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Supreme Court to rule on Louisiana abortion rules by end of summer
The U.S. Supreme Court will likely decide by the end of the summer whether a controversial Louisiana abortion law that imposes restrictions on physicians can stand.
Justices heard oral arguments March 4, 2020, in June Medicare Services v. Russo, which centers on a Louisiana law requiring physicians who perform abortions to have admitting privileges at a nearby hospital. Doctors who perform abortions without admitting privileges at a hospital within 30 miles face fines and imprisonment, while clinics that violate the law can have their licenses revoked, according to the state law, originally passed in 2014. In 2016, the Supreme Court in 2016 heard a similar case – Whole Woman’s Health v. Hellerstedt – concerning a comparable law in Texas. In that case, the justices struck down the measure as unconstitutional.
During oral arguments, Julie Rikelman an attorney representing June Medical Services, said that the Louisiana law is identical to the abortion law in Texas, and she argued that justices should reach the same conclusion.
“The district court found this law would leave Louisiana with just one clinic in one state to serve about 10,000 people per year,” Ms. Rikelman said during oral arguments. “That would mean that hundreds of thousands of women would now live more than 150 miles from the closest provider. And the burdens were actually more severe than this court found in Whole Woman’s Health.”
Elizabeth Murrill, solicitor general of Louisiana, argued that the Louisiana law was justified, and that the 5th U.S. Circuit Court of Appeals was correct when it reversed a district court decision and upheld the law.
“The 5th Circuit correctly held that the plaintiffs in this case failed to carry their burden – their heavy burden of proof that is required to facially invalidate a state law,” Ms. Murrill said during oral arguments. “Louisiana’s decision to require abortion providers to have admitting privileges was justified by abundant evidence of life-threatening health and safety violations, malpractice, noncompliance with professional licensing rules, legislative testimony from postabortive women, [and] testimony from doctors who took care of abortion providers’ abandoned patients.”
During arguments, Justice Ruth Bader Ginsburg questioned the reasoning behind the 30-mile privileges rule, expressing doubt at the state’s justification for the requirement. “What sense does the 30-mile limit make, considering that – certainly for medication abortions and for the overwhelming number of other abortions ... if the woman has a problem, it will be her local hospital that ... she will need to go to for the care, not something 30 miles from the clinic.”
Ms. Murrill responded that the Louisiana regulation is consistent with surgery and ambulatory surgery regulations and aligns with the state’s regulatory structure.
“We had evidence in the record of women who did require transfers,” Ms. Murrill said. “[An abortion provider] testified unambiguously that he had to transfer four patients who had punctured uteruses and were hemorrhaging.”
Whether the plaintiffs have standing to sue is a key question. As a general rule, a plaintiff can only sue to protect their own rights, unless the plaintiff has a close relationship with a third party and there are barriers that prevent the third party from suing. Attorneys for Louisiana contend that the plaintiffs – the medical clinic and several physicians – have no right to sue because their rights are not at stake, and that there is no obstacle to patients suing over the law.
Since the Louisiana law is intended to protect women from “unscrupulous and incompetent abortion providers,” the state argues also that there is a conflict of interest between the physicians and the patients on whose behalf they are suing.
During arguments, Justice Samuel Alito Jr. repeatedly questioned Ms. Rikelman on the plaintiffs’ right to sue, conveying doubt that the plaintiffs were on solid legal ground.
“Would you agree with the general proposition that a party should not be able to sue ostensibly to protect the rights of other people, if there is a real conflict of interest between the party who is suing and those whose rights the party claims to be attempting to defend?” Associate Justice Alito asked during oral arguments.
The hearing ended with no clear picture of how some justices were leaning. Justice Clarence Thomas and Justice Neil Gorsuch remained silent during arguments and asked no questions. Chief Justice John Roberts Jr., and Justice Brett Kavanaugh questioned whether all admitting privileges laws were unconstitutional or if a state-by-state analysis is required. Near the end of the hearing, Justice Stephen Breyer stressed that more research and fact-finding is necessary before the court can reach a decision.
“We’re not going to solve this at oral argument,” he said.
A decision by the Supreme Court is expected by August 2020.
The U.S. Supreme Court will likely decide by the end of the summer whether a controversial Louisiana abortion law that imposes restrictions on physicians can stand.
Justices heard oral arguments March 4, 2020, in June Medicare Services v. Russo, which centers on a Louisiana law requiring physicians who perform abortions to have admitting privileges at a nearby hospital. Doctors who perform abortions without admitting privileges at a hospital within 30 miles face fines and imprisonment, while clinics that violate the law can have their licenses revoked, according to the state law, originally passed in 2014. In 2016, the Supreme Court in 2016 heard a similar case – Whole Woman’s Health v. Hellerstedt – concerning a comparable law in Texas. In that case, the justices struck down the measure as unconstitutional.
During oral arguments, Julie Rikelman an attorney representing June Medical Services, said that the Louisiana law is identical to the abortion law in Texas, and she argued that justices should reach the same conclusion.
“The district court found this law would leave Louisiana with just one clinic in one state to serve about 10,000 people per year,” Ms. Rikelman said during oral arguments. “That would mean that hundreds of thousands of women would now live more than 150 miles from the closest provider. And the burdens were actually more severe than this court found in Whole Woman’s Health.”
Elizabeth Murrill, solicitor general of Louisiana, argued that the Louisiana law was justified, and that the 5th U.S. Circuit Court of Appeals was correct when it reversed a district court decision and upheld the law.
“The 5th Circuit correctly held that the plaintiffs in this case failed to carry their burden – their heavy burden of proof that is required to facially invalidate a state law,” Ms. Murrill said during oral arguments. “Louisiana’s decision to require abortion providers to have admitting privileges was justified by abundant evidence of life-threatening health and safety violations, malpractice, noncompliance with professional licensing rules, legislative testimony from postabortive women, [and] testimony from doctors who took care of abortion providers’ abandoned patients.”
During arguments, Justice Ruth Bader Ginsburg questioned the reasoning behind the 30-mile privileges rule, expressing doubt at the state’s justification for the requirement. “What sense does the 30-mile limit make, considering that – certainly for medication abortions and for the overwhelming number of other abortions ... if the woman has a problem, it will be her local hospital that ... she will need to go to for the care, not something 30 miles from the clinic.”
Ms. Murrill responded that the Louisiana regulation is consistent with surgery and ambulatory surgery regulations and aligns with the state’s regulatory structure.
“We had evidence in the record of women who did require transfers,” Ms. Murrill said. “[An abortion provider] testified unambiguously that he had to transfer four patients who had punctured uteruses and were hemorrhaging.”
Whether the plaintiffs have standing to sue is a key question. As a general rule, a plaintiff can only sue to protect their own rights, unless the plaintiff has a close relationship with a third party and there are barriers that prevent the third party from suing. Attorneys for Louisiana contend that the plaintiffs – the medical clinic and several physicians – have no right to sue because their rights are not at stake, and that there is no obstacle to patients suing over the law.
Since the Louisiana law is intended to protect women from “unscrupulous and incompetent abortion providers,” the state argues also that there is a conflict of interest between the physicians and the patients on whose behalf they are suing.
During arguments, Justice Samuel Alito Jr. repeatedly questioned Ms. Rikelman on the plaintiffs’ right to sue, conveying doubt that the plaintiffs were on solid legal ground.
“Would you agree with the general proposition that a party should not be able to sue ostensibly to protect the rights of other people, if there is a real conflict of interest between the party who is suing and those whose rights the party claims to be attempting to defend?” Associate Justice Alito asked during oral arguments.
The hearing ended with no clear picture of how some justices were leaning. Justice Clarence Thomas and Justice Neil Gorsuch remained silent during arguments and asked no questions. Chief Justice John Roberts Jr., and Justice Brett Kavanaugh questioned whether all admitting privileges laws were unconstitutional or if a state-by-state analysis is required. Near the end of the hearing, Justice Stephen Breyer stressed that more research and fact-finding is necessary before the court can reach a decision.
“We’re not going to solve this at oral argument,” he said.
A decision by the Supreme Court is expected by August 2020.
The U.S. Supreme Court will likely decide by the end of the summer whether a controversial Louisiana abortion law that imposes restrictions on physicians can stand.
Justices heard oral arguments March 4, 2020, in June Medicare Services v. Russo, which centers on a Louisiana law requiring physicians who perform abortions to have admitting privileges at a nearby hospital. Doctors who perform abortions without admitting privileges at a hospital within 30 miles face fines and imprisonment, while clinics that violate the law can have their licenses revoked, according to the state law, originally passed in 2014. In 2016, the Supreme Court in 2016 heard a similar case – Whole Woman’s Health v. Hellerstedt – concerning a comparable law in Texas. In that case, the justices struck down the measure as unconstitutional.
During oral arguments, Julie Rikelman an attorney representing June Medical Services, said that the Louisiana law is identical to the abortion law in Texas, and she argued that justices should reach the same conclusion.
“The district court found this law would leave Louisiana with just one clinic in one state to serve about 10,000 people per year,” Ms. Rikelman said during oral arguments. “That would mean that hundreds of thousands of women would now live more than 150 miles from the closest provider. And the burdens were actually more severe than this court found in Whole Woman’s Health.”
Elizabeth Murrill, solicitor general of Louisiana, argued that the Louisiana law was justified, and that the 5th U.S. Circuit Court of Appeals was correct when it reversed a district court decision and upheld the law.
“The 5th Circuit correctly held that the plaintiffs in this case failed to carry their burden – their heavy burden of proof that is required to facially invalidate a state law,” Ms. Murrill said during oral arguments. “Louisiana’s decision to require abortion providers to have admitting privileges was justified by abundant evidence of life-threatening health and safety violations, malpractice, noncompliance with professional licensing rules, legislative testimony from postabortive women, [and] testimony from doctors who took care of abortion providers’ abandoned patients.”
During arguments, Justice Ruth Bader Ginsburg questioned the reasoning behind the 30-mile privileges rule, expressing doubt at the state’s justification for the requirement. “What sense does the 30-mile limit make, considering that – certainly for medication abortions and for the overwhelming number of other abortions ... if the woman has a problem, it will be her local hospital that ... she will need to go to for the care, not something 30 miles from the clinic.”
Ms. Murrill responded that the Louisiana regulation is consistent with surgery and ambulatory surgery regulations and aligns with the state’s regulatory structure.
“We had evidence in the record of women who did require transfers,” Ms. Murrill said. “[An abortion provider] testified unambiguously that he had to transfer four patients who had punctured uteruses and were hemorrhaging.”
Whether the plaintiffs have standing to sue is a key question. As a general rule, a plaintiff can only sue to protect their own rights, unless the plaintiff has a close relationship with a third party and there are barriers that prevent the third party from suing. Attorneys for Louisiana contend that the plaintiffs – the medical clinic and several physicians – have no right to sue because their rights are not at stake, and that there is no obstacle to patients suing over the law.
Since the Louisiana law is intended to protect women from “unscrupulous and incompetent abortion providers,” the state argues also that there is a conflict of interest between the physicians and the patients on whose behalf they are suing.
During arguments, Justice Samuel Alito Jr. repeatedly questioned Ms. Rikelman on the plaintiffs’ right to sue, conveying doubt that the plaintiffs were on solid legal ground.
“Would you agree with the general proposition that a party should not be able to sue ostensibly to protect the rights of other people, if there is a real conflict of interest between the party who is suing and those whose rights the party claims to be attempting to defend?” Associate Justice Alito asked during oral arguments.
The hearing ended with no clear picture of how some justices were leaning. Justice Clarence Thomas and Justice Neil Gorsuch remained silent during arguments and asked no questions. Chief Justice John Roberts Jr., and Justice Brett Kavanaugh questioned whether all admitting privileges laws were unconstitutional or if a state-by-state analysis is required. Near the end of the hearing, Justice Stephen Breyer stressed that more research and fact-finding is necessary before the court can reach a decision.
“We’re not going to solve this at oral argument,” he said.
A decision by the Supreme Court is expected by August 2020.
ACC is canceled. Now what?
The American College of Cardiology has canceled its annual scientific sessions scheduled for March 28-30 in Chicago because of the ongoing coronavirus disease 2019 (COVID-19), it announced on March 9.
The “difficult decision” to cancel ACC.20/WCC, held together with the World Congress of Cardiology this year, was made not only in consideration of information and guidance from the Centers for Disease Control and Prevention and the World Health Organization, but also because institutions are increasingly putting travel restrictions on personnel.
“With an ever-increasing number of ACC members on the front lines of preparing and reacting to the COVID-19 outbreak worldwide, it is in the best interest of everyone to cancel the meeting and ensure our members are able to do what they do best – help and heal,” ACC President Richard J. Kovacs, MD, said in a press statement.
Here are key points from the college, according to an FAQ page created for attendees:
- The meeting is canceled, not postponed. The meeting’s tremendous size and years-long organizational requirements make rescheduling in 2020 impossible.
- All ancillary events are canceled. This includes independent certified sessions and noncertified prime-time exhibitor events, run by the ACC, exhibitors, nonprofits, universities, and others.
- Registration fees will be refunded, but no travel or hotel expenses. If you booked your hotel through ACC’s housing block, Experient will automatically cancel the reservation. You’ll have to cancel your flight directly. The major airlines are rolling out refund and change fee policies in response to the COVID-19–related cancellations, Market Watch reported.
- Late-breakers and simultaneous publications, virtually. Organizers are working on virtual presentations. Priorities listed include embargoed Late-Breaking Clinical Trial presentations, and studies to be published simultaneously with presentations in journals. Whether other presentations will occur as scheduled has yet to be worked out.
- Presenters, stay tuned. If you were planning on presenting science, the organizers stress that you should continue your preparations as options for virtual presentations are worked out.
MDedge Cardiology will bring you the latest news from ACC.20/WCC as usual.
