliers. But the impact has been particularly hard on liquid systems, the delivery system choice of not only many Medicare beneficiaries but also is the modality of choice for patients with clear need for high flow oxygen. While delivery in the home for high flow needs can be met by some stationary concentrators, the virtual disappearance of liquid systems, attributable to pricing triggered by competitive bidding, results in many ILD patients unable to leave their homes. The only effective solution is a legislative one.
• Section 603. This provision of the Balanced Budget Act of 2015 was designed to inhibit hospital purchases of certain physician practices that were based on aberrations within the Medicare payment system that rewarded hospitals significantly more than the same service provided in a physician office. For example, a physician office-based sleep lab may be able to bill Medicare for a particular service, but if the hospital purchases that physician practice and bills for the same service, it might receive upwards of twice as much payment.
While all involved seem to agree that this provision was not intended to target pulmonary rehabilitation services, it is being hit particularly hard by CMS rules implementing the statute. Any new pulmonary rehab program that is not within 250 yards of the main hospital campus must bill at the physician fee schedule rate, a rate about half of the hospital outpatient rate. Furthermore, existing programs that choose to expand must do so within the confines of their specific current location, unable to move a floor away. Doing so would trigger the reduced payment methodology.
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CMS agrees this is clearly an example of unintended consequences, but CMS also acknowledges it does not have the authority to remedy the situation. The agency itself signaled the only way to exempt pulmonary rehabilitation services is to seek Congressional action.
And now to the “sausage” part of the equation. Congressional action on virtually anything except renaming a post office becomes a political, as well as substantive, challenge. Here are just some of the considerations that must be addressed by any legislative strategy.
1. Any “fix” must be clinically sound and supported across a broad cross section of physician and patient groups. And the fix must give some level of flexibility to CMS to implement it in a reasonable way but tie their hands to force changes in policy.
2. Any “fix” must have a strong political strategy that can muster support within key Congressional committees (House Ways & Means Committee and Energy & Commerce Committee, along with the Senate Finance Committee, let alone 218 votes in the House and 51 votes in the Senate.
Given these issues, almost regardless of the political environment, it is time to begin working on substantive solutions so that when the political climate improves, pulmonary medicine is ready to move forward with a coordinated cohesive strategy.
The old adage of not wanting to see how laws or sausage is made holds true today, perhaps more so than ever. But certain clinical realities within pulmonary medicine virtually ensure that legislation is actually part of any reasonable solution.
NAMDRC has initiated an outreach to all the key medical, allied health, and patient societies that focus on pulmonary medicine to determine if consensus can be reached on a focused laundry list of issues that, for varying reasons, lean toward Congress for legislative solutions.
Here is a list of some of the issues under discussion:
• Home mechanical ventilation. Under current law, “ventilators” are covered items under the durable medical equipment benefit. In the 1990s, in order to circumvent statutory requirements that ventilators be paid under a “frequent and substantial servicing” payment methodology, HCFA (now CMS) created a new category – respiratory assist devices and declared that these devices, despite classification by FDA as ventilators, are not ventilators in reality, and the payment methodology, therefore, does not apply.
Over the past several years, the pulmonary medicine community tried its best to convince CMS that its rules were problematic, archaic, and costing the Medicare program tens of millions of dollars in unnecessary expenditures. A formal submission to CMS, a request for a National Coverage Determination reconsideration, was denied with a phrase now echoed throughout health care, “it’s complicated.” The only effective solution is a legislative one.
• High flow oxygen therapy for ILD patients. Oxygen remains the largest single component of the durable medical equipment benefit and, largely due to competitive bidding, has seen payment drop dramatically since the implementation of competitive bidding.
One can easily argue that competitive pricing is self-inflicted by the DME industry as the rates are set through a complicated formula based on bids from suppliers. But the impact has been particularly hard on liquid systems, the delivery system choice of not only many Medicare beneficiaries but also is the modality of choice for patients with clear need for high flow oxygen. While delivery in the home for high flow needs can be met by some stationary concentrators, the virtual disappearance of liquid systems, attributable to pricing triggered by competitive bidding, results in many ILD patients unable to leave their homes. The only effective solution is a legislative one.
• Section 603. This provision of the Balanced Budget Act of 2015 was designed to inhibit hospital purchases of certain physician practices that were based on aberrations within the Medicare payment system that rewarded hospitals significantly more than the same service provided in a physician office. For example, a physician office-based sleep lab may be able to bill Medicare for a particular service, but if the hospital purchases that physician practice and bills for the same service, it might receive upwards of twice as much payment.
While all involved seem to agree that this provision was not intended to target pulmonary rehabilitation services, it is being hit particularly hard by CMS rules implementing the statute. Any new pulmonary rehab program that is not within 250 yards of the main hospital campus must bill at the physician fee schedule rate, a rate about half of the hospital outpatient rate. Furthermore, existing programs that choose to expand must do so within the confines of their specific current location, unable to move a floor away. Doing so would trigger the reduced payment methodology.
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CMS agrees this is clearly an example of unintended consequences, but CMS also acknowledges it does not have the authority to remedy the situation. The agency itself signaled the only way to exempt pulmonary rehabilitation services is to seek Congressional action.
And now to the “sausage” part of the equation. Congressional action on virtually anything except renaming a post office becomes a political, as well as substantive, challenge. Here are just some of the considerations that must be addressed by any legislative strategy.
1. Any “fix” must be clinically sound and supported across a broad cross section of physician and patient groups. And the fix must give some level of flexibility to CMS to implement it in a reasonable way but tie their hands to force changes in policy.
2. Any “fix” must have a strong political strategy that can muster support within key Congressional committees (House Ways & Means Committee and Energy & Commerce Committee, along with the Senate Finance Committee, let alone 218 votes in the House and 51 votes in the Senate.
Given these issues, almost regardless of the political environment, it is time to begin working on substantive solutions so that when the political climate improves, pulmonary medicine is ready to move forward with a coordinated cohesive strategy.
