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Drug price alerts convince 12% of clinicians to change prescriptions
, according to findings from a study published in JAMA Internal Medicine.
The findings suggest that incorporating the alerts into electronic health record software could be useful for reducing patient expenses, said lead author Anna D. Sinaiko, PhD, assistant professor of health economics and policy at Harvard T. H. Chan School of Public Health, Boston. Showing clinicians the actual prices of medications their patient would pay led to changes in one in six orders when the potential cost savings to the patient was $20 or more, she said.
“This suggests that clinicians are taking medication out-of-pocket prices into account when they are most meaningful for patients.”
Such “real-time benefit tools” provide more meaningful information about patient drug prices in clinical settings than has previously been available, Dr. Sinaiko said. They provide out-of-pocket price estimates specific to individual patients and account for their health plans as opposed to symbols or colors indicating drugs that are more or less expensive, which has been the status quo.
Also, she said, Medicare has promoted the use of these tools by health systems and health plans.
Dr. Sinaiko and colleagues examined EHR data for 103,953 primary care clinic encounters with 72,420 patients in the University of Colorado Health system (81.5% White; 59.5% female; 51.4% aged 65 years or older; 51.9% on Medicare). The patients were treated from July 2019 to July 2022 by 889 clinicians (physicians, nurse practitioners, and physician assistants), who wrote nearly 1.9 million medication orders. Of those orders, 181,887 (9.7%) included a price estimate.
For each prescription, the EHR displayed out-of-pocket costs for patients and offered alternative drugs if those drugs were at least 15 cents cheaper or if they were available at an on-site pharmacy.
Clinicians changed prescriptions 12.3% of the time after they saw price information. The percentage went up to 14% when possible cost savings were $5 or more.
Researchers also found that, while there was the option for clinicians to click a button in the EHR and learn a patient’s specific medication price before ordering a drug, very few clinicians requested price estimates directly, Dr. Sinaiko said. Fewer than 1% (0.9%) did so. The other 99.1% did not, meaning they received information about prices via alerts only after ordering prescriptions.
Researchers also found that clinicians weren’t more likely to change psychiatric medications when the cost savings for the patient was higher. The demographics of patients – such as whether they were poorer or richer – didn’t affect the willingness of clinicians to change prescriptions after receiving price information.
In the big picture, Dr. Sinaiko said, “The fact that medication orders were changed more often when the potential cost savings for patients were larger suggests to me that clinicians were taking out-of-pocket cost into account when it was most salient for the patient.”
It’s not clear, however, why clinicians did not revise more prescriptions to help patients save money.
One theory is that they may ignore the alerts because of “alert fatigue,” she said. “I’d like to know if clinicians discount or ignore the price estimate because they don’t know where it comes from or whether it is accurate. It’s also possible that clinicians discuss the option to change a medication order with their patient, and for reasons other than cost, they decide to keep the original selection. This suggests that clinicians might be using price information to guide