[email protected]
The American College of Cardiology has canceled its annual scientific sessions scheduled for March 28-30 in Chicago because of the ongoing coronavirus disease 2019 (COVID-19), it announced on March 9.
The “difficult decision” to cancel ACC.20/WCC, held together with the World Congress of Cardiology this year, was made not only in consideration of information and guidance from the Centers for Disease Control and Prevention and the World Health Organization, but also because institutions are increasingly putting travel restrictions on personnel.
“With an ever-increasing number of ACC members on the front lines of preparing and reacting to the COVID-19 outbreak worldwide, it is in the best interest of everyone to cancel the meeting and ensure our members are able to do what they do best – help and heal,” ACC President Richard J. Kovacs, MD, said in a press statement.
Here are key points from the college, according to an FAQ page created for attendees:
- The meeting is canceled, not postponed. The meeting’s tremendous size and years-long organizational requirements make rescheduling in 2020 impossible.
- All ancillary events are canceled. This includes independent certified sessions and noncertified prime-time exhibitor events, run by the ACC, exhibitors, nonprofits, universities, and others.
- Registration fees will be refunded, but no travel or hotel expenses. If you booked your hotel through ACC’s housing block, Experient will automatically cancel the reservation. You’ll have to cancel your flight directly. The major airlines are rolling out refund and change fee policies in response to the COVID-19–related cancellations, Market Watch reported.
- Late-breakers and simultaneous publications, virtually. Organizers are working on virtual presentations. Priorities listed include embargoed Late-Breaking Clinical Trial presentations, and studies to be published simultaneously with presentations in journals. Whether other presentations will occur as scheduled has yet to be worked out.
- Presenters, stay tuned. If you were planning on presenting science, the organizers stress that you should continue your preparations as options for virtual presentations are worked out.
MDedge Cardiology will bring you the latest news from ACC.20/WCC as usual.
[email protected]
The American College of Cardiology has canceled its annual scientific sessions scheduled for March 28-30 in Chicago because of the ongoing coronavirus disease 2019 (COVID-19), it announced on March 9.
The “difficult decision” to cancel ACC.20/WCC, held together with the World Congress of Cardiology this year, was made not only in consideration of information and guidance from the Centers for Disease Control and Prevention and the World Health Organization, but also because institutions are increasingly putting travel restrictions on personnel.
“With an ever-increasing number of ACC members on the front lines of preparing and reacting to the COVID-19 outbreak worldwide, it is in the best interest of everyone to cancel the meeting and ensure our members are able to do what they do best – help and heal,” ACC President Richard J. Kovacs, MD, said in a press statement.
Here are key points from the college, according to an FAQ page created for attendees:
- The meeting is canceled, not postponed. The meeting’s tremendous size and years-long organizational requirements make rescheduling in 2020 impossible.
- All ancillary events are canceled. This includes independent certified sessions and noncertified prime-time exhibitor events, run by the ACC, exhibitors, nonprofits, universities, and others.
- Registration fees will be refunded, but no travel or hotel expenses. If you booked your hotel through ACC’s housing block, Experient will automatically cancel the reservation. You’ll have to cancel your flight directly. The major airlines are rolling out refund and change fee policies in response to the COVID-19–related cancellations, Market Watch reported.
- Late-breakers and simultaneous publications, virtually. Organizers are working on virtual presentations. Priorities listed include embargoed Late-Breaking Clinical Trial presentations, and studies to be published simultaneously with presentations in journals. Whether other presentations will occur as scheduled has yet to be worked out.
- Presenters, stay tuned. If you were planning on presenting science, the organizers stress that you should continue your preparations as options for virtual presentations are worked out.
MDedge Cardiology will bring you the latest news from ACC.20/WCC as usual.
[email protected]
Is there empathy erosion?
You learned a lot of things in medical school. But there must have been some things that you unlearned on the way to your degree. For instance, you unlearned that you could catch a cold by playing outside on a cold damp day without your jacket. You unlearned that handling a toad would give you warts.
The authors of a recent study suggest that over your 4 years in medical school you also unlearned how to be empathetic (“Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools,” Acad Med. 2020 Jan 21. doi: 10.1097/ACM.0000000000003175). The researchers surveyed more than 10,000 medical students at nearly 50 DO-granting medical schools using standardized questionnaire called the Jefferson Scale of Empathy. They discovered that the students in the clinical phase (years 3 and 4) had lower “empathy scores” than the students in the preclinical phase of their education (years 1 and 2). This decline was statistically significant but “negligible” in magnitude. One wonders why they even chose to publish their results, particularly when the number of respondents to the web-based survey declined with each successive year in medical school. Having looked at the a sample of some of the questions being asked, I can understand why third- and fourth-year students couldn’t be bothered to respond. They were too busy to answer a few dozen “lame” questions.
There may be a decline in empathy over the course our medical training, but I’m not sure that this study can speak to it. An older study found that although medical students scores on a self-administered scale declined between the second and third year, the observed empathetic behavior actually increased. If I had to choose, I would lean more heavily on the results of the behavioral observations.
Certainly, we all changed over the course of our medical education. Including postgraduate training, it may have lasted a decade or more. We saw hundreds of patients, observed life and death on a scale and with an intensity that most of us previously had never experienced. Our perspective changed from being a naive observer to playing the role of an active participant. Did that change include a decline in our capacity for empathy?
Something had to change. We found quickly that we didn’t have the time or emotional energy to learn as much about the person hiding behind every complaint as we once thought we should. We had to cut corners. Sometimes we cut too many. On the other hand, as we saw more patients we may have learned more efficient ways of discovering what we needed to know about them to become an effective and caring physician. If we found ourselves in a specialty in which patients have a high mortality, we were forced to learn ways of protecting ourselves from the emotional damage.
What would you call this process? Was it empathy erosion? Was it a hardening or toughening? Or was it simply maturation? Whatever term you use, it was an obligatory process if we hoped to survive. However, not all of us have done it well. Some of us have narrowed our focus to see only the complaint and the diagnosis, and we too often fail to see the human hiding in plain sight.
For those of us who completed our training with our empathy intact, was this the result of a genetic gift or the atmosphere our parents had created at home? I suspect that in most cases our capacity for empathy as physicians was nurtured and enhanced by the role models we encountered during our training. The mentors we most revered were those who had already been through the annealing process of medical school and specialty training and become even more skilled at caring than when they left college. It is an intangible that can’t be taught. Sadly, there is no way of guaranteeing that everyone who enters medical school will be exposed to or benefit from even one of these master physicians.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
You learned a lot of things in medical school. But there must have been some things that you unlearned on the way to your degree. For instance, you unlearned that you could catch a cold by playing outside on a cold damp day without your jacket. You unlearned that handling a toad would give you warts.
The authors of a recent study suggest that over your 4 years in medical school you also unlearned how to be empathetic (“Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools,” Acad Med. 2020 Jan 21. doi: 10.1097/ACM.0000000000003175). The researchers surveyed more than 10,000 medical students at nearly 50 DO-granting medical schools using standardized questionnaire called the Jefferson Scale of Empathy. They discovered that the students in the clinical phase (years 3 and 4) had lower “empathy scores” than the students in the preclinical phase of their education (years 1 and 2). This decline was statistically significant but “negligible” in magnitude. One wonders why they even chose to publish their results, particularly when the number of respondents to the web-based survey declined with each successive year in medical school. Having looked at the a sample of some of the questions being asked, I can understand why third- and fourth-year students couldn’t be bothered to respond. They were too busy to answer a few dozen “lame” questions.
There may be a decline in empathy over the course our medical training, but I’m not sure that this study can speak to it. An older study found that although medical students scores on a self-administered scale declined between the second and third year, the observed empathetic behavior actually increased. If I had to choose, I would lean more heavily on the results of the behavioral observations.
Certainly, we all changed over the course of our medical education. Including postgraduate training, it may have lasted a decade or more. We saw hundreds of patients, observed life and death on a scale and with an intensity that most of us previously had never experienced. Our perspective changed from being a naive observer to playing the role of an active participant. Did that change include a decline in our capacity for empathy?
Something had to change. We found quickly that we didn’t have the time or emotional energy to learn as much about the person hiding behind every complaint as we once thought we should. We had to cut corners. Sometimes we cut too many. On the other hand, as we saw more patients we may have learned more efficient ways of discovering what we needed to know about them to become an effective and caring physician. If we found ourselves in a specialty in which patients have a high mortality, we were forced to learn ways of protecting ourselves from the emotional damage.
What would you call this process? Was it empathy erosion? Was it a hardening or toughening? Or was it simply maturation? Whatever term you use, it was an obligatory process if we hoped to survive. However, not all of us have done it well. Some of us have narrowed our focus to see only the complaint and the diagnosis, and we too often fail to see the human hiding in plain sight.
For those of us who completed our training with our empathy intact, was this the result of a genetic gift or the atmosphere our parents had created at home? I suspect that in most cases our capacity for empathy as physicians was nurtured and enhanced by the role models we encountered during our training. The mentors we most revered were those who had already been through the annealing process of medical school and specialty training and become even more skilled at caring than when they left college. It is an intangible that can’t be taught. Sadly, there is no way of guaranteeing that everyone who enters medical school will be exposed to or benefit from even one of these master physicians.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
You learned a lot of things in medical school. But there must have been some things that you unlearned on the way to your degree. For instance, you unlearned that you could catch a cold by playing outside on a cold damp day without your jacket. You unlearned that handling a toad would give you warts.
The authors of a recent study suggest that over your 4 years in medical school you also unlearned how to be empathetic (“Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools,” Acad Med. 2020 Jan 21. doi: 10.1097/ACM.0000000000003175). The researchers surveyed more than 10,000 medical students at nearly 50 DO-granting medical schools using standardized questionnaire called the Jefferson Scale of Empathy. They discovered that the students in the clinical phase (years 3 and 4) had lower “empathy scores” than the students in the preclinical phase of their education (years 1 and 2). This decline was statistically significant but “negligible” in magnitude. One wonders why they even chose to publish their results, particularly when the number of respondents to the web-based survey declined with each successive year in medical school. Having looked at the a sample of some of the questions being asked, I can understand why third- and fourth-year students couldn’t be bothered to respond. They were too busy to answer a few dozen “lame” questions.
There may be a decline in empathy over the course our medical training, but I’m not sure that this study can speak to it. An older study found that although medical students scores on a self-administered scale declined between the second and third year, the observed empathetic behavior actually increased. If I had to choose, I would lean more heavily on the results of the behavioral observations.
Certainly, we all changed over the course of our medical education. Including postgraduate training, it may have lasted a decade or more. We saw hundreds of patients, observed life and death on a scale and with an intensity that most of us previously had never experienced. Our perspective changed from being a naive observer to playing the role of an active participant. Did that change include a decline in our capacity for empathy?
Something had to change. We found quickly that we didn’t have the time or emotional energy to learn as much about the person hiding behind every complaint as we once thought we should. We had to cut corners. Sometimes we cut too many. On the other hand, as we saw more patients we may have learned more efficient ways of discovering what we needed to know about them to become an effective and caring physician. If we found ourselves in a specialty in which patients have a high mortality, we were forced to learn ways of protecting ourselves from the emotional damage.
What would you call this process? Was it empathy erosion? Was it a hardening or toughening? Or was it simply maturation? Whatever term you use, it was an obligatory process if we hoped to survive. However, not all of us have done it well. Some of us have narrowed our focus to see only the complaint and the diagnosis, and we too often fail to see the human hiding in plain sight.
For those of us who completed our training with our empathy intact, was this the result of a genetic gift or the atmosphere our parents had created at home? I suspect that in most cases our capacity for empathy as physicians was nurtured and enhanced by the role models we encountered during our training. The mentors we most revered were those who had already been through the annealing process of medical school and specialty training and become even more skilled at caring than when they left college. It is an intangible that can’t be taught. Sadly, there is no way of guaranteeing that everyone who enters medical school will be exposed to or benefit from even one of these master physicians.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Researchers honored by ACS, IASLC
The International Association for the Study of Lung Cancer (IASLC) is naming the Translational Research Lectureship Award after Fred R. Hirsch, MD, PhD, of the Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai, New York.
Dr. Hirsch was a longtime member of the IASLC and served as chief executive officer of the association from 2013 through October 2018. During this time, Dr. Hirsch grew the IASLC staff from 5 to 23 people and doubled the organization’s membership. The IASLC World Conference on Lung Cancer became an annual meeting under Dr. Hirsch’s direction and reported record attendance, according to their website.
The recipient of the Fred R. Hirsch Lectureship Award for Translational Research will be recognized at the IASLC 2020 World Conference on Lung Cancer, which is set to take place in Singapore on August 9-12, 2020.
In other news, the American Cancer Society (ACS) announced that it has awarded the 2020 Medal of Honor to three researchers. The recipients will be recognized at a black-tie ceremony in New York on Nov. 11, 2020.
Lewis C. Cantley, PhD, of Weill Cornell Medicine, New York, won the Medal of Honor for Basic Research. This award honors researchers whose work will have a “lasting impact on the cancer field” or who have made important discoveries or inventions within the field, according to the ACS.
Dr. Cantley won the award for research that has improved our understanding of cancer metabolism. He is known for his contributions to the discovery and study of phosphoinositide 3-kinase, which plays a role in many cancers and has become a target for therapies.
Leslie Bernstein, PhD, of City of Hope National Medical Center in Duarte, Calif., has won the Medal of Honor in Cancer Control. This award honors individuals who have made strides in public health, public communication, or public policy that have had an impact on cancer control.
Dr. Bernstein won the award for her work linking physical activity to a reduced risk of breast cancer. She is currently investigating links between hormone exposures, physical activity, obesity, and cancer, as well as examining how breast cancer impacts patients’ lives after treatment.
Ching-Hon Pui, MD, of St. Jude Children’s Research Hospital in Memphis, Tenn., has won the Medal of Honor in Clinical Research. This award honors researchers whose work has significantly improved cancer patients’ outcomes.