The old adage of not wanting to see how laws or sausage is made holds true today, perhaps more so than ever. But certain clinical realities within pulmonary medicine virtually ensure that legislation is actually part of any reasonable solution.
NAMDRC has initiated an outreach to all the key medical, allied health, and patient societies that focus on pulmonary medicine to determine if consensus can be reached on a focused laundry list of issues that, for varying reasons, lean toward Congress for legislative solutions.
Here is a list of some of the issues under discussion:
• Home mechanical ventilation. Under current law, “ventilators” are covered items under the durable medical equipment benefit. In the 1990s, in order to circumvent statutory requirements that ventilators be paid under a “frequent and substantial servicing” payment methodology, HCFA (now CMS) created a new category – respiratory assist devices and declared that these devices, despite classification by FDA as ventilators, are not ventilators in reality, and the payment methodology, therefore, does not apply.
Over the past several years, the pulmonary medicine community tried its best to convince CMS that its rules were problematic, archaic, and costing the Medicare program tens of millions of dollars in unnecessary expenditures. A formal submission to CMS, a request for a National Coverage Determination reconsideration, was denied with a phrase now echoed throughout health care, “it’s complicated.” The only effective solution is a legislative one.
• High flow oxygen therapy for ILD patients. Oxygen remains the largest single component of the durable medical equipment benefit and, largely due to competitive bidding, has seen payment drop dramatically since the implementation of competitive bidding.
One can easily argue that competitive pricing is self-inflicted by the DME industry as the rates are set through a complicated formula based on bids from suppliers. But the impact has been particularly hard on liquid systems, the delivery system choice of not only many Medicare beneficiaries but also is the modality of choice for patients with clear need for high flow oxygen. While delivery in the home for high flow needs can be met by some stationary concentrators, the virtual disappearance of liquid systems, attributable to pricing triggered by competitive bidding, results in many ILD patients unable to leave their homes. The only effective solution is a legislative one.
• Section 603. This provision of the Balanced Budget Act of 2015 was designed to inhibit hospital purchases of certain physician practices that were based on aberrations within the Medicare payment system that rewarded hospitals significantly more than the same service provided in a physician office. For example, a physician office-based sleep lab may be able to bill Medicare for a particular service, but if the hospital purchases that physician practice and bills for the same service, it might receive upwards of twice as much payment.
While all involved seem to agree that this provision was not intended to target pulmonary rehabilitation services, it is being hit particularly hard by CMS rules implementing the statute. Any new pulmonary rehab program that is not within 250 yards of the main hospital campus must bill at the physician fee schedule rate, a rate about half of the hospital outpatient rate. Furthermore, existing programs that choose to expand must do so within the confines of their specific current location, unable to move a floor away. Doing so would trigger the reduced payment methodology.
[[{"fid":"197721","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"class":"media-element file-medstat-image-flush-right","data-delta":"1","format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Phil Porte","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"class":"media-element file-medstat-image-flush-right","data-delta":"1","format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Phil Porte","field_file_image_credit[und][0][value]":""}}}]]
CMS agrees this is clearly an example of unintended consequences, but CMS also acknowledges it does not have the authority to remedy the situation. The agency itself signaled the only way to exempt pulmonary rehabilitation services is to seek Congressional action.
And now to the “sausage” part of the equation. Congressional action on virtually anything except renaming a post office becomes a political, as well as substantive, challenge. Here are just some of the considerations that must be addressed by any legislative strategy.
1. Any “fix” must be clinically sound and supported across a broad cross section of physician and patient groups. And the fix must give some level of flexibility to CMS to implement it in a reasonable way but tie their hands to force changes in policy.
2. Any “fix” must have a strong political strategy that can muster support within key Congressional committees (House Ways & Means Committee and Energy & Commerce Committee, along with the Senate Finance Committee, let alone 218 votes in the House and 51 votes in the Senate.
Given these issues, almost regardless of the political environment, it is time to begin working on substantive solutions so that when the political climate improves, pulmonary medicine is ready to move forward with a coordinated cohesive strategy.
Catching Up With Our CHEST Past Presidents
Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with Dr. Goldberg.
I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.
And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.
Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.
All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili
My greatest learning was the importance of mentorship – both for the mentor and mentee. This fosters communication that enables learning and growth in our abilities to serve others by the profession we love.
http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship
http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat
Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with Dr. Goldberg.
I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.
And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.
Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.
All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili
My greatest learning was the importance of mentorship – both for the mentor and mentee. This fosters communication that enables learning and growth in our abilities to serve others by the profession we love.
http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship
http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat
Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with Dr. Goldberg.
I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.
And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.
Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.
All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili
My greatest learning was the importance of mentorship – both for the mentor and mentee. This fosters communication that enables learning and growth in our abilities to serve others by the profession we love.
http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship
http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat
Pulmonary Perspectives ® Immigrants in Health Care
July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.
I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.
The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.1 They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.
The 2015 Educational Commission for Foreign Medical Graduates (ECFMG) reported that a quarter of practicing physicians in the United States are international medical graduates (IMGs) and a fifth of all residency applicants were IMGs.2 Measuring the impact of the IMGs who have come to America is difficult to quantify but can be assessed by countless anecdotes and success stories. Forty-two percent of researchers at the seven top cancer research centers in the United States are immigrants. This is impressive considering that only about a tenth of the United States population is foreign born. Twenty-eight American Nobel prize winners in Medicine since 1960 are immigrants and taking a broader view as seen in Figure 1, almost 28% of physicians and 22% of RNs in the United States are foreign born.3,4 That does not take into account those like myself, first generation children who chose to enter this field of work out of respect for what their parents had accomplished.
The American College of Chest Physicians (CHEST), over the past 15 years, has had several Presidents who are American immigrants. One of them, Dr. Kalpalatha K. Guntupalli, President 2009-2010, I have met, and I was humbled by the experience. She is brilliant, kind, and modest and without her knowing, she has served as one of the role models for my career.