Dr. Pui won the award for his work in childhood acute lymphoblastic leukemia. Dr. Pui’s work has led to increased global treatment access, improved survival rates, and better quality of life for patients with childhood acute lymphoblastic leukemia.
The International Association for the Study of Lung Cancer (IASLC) is naming the Translational Research Lectureship Award after Fred R. Hirsch, MD, PhD, of the Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai, New York.
Dr. Hirsch was a longtime member of the IASLC and served as chief executive officer of the association from 2013 through October 2018. During this time, Dr. Hirsch grew the IASLC staff from 5 to 23 people and doubled the organization’s membership. The IASLC World Conference on Lung Cancer became an annual meeting under Dr. Hirsch’s direction and reported record attendance, according to their website.
The recipient of the Fred R. Hirsch Lectureship Award for Translational Research will be recognized at the IASLC 2020 World Conference on Lung Cancer, which is set to take place in Singapore on August 9-12, 2020.
In other news, the American Cancer Society (ACS) announced that it has awarded the 2020 Medal of Honor to three researchers. The recipients will be recognized at a black-tie ceremony in New York on Nov. 11, 2020.
Lewis C. Cantley, PhD, of Weill Cornell Medicine, New York, won the Medal of Honor for Basic Research. This award honors researchers whose work will have a “lasting impact on the cancer field” or who have made important discoveries or inventions within the field, according to the ACS.
Dr. Cantley won the award for research that has improved our understanding of cancer metabolism. He is known for his contributions to the discovery and study of phosphoinositide 3-kinase, which plays a role in many cancers and has become a target for therapies.
Leslie Bernstein, PhD, of City of Hope National Medical Center in Duarte, Calif., has won the Medal of Honor in Cancer Control. This award honors individuals who have made strides in public health, public communication, or public policy that have had an impact on cancer control.
Dr. Bernstein won the award for her work linking physical activity to a reduced risk of breast cancer. She is currently investigating links between hormone exposures, physical activity, obesity, and cancer, as well as examining how breast cancer impacts patients’ lives after treatment.
Ching-Hon Pui, MD, of St. Jude Children’s Research Hospital in Memphis, Tenn., has won the Medal of Honor in Clinical Research. This award honors researchers whose work has significantly improved cancer patients’ outcomes.
Dr. Pui won the award for his work in childhood acute lymphoblastic leukemia. Dr. Pui’s work has led to increased global treatment access, improved survival rates, and better quality of life for patients with childhood acute lymphoblastic leukemia.
The International Association for the Study of Lung Cancer (IASLC) is naming the Translational Research Lectureship Award after Fred R. Hirsch, MD, PhD, of the Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai, New York.
Dr. Hirsch was a longtime member of the IASLC and served as chief executive officer of the association from 2013 through October 2018. During this time, Dr. Hirsch grew the IASLC staff from 5 to 23 people and doubled the organization’s membership. The IASLC World Conference on Lung Cancer became an annual meeting under Dr. Hirsch’s direction and reported record attendance, according to their website.
The recipient of the Fred R. Hirsch Lectureship Award for Translational Research will be recognized at the IASLC 2020 World Conference on Lung Cancer, which is set to take place in Singapore on August 9-12, 2020.
In other news, the American Cancer Society (ACS) announced that it has awarded the 2020 Medal of Honor to three researchers. The recipients will be recognized at a black-tie ceremony in New York on Nov. 11, 2020.
Lewis C. Cantley, PhD, of Weill Cornell Medicine, New York, won the Medal of Honor for Basic Research. This award honors researchers whose work will have a “lasting impact on the cancer field” or who have made important discoveries or inventions within the field, according to the ACS.
Dr. Cantley won the award for research that has improved our understanding of cancer metabolism. He is known for his contributions to the discovery and study of phosphoinositide 3-kinase, which plays a role in many cancers and has become a target for therapies.
Leslie Bernstein, PhD, of City of Hope National Medical Center in Duarte, Calif., has won the Medal of Honor in Cancer Control. This award honors individuals who have made strides in public health, public communication, or public policy that have had an impact on cancer control.
Dr. Bernstein won the award for her work linking physical activity to a reduced risk of breast cancer. She is currently investigating links between hormone exposures, physical activity, obesity, and cancer, as well as examining how breast cancer impacts patients’ lives after treatment.
Ching-Hon Pui, MD, of St. Jude Children’s Research Hospital in Memphis, Tenn., has won the Medal of Honor in Clinical Research. This award honors researchers whose work has significantly improved cancer patients’ outcomes.
Dr. Pui won the award for his work in childhood acute lymphoblastic leukemia. Dr. Pui’s work has led to increased global treatment access, improved survival rates, and better quality of life for patients with childhood acute lymphoblastic leukemia.
Telehealth seen as a key tool to help fight COVID-19
Telehealth is increasingly being viewed as a key way to help fight the COVID-19 outbreak in the United States. Recognizing the potential of this technology to slow the spread of the disease, the House of Representatives included a provision in an $8.3 billion emergency response bill it approved today that would temporarily lift restrictions on Medicare telehealth coverage to assist in the efforts to contain the virus.
Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC), said that hospitals should be prepared to use telehealth as one of their tools in fighting the outbreak, according to a recent news release from the American Hospital Association (AHA).
Congress is responding to that need by including the service in the new coronavirus legislation now headed to the Senate, after the funding bill was approved in a 415-2 vote by the House.
The bill empowers the Secretary of Health and Human Services (HHS) to “waive or modify application of certain Medicare requirements with respect to telehealth services furnished during certain emergency periods.”
While the measure adds telehealth to the waiver authority that the HHS secretary currently has during national emergencies, it’s only for the coronavirus crisis in this case, Krista Drobac, executive director of the Alliance for Connected Care, told Medscape Medical News.
The waiver would apply to originating sites of telehealth visits, she noted. Thus Medicare coverage of telemedicine would be expanded beyond rural areas.
In addition, the waiver would allow coverage of virtual visits conducted on smartphones with audio and video capabilities. A “qualified provider,” as defined by the legislation, would be a practitioner who has an established relationship with the patient or who is in the same practice as the provider who has that relationship.
An advantage of telehealth, proponents say, is that it can enable people who believe they have COVID-19 to be seen at home rather than visit offices or emergency departments (EDs) where they might spread the disease or be in proximity to others who have it.
In an editorial published March 2 in Modern Healthcare, medical directors from Stanford Medicine, MedStar Health, and Intermountain Healthcare also noted that telehealth can give patients 24/7 access to care, allow surveillance of patients at risk while keeping them at home, ensure that treatment in hospitals is reserved for high-need patients, and enable providers to triage and screen more patients than can be handled in brick-and-mortar care settings.
However, telehealth screening would allow physicians only to judge whether a patient’s symptoms might be indicative of COVID-19, the Alliance for Connected Care, a telehealth advocacy group, noted in a letter to Congressional leaders. Patients would still have to be seen in person to be tested for the disease.
The group, which represents technology companies, health insurers, pharmacies, and other healthcare players, has been lobbying Congress to include telehealth in federal funds to combat the outbreak.
The American Telemedicine Association (ATA) also supports this goal, ATA President Joseph Kvedar, MD, told Medscape Medical News. And the authors of the Modern Healthcare editorial also advocated for this legislative solution. Because the fatality rate for COVID-19 is significantly higher for older people than for other age groups, they noted, telehealth should be an economically viable option for all seniors.
The Centers for Medicare and Medicaid Services (CMS) long covered telemedicine only in rural areas and only when initiated in healthcare settings. Recently, however, CMS loosened its approach to some extent. Virtual “check-in visits” can now be initiated from any location, including home, to determine whether a Medicare patient needs to be seen in the office. In addition, CMS allows Medicare Advantage plans to offer telemedicine as a core benefit.
Are healthcare systems prepared?
Some large healthcare systems such as Stanford, MedStar, and Intermountain are already using telehealth to diagnose and treat patients who have traditional influenza. Telehealth providers at Stanford estimate that almost 50% of these patients are being prescribed the antiviral drug Tamiflu.
It’s unclear whether other healthcare systems are this well prepared to offer telehealth on a large scale. But, according to an AHA survey, Kvedar noted, three quarters of AHA members are engaged in some form of telehealth.
Drobac said “it wouldn’t require too much effort” to ramp up a wide-scale telehealth program that could help reduce the impact of the outbreak. “The technology is there,” she noted. “You need a HIPAA-compliant telehealth platform, but there are so many out there.”
Kvedar agreed. To begin with, he said, hospitals might sequester patients who visit the ED with COVID-19 symptoms in a video-equipped “isolation room.” Staff members could then do the patient intake from a different location in the hospital.
He admitted that this approach would be infeasible if a lot of patients arrived in EDs with coronavirus symptoms. However, Kvedar noted, “All the tools are in place to go well beyond that. American Well, Teladoc, and others are all offering ways to get out in front of this. There are plenty of vendors out there, and most people have a connected cell phone that you can do a video call on.”
Hospital leaders would have to decide whether to embrace telehealth, which would mean less use of services in their institutions, he said. “But it would be for the greater good of the public.”
Kvedar recalled that there was some use of telehealth in the New York area after 9/11. Telehealth was also used in the aftermath of Hurricane Katrina in 2005. But the ATA president, who is also vice president of connected health at Partners HealthCare in Boston, noted that the COVID-19 outbreak is the first public health emergency to occur in the era of Skype and smartphones.
If Congress does ultimately authorize CMS to cover telehealth across the board during this emergency, might that lead to a permanent change in Medicare coverage policy? Kvedar wouldn’t venture an opinion. “However, the current CMS leadership has been incredibly telehealth friendly,” he said. “So it’s possible they would [embrace a lifting of restrictions]. As patients get a sense of this modality of care and how convenient it is for them, they’ll start asking for more.”
Meanwhile, he said, the telehealth opportunity goes beyond video visits with doctors to mitigate the outbreak. Telehealth data could also be used to track disease spread, similar to how researchers have studied Google searches to predict the spread of the flu, he noted.
Teladoc, a major telehealth vendor, recently told stock analysts it’s already working with the CDC on disease surveillance, according to a report in FierceHealthcare.
This article first appeared on Medscape.com.
Telehealth is increasingly being viewed as a key way to help fight the COVID-19 outbreak in the United States. Recognizing the potential of this technology to slow the spread of the disease, the House of Representatives included a provision in an $8.3 billion emergency response bill it approved today that would temporarily lift restrictions on Medicare telehealth coverage to assist in the efforts to contain the virus.
Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC), said that hospitals should be prepared to use telehealth as one of their tools in fighting the outbreak, according to a recent news release from the American Hospital Association (AHA).
Congress is responding to that need by including the service in the new coronavirus legislation now headed to the Senate, after the funding bill was approved in a 415-2 vote by the House.
The bill empowers the Secretary of Health and Human Services (HHS) to “waive or modify application of certain Medicare requirements with respect to telehealth services furnished during certain emergency periods.”
While the measure adds telehealth to the waiver authority that the HHS secretary currently has during national emergencies, it’s only for the coronavirus crisis in this case, Krista Drobac, executive director of the Alliance for Connected Care, told Medscape Medical News.
The waiver would apply to originating sites of telehealth visits, she noted. Thus Medicare coverage of telemedicine would be expanded beyond rural areas.
In addition, the waiver would allow coverage of virtual visits conducted on smartphones with audio and video capabilities. A “qualified provider,” as defined by the legislation, would be a practitioner who has an established relationship with the patient or who is in the same practice as the provider who has that relationship.
An advantage of telehealth, proponents say, is that it can enable people who believe they have COVID-19 to be seen at home rather than visit offices or emergency departments (EDs) where they might spread the disease or be in proximity to others who have it.
In an editorial published March 2 in Modern Healthcare, medical directors from Stanford Medicine, MedStar Health, and Intermountain Healthcare also noted that telehealth can give patients 24/7 access to care, allow surveillance of patients at risk while keeping them at home, ensure that treatment in hospitals is reserved for high-need patients, and enable providers to triage and screen more patients than can be handled in brick-and-mortar care settings.
However, telehealth screening would allow physicians only to judge whether a patient’s symptoms might be indicative of COVID-19, the Alliance for Connected Care, a telehealth advocacy group, noted in a letter to Congressional leaders. Patients would still have to be seen in person to be tested for the disease.
The group, which represents technology companies, health insurers, pharmacies, and other healthcare players, has been lobbying Congress to include telehealth in federal funds to combat the outbreak.
The American Telemedicine Association (ATA) also supports this goal, ATA President Joseph Kvedar, MD, told Medscape Medical News. And the authors of the Modern Healthcare editorial also advocated for this legislative solution. Because the fatality rate for COVID-19 is significantly higher for older people than for other age groups, they noted, telehealth should be an economically viable option for all seniors.
The Centers for Medicare and Medicaid Services (CMS) long covered telemedicine only in rural areas and only when initiated in healthcare settings. Recently, however, CMS loosened its approach to some extent. Virtual “check-in visits” can now be initiated from any location, including home, to determine whether a Medicare patient needs to be seen in the office. In addition, CMS allows Medicare Advantage plans to offer telemedicine as a core benefit.
Are healthcare systems prepared?
Some large healthcare systems such as Stanford, MedStar, and Intermountain are already using telehealth to diagnose and treat patients who have traditional influenza. Telehealth providers at Stanford estimate that almost 50% of these patients are being prescribed the antiviral drug Tamiflu.
It’s unclear whether other healthcare systems are this well prepared to offer telehealth on a large scale. But, according to an AHA survey, Kvedar noted, three quarters of AHA members are engaged in some form of telehealth.
Drobac said “it wouldn’t require too much effort” to ramp up a wide-scale telehealth program that could help reduce the impact of the outbreak. “The technology is there,” she noted. “You need a HIPAA-compliant telehealth platform, but there are so many out there.”
Kvedar agreed. To begin with, he said, hospitals might sequester patients who visit the ED with COVID-19 symptoms in a video-equipped “isolation room.” Staff members could then do the patient intake from a different location in the hospital.
He admitted that this approach would be infeasible if a lot of patients arrived in EDs with coronavirus symptoms. However, Kvedar noted, “All the tools are in place to go well beyond that. American Well, Teladoc, and others are all offering ways to get out in front of this. There are plenty of vendors out there, and most people have a connected cell phone that you can do a video call on.”
Hospital leaders would have to decide whether to embrace telehealth, which would mean less use of services in their institutions, he said. “But it would be for the greater good of the public.”
Kvedar recalled that there was some use of telehealth in the New York area after 9/11. Telehealth was also used in the aftermath of Hurricane Katrina in 2005. But the ATA president, who is also vice president of connected health at Partners HealthCare in Boston, noted that the COVID-19 outbreak is the first public health emergency to occur in the era of Skype and smartphones.
If Congress does ultimately authorize CMS to cover telehealth across the board during this emergency, might that lead to a permanent change in Medicare coverage policy? Kvedar wouldn’t venture an opinion. “However, the current CMS leadership has been incredibly telehealth friendly,” he said. “So it’s possible they would [embrace a lifting of restrictions]. As patients get a sense of this modality of care and how convenient it is for them, they’ll start asking for more.”
Meanwhile, he said, the telehealth opportunity goes beyond video visits with doctors to mitigate the outbreak. Telehealth data could also be used to track disease spread, similar to how researchers have studied Google searches to predict the spread of the flu, he noted.
Teladoc, a major telehealth vendor, recently told stock analysts it’s already working with the CDC on disease surveillance, according to a report in FierceHealthcare.
This article first appeared on Medscape.com.
Telehealth is increasingly being viewed as a key way to help fight the COVID-19 outbreak in the United States. Recognizing the potential of this technology to slow the spread of the disease, the House of Representatives included a provision in an $8.3 billion emergency response bill it approved today that would temporarily lift restrictions on Medicare telehealth coverage to assist in the efforts to contain the virus.
Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC), said that hospitals should be prepared to use telehealth as one of their tools in fighting the outbreak, according to a recent news release from the American Hospital Association (AHA).
Congress is responding to that need by including the service in the new coronavirus legislation now headed to the Senate, after the funding bill was approved in a 415-2 vote by the House.
The bill empowers the Secretary of Health and Human Services (HHS) to “waive or modify application of certain Medicare requirements with respect to telehealth services furnished during certain emergency periods.”
While the measure adds telehealth to the waiver authority that the HHS secretary currently has during national emergencies, it’s only for the coronavirus crisis in this case, Krista Drobac, executive director of the Alliance for Connected Care, told Medscape Medical News.
The waiver would apply to originating sites of telehealth visits, she noted. Thus Medicare coverage of telemedicine would be expanded beyond rural areas.
In addition, the waiver would allow coverage of virtual visits conducted on smartphones with audio and video capabilities. A “qualified provider,” as defined by the legislation, would be a practitioner who has an established relationship with the patient or who is in the same practice as the provider who has that relationship.
An advantage of telehealth, proponents say, is that it can enable people who believe they have COVID-19 to be seen at home rather than visit offices or emergency departments (EDs) where they might spread the disease or be in proximity to others who have it.
In an editorial published March 2 in Modern Healthcare, medical directors from Stanford Medicine, MedStar Health, and Intermountain Healthcare also noted that telehealth can give patients 24/7 access to care, allow surveillance of patients at risk while keeping them at home, ensure that treatment in hospitals is reserved for high-need patients, and enable providers to triage and screen more patients than can be handled in brick-and-mortar care settings.
However, telehealth screening would allow physicians only to judge whether a patient’s symptoms might be indicative of COVID-19, the Alliance for Connected Care, a telehealth advocacy group, noted in a letter to Congressional leaders. Patients would still have to be seen in person to be tested for the disease.
The group, which represents technology companies, health insurers, pharmacies, and other healthcare players, has been lobbying Congress to include telehealth in federal funds to combat the outbreak.
The American Telemedicine Association (ATA) also supports this goal, ATA President Joseph Kvedar, MD, told Medscape Medical News. And the authors of the Modern Healthcare editorial also advocated for this legislative solution. Because the fatality rate for COVID-19 is significantly higher for older people than for other age groups, they noted, telehealth should be an economically viable option for all seniors.
The Centers for Medicare and Medicaid Services (CMS) long covered telemedicine only in rural areas and only when initiated in healthcare settings. Recently, however, CMS loosened its approach to some extent. Virtual “check-in visits” can now be initiated from any location, including home, to determine whether a Medicare patient needs to be seen in the office. In addition, CMS allows Medicare Advantage plans to offer telemedicine as a core benefit.
Are healthcare systems prepared?
Some large healthcare systems such as Stanford, MedStar, and Intermountain are already using telehealth to diagnose and treat patients who have traditional influenza. Telehealth providers at Stanford estimate that almost 50% of these patients are being prescribed the antiviral drug Tamiflu.
It’s unclear whether other healthcare systems are this well prepared to offer telehealth on a large scale. But, according to an AHA survey, Kvedar noted, three quarters of AHA members are engaged in some form of telehealth.
Drobac said “it wouldn’t require too much effort” to ramp up a wide-scale telehealth program that could help reduce the impact of the outbreak. “The technology is there,” she noted. “You need a HIPAA-compliant telehealth platform, but there are so many out there.”
Kvedar agreed. To begin with, he said, hospitals might sequester patients who visit the ED with COVID-19 symptoms in a video-equipped “isolation room.” Staff members could then do the patient intake from a different location in the hospital.
He admitted that this approach would be infeasible if a lot of patients arrived in EDs with coronavirus symptoms. However, Kvedar noted, “All the tools are in place to go well beyond that. American Well, Teladoc, and others are all offering ways to get out in front of this. There are plenty of vendors out there, and most people have a connected cell phone that you can do a video call on.”
Hospital leaders would have to decide whether to embrace telehealth, which would mean less use of services in their institutions, he said. “But it would be for the greater good of the public.”
Kvedar recalled that there was some use of telehealth in the New York area after 9/11. Telehealth was also used in the aftermath of Hurricane Katrina in 2005. But the ATA president, who is also vice president of connected health at Partners HealthCare in Boston, noted that the COVID-19 outbreak is the first public health emergency to occur in the era of Skype and smartphones.
If Congress does ultimately authorize CMS to cover telehealth across the board during this emergency, might that lead to a permanent change in Medicare coverage policy? Kvedar wouldn’t venture an opinion. “However, the current CMS leadership has been incredibly telehealth friendly,” he said. “So it’s possible they would [embrace a lifting of restrictions]. As patients get a sense of this modality of care and how convenient it is for them, they’ll start asking for more.”
Meanwhile, he said, the telehealth opportunity goes beyond video visits with doctors to mitigate the outbreak. Telehealth data could also be used to track disease spread, similar to how researchers have studied Google searches to predict the spread of the flu, he noted.
Teladoc, a major telehealth vendor, recently told stock analysts it’s already working with the CDC on disease surveillance, according to a report in FierceHealthcare.
This article first appeared on Medscape.com.
Gender pronouns in EMR preferred by many gender nonconforming teens
Most transgender and gender nonconforming youth would like their preferred name and pronouns be recorded throughout their EMRs, but very few are ever asked for that identity information outside of gender specialty clinic settings, according to a recent research letter in JAMA Pediatrics.
The findings are not surprising, said Cora Breuner, MD, a professor of pediatrics in adolescent medicine at Seattle Children’s Hospital in Washington, because “we know that use of gender-affirming language when accessing health care is extremely important to transgender youth.”
“Use of gender-affirming language in the health care system is associated with improved mental health outcomes in this population,” Dr Breuner said in an interview.
But the authors of the study noted that EMRs often lack the functions needed to provide gender-affirming care.
“To better support this vulnerable group of youths, health systems and EMRs should allow for EMR-wide name and pronoun documentation, even when a patient has not legally changed their name,” Gina M. Sequeira, MD, of UPMC Children’s Hospital of Pittsburgh and associates wrote.
Although many providers have begun routinely asking patients for both their gender identity and their sex assigned at birth, these questions leave out a patient’s preferred name and pronouns – crucial components of respectful and affirming care, the authors explained.
At a specialty gender clinic, the authors surveyed 204 transgender youths, aged 12-26 years, regarding how their name and pronouns are recorded in their EMR files. Just over half the respondents were under age 18 years (56%), and most were white (86%). Most were transmasculine (59%), with 21% transfeminine and 20% nonbinary.
Most respondents (69%) went by a name other than their legal one, yet only 9% said they were frequently or always asked in clinical settings outside specialty gender centers whether they wanted their preferred name and pronouns noted in the EMR.
A majority (79%), however, said they wanted their name and pronouns noted throughout their EMR. The youths’ preferences varied according to their gender identity and how many people were aware of their gender identity, but not by age, race/ethnicity, or perceived amount of parental support.
Only two-thirds (67%) of 42 transfeminine patients wished their EMR to include their preferred name, compared with most (85%) of 121 transmasculine patients and nearly all (92%) of 37 nonbinary respondents (P = .007). Pronouns preferences were similar: All but one nonbinary respondent wanted their pronouns in the EMR, compared with 84% of transmasculine and 64% of transfeminine respondents (P=.0003).
“It may be that transfeminine patients have more pressure to ‘stay’ their assigned gender,” Dr Breuner said regarding these findings. “ ‘Outness’ may be challenging, and thus they remain in their traditional gender norms, but further research on this theory is warranted.”
Among those who were “out to everyone,” most (88%) wanted their preferred name and pronouns recorded in the EMR, and the proportion was similar for those “out to most.” But only 65% of those “out to few or no one” preferred their name and pronouns be noted in the EMR, a similar proportion for those “out to some.”
Of 7 youths who did not wish to include their name and pronouns throughout their EMR, all but one said they didn’t think it was necessary because they believed they already “passed” well enough as their gender. Just one person said they did not want name and pronouns recorded for confidentiality reasons.
However, confidentiality is still an important consideration particularly for minors, the authors and Dr. Breuner pointed out.
“It is essential to discuss confidentiality with the youth as parents may have access to the medical records younger than 18 years of age,” Dr. Breuner said.
The authors noted the study’s limitation in using a convenience sample but they and Dr. Breuner said that the findings still demonstrate transgender youths’ desire for EMRs to include their name and pronouns.
The research was funded by grants from the National Institutes of Health. The authors had no industry disclosures.
SOURCE: Sequeira GM et al. JAMA Pediatrics. 2020 Feb 23. doi: 10.1001/jamapediatrics.2019.6071.
Most transgender and gender nonconforming youth would like their preferred name and pronouns be recorded throughout their EMRs, but very few are ever asked for that identity information outside of gender specialty clinic settings, according to a recent research letter in JAMA Pediatrics.
The findings are not surprising, said Cora Breuner, MD, a professor of pediatrics in adolescent medicine at Seattle Children’s Hospital in Washington, because “we know that use of gender-affirming language when accessing health care is extremely important to transgender youth.”
“Use of gender-affirming language in the health care system is associated with improved mental health outcomes in this population,” Dr Breuner said in an interview.
But the authors of the study noted that EMRs often lack the functions needed to provide gender-affirming care.
“To better support this vulnerable group of youths, health systems and EMRs should allow for EMR-wide name and pronoun documentation, even when a patient has not legally changed their name,” Gina M. Sequeira, MD, of UPMC Children’s Hospital of Pittsburgh and associates wrote.
Although many providers have begun routinely asking patients for both their gender identity and their sex assigned at birth, these questions leave out a patient’s preferred name and pronouns – crucial components of respectful and affirming care, the authors explained.
At a specialty gender clinic, the authors surveyed 204 transgender youths, aged 12-26 years, regarding how their name and pronouns are recorded in their EMR files. Just over half the respondents were under age 18 years (56%), and most were white (86%). Most were transmasculine (59%), with 21% transfeminine and 20% nonbinary.
Most respondents (69%) went by a name other than their legal one, yet only 9% said they were frequently or always asked in clinical settings outside specialty gender centers whether they wanted their preferred name and pronouns noted in the EMR.
A majority (79%), however, said they wanted their name and pronouns noted throughout their EMR. The youths’ preferences varied according to their gender identity and how many people were aware of their gender identity, but not by age, race/ethnicity, or perceived amount of parental support.
Only two-thirds (67%) of 42 transfeminine patients wished their EMR to include their preferred name, compared with most (85%) of 121 transmasculine patients and nearly all (92%) of 37 nonbinary respondents (P = .007). Pronouns preferences were similar: All but one nonbinary respondent wanted their pronouns in the EMR, compared with 84% of transmasculine and 64% of transfeminine respondents (P=.0003).
“It may be that transfeminine patients have more pressure to ‘stay’ their assigned gender,” Dr Breuner said regarding these findings. “ ‘Outness’ may be challenging, and thus they remain in their traditional gender norms, but further research on this theory is warranted.”
Among those who were “out to everyone,” most (88%) wanted their preferred name and pronouns recorded in the EMR, and the proportion was similar for those “out to most.” But only 65% of those “out to few or no one” preferred their name and pronouns be noted in the EMR, a similar proportion for those “out to some.”
Of 7 youths who did not wish to include their name and pronouns throughout their EMR, all but one said they didn’t think it was necessary because they believed they already “passed” well enough as their gender. Just one person said they did not want name and pronouns recorded for confidentiality reasons.
However, confidentiality is still an important consideration particularly for minors, the authors and Dr. Breuner pointed out.
“It is essential to discuss confidentiality with the youth as parents may have access to the medical records younger than 18 years of age,” Dr. Breuner said.
The authors noted the study’s limitation in using a convenience sample but they and Dr. Breuner said that the findings still demonstrate transgender youths’ desire for EMRs to include their name and pronouns.
The research was funded by grants from the National Institutes of Health. The authors had no industry disclosures.