I applaud CHEST for standing with other member organizations to oppose the immigration hiatus (Letter to John F. Kelly, Secretary of Homeland Security. Feb 7, 2017). The medical organizations made four concrete proposals:
• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;
• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;
• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and
• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.
These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?
1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.
2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.
3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.
4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).
July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.
I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.
The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.1 They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.
The 2015 Educational Commission for Foreign Medical Graduates (ECFMG) reported that a quarter of practicing physicians in the United States are international medical graduates (IMGs) and a fifth of all residency applicants were IMGs.2 Measuring the impact of the IMGs who have come to America is difficult to quantify but can be assessed by countless anecdotes and success stories. Forty-two percent of researchers at the seven top cancer research centers in the United States are immigrants. This is impressive considering that only about a tenth of the United States population is foreign born. Twenty-eight American Nobel prize winners in Medicine since 1960 are immigrants and taking a broader view as seen in Figure 1, almost 28% of physicians and 22% of RNs in the United States are foreign born.3,4 That does not take into account those like myself, first generation children who chose to enter this field of work out of respect for what their parents had accomplished.
The American College of Chest Physicians (CHEST), over the past 15 years, has had several Presidents who are American immigrants. One of them, Dr. Kalpalatha K. Guntupalli, President 2009-2010, I have met, and I was humbled by the experience. She is brilliant, kind, and modest and without her knowing, she has served as one of the role models for my career.
I applaud CHEST for standing with other member organizations to oppose the immigration hiatus (Letter to John F. Kelly, Secretary of Homeland Security. Feb 7, 2017). The medical organizations made four concrete proposals:
• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;
• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;
• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and
• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.
These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?
1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.
2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.
3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.
4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).
July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.
I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.
The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.1 They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.
The 2015 Educational Commission for Foreign Medical Graduates (ECFMG) reported that a quarter of practicing physicians in the United States are international medical graduates (IMGs) and a fifth of all residency applicants were IMGs.2 Measuring the impact of the IMGs who have come to America is difficult to quantify but can be assessed by countless anecdotes and success stories. Forty-two percent of researchers at the seven top cancer research centers in the United States are immigrants. This is impressive considering that only about a tenth of the United States population is foreign born. Twenty-eight American Nobel prize winners in Medicine since 1960 are immigrants and taking a broader view as seen in Figure 1, almost 28% of physicians and 22% of RNs in the United States are foreign born.3,4 That does not take into account those like myself, first generation children who chose to enter this field of work out of respect for what their parents had accomplished.
The American College of Chest Physicians (CHEST), over the past 15 years, has had several Presidents who are American immigrants. One of them, Dr. Kalpalatha K. Guntupalli, President 2009-2010, I have met, and I was humbled by the experience. She is brilliant, kind, and modest and without her knowing, she has served as one of the role models for my career.
I applaud CHEST for standing with other member organizations to oppose the immigration hiatus (Letter to John F. Kelly, Secretary of Homeland Security. Feb 7, 2017). The medical organizations made four concrete proposals:
• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;
• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;
• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and
• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.
These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?
1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.
2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.
3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.
4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).
Letter to CHEST Leaders, Members, and Friends
Dear CHEST Leaders, Members, and Friends:
The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.
FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.
FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.
At the World Health Assembly, FIRS proclaimed September 25 as World Lung Day and hopes to use this as a rallying point for advocacy related to respiratory health or air quality. Lung Disease is the only major chronic disease that does not have a World Day. FIRS produced a Charter for Lung Health (www.firsnet.org/publications/charter) and hopes to have 100,000 persons sign on to it. FIRS also seeks to have lung-health organizations sign on and develop activities that can be carried out to celebrate lung health. Uruguay was the first country to sign the charter. The logos of the organizations who have signed the charter are on the FIRS website at firsnet.org. Activities being planned include editorials, newsletters, and letters-to-the-editor articles, legislative proclamations, social media exposure, and free spirometry, smoking cessation guidance, and carbon monoxide testing, but FIRS is looking for many more ways to celebrate healthy lungs on September 25 and many more partners!
Sixty-five million people suffer from chronic obstructive pulmonary disease and 3 million die of it each year, making it the third leading cause of death worldwide; 10 million people develop tuberculosis and 1.4 million die of it each year, making it the most common deadly infectious disease; 1.6 million people die of lung cancer each year, making it the most deadly cancer; 334 million people suffer from asthma, making it the most common chronic disease of childhood; pneumonia kills millions of people each year, making it a leading cause of death in the very young and very old. At least 2 billion people are exposed to toxic indoor smoke; 1 billion inhale polluted outdoor air; and 1 billion are exposed to tobacco smoke, and the tragedy is that many conditions are getting worse. We cannot sit still and allow this to happen.
FIRS proposes a multipronged campaign to combat lung disease to bring together all people concerned with lung health. It starts with naming September 25 World Lung Day and calling on respiratory health organizations to pledge to improve lung health and help identify ways to celebrate this day.
Please sign up, and share this call for action with your professional, advocacy, and social networks, and those of your friends and families. Please do your part as global citizens to improve lung health. To do so, organizations should indicate they wish to sign on and send their logo to Betty Sax, FIRS Secretariat, [email protected]. Organizations should also encourage individuals to sign on and show that they are committed to increasing awareness and action to promote global lung health.
Thank you.
Gerard Silvestri, MD, MS, FCCP
CHEST President
Darcy Marciniuk, MD, FCCP
CHEST FIRS Liaison
Dear CHEST Leaders, Members, and Friends:
The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.
FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.
FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.
At the World Health Assembly, FIRS proclaimed September 25 as World Lung Day and hopes to use this as a rallying point for advocacy related to respiratory health or air quality. Lung Disease is the only major chronic disease that does not have a World Day. FIRS produced a Charter for Lung Health (www.firsnet.org/publications/charter) and hopes to have 100,000 persons sign on to it. FIRS also seeks to have lung-health organizations sign on and develop activities that can be carried out to celebrate lung health. Uruguay was the first country to sign the charter. The logos of the organizations who have signed the charter are on the FIRS website at firsnet.org. Activities being planned include editorials, newsletters, and letters-to-the-editor articles, legislative proclamations, social media exposure, and free spirometry, smoking cessation guidance, and carbon monoxide testing, but FIRS is looking for many more ways to celebrate healthy lungs on September 25 and many more partners!