SOURCE: Sequeira GM et al. JAMA Pediatrics. 2020 Feb 23. doi: 10.1001/jamapediatrics.2019.6071.
Most transgender and gender nonconforming youth would like their preferred name and pronouns be recorded throughout their EMRs, but very few are ever asked for that identity information outside of gender specialty clinic settings, according to a recent research letter in JAMA Pediatrics.
The findings are not surprising, said Cora Breuner, MD, a professor of pediatrics in adolescent medicine at Seattle Children’s Hospital in Washington, because “we know that use of gender-affirming language when accessing health care is extremely important to transgender youth.”
“Use of gender-affirming language in the health care system is associated with improved mental health outcomes in this population,” Dr Breuner said in an interview.
But the authors of the study noted that EMRs often lack the functions needed to provide gender-affirming care.
“To better support this vulnerable group of youths, health systems and EMRs should allow for EMR-wide name and pronoun documentation, even when a patient has not legally changed their name,” Gina M. Sequeira, MD, of UPMC Children’s Hospital of Pittsburgh and associates wrote.
Although many providers have begun routinely asking patients for both their gender identity and their sex assigned at birth, these questions leave out a patient’s preferred name and pronouns – crucial components of respectful and affirming care, the authors explained.
At a specialty gender clinic, the authors surveyed 204 transgender youths, aged 12-26 years, regarding how their name and pronouns are recorded in their EMR files. Just over half the respondents were under age 18 years (56%), and most were white (86%). Most were transmasculine (59%), with 21% transfeminine and 20% nonbinary.
Most respondents (69%) went by a name other than their legal one, yet only 9% said they were frequently or always asked in clinical settings outside specialty gender centers whether they wanted their preferred name and pronouns noted in the EMR.
A majority (79%), however, said they wanted their name and pronouns noted throughout their EMR. The youths’ preferences varied according to their gender identity and how many people were aware of their gender identity, but not by age, race/ethnicity, or perceived amount of parental support.
Only two-thirds (67%) of 42 transfeminine patients wished their EMR to include their preferred name, compared with most (85%) of 121 transmasculine patients and nearly all (92%) of 37 nonbinary respondents (P = .007). Pronouns preferences were similar: All but one nonbinary respondent wanted their pronouns in the EMR, compared with 84% of transmasculine and 64% of transfeminine respondents (P=.0003).
“It may be that transfeminine patients have more pressure to ‘stay’ their assigned gender,” Dr Breuner said regarding these findings. “ ‘Outness’ may be challenging, and thus they remain in their traditional gender norms, but further research on this theory is warranted.”
Among those who were “out to everyone,” most (88%) wanted their preferred name and pronouns recorded in the EMR, and the proportion was similar for those “out to most.” But only 65% of those “out to few or no one” preferred their name and pronouns be noted in the EMR, a similar proportion for those “out to some.”
Of 7 youths who did not wish to include their name and pronouns throughout their EMR, all but one said they didn’t think it was necessary because they believed they already “passed” well enough as their gender. Just one person said they did not want name and pronouns recorded for confidentiality reasons.
However, confidentiality is still an important consideration particularly for minors, the authors and Dr. Breuner pointed out.
“It is essential to discuss confidentiality with the youth as parents may have access to the medical records younger than 18 years of age,” Dr. Breuner said.
The authors noted the study’s limitation in using a convenience sample but they and Dr. Breuner said that the findings still demonstrate transgender youths’ desire for EMRs to include their name and pronouns.
The research was funded by grants from the National Institutes of Health. The authors had no industry disclosures.
SOURCE: Sequeira GM et al. JAMA Pediatrics. 2020 Feb 23. doi: 10.1001/jamapediatrics.2019.6071.
FROM JAMA PEDIATRICS
More pediatricians employ developmental screening tools
Pediatricians’ reported use of developmental screening tools increased significantly to 63% from 2002 to 2016, based on survey data from more than 1,000 pediatricians at three time points.
“In 2001, an AAP [American Academy of Pediatrics] policy statement called for pediatricians to screen all children for developmental disorders during routine well-child visits,” Paul H. Lipkin, MD, of the Kennedy Krieger Institute, Baltimore, and colleagues wrote in Pediatrics. “However, only 23% of pediatricians in 2002 reported using a standardized developmental screening tool, citing lack of time, staff, and reimbursement as barriers.”
To determine trends in pediatricians’ use of recommended screening tools, the researchers reviewed data from the American Academy of Pediatrics Periodic Surveys in 2002, 2009, and 2016 that included 562, 532, and 469 respondents, respectively.
The percentage of pediatricians who reported using screening tools increased from 21% in 2002 to 63% in 2016 (P less than .001). In addition, The screening tool with the greatest increase in use was the Ages and Stages Questionnaire (ASQ), reportedly used by 48% of pediatricians in 2016, up from 9% in 2002 (P less than .001).
Most reported barriers to screening, including time constraints, inadequate reimbursement, lack of staff to perform screenings, belief that screening is not an appropriate role for pediatricians, and lack of confidence in the screening effectiveness, declined over the study period. However, the percentage of pediatricians who reported lack of available treatment options as a barrier to screening increased from 9% in 2002 to 21% in 2016, the researchers noted.
The average ages of the survey respondents at the 2002, 2009, and 2016 time points were 44, 47, and 49 years, respectively, and the majority (44%, 45%, and 49%) worked in suburban practice areas.
The study findings were limited by several factors, including the use of self-reports, the potential bias of pediatricians to overestimate some of their developmental practices, and potential over- or underreporting if autism spectrum disorder screening was mistakenly included, Dr. Lipkin and associates noted. The results suggest that use of standardized screening has increased, but more attention is needed to improve screening and referrals.
Potential improvements include adding screening tests and referrals to EHRs, and improving communication between medical practices and community-based intervention, therapy, and education programs, they concluded.
The study findings can be seen as encouraging, but one-third of pediatricians still reported not using formal screening instruments, commonly citing lack of time and suboptimal reimbursement, Mei Elansary, MD, and Michael Silverstein, MD, both of Boston University, said in an accompanying editorial.
However, “Although time and financial barriers are real, it is also likely that some of the residual gaps in guideline-concordant practice reflect variability among pediatricians in their perception of the clinical relevance of certain developmental problems that require formal instruments to identify and in the availability and effectiveness of services targeted to children with these less severe developmental issues,” they said. The path for screening children with developmental risk factors but not obviously severe delays may not be straightforward, and many pediatricians rely on their clinical judgment, they emphasized.
“As important as developing strategies to achieve more widespread developmental screening, therefore, is developing a greater understanding of the root causes of practice variation and determining the range of viable clinical practices that lead to better developmental outcomes,” Dr. Elansary and Dr. Silverstein concluded.
The study was supported by the American Academy of Pediatrics, the Department of Health & Human Services, the Health Resources and Services Administration, and the Department of Education Office of Special Education Programs. The researchers had no financial conflicts to disclose.
Editorialist Dr. Silverstein disclosed an award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the editorial was funded by the National Institutes of Health. Dr. Silverstein is a member of the U.S. Preventive Services Task Force. Dr. Elansary had no relevant financial disclosures.
SOURCES: Lipkin PH et al. Pediatrics. 2020 Mar 2. doi: 10.1542/peds.2019-0851; Elansary M, Silverstein M. Pediatrics. 2020 Mar 2. doi: 10.1542/peds.2020-0164.
Pediatricians’ reported use of developmental screening tools increased significantly to 63% from 2002 to 2016, based on survey data from more than 1,000 pediatricians at three time points.
“In 2001, an AAP [American Academy of Pediatrics] policy statement called for pediatricians to screen all children for developmental disorders during routine well-child visits,” Paul H. Lipkin, MD, of the Kennedy Krieger Institute, Baltimore, and colleagues wrote in Pediatrics. “However, only 23% of pediatricians in 2002 reported using a standardized developmental screening tool, citing lack of time, staff, and reimbursement as barriers.”
To determine trends in pediatricians’ use of recommended screening tools, the researchers reviewed data from the American Academy of Pediatrics Periodic Surveys in 2002, 2009, and 2016 that included 562, 532, and 469 respondents, respectively.
The percentage of pediatricians who reported using screening tools increased from 21% in 2002 to 63% in 2016 (P less than .001). In addition, The screening tool with the greatest increase in use was the Ages and Stages Questionnaire (ASQ), reportedly used by 48% of pediatricians in 2016, up from 9% in 2002 (P less than .001).
Most reported barriers to screening, including time constraints, inadequate reimbursement, lack of staff to perform screenings, belief that screening is not an appropriate role for pediatricians, and lack of confidence in the screening effectiveness, declined over the study period. However, the percentage of pediatricians who reported lack of available treatment options as a barrier to screening increased from 9% in 2002 to 21% in 2016, the researchers noted.
The average ages of the survey respondents at the 2002, 2009, and 2016 time points were 44, 47, and 49 years, respectively, and the majority (44%, 45%, and 49%) worked in suburban practice areas.
The study findings were limited by several factors, including the use of self-reports, the potential bias of pediatricians to overestimate some of their developmental practices, and potential over- or underreporting if autism spectrum disorder screening was mistakenly included, Dr. Lipkin and associates noted. The results suggest that use of standardized screening has increased, but more attention is needed to improve screening and referrals.
Potential improvements include adding screening tests and referrals to EHRs, and improving communication between medical practices and community-based intervention, therapy, and education programs, they concluded.
The study findings can be seen as encouraging, but one-third of pediatricians still reported not using formal screening instruments, commonly citing lack of time and suboptimal reimbursement, Mei Elansary, MD, and Michael Silverstein, MD, both of Boston University, said in an accompanying editorial.
However, “Although time and financial barriers are real, it is also likely that some of the residual gaps in guideline-concordant practice reflect variability among pediatricians in their perception of the clinical relevance of certain developmental problems that require formal instruments to identify and in the availability and effectiveness of services targeted to children with these less severe developmental issues,” they said. The path for screening children with developmental risk factors but not obviously severe delays may not be straightforward, and many pediatricians rely on their clinical judgment, they emphasized.
“As important as developing strategies to achieve more widespread developmental screening, therefore, is developing a greater understanding of the root causes of practice variation and determining the range of viable clinical practices that lead to better developmental outcomes,” Dr. Elansary and Dr. Silverstein concluded.
The study was supported by the American Academy of Pediatrics, the Department of Health & Human Services, the Health Resources and Services Administration, and the Department of Education Office of Special Education Programs. The researchers had no financial conflicts to disclose.
Editorialist Dr. Silverstein disclosed an award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the editorial was funded by the National Institutes of Health. Dr. Silverstein is a member of the U.S. Preventive Services Task Force. Dr. Elansary had no relevant financial disclosures.
SOURCES: Lipkin PH et al. Pediatrics. 2020 Mar 2. doi: 10.1542/peds.2019-0851; Elansary M, Silverstein M. Pediatrics. 2020 Mar 2. doi: 10.1542/peds.2020-0164.
Pediatricians’ reported use of developmental screening tools increased significantly to 63% from 2002 to 2016, based on survey data from more than 1,000 pediatricians at three time points.
“In 2001, an AAP [American Academy of Pediatrics] policy statement called for pediatricians to screen all children for developmental disorders during routine well-child visits,” Paul H. Lipkin, MD, of the Kennedy Krieger Institute, Baltimore, and colleagues wrote in Pediatrics. “However, only 23% of pediatricians in 2002 reported using a standardized developmental screening tool, citing lack of time, staff, and reimbursement as barriers.”
To determine trends in pediatricians’ use of recommended screening tools, the researchers reviewed data from the American Academy of Pediatrics Periodic Surveys in 2002, 2009, and 2016 that included 562, 532, and 469 respondents, respectively.
The percentage of pediatricians who reported using screening tools increased from 21% in 2002 to 63% in 2016 (P less than .001). In addition, The screening tool with the greatest increase in use was the Ages and Stages Questionnaire (ASQ), reportedly used by 48% of pediatricians in 2016, up from 9% in 2002 (P less than .001).
Most reported barriers to screening, including time constraints, inadequate reimbursement, lack of staff to perform screenings, belief that screening is not an appropriate role for pediatricians, and lack of confidence in the screening effectiveness, declined over the study period. However, the percentage of pediatricians who reported lack of available treatment options as a barrier to screening increased from 9% in 2002 to 21% in 2016, the researchers noted.
The average ages of the survey respondents at the 2002, 2009, and 2016 time points were 44, 47, and 49 years, respectively, and the majority (44%, 45%, and 49%) worked in suburban practice areas.
The study findings were limited by several factors, including the use of self-reports, the potential bias of pediatricians to overestimate some of their developmental practices, and potential over- or underreporting if autism spectrum disorder screening was mistakenly included, Dr. Lipkin and associates noted. The results suggest that use of standardized screening has increased, but more attention is needed to improve screening and referrals.
Potential improvements include adding screening tests and referrals to EHRs, and improving communication between medical practices and community-based intervention, therapy, and education programs, they concluded.
The study findings can be seen as encouraging, but one-third of pediatricians still reported not using formal screening instruments, commonly citing lack of time and suboptimal reimbursement, Mei Elansary, MD, and Michael Silverstein, MD, both of Boston University, said in an accompanying editorial.
However, “Although time and financial barriers are real, it is also likely that some of the residual gaps in guideline-concordant practice reflect variability among pediatricians in their perception of the clinical relevance of certain developmental problems that require formal instruments to identify and in the availability and effectiveness of services targeted to children with these less severe developmental issues,” they said. The path for screening children with developmental risk factors but not obviously severe delays may not be straightforward, and many pediatricians rely on their clinical judgment, they emphasized.
“As important as developing strategies to achieve more widespread developmental screening, therefore, is developing a greater understanding of the root causes of practice variation and determining the range of viable clinical practices that lead to better developmental outcomes,” Dr. Elansary and Dr. Silverstein concluded.
The study was supported by the American Academy of Pediatrics, the Department of Health & Human Services, the Health Resources and Services Administration, and the Department of Education Office of Special Education Programs. The researchers had no financial conflicts to disclose.
Editorialist Dr. Silverstein disclosed an award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the editorial was funded by the National Institutes of Health. Dr. Silverstein is a member of the U.S. Preventive Services Task Force. Dr. Elansary had no relevant financial disclosures.
SOURCES: Lipkin PH et al. Pediatrics. 2020 Mar 2. doi: 10.1542/peds.2019-0851; Elansary M, Silverstein M. Pediatrics. 2020 Mar 2. doi: 10.1542/peds.2020-0164.
FROM PEDIATRICS
Breach of migrant youths’ confidentiality is unethical, unacceptable
We are in the healing profession. We practice a trade. We are doctors, therapists, counselors. We work with children, adults, and couples. We document the physical form of our patient after examination, setting the stage for interventions that heal and alleviate suffering. With those who we do not touch physically, we hold out our psychological arms to embrace them in a therapeutic relationship.
We are privileged to appreciate their deeper selves through voice, unsaid words, and body language. A trust evolves (or might not); deeper exploration where our intuition and technical skill discover what troubles the soul. Healing begins as a delicate dance: As trust is earned, our patients risk vulnerability by revealing their weakest selves.
As healers, we often find ourselves adrift with our own insecurities, our own histories that make us human; our styles may differ but training and the tenets and guidelines set by our professional societies keep us in safe waters. These guidelines are informed by the science of health care research and vetted through centuries of observation and experience of process. “Do no harm” is perhaps one of the major rules of engaging with patients. The scaffolding that our code of ethics provides healing professions trumps external pressures to deviate. If you violate these codes, the consequences are borne by the patient and the potential loss of your license.
Some of you may have read about Kevin Euceda, an adolescent who reportedly was waiting for his immigration interview and ordered to undergo mandatory therapy as part of the immigration protocol. Kevin revealed to his therapist the history of violence he experienced as a child growing up in Honduras. His subsequent initiation into a gang was the only option he had to escape a violent death. Those of us who work with youth from gang cultures know fully that allegiance to a gang is a means to find an identity and brotherhood with the payment by a lifestyle of violence. A therapist faced with this information does not judge but helps the person deal with PTSD, nightmares, and guilt that become part of an identity just as the memories of mines blowing up in the face of combat affect veterans.
But the therapist, who reportedly holds a master’s in rehabilitation counseling and was “a year away from passing her licensing exam,” according to an article published in the Washington Post, followed policy of the Office of Refugee Resettlement. The therapist betrayed Kevin by reporting the information he shared with her confidentially to Immigration and Customs Enforcement. The reason the therapist gave for the breach was that she was compelled do so because Kevin reported participating in gang activity in Honduras. Subsequently, Kevin was sent to a high-security detention center – and is now facing deportation.
Betraying a patient, profession
Therapy begins as a contract between patient and therapist. The contract stipulates that all that transpires in the process of therapy (usually a 50-minute block of time, usually weekly) is information held by the therapist and patient – and is not to be shared with anyone, including parents, guardians, legal entities, and health care agencies. This allows the gradual sharing of events, emotions, behaviors, and reactions akin to peeling an onion. Memories, reactions, and feelings assist the therapist as they start their quest of discovery of the conflict and how to resolve it. Trust is the central tenet of this journey. The patient thinks: “You will hear me; you will see me you will understand me and help me understand myself.” The doctor responds: “Even I don’t yet know fully what ails you; we will discover that together. … I will not fail your trust.”
So how does this interface with external pressures? The constitution of a free country provides some inviolable protections that prevent derailment of the codes of ethics based on science. The fine line between what are considered sacrosanct ethics of a field – be it health care, climatology, or architecture – and what could be sacrificed in the name of prevailing forces (political or otherwise) has to be under constant scrutiny by the members of the guild. In health care, when patients cannot trust the science, its implementation, or is let down by the clinician, they are unlikely to benefit from treatment. A foundation of distrust paves the way for future therapeutic relationships that are stained with distrust and noncompliance.
The ethics guidelines of the American Academy of Psychiatry and the Law specify that psychiatrists in forensic roles “should be clear about limitations on confidentiality in the treatment relationship and ensure that these limitations are communicated to the patient.” Again, the therapist in this case is not a psychiatrist, but I would argue that the same rules would apply.
It is reassuring to know that several key groups, including the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, have all condemned the therapist’s actions. Psychiatrists and other mental health professionals must do no harm. We must not stand idly by and allow the kind of professional breach that happened to Kevin continue. Patients who confide in mental health professionals with the promise of confidentiality must be able to do so without fear. Only with confidentiality can the therapeutic relationship thrive.
Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy, at Virginia Commonwealth University, Richmond.
We are in the healing profession. We practice a trade. We are doctors, therapists, counselors. We work with children, adults, and couples. We document the physical form of our patient after examination, setting the stage for interventions that heal and alleviate suffering. With those who we do not touch physically, we hold out our psychological arms to embrace them in a therapeutic relationship.
We are privileged to appreciate their deeper selves through voice, unsaid words, and body language. A trust evolves (or might not); deeper exploration where our intuition and technical skill discover what troubles the soul. Healing begins as a delicate dance: As trust is earned, our patients risk vulnerability by revealing their weakest selves.
As healers, we often find ourselves adrift with our own insecurities, our own histories that make us human; our styles may differ but training and the tenets and guidelines set by our professional societies keep us in safe waters. These guidelines are informed by the science of health care research and vetted through centuries of observation and experience of process. “Do no harm” is perhaps one of the major rules of engaging with patients. The scaffolding that our code of ethics provides healing professions trumps external pressures to deviate. If you violate these codes, the consequences are borne by the patient and the potential loss of your license.
Some of you may have read about Kevin Euceda, an adolescent who reportedly was waiting for his immigration interview and ordered to undergo mandatory therapy as part of the immigration protocol. Kevin revealed to his therapist the history of violence he experienced as a child growing up in Honduras. His subsequent initiation into a gang was the only option he had to escape a violent death. Those of us who work with youth from gang cultures know fully that allegiance to a gang is a means to find an identity and brotherhood with the payment by a lifestyle of violence. A therapist faced with this information does not judge but helps the person deal with PTSD, nightmares, and guilt that become part of an identity just as the memories of mines blowing up in the face of combat affect veterans.
But the therapist, who reportedly holds a master’s in rehabilitation counseling and was “a year away from passing her licensing exam,” according to an article published in the Washington Post, followed policy of the Office of Refugee Resettlement. The therapist betrayed Kevin by reporting the information he shared with her confidentially to Immigration and Customs Enforcement. The reason the therapist gave for the breach was that she was compelled do so because Kevin reported participating in gang activity in Honduras. Subsequently, Kevin was sent to a high-security detention center – and is now facing deportation.
Betraying a patient, profession
Therapy begins as a contract between patient and therapist. The contract stipulates that all that transpires in the process of therapy (usually a 50-minute block of time, usually weekly) is information held by the therapist and patient – and is not to be shared with anyone, including parents, guardians, legal entities, and health care agencies. This allows the gradual sharing of events, emotions, behaviors, and reactions akin to peeling an onion. Memories, reactions, and feelings assist the therapist as they start their quest of discovery of the conflict and how to resolve it. Trust is the central tenet of this journey. The patient thinks: “You will hear me; you will see me you will understand me and help me understand myself.” The doctor responds: “Even I don’t yet know fully what ails you; we will discover that together. … I will not fail your trust.”
So how does this interface with external pressures? The constitution of a free country provides some inviolable protections that prevent derailment of the codes of ethics based on science. The fine line between what are considered sacrosanct ethics of a field – be it health care, climatology, or architecture – and what could be sacrificed in the name of prevailing forces (political or otherwise) has to be under constant scrutiny by the members of the guild. In health care, when patients cannot trust the science, its implementation, or is let down by the clinician, they are unlikely to benefit from treatment. A foundation of distrust paves the way for future therapeutic relationships that are stained with distrust and noncompliance.
The ethics guidelines of the American Academy of Psychiatry and the Law specify that psychiatrists in forensic roles “should be clear about limitations on confidentiality in the treatment relationship and ensure that these limitations are communicated to the patient.” Again, the therapist in this case is not a psychiatrist, but I would argue that the same rules would apply.
It is reassuring to know that several key groups, including the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, have all condemned the therapist’s actions. Psychiatrists and other mental health professionals must do no harm. We must not stand idly by and allow the kind of professional breach that happened to Kevin continue. Patients who confide in mental health professionals with the promise of confidentiality must be able to do so without fear. Only with confidentiality can the therapeutic relationship thrive.
Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy, at Virginia Commonwealth University, Richmond.
We are in the healing profession. We practice a trade. We are doctors, therapists, counselors. We work with children, adults, and couples. We document the physical form of our patient after examination, setting the stage for interventions that heal and alleviate suffering. With those who we do not touch physically, we hold out our psychological arms to embrace them in a therapeutic relationship.
We are privileged to appreciate their deeper selves through voice, unsaid words, and body language. A trust evolves (or might not); deeper exploration where our intuition and technical skill discover what troubles the soul. Healing begins as a delicate dance: As trust is earned, our patients risk vulnerability by revealing their weakest selves.
As healers, we often find ourselves adrift with our own insecurities, our own histories that make us human; our styles may differ but training and the tenets and guidelines set by our professional societies keep us in safe waters. These guidelines are informed by the science of health care research and vetted through centuries of observation and experience of process. “Do no harm” is perhaps one of the major rules of engaging with patients. The scaffolding that our code of ethics provides healing professions trumps external pressures to deviate. If you violate these codes, the consequences are borne by the patient and the potential loss of your license.
Some of you may have read about Kevin Euceda, an adolescent who reportedly was waiting for his immigration interview and ordered to undergo mandatory therapy as part of the immigration protocol. Kevin revealed to his therapist the history of violence he experienced as a child growing up in Honduras. His subsequent initiation into a gang was the only option he had to escape a violent death. Those of us who work with youth from gang cultures know fully that allegiance to a gang is a means to find an identity and brotherhood with the payment by a lifestyle of violence. A therapist faced with this information does not judge but helps the person deal with PTSD, nightmares, and guilt that become part of an identity just as the memories of mines blowing up in the face of combat affect veterans.
But the therapist, who reportedly holds a master’s in rehabilitation counseling and was “a year away from passing her licensing exam,” according to an article published in the Washington Post, followed policy of the Office of Refugee Resettlement. The therapist betrayed Kevin by reporting the information he shared with her confidentially to Immigration and Customs Enforcement. The reason the therapist gave for the breach was that she was compelled do so because Kevin reported participating in gang activity in Honduras. Subsequently, Kevin was sent to a high-security detention center – and is now facing deportation.
Betraying a patient, profession
Therapy begins as a contract between patient and therapist. The contract stipulates that all that transpires in the process of therapy (usually a 50-minute block of time, usually weekly) is information held by the therapist and patient – and is not to be shared with anyone, including parents, guardians, legal entities, and health care agencies. This allows the gradual sharing of events, emotions, behaviors, and reactions akin to peeling an onion. Memories, reactions, and feelings assist the therapist as they start their quest of discovery of the conflict and how to resolve it. Trust is the central tenet of this journey. The patient thinks: “You will hear me; you will see me you will understand me and help me understand myself.” The doctor responds: “Even I don’t yet know fully what ails you; we will discover that together. … I will not fail your trust.”
So how does this interface with external pressures? The constitution of a free country provides some inviolable protections that prevent derailment of the codes of ethics based on science. The fine line between what are considered sacrosanct ethics of a field – be it health care, climatology, or architecture – and what could be sacrificed in the name of prevailing forces (political or otherwise) has to be under constant scrutiny by the members of the guild. In health care, when patients cannot trust the science, its implementation, or is let down by the clinician, they are unlikely to benefit from treatment. A foundation of distrust paves the way for future therapeutic relationships that are stained with distrust and noncompliance.
The ethics guidelines of the American Academy of Psychiatry and the Law specify that psychiatrists in forensic roles “should be clear about limitations on confidentiality in the treatment relationship and ensure that these limitations are communicated to the patient.” Again, the therapist in this case is not a psychiatrist, but I would argue that the same rules would apply.
It is reassuring to know that several key groups, including the American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, have all condemned the therapist’s actions. Psychiatrists and other mental health professionals must do no harm. We must not stand idly by and allow the kind of professional breach that happened to Kevin continue. Patients who confide in mental health professionals with the promise of confidentiality must be able to do so without fear. Only with confidentiality can the therapeutic relationship thrive.
Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy, at Virginia Commonwealth University, Richmond.
Survey: 2020 will see more attacks on ACA
When physicians gaze into their crystal balls to predict what’s coming in 2020, they see continued efforts to defund the Affordable Care Act – meaning the ACA will still be around to be defunded – but they don’t see a lot of support for universal health care, according to health care market research company InCrowd.
Expectations for universal health care came in at 18% of the 100 generalists and 101 specialists who responded to InCrowd’s fifth annual health care predictions survey, which left 82% who thought that “election outcomes will result in universal healthcare support” was somewhat or very unlikely in 2020.
One respondent, a specialist from California, commented that “the global data on universal healthcare for all shows that it results in overall improved population health. Unfortunately, we are so polarized in the US against universal healthcare driven by bias from health insurance companies and decision makers that are quick to ignore scientific data.”
This was the first time InCrowd asked physicians about universal health care, but ACA-related predictions have been included before, and all three scenarios presented were deemed to be increasingly likely, compared with 2019.
Respondents thought that federal government defunding was more likely to occur in 2020 (80%) than in 2019 (73%), but increased majorities also said that preexisting conditions coverage would continue (78% in 2020 vs. 70% in 2019) and that the ACA would remain in place (74% in 2020 vs. 60% in 2019), InCrowd reported after the survey, which was conducted from Dec. 30, 2019, to Jan. 2, 2020.