Sixty-five million people suffer from chronic obstructive pulmonary disease and 3 million die of it each year, making it the third leading cause of death worldwide; 10 million people develop tuberculosis and 1.4 million die of it each year, making it the most common deadly infectious disease; 1.6 million people die of lung cancer each year, making it the most deadly cancer; 334 million people suffer from asthma, making it the most common chronic disease of childhood; pneumonia kills millions of people each year, making it a leading cause of death in the very young and very old. At least 2 billion people are exposed to toxic indoor smoke; 1 billion inhale polluted outdoor air; and 1 billion are exposed to tobacco smoke, and the tragedy is that many conditions are getting worse. We cannot sit still and allow this to happen.
FIRS proposes a multipronged campaign to combat lung disease to bring together all people concerned with lung health. It starts with naming September 25 World Lung Day and calling on respiratory health organizations to pledge to improve lung health and help identify ways to celebrate this day.
Please sign up, and share this call for action with your professional, advocacy, and social networks, and those of your friends and families. Please do your part as global citizens to improve lung health. To do so, organizations should indicate they wish to sign on and send their logo to Betty Sax, FIRS Secretariat, [email protected]. Organizations should also encourage individuals to sign on and show that they are committed to increasing awareness and action to promote global lung health.
Thank you.
Gerard Silvestri, MD, MS, FCCP
CHEST President
Darcy Marciniuk, MD, FCCP
CHEST FIRS Liaison
Dear CHEST Leaders, Members, and Friends:
The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.
FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.
FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.
At the World Health Assembly, FIRS proclaimed September 25 as World Lung Day and hopes to use this as a rallying point for advocacy related to respiratory health or air quality. Lung Disease is the only major chronic disease that does not have a World Day. FIRS produced a Charter for Lung Health (www.firsnet.org/publications/charter) and hopes to have 100,000 persons sign on to it. FIRS also seeks to have lung-health organizations sign on and develop activities that can be carried out to celebrate lung health. Uruguay was the first country to sign the charter. The logos of the organizations who have signed the charter are on the FIRS website at firsnet.org. Activities being planned include editorials, newsletters, and letters-to-the-editor articles, legislative proclamations, social media exposure, and free spirometry, smoking cessation guidance, and carbon monoxide testing, but FIRS is looking for many more ways to celebrate healthy lungs on September 25 and many more partners!
Sixty-five million people suffer from chronic obstructive pulmonary disease and 3 million die of it each year, making it the third leading cause of death worldwide; 10 million people develop tuberculosis and 1.4 million die of it each year, making it the most common deadly infectious disease; 1.6 million people die of lung cancer each year, making it the most deadly cancer; 334 million people suffer from asthma, making it the most common chronic disease of childhood; pneumonia kills millions of people each year, making it a leading cause of death in the very young and very old. At least 2 billion people are exposed to toxic indoor smoke; 1 billion inhale polluted outdoor air; and 1 billion are exposed to tobacco smoke, and the tragedy is that many conditions are getting worse. We cannot sit still and allow this to happen.
FIRS proposes a multipronged campaign to combat lung disease to bring together all people concerned with lung health. It starts with naming September 25 World Lung Day and calling on respiratory health organizations to pledge to improve lung health and help identify ways to celebrate this day.
Please sign up, and share this call for action with your professional, advocacy, and social networks, and those of your friends and families. Please do your part as global citizens to improve lung health. To do so, organizations should indicate they wish to sign on and send their logo to Betty Sax, FIRS Secretariat, [email protected]. Organizations should also encourage individuals to sign on and show that they are committed to increasing awareness and action to promote global lung health.
Thank you.
Gerard Silvestri, MD, MS, FCCP
CHEST President
Darcy Marciniuk, MD, FCCP
CHEST FIRS Liaison
Critical Care Commentary Conscience Rights, Medical Training, and Critical Care Editor’s Note:
When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.
Lee Morrow, MD, FCCP
“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson
(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)
What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.
By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.
If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.
By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.
In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.
One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).
As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.
Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).
It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.
Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.
Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).
When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.
Lee Morrow, MD, FCCP
“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson
(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)
What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.
By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.
If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.
By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.
In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.
One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).
As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.
Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).
It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.
Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.
Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).
When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.
Lee Morrow, MD, FCCP
“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson
(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)
What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.
By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.
If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.
By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.
In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.
One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).
As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.
Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).
It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.
Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.
Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).
Vaccination: An Important Step in Protecting Health
Patients with chronic lung conditions, like COPD and asthma, need to take extra steps to manage their condition and ensure the healthiest possible future. One important step that may not always be top of mind is vaccination, which can protect against common preventable diseases that may be very serious for those with respiratory conditions. CDC recommends adults with COPD, asthma, and other lung diseases get an annual flu vaccine, as well as stay up to date with pneumococcal and other recommended vaccines. Additional vaccines may be indicated based on age, job, travel locations, and lifestyle.
COPD and asthma cause airways to swell and become blocked with mucus, making it hard to breathe. Certain vaccine-preventable diseases can make this even worse. Adults with COPD and asthma are at increased risk of complications from influenza, including pneumonia and hospitalization. They are also at higher risk for invasive pneumococcal disease and more likely to develop infections including bacteremia and meningitis. Each year, thousands of adults needlessly suffer, are hospitalized, and even die of diseases that could be prevented by vaccines. Despite increased risks, less than half of adults under 65 years with COPD and asthma have received influenza and pneumococcal vaccination (National Health Information Survey 2015).
Find the latest recommended adult immunization schedule at www.cdc.gov/vaccines/hcp/adults.