A respondent who thought the ACA will be eliminated said, “I have as many uninsured today as before the ACA. They are just different. Mainly younger patients who spend less in a year on healthcare than one month’s premium.” Another suggested that eliminateing it “will limit access to care and overload [emergency departments]. More people will die.”
Cost was addressed in a separate survey question that asked how physicians could help to reduce health care spending in 2020.
The leading answer, given by 37% of respondents, was for physicians to “inform themselves of costs and adapt cost-saving prescription practices.” Next came “limit use of expensive tests and scans” with 21%, followed by “prescribe generics when possible” at 20%, which was a substantial drop from the 38% it garnered in 2019, InCrowd noted.
“Participation in [shared savings] programs and risk-based incentive programs and pay-for-performance programs” would provide “better stewardship of resources,” a primary care physician from Michigan wrote.
When the survey turned to pharmaceutical industry predictions for 2020, cost was the major issue.
“What’s interesting about this year’s data is that we’re seeing less emphasis on the importance of bringing innovative, new therapies to market faster … versus expanding affordability, which was nearly a unanimous top priority for respondents,” Daniel S. Fitzgerald, InCrowd’s CEO and president, said in a separate statement.
When physicians gaze into their crystal balls to predict what’s coming in 2020, they see continued efforts to defund the Affordable Care Act – meaning the ACA will still be around to be defunded – but they don’t see a lot of support for universal health care, according to health care market research company InCrowd.
Expectations for universal health care came in at 18% of the 100 generalists and 101 specialists who responded to InCrowd’s fifth annual health care predictions survey, which left 82% who thought that “election outcomes will result in universal healthcare support” was somewhat or very unlikely in 2020.
One respondent, a specialist from California, commented that “the global data on universal healthcare for all shows that it results in overall improved population health. Unfortunately, we are so polarized in the US against universal healthcare driven by bias from health insurance companies and decision makers that are quick to ignore scientific data.”
This was the first time InCrowd asked physicians about universal health care, but ACA-related predictions have been included before, and all three scenarios presented were deemed to be increasingly likely, compared with 2019.
Respondents thought that federal government defunding was more likely to occur in 2020 (80%) than in 2019 (73%), but increased majorities also said that preexisting conditions coverage would continue (78% in 2020 vs. 70% in 2019) and that the ACA would remain in place (74% in 2020 vs. 60% in 2019), InCrowd reported after the survey, which was conducted from Dec. 30, 2019, to Jan. 2, 2020.
A respondent who thought the ACA will be eliminated said, “I have as many uninsured today as before the ACA. They are just different. Mainly younger patients who spend less in a year on healthcare than one month’s premium.” Another suggested that eliminateing it “will limit access to care and overload [emergency departments]. More people will die.”
Cost was addressed in a separate survey question that asked how physicians could help to reduce health care spending in 2020.
The leading answer, given by 37% of respondents, was for physicians to “inform themselves of costs and adapt cost-saving prescription practices.” Next came “limit use of expensive tests and scans” with 21%, followed by “prescribe generics when possible” at 20%, which was a substantial drop from the 38% it garnered in 2019, InCrowd noted.
“Participation in [shared savings] programs and risk-based incentive programs and pay-for-performance programs” would provide “better stewardship of resources,” a primary care physician from Michigan wrote.
When the survey turned to pharmaceutical industry predictions for 2020, cost was the major issue.
“What’s interesting about this year’s data is that we’re seeing less emphasis on the importance of bringing innovative, new therapies to market faster … versus expanding affordability, which was nearly a unanimous top priority for respondents,” Daniel S. Fitzgerald, InCrowd’s CEO and president, said in a separate statement.
When physicians gaze into their crystal balls to predict what’s coming in 2020, they see continued efforts to defund the Affordable Care Act – meaning the ACA will still be around to be defunded – but they don’t see a lot of support for universal health care, according to health care market research company InCrowd.
Expectations for universal health care came in at 18% of the 100 generalists and 101 specialists who responded to InCrowd’s fifth annual health care predictions survey, which left 82% who thought that “election outcomes will result in universal healthcare support” was somewhat or very unlikely in 2020.
One respondent, a specialist from California, commented that “the global data on universal healthcare for all shows that it results in overall improved population health. Unfortunately, we are so polarized in the US against universal healthcare driven by bias from health insurance companies and decision makers that are quick to ignore scientific data.”
This was the first time InCrowd asked physicians about universal health care, but ACA-related predictions have been included before, and all three scenarios presented were deemed to be increasingly likely, compared with 2019.
Respondents thought that federal government defunding was more likely to occur in 2020 (80%) than in 2019 (73%), but increased majorities also said that preexisting conditions coverage would continue (78% in 2020 vs. 70% in 2019) and that the ACA would remain in place (74% in 2020 vs. 60% in 2019), InCrowd reported after the survey, which was conducted from Dec. 30, 2019, to Jan. 2, 2020.
A respondent who thought the ACA will be eliminated said, “I have as many uninsured today as before the ACA. They are just different. Mainly younger patients who spend less in a year on healthcare than one month’s premium.” Another suggested that eliminateing it “will limit access to care and overload [emergency departments]. More people will die.”
Cost was addressed in a separate survey question that asked how physicians could help to reduce health care spending in 2020.
The leading answer, given by 37% of respondents, was for physicians to “inform themselves of costs and adapt cost-saving prescription practices.” Next came “limit use of expensive tests and scans” with 21%, followed by “prescribe generics when possible” at 20%, which was a substantial drop from the 38% it garnered in 2019, InCrowd noted.
“Participation in [shared savings] programs and risk-based incentive programs and pay-for-performance programs” would provide “better stewardship of resources,” a primary care physician from Michigan wrote.
When the survey turned to pharmaceutical industry predictions for 2020, cost was the major issue.
“What’s interesting about this year’s data is that we’re seeing less emphasis on the importance of bringing innovative, new therapies to market faster … versus expanding affordability, which was nearly a unanimous top priority for respondents,” Daniel S. Fitzgerald, InCrowd’s CEO and president, said in a separate statement.
Is telerheumatology the future of rheumatology?
MAUI, HAWAII – Alvin F. Wells, MD, PhD, believes he’s seen the future of rheumatology. So he’s taken a deep dive into telerheumatology, going all in.
“Whether you’re in academic, private, or hospital-based practice, in 2020 if you are not thinking about telerheumatology, you and your practice will not be able to compete with growing patient demands, expectations, and need for clinical monitoring. If you do not have a digital/virtual strategy, you do not have a health care strategy,” he asserted at the 2020 Rheumatology Winter Clinical Symposium.
“Begin now,” the rheumatologist advised.
In pursuit of his own telerheumatology strategy, he holds licenses to practice medicine in five states and has licensure pending in five others.
“My goal is to cover 20% of the U.S., so if the local guys can’t see the patients, I can see them virtually,” he explained. “The days of waiting 4-6 months to be seen by a rheumatologist are gone.”
Rheumatologists are already in short supply in most of the country, and a major shortage looms ahead as older practitioners retire. Telerheumatology can help fill that unmet need. But the specialty is behind the curve. In a survey that rated the medical specialties most engaged in telemedicine, the top three spots were held by radiology, psychiatry, and internal medicine. Rheumatology didn’t even crack the top 10, noted Dr. Wells, director of the Rheumatology and Immunotherapy Center in Franklin, Wisc., and a part-time faculty member at Duke University, the Medical College of Wisconsin, and the Karolinska Institute.
Yet telemedicine is primed for rheumatologic takeoff. Notably, the 2019 update of the American College of Rheumatology recommendations on rheumatoid arthritis disease activity measures incorporates the RAPID3 (Routine Assessment of Patient Index Data) as an endorsed three-question clinical assessment that doesn’t involve a physical exam or laboratory work. The ACR update is recognition that, while every rheumatology patient needs an initial physical exam along with follow-up physical exams at various rates, many patients with well-controlled disease don’t need a physical exam at every physician encounter, he said.
Telerheumatology saves time for both patient and physician. The patient saves travel time, doesn’t miss work, avoids having to arrange for child care in order to make a face-to-face clinic visit, and can schedule more frequent virtual follow-up visits. For the practitioner, telerheumatology means additional consults and – here’s the big one – “You never run behind,” according to Dr. Wells. “For a 15-minute appointment, the patient gets a 5-minute warning, then a 2-minute warning, and at 15 minutes the link is cut. If the fibromyalgia patients want 30 minutes, they pay for 30 minutes.”
He sees the strictly enforced, impersonally delivered electronic time limits as key to running an efficient practice.
“The patients with osteoarthritis who hate the nodules, the fibromyalgia patients because they’re hurting all over, the patients with back pain – you’ve really got to limit those patients because otherwise you’ll be running 30-40 minutes behind for a scheduled 15-minute visit,” he explained.
One rheumatologist’s telemedicine practice
Dr. Wells currently utilizes the Epic electronic health record integrated with a Zoom videoconferencing platform for real-time virtual patient encounters. But he noted that other virtual platforms are available, including Health Tap, American Well, MySpecialistMD, MDLIVE, and TelaDoc. The American Telemedicine Association is a valuable resource for state-by-state medicolegal, reimbursement, and how-to-do-it questions.
At present, he reserves two daily time slots for telerheumatology: one at 8:30-9:00 a.m., the other at 4:30-5:00 p.m. These can be filled with four 15-minute live consults or two 30-minute consults. His goal is to eventually make telerheumatology 20% of his patient load of about 100 patients per week.
His typical 15-minute virtual visit proceeds as follows: It begins with a 3-minute subjective patient assessment, followed by a 5-minute objective assessment which includes the RAPID3, a brief Health Assessment Questionnaire (HAQ) addressing the patient’s pain and overall satisfaction, a virtual joint inspection, the use of high-quality teleultrasound and other technology when warranted, and capture of relevant still photos. This is followed by 5 minutes to relay the treatment plan, and finally a 2-minute recap and summary.
“No niceties. We cut right to the chase,” he noted.
He documents the patient encounter as he goes, dictating his notes throughout the visit.
“When I walk out of the room, I’m done. It’s on to the next patient,” Dr. Wells said.
The reimbursement picture is improving, although major hurdles remain. At present, 48 states and the District of Columbia reimburse for live video telemedicine through Medicaid. And in January 2020, Aetna announced it covers reimbursement for telemedicine in all of its fully insured health plans via the Teladoc platform. Dr. Wells’ patients pay for their telerheumatology out of pocket if their insurance doesn’t cover it.
Telemedicine caveats
Dr. Wells shared his telerheumatology experience as the first half of a point/counterpoint session on telemedicine’s future in the specialty. His debate opponent, Orrin M. Troum, MD, announced at the outset that he is quite interested in getting into telerheumatology; however, while looking into it he has come across issues that for now give him pause and that other rheumatologists need to be aware of.
Legal risks. The telemedicine movement has gotten big enough to draw the scrutiny of federal prosecutors and regulatory enforcement officials. In April 2018, the Department of Health & Human Services Office of the Inspector General (OIG) issued a report that concluded that one-third of all examined telemedicine claims were improper.
“Just imagine who might come knocking on your door,” he said.
Among the most common offenses, according to the OIG, were claims for services outside the limited range currently covered; lack of the requisite HIPAA-compliant two-way audio and visual communication technology with fully encrypted data transmission; services billed by institutional providers not defined by Medicare as telemedicine-eligible; and claims for services received by patients who weren’t located in an officially designated Health Professional Shortage Area or in a rural county as determined by the U.S. Census Bureau.
Telemedicine is no panacea for out-of-control health care costs. A RAND study of participants in the California Public Employees’ Retirement System (CalPERS) concluded that only 12% of beneficiaries who used direct-to-consumer telemedicine did so to replace provider visits. The other 88% added on telemedicine as an additional service. So while telemedicine increased patient access to health care, it also increased the overall cost, observed Dr. Troum, a rheumatologist at the University of Southern California, Los Angeles, and in private practice in Santa Monica, Calif.
Talk to your attorney and malpractice insurer before embarking on telerheumatology. Physicians could potentially lose their medical malpractice insurance if they use telemedicine to treat patients located in states where they aren’t licensed to practice, even if through inadvertent error.
Telemedicine isn’t appropriate for all patients. Nearly a decade ago, rheumatologists at Dartmouth-Hitchcock Medical Center launched a telerheumatology service in order to bring specialty care to the largely rural populations of New Hampshire and Vermont. In a review of the experience that included interviews with both patients and providers, investigators concluded that telerheumatology successfully increased access to specialty care in underserved locations and got good satisfaction scores from both providers and beneficiaries. However, fully 19% of patients were found to be inappropriate for their telerheumatology visit, mainly because their disease was too complex or the underlying diagnosis was unclear.
“Almost one-fifth of their patients were inappropriate for telerheumatology. The question is, how are you supposed to know that ahead of time?” Dr. Troum asked.
Patient satisfaction. Dr. Troum’s reading of the literature on patient satisfaction with telerheumatology, coupled with his own extensive experience in clinical practice, makes him think that many of his younger patients with less disease activity might welcome a telerheumatology option, even with strict time boundaries. But his older patients with more disease activity are a different story.
“Typically my middle-aged and older patients won’t accept that without a lot of convincing,” he commented.
Dr. Wells and Dr. Troum had no relevant disclosures regarding their presentations.
MAUI, HAWAII – Alvin F. Wells, MD, PhD, believes he’s seen the future of rheumatology. So he’s taken a deep dive into telerheumatology, going all in.
“Whether you’re in academic, private, or hospital-based practice, in 2020 if you are not thinking about telerheumatology, you and your practice will not be able to compete with growing patient demands, expectations, and need for clinical monitoring. If you do not have a digital/virtual strategy, you do not have a health care strategy,” he asserted at the 2020 Rheumatology Winter Clinical Symposium.
“Begin now,” the rheumatologist advised.
In pursuit of his own telerheumatology strategy, he holds licenses to practice medicine in five states and has licensure pending in five others.
“My goal is to cover 20% of the U.S., so if the local guys can’t see the patients, I can see them virtually,” he explained. “The days of waiting 4-6 months to be seen by a rheumatologist are gone.”
Rheumatologists are already in short supply in most of the country, and a major shortage looms ahead as older practitioners retire. Telerheumatology can help fill that unmet need. But the specialty is behind the curve. In a survey that rated the medical specialties most engaged in telemedicine, the top three spots were held by radiology, psychiatry, and internal medicine. Rheumatology didn’t even crack the top 10, noted Dr. Wells, director of the Rheumatology and Immunotherapy Center in Franklin, Wisc., and a part-time faculty member at Duke University, the Medical College of Wisconsin, and the Karolinska Institute.
Yet telemedicine is primed for rheumatologic takeoff. Notably, the 2019 update of the American College of Rheumatology recommendations on rheumatoid arthritis disease activity measures incorporates the RAPID3 (Routine Assessment of Patient Index Data) as an endorsed three-question clinical assessment that doesn’t involve a physical exam or laboratory work. The ACR update is recognition that, while every rheumatology patient needs an initial physical exam along with follow-up physical exams at various rates, many patients with well-controlled disease don’t need a physical exam at every physician encounter, he said.
Telerheumatology saves time for both patient and physician. The patient saves travel time, doesn’t miss work, avoids having to arrange for child care in order to make a face-to-face clinic visit, and can schedule more frequent virtual follow-up visits. For the practitioner, telerheumatology means additional consults and – here’s the big one – “You never run behind,” according to Dr. Wells. “For a 15-minute appointment, the patient gets a 5-minute warning, then a 2-minute warning, and at 15 minutes the link is cut. If the fibromyalgia patients want 30 minutes, they pay for 30 minutes.”
He sees the strictly enforced, impersonally delivered electronic time limits as key to running an efficient practice.
“The patients with osteoarthritis who hate the nodules, the fibromyalgia patients because they’re hurting all over, the patients with back pain – you’ve really got to limit those patients because otherwise you’ll be running 30-40 minutes behind for a scheduled 15-minute visit,” he explained.
One rheumatologist’s telemedicine practice
Dr. Wells currently utilizes the Epic electronic health record integrated with a Zoom videoconferencing platform for real-time virtual patient encounters. But he noted that other virtual platforms are available, including Health Tap, American Well, MySpecialistMD, MDLIVE, and TelaDoc. The American Telemedicine Association is a valuable resource for state-by-state medicolegal, reimbursement, and how-to-do-it questions.
At present, he reserves two daily time slots for telerheumatology: one at 8:30-9:00 a.m., the other at 4:30-5:00 p.m. These can be filled with four 15-minute live consults or two 30-minute consults. His goal is to eventually make telerheumatology 20% of his patient load of about 100 patients per week.
His typical 15-minute virtual visit proceeds as follows: It begins with a 3-minute subjective patient assessment, followed by a 5-minute objective assessment which includes the RAPID3, a brief Health Assessment Questionnaire (HAQ) addressing the patient’s pain and overall satisfaction, a virtual joint inspection, the use of high-quality teleultrasound and other technology when warranted, and capture of relevant still photos. This is followed by 5 minutes to relay the treatment plan, and finally a 2-minute recap and summary.
“No niceties. We cut right to the chase,” he noted.
He documents the patient encounter as he goes, dictating his notes throughout the visit.
“When I walk out of the room, I’m done. It’s on to the next patient,” Dr. Wells said.
The reimbursement picture is improving, although major hurdles remain. At present, 48 states and the District of Columbia reimburse for live video telemedicine through Medicaid. And in January 2020, Aetna announced it covers reimbursement for telemedicine in all of its fully insured health plans via the Teladoc platform. Dr. Wells’ patients pay for their telerheumatology out of pocket if their insurance doesn’t cover it.
Telemedicine caveats
Dr. Wells shared his telerheumatology experience as the first half of a point/counterpoint session on telemedicine’s future in the specialty. His debate opponent, Orrin M. Troum, MD, announced at the outset that he is quite interested in getting into telerheumatology; however, while looking into it he has come across issues that for now give him pause and that other rheumatologists need to be aware of.
Legal risks. The telemedicine movement has gotten big enough to draw the scrutiny of federal prosecutors and regulatory enforcement officials. In April 2018, the Department of Health & Human Services Office of the Inspector General (OIG) issued a report that concluded that one-third of all examined telemedicine claims were improper.
“Just imagine who might come knocking on your door,” he said.
Among the most common offenses, according to the OIG, were claims for services outside the limited range currently covered; lack of the requisite HIPAA-compliant two-way audio and visual communication technology with fully encrypted data transmission; services billed by institutional providers not defined by Medicare as telemedicine-eligible; and claims for services received by patients who weren’t located in an officially designated Health Professional Shortage Area or in a rural county as determined by the U.S. Census Bureau.
Telemedicine is no panacea for out-of-control health care costs. A RAND study of participants in the California Public Employees’ Retirement System (CalPERS) concluded that only 12% of beneficiaries who used direct-to-consumer telemedicine did so to replace provider visits. The other 88% added on telemedicine as an additional service. So while telemedicine increased patient access to health care, it also increased the overall cost, observed Dr. Troum, a rheumatologist at the University of Southern California, Los Angeles, and in private practice in Santa Monica, Calif.
Talk to your attorney and malpractice insurer before embarking on telerheumatology. Physicians could potentially lose their medical malpractice insurance if they use telemedicine to treat patients located in states where they aren’t licensed to practice, even if through inadvertent error.
Telemedicine isn’t appropriate for all patients. Nearly a decade ago, rheumatologists at Dartmouth-Hitchcock Medical Center launched a telerheumatology service in order to bring specialty care to the largely rural populations of New Hampshire and Vermont. In a review of the experience that included interviews with both patients and providers, investigators concluded that telerheumatology successfully increased access to specialty care in underserved locations and got good satisfaction scores from both providers and beneficiaries. However, fully 19% of patients were found to be inappropriate for their telerheumatology visit, mainly because their disease was too complex or the underlying diagnosis was unclear.
“Almost one-fifth of their patients were inappropriate for telerheumatology. The question is, how are you supposed to know that ahead of time?” Dr. Troum asked.
Patient satisfaction. Dr. Troum’s reading of the literature on patient satisfaction with telerheumatology, coupled with his own extensive experience in clinical practice, makes him think that many of his younger patients with less disease activity might welcome a telerheumatology option, even with strict time boundaries. But his older patients with more disease activity are a different story.
“Typically my middle-aged and older patients won’t accept that without a lot of convincing,” he commented.
Dr. Wells and Dr. Troum had no relevant disclosures regarding their presentations.
MAUI, HAWAII – Alvin F. Wells, MD, PhD, believes he’s seen the future of rheumatology. So he’s taken a deep dive into telerheumatology, going all in.
“Whether you’re in academic, private, or hospital-based practice, in 2020 if you are not thinking about telerheumatology, you and your practice will not be able to compete with growing patient demands, expectations, and need for clinical monitoring. If you do not have a digital/virtual strategy, you do not have a health care strategy,” he asserted at the 2020 Rheumatology Winter Clinical Symposium.
“Begin now,” the rheumatologist advised.
In pursuit of his own telerheumatology strategy, he holds licenses to practice medicine in five states and has licensure pending in five others.
“My goal is to cover 20% of the U.S., so if the local guys can’t see the patients, I can see them virtually,” he explained. “The days of waiting 4-6 months to be seen by a rheumatologist are gone.”
Rheumatologists are already in short supply in most of the country, and a major shortage looms ahead as older practitioners retire. Telerheumatology can help fill that unmet need. But the specialty is behind the curve. In a survey that rated the medical specialties most engaged in telemedicine, the top three spots were held by radiology, psychiatry, and internal medicine. Rheumatology didn’t even crack the top 10, noted Dr. Wells, director of the Rheumatology and Immunotherapy Center in Franklin, Wisc., and a part-time faculty member at Duke University, the Medical College of Wisconsin, and the Karolinska Institute.
Yet telemedicine is primed for rheumatologic takeoff. Notably, the 2019 update of the American College of Rheumatology recommendations on rheumatoid arthritis disease activity measures incorporates the RAPID3 (Routine Assessment of Patient Index Data) as an endorsed three-question clinical assessment that doesn’t involve a physical exam or laboratory work. The ACR update is recognition that, while every rheumatology patient needs an initial physical exam along with follow-up physical exams at various rates, many patients with well-controlled disease don’t need a physical exam at every physician encounter, he said.
Telerheumatology saves time for both patient and physician. The patient saves travel time, doesn’t miss work, avoids having to arrange for child care in order to make a face-to-face clinic visit, and can schedule more frequent virtual follow-up visits. For the practitioner, telerheumatology means additional consults and – here’s the big one – “You never run behind,” according to Dr. Wells. “For a 15-minute appointment, the patient gets a 5-minute warning, then a 2-minute warning, and at 15 minutes the link is cut. If the fibromyalgia patients want 30 minutes, they pay for 30 minutes.”
He sees the strictly enforced, impersonally delivered electronic time limits as key to running an efficient practice.
“The patients with osteoarthritis who hate the nodules, the fibromyalgia patients because they’re hurting all over, the patients with back pain – you’ve really got to limit those patients because otherwise you’ll be running 30-40 minutes behind for a scheduled 15-minute visit,” he explained.
One rheumatologist’s telemedicine practice
Dr. Wells currently utilizes the Epic electronic health record integrated with a Zoom videoconferencing platform for real-time virtual patient encounters. But he noted that other virtual platforms are available, including Health Tap, American Well, MySpecialistMD, MDLIVE, and TelaDoc. The American Telemedicine Association is a valuable resource for state-by-state medicolegal, reimbursement, and how-to-do-it questions.
At present, he reserves two daily time slots for telerheumatology: one at 8:30-9:00 a.m., the other at 4:30-5:00 p.m. These can be filled with four 15-minute live consults or two 30-minute consults. His goal is to eventually make telerheumatology 20% of his patient load of about 100 patients per week.
His typical 15-minute virtual visit proceeds as follows: It begins with a 3-minute subjective patient assessment, followed by a 5-minute objective assessment which includes the RAPID3, a brief Health Assessment Questionnaire (HAQ) addressing the patient’s pain and overall satisfaction, a virtual joint inspection, the use of high-quality teleultrasound and other technology when warranted, and capture of relevant still photos. This is followed by 5 minutes to relay the treatment plan, and finally a 2-minute recap and summary.
“No niceties. We cut right to the chase,” he noted.
He documents the patient encounter as he goes, dictating his notes throughout the visit.
“When I walk out of the room, I’m done. It’s on to the next patient,” Dr. Wells said.
The reimbursement picture is improving, although major hurdles remain. At present, 48 states and the District of Columbia reimburse for live video telemedicine through Medicaid. And in January 2020, Aetna announced it covers reimbursement for telemedicine in all of its fully insured health plans via the Teladoc platform. Dr. Wells’ patients pay for their telerheumatology out of pocket if their insurance doesn’t cover it.
Telemedicine caveats
Dr. Wells shared his telerheumatology experience as the first half of a point/counterpoint session on telemedicine’s future in the specialty. His debate opponent, Orrin M. Troum, MD, announced at the outset that he is quite interested in getting into telerheumatology; however, while looking into it he has come across issues that for now give him pause and that other rheumatologists need to be aware of.
Legal risks. The telemedicine movement has gotten big enough to draw the scrutiny of federal prosecutors and regulatory enforcement officials. In April 2018, the Department of Health & Human Services Office of the Inspector General (OIG) issued a report that concluded that one-third of all examined telemedicine claims were improper.
“Just imagine who might come knocking on your door,” he said.
Among the most common offenses, according to the OIG, were claims for services outside the limited range currently covered; lack of the requisite HIPAA-compliant two-way audio and visual communication technology with fully encrypted data transmission; services billed by institutional providers not defined by Medicare as telemedicine-eligible; and claims for services received by patients who weren’t located in an officially designated Health Professional Shortage Area or in a rural county as determined by the U.S. Census Bureau.
Telemedicine is no panacea for out-of-control health care costs. A RAND study of participants in the California Public Employees’ Retirement System (CalPERS) concluded that only 12% of beneficiaries who used direct-to-consumer telemedicine did so to replace provider visits. The other 88% added on telemedicine as an additional service. So while telemedicine increased patient access to health care, it also increased the overall cost, observed Dr. Troum, a rheumatologist at the University of Southern California, Los Angeles, and in private practice in Santa Monica, Calif.
Talk to your attorney and malpractice insurer before embarking on telerheumatology. Physicians could potentially lose their medical malpractice insurance if they use telemedicine to treat patients located in states where they aren’t licensed to practice, even if through inadvertent error.
Telemedicine isn’t appropriate for all patients. Nearly a decade ago, rheumatologists at Dartmouth-Hitchcock Medical Center launched a telerheumatology service in order to bring specialty care to the largely rural populations of New Hampshire and Vermont. In a review of the experience that included interviews with both patients and providers, investigators concluded that telerheumatology successfully increased access to specialty care in underserved locations and got good satisfaction scores from both providers and beneficiaries. However, fully 19% of patients were found to be inappropriate for their telerheumatology visit, mainly because their disease was too complex or the underlying diagnosis was unclear.
“Almost one-fifth of their patients were inappropriate for telerheumatology. The question is, how are you supposed to know that ahead of time?” Dr. Troum asked.
Patient satisfaction. Dr. Troum’s reading of the literature on patient satisfaction with telerheumatology, coupled with his own extensive experience in clinical practice, makes him think that many of his younger patients with less disease activity might welcome a telerheumatology option, even with strict time boundaries. But his older patients with more disease activity are a different story.
“Typically my middle-aged and older patients won’t accept that without a lot of convincing,” he commented.
Dr. Wells and Dr. Troum had no relevant disclosures regarding their presentations.
REPORTING FROM RWCS 2020