Patients with chronic lung conditions, like COPD and asthma, need to take extra steps to manage their condition and ensure the healthiest possible future. One important step that may not always be top of mind is vaccination, which can protect against common preventable diseases that may be very serious for those with respiratory conditions. CDC recommends adults with COPD, asthma, and other lung diseases get an annual flu vaccine, as well as stay up to date with pneumococcal and other recommended vaccines. Additional vaccines may be indicated based on age, job, travel locations, and lifestyle.
COPD and asthma cause airways to swell and become blocked with mucus, making it hard to breathe. Certain vaccine-preventable diseases can make this even worse. Adults with COPD and asthma are at increased risk of complications from influenza, including pneumonia and hospitalization. They are also at higher risk for invasive pneumococcal disease and more likely to develop infections including bacteremia and meningitis. Each year, thousands of adults needlessly suffer, are hospitalized, and even die of diseases that could be prevented by vaccines. Despite increased risks, less than half of adults under 65 years with COPD and asthma have received influenza and pneumococcal vaccination (National Health Information Survey 2015).
Find the latest recommended adult immunization schedule at www.cdc.gov/vaccines/hcp/adults.
Patients with chronic lung conditions, like COPD and asthma, need to take extra steps to manage their condition and ensure the healthiest possible future. One important step that may not always be top of mind is vaccination, which can protect against common preventable diseases that may be very serious for those with respiratory conditions. CDC recommends adults with COPD, asthma, and other lung diseases get an annual flu vaccine, as well as stay up to date with pneumococcal and other recommended vaccines. Additional vaccines may be indicated based on age, job, travel locations, and lifestyle.
COPD and asthma cause airways to swell and become blocked with mucus, making it hard to breathe. Certain vaccine-preventable diseases can make this even worse. Adults with COPD and asthma are at increased risk of complications from influenza, including pneumonia and hospitalization. They are also at higher risk for invasive pneumococcal disease and more likely to develop infections including bacteremia and meningitis. Each year, thousands of adults needlessly suffer, are hospitalized, and even die of diseases that could be prevented by vaccines. Despite increased risks, less than half of adults under 65 years with COPD and asthma have received influenza and pneumococcal vaccination (National Health Information Survey 2015).
Find the latest recommended adult immunization schedule at www.cdc.gov/vaccines/hcp/adults.
NETWORKS Health-care weaponization, PTSD, depression in caregivers Disaster Response Practice Operations Transplant Women’s Health
The tragic weaponization of health care
The Syrian conflict has highlighted the dangers to health-care workers (HCWs) in humanitarian crises. The Lancet-American University of Beirut Commission on Syria reports on the weaponization of health care in Syria – a strategy of depriving people of their health-care needs. Targeting of HCWs was recognized early in the Syrian war with targeting of health-care facilities being frequently reported throughout the conflict. HCWs facing extreme supply shortages have been reported to resort to desperate measures: using urine bags with added anticoagulants for blood collection and crafting homemade external fixators for fractures. Sadly, the Syrian conflict is not unique. The International Committee of the Red Cross (ICRC) documented 2,398 episodes of violence directed at health facilities in 11 countries affected by armed conflict between 2012 and 2014 alone. In Syria and elsewhere, the exodus of trained medical personnel, due to lack of medical training in trauma, emergency medicine, and intensive care, puts populations at further risk in these regions. The Inte
Dr. Maves is a military service member. The opinions expressed herein are his own and do not necessarily reflect the official opinions of the Department of the Navy, Department of Defense, or the US Government.
Rashmi Mishra, MD
Fellow-in-Training Member
Ryan Maves, MD, FCCP
Steering Committee Member
The House AHCA /Senate BCRA compared with ACA (Affordable Care Act)
Health-care costs are a fundamental driver of insurance costs, which leads to challenges to coverage affordability for millions of families. There is ongoing debate whether the current law (Affordable Care Act [ACA/Obamacare]) and the republican alternatives (American Healthcare Act [AHCA] and Better Care Reconciliation Act [BCRA]) do enough to address the cost challenges. Here is a brief summary of the key similarities and differences.
Similarities: (1) Children will be covered up to age 26. (2) Coverage of pre-existing conditions continues (high risk pools will be subsidized by a state government but premiums are up to twice as much as individual coverage). (3) Tax credit (based on age and family size rather than income level). (4) Insurance can charge older customers more than younger (up to 3X under ACA, 5X under AHCA/BCRA). (5) No annual or lifetime payout limit (but states may apply waivers allowing insurers to apply limits).
Differences: (1) Insurance will no longer be mandatory (no individual or employer mandates, but there is a 30% increase in premiums for 1 year for not maintaining individual continuous coverage). (2) Medicaid expansion (expanded under ACA to 133% of po
Health-care reform undoubtedly is complicated, and there are a lot of questions in the air about the future of health care under the Trump Administration. Few certainties: change is coming, MACRA is here to stay.
Adel Bassily-Marcus, MD, FCCP
NetWork Chair
Posttraumatic Stress Disorder Post-Lung Transplant
The majority of transplant physicians are mainly concerned with issues posttransplant that are focused on the graft function. But recently, neurocognition and posttransplant posttraumatic stress disorder have been found to have significant impact on quality of life and mortality after transplantation. Posttraumatic stress disorder (PTSD) is described as re-experiencing a traumatic event in addition to having avoidant and hyperarousal symptoms, which last for a period of at least 1 month. Studies of PTSD in solid organ transplant recipients have revealed a significantly higher prevalence of PTSD symptoms (10% to 17%) compared with the general population (prevalence of 3.5% to 6%). In one study of heart transplant recipients, patients who met the criteria for PTSD in the first year posttransplant had a higher risk for 3-year mortality (OR=13.74) [Dew et al. J Heart Lung Transplant. 1999;18[6]:549-562].
Lung transplant recipients are at a high risk for developing PTSD due to exposure to several traumatic events, such as a life-threatening exacerbation of the underlying lung disease, undergoing transplant surgery, intensive care unit stay, delirium and episodes of infection, and acute and chronic rejection. However, data regarding the prevalence and risk factors for PTSD post-lung transplant are limited.
The prevalence of PTSD post lung transplantation has been reported to be 12.6% to 15.8%. In lung transplant recipients with clinically significant PTSD symptomatology; the presence of symptoms of re-experiencing (29.5%) and arousal (33.8%) were more common than avoidant symptoms (18.4%) [Gries et al. J Heart Lung Transplant. 2013; 32[5]: 525-532]. In another study by Dew et al, in 178 lung transplant recipients, all PTSD occurred in the early months posttransplant with a median duration of symptoms of 12 months (IQR 7.2 to 18.5 months) [Dew et al. Gen. Hosp Psychiatry. 2012;34:127-138]. A higher burden of PTSD is noted in patients who are younger, have a lo
The challenges that remain include determining the true prevalence of PTSD in the lung transplant recipient in the LAS era using standard diagnostic criteria, documenting the adverse effects of PTSD on medical compliance, morbidity, and mortality; and developing interventions to mitigate the adverse effects of PTSD through well-designed multicenter prospective studies.
Vivek Ahya, MD
Steering Committee Member
Caregiver Burden in the ICU and Beyond
Family members of patients in the ICU who transition to the role of caregivers following discharge are at high risk for psychosocial distress. Post-intensive care syndrome-family (PICS-F) describes the symptoms of depression, posttraumatic stress, and anxiety commonly found in this population (Davidson et al. Crit Care Med. 2012;4(2):618-624). Women are more commonly called upon to adopt the role of caregiver for family members with chronic medical conditions or mental illnesses. Worldwide estimates indicate that 57% to 81% of all caregivers are women (Sharma et al. World J Psych. 2016;6[2]:7-17).
Family burden begins during the acute phase of critical illness. As surrogate decision-makers, they frequently face decisional conflict and decisional regret, especially in scenarios that limit life-sustaining therapies (Long et al. Curr Opin Crit Care. 2016;22:613-620). The prevalence of PICS-F is high as family members attempt to balance their role in the ICU with personal obligations (Choi et al. J Korean Acad Nurs. 2016;[46]2:159-167). Those who perceive that they are not receiving complete information from the medical team, and who do not find their physician comforting, have been shown to suffer a greater symptom burden (Davidson et al).
With the growing older adult population, and increased ICU survival, family members are often called upon to serve as caretakers to the chronically critically ill (Choi et al.). These caregivers have more depressive symptoms, worse health outcomes, and significant professional and personal lifestyle disruptions (Cameron, et al. N Engl J Med. 2016;[374]19:1831-1841). In many caregivers, depressive symptoms persist at 1 year after ICU admission, with rates comparable to caretakers of patients with dementia (Haines et al. Crit Care Med. 2015;(43)5:1112-1120). Caregivers who are younger, female, minorities, and those with pre-existing depression are at especially high risk for worse mental health outcomes (Davidson et al; Cameron et al).
Caregivers of ICU survivors are vulnerable and undersupported. Interventions such as ICU diaries, telephone-based mindfulness exercises, and stress management strategies have shown promise in alleviating PICS-F symptoms (Choi et al.). During the acute ICU stay, how medical providers communicate, and how we help family members make sense of what has happened and their new roles as caregivers have an impact (Davidson et al.). From an individual in a study of psychosocial morbidity in caregivers of ICU survivors: “Leaving the hospital is not the end for some people. The next place is just as hard, sometimes worse” (Haines et al. Further studies are needed to identify interventions that will truly address this population’s unique needs.
Margaret Pisani, MD, FCCP
Steering Committee Member
Nicole Bournival, MD
Fellow-in-Training Member
The tragic weaponization of health care
The Syrian conflict has highlighted the dangers to health-care workers (HCWs) in humanitarian crises. The Lancet-American University of Beirut Commission on Syria reports on the weaponization of health care in Syria – a strategy of depriving people of their health-care needs. Targeting of HCWs was recognized early in the Syrian war with targeting of health-care facilities being frequently reported throughout the conflict. HCWs facing extreme supply shortages have been reported to resort to desperate measures: using urine bags with added anticoagulants for blood collection and crafting homemade external fixators for fractures. Sadly, the Syrian conflict is not unique. The International Committee of the Red Cross (ICRC) documented 2,398 episodes of violence directed at health facilities in 11 countries affected by armed conflict between 2012 and 2014 alone. In Syria and elsewhere, the exodus of trained medical personnel, due to lack of medical training in trauma, emergency medicine, and intensive care, puts populations at further risk in these regions. The Inte
Dr. Maves is a military service member. The opinions expressed herein are his own and do not necessarily reflect the official opinions of the Department of the Navy, Department of Defense, or the US Government.
Rashmi Mishra, MD
Fellow-in-Training Member
Ryan Maves, MD, FCCP
Steering Committee Member
The House AHCA /Senate BCRA compared with ACA (Affordable Care Act)
Health-care costs are a fundamental driver of insurance costs, which leads to challenges to coverage affordability for millions of families. There is ongoing debate whether the current law (Affordable Care Act [ACA/Obamacare]) and the republican alternatives (American Healthcare Act [AHCA] and Better Care Reconciliation Act [BCRA]) do enough to address the cost challenges. Here is a brief summary of the key similarities and differences.
Similarities: (1) Children will be covered up to age 26. (2) Coverage of pre-existing conditions continues (high risk pools will be subsidized by a state government but premiums are up to twice as much as individual coverage). (3) Tax credit (based on age and family size rather than income level). (4) Insurance can charge older customers more than younger (up to 3X under ACA, 5X under AHCA/BCRA). (5) No annual or lifetime payout limit (but states may apply waivers allowing insurers to apply limits).
Differences: (1) Insurance will no longer be mandatory (no individual or employer mandates, but there is a 30% increase in premiums for 1 year for not maintaining individual continuous coverage). (2) Medicaid expansion (expanded under ACA to 133% of po
Health-care reform undoubtedly is complicated, and there are a lot of questions in the air about the future of health care under the Trump Administration. Few certainties: change is coming, MACRA is here to stay.
Adel Bassily-Marcus, MD, FCCP
NetWork Chair
Posttraumatic Stress Disorder Post-Lung Transplant
The majority of transplant physicians are mainly concerned with issues posttransplant that are focused on the graft function. But recently, neurocognition and posttransplant posttraumatic stress disorder have been found to have significant impact on quality of life and mortality after transplantation. Posttraumatic stress disorder (PTSD) is described as re-experiencing a traumatic event in addition to having avoidant and hyperarousal symptoms, which last for a period of at least 1 month. Studies of PTSD in solid organ transplant recipients have revealed a significantly higher prevalence of PTSD symptoms (10% to 17%) compared with the general population (prevalence of 3.5% to 6%). In one study of heart transplant recipients, patients who met the criteria for PTSD in the first year posttransplant had a higher risk for 3-year mortality (OR=13.74) [Dew et al. J Heart Lung Transplant. 1999;18[6]:549-562].
Lung transplant recipients are at a high risk for developing PTSD due to exposure to several traumatic events, such as a life-threatening exacerbation of the underlying lung disease, undergoing transplant surgery, intensive care unit stay, delirium and episodes of infection, and acute and chronic rejection. However, data regarding the prevalence and risk factors for PTSD post-lung transplant are limited.
The prevalence of PTSD post lung transplantation has been reported to be 12.6% to 15.8%. In lung transplant recipients with clinically significant PTSD symptomatology; the presence of symptoms of re-experiencing (29.5%) and arousal (33.8%) were more common than avoidant symptoms (18.4%) [Gries et al. J Heart Lung Transplant. 2013; 32[5]: 525-532]. In another study by Dew et al, in 178 lung transplant recipients, all PTSD occurred in the early months posttransplant with a median duration of symptoms of 12 months (IQR 7.2 to 18.5 months) [Dew et al. Gen. Hosp Psychiatry. 2012;34:127-138]. A higher burden of PTSD is noted in patients who are younger, have a lo
The challenges that remain include determining the true prevalence of PTSD in the lung transplant recipient in the LAS era using standard diagnostic criteria, documenting the adverse effects of PTSD on medical compliance, morbidity, and mortality; and developing interventions to mitigate the adverse effects of PTSD through well-designed multicenter prospective studies.
Vivek Ahya, MD
Steering Committee Member
Caregiver Burden in the ICU and Beyond
Family members of patients in the ICU who transition to the role of caregivers following discharge are at high risk for psychosocial distress. Post-intensive care syndrome-family (PICS-F) describes the symptoms of depression, posttraumatic stress, and anxiety commonly found in this population (Davidson et al. Crit Care Med. 2012;4(2):618-624). Women are more commonly called upon to adopt the role of caregiver for family members with chronic medical conditions or mental illnesses. Worldwide estimates indicate that 57% to 81% of all caregivers are women (Sharma et al. World J Psych. 2016;6[2]:7-17).
Family burden begins during the acute phase of critical illness. As surrogate decision-makers, they frequently face decisional conflict and decisional regret, especially in scenarios that limit life-sustaining therapies (Long et al. Curr Opin Crit Care. 2016;22:613-620). The prevalence of PICS-F is high as family members attempt to balance their role in the ICU with personal obligations (Choi et al. J Korean Acad Nurs. 2016;[46]2:159-167). Those who perceive that they are not receiving complete information from the medical team, and who do not find their physician comforting, have been shown to suffer a greater symptom burden (Davidson et al).
With the growing older adult population, and increased ICU survival, family members are often called upon to serve as caretakers to the chronically critically ill (Choi et al.). These caregivers have more depressive symptoms, worse health outcomes, and significant professional and personal lifestyle disruptions (Cameron, et al. N Engl J Med. 2016;[374]19:1831-1841). In many caregivers, depressive symptoms persist at 1 year after ICU admission, with rates comparable to caretakers of patients with dementia (Haines et al. Crit Care Med. 2015;(43)5:1112-1120). Caregivers who are younger, female, minorities, and those with pre-existing depression are at especially high risk for worse mental health outcomes (Davidson et al; Cameron et al).
Caregivers of ICU survivors are vulnerable and undersupported. Interventions such as ICU diaries, telephone-based mindfulness exercises, and stress management strategies have shown promise in alleviating PICS-F symptoms (Choi et al.). During the acute ICU stay, how medical providers communicate, and how we help family members make sense of what has happened and their new roles as caregivers have an impact (Davidson et al.). From an individual in a study of psychosocial morbidity in caregivers of ICU survivors: “Leaving the hospital is not the end for some people. The next place is just as hard, sometimes worse” (Haines et al. Further studies are needed to identify interventions that will truly address this population’s unique needs.
Margaret Pisani, MD, FCCP
Steering Committee Member
Nicole Bournival, MD
Fellow-in-Training Member
The tragic weaponization of health care
The Syrian conflict has highlighted the dangers to health-care workers (HCWs) in humanitarian crises. The Lancet-American University of Beirut Commission on Syria reports on the weaponization of health care in Syria – a strategy of depriving people of their health-care needs. Targeting of HCWs was recognized early in the Syrian war with targeting of health-care facilities being frequently reported throughout the conflict. HCWs facing extreme supply shortages have been reported to resort to desperate measures: using urine bags with added anticoagulants for blood collection and crafting homemade external fixators for fractures. Sadly, the Syrian conflict is not unique. The International Committee of the Red Cross (ICRC) documented 2,398 episodes of violence directed at health facilities in 11 countries affected by armed conflict between 2012 and 2014 alone. In Syria and elsewhere, the exodus of trained medical personnel, due to lack of medical training in trauma, emergency medicine, and intensive care, puts populations at further risk in these regions. The Inte
Dr. Maves is a military service member. The opinions expressed herein are his own and do not necessarily reflect the official opinions of the Department of the Navy, Department of Defense, or the US Government.
Rashmi Mishra, MD
Fellow-in-Training Member
Ryan Maves, MD, FCCP
Steering Committee Member
The House AHCA /Senate BCRA compared with ACA (Affordable Care Act)
Health-care costs are a fundamental driver of insurance costs, which leads to challenges to coverage affordability for millions of families. There is ongoing debate whether the current law (Affordable Care Act [ACA/Obamacare]) and the republican alternatives (American Healthcare Act [AHCA] and Better Care Reconciliation Act [BCRA]) do enough to address the cost challenges. Here is a brief summary of the key similarities and differences.
Similarities: (1) Children will be covered up to age 26. (2) Coverage of pre-existing conditions continues (high risk pools will be subsidized by a state government but premiums are up to twice as much as individual coverage). (3) Tax credit (based on age and family size rather than income level). (4) Insurance can charge older customers more than younger (up to 3X under ACA, 5X under AHCA/BCRA). (5) No annual or lifetime payout limit (but states may apply waivers allowing insurers to apply limits).
Differences: (1) Insurance will no longer be mandatory (no individual or employer mandates, but there is a 30% increase in premiums for 1 year for not maintaining individual continuous coverage). (2) Medicaid expansion (expanded under ACA to 133% of po
Health-care reform undoubtedly is complicated, and there are a lot of questions in the air about the future of health care under the Trump Administration. Few certainties: change is coming, MACRA is here to stay.
Adel Bassily-Marcus, MD, FCCP
NetWork Chair
Posttraumatic Stress Disorder Post-Lung Transplant
The majority of transplant physicians are mainly concerned with issues posttransplant that are focused on the graft function. But recently, neurocognition and posttransplant posttraumatic stress disorder have been found to have significant impact on quality of life and mortality after transplantation. Posttraumatic stress disorder (PTSD) is described as re-experiencing a traumatic event in addition to having avoidant and hyperarousal symptoms, which last for a period of at least 1 month. Studies of PTSD in solid organ transplant recipients have revealed a significantly higher prevalence of PTSD symptoms (10% to 17%) compared with the general population (prevalence of 3.5% to 6%). In one study of heart transplant recipients, patients who met the criteria for PTSD in the first year posttransplant had a higher risk for 3-year mortality (OR=13.74) [Dew et al. J Heart Lung Transplant. 1999;18[6]:549-562].
Lung transplant recipients are at a high risk for developing PTSD due to exposure to several traumatic events, such as a life-threatening exacerbation of the underlying lung disease, undergoing transplant surgery, intensive care unit stay, delirium and episodes of infection, and acute and chronic rejection. However, data regarding the prevalence and risk factors for PTSD post-lung transplant are limited.
The prevalence of PTSD post lung transplantation has been reported to be 12.6% to 15.8%. In lung transplant recipients with clinically significant PTSD symptomatology; the presence of symptoms of re-experiencing (29.5%) and arousal (33.8%) were more common than avoidant symptoms (18.4%) [Gries et al. J Heart Lung Transplant. 2013; 32[5]: 525-532]. In another study by Dew et al, in 178 lung transplant recipients, all PTSD occurred in the early months posttransplant with a median duration of symptoms of 12 months (IQR 7.2 to 18.5 months) [Dew et al. Gen. Hosp Psychiatry. 2012;34:127-138]. A higher burden of PTSD is noted in patients who are younger, have a lo
The challenges that remain include determining the true prevalence of PTSD in the lung transplant recipient in the LAS era using standard diagnostic criteria, documenting the adverse effects of PTSD on medical compliance, morbidity, and mortality; and developing interventions to mitigate the adverse effects of PTSD through well-designed multicenter prospective studies.
Vivek Ahya, MD
Steering Committee Member
Caregiver Burden in the ICU and Beyond
Family members of patients in the ICU who transition to the role of caregivers following discharge are at high risk for psychosocial distress. Post-intensive care syndrome-family (PICS-F) describes the symptoms of depression, posttraumatic stress, and anxiety commonly found in this population (Davidson et al. Crit Care Med. 2012;4(2):618-624). Women are more commonly called upon to adopt the role of caregiver for family members with chronic medical conditions or mental illnesses. Worldwide estimates indicate that 57% to 81% of all caregivers are women (Sharma et al. World J Psych. 2016;6[2]:7-17).
Family burden begins during the acute phase of critical illness. As surrogate decision-makers, they frequently face decisional conflict and decisional regret, especially in scenarios that limit life-sustaining therapies (Long et al. Curr Opin Crit Care. 2016;22:613-620). The prevalence of PICS-F is high as family members attempt to balance their role in the ICU with personal obligations (Choi et al. J Korean Acad Nurs. 2016;[46]2:159-167). Those who perceive that they are not receiving complete information from the medical team, and who do not find their physician comforting, have been shown to suffer a greater symptom burden (Davidson et al).
With the growing older adult population, and increased ICU survival, family members are often called upon to serve as caretakers to the chronically critically ill (Choi et al.). These caregivers have more depressive symptoms, worse health outcomes, and significant professional and personal lifestyle disruptions (Cameron, et al. N Engl J Med. 2016;[374]19:1831-1841). In many caregivers, depressive symptoms persist at 1 year after ICU admission, with rates comparable to caretakers of patients with dementia (Haines et al. Crit Care Med. 2015;(43)5:1112-1120). Caregivers who are younger, female, minorities, and those with pre-existing depression are at especially high risk for worse mental health outcomes (Davidson et al; Cameron et al).
Caregivers of ICU survivors are vulnerable and undersupported. Interventions such as ICU diaries, telephone-based mindfulness exercises, and stress management strategies have shown promise in alleviating PICS-F symptoms (Choi et al.). During the acute ICU stay, how medical providers communicate, and how we help family members make sense of what has happened and their new roles as caregivers have an impact (Davidson et al.). From an individual in a study of psychosocial morbidity in caregivers of ICU survivors: “Leaving the hospital is not the end for some people. The next place is just as hard, sometimes worse” (Haines et al. Further studies are needed to identify interventions that will truly address this population’s unique needs.
Margaret Pisani, MD, FCCP
Steering Committee Member
Nicole Bournival, MD
Fellow-in-Training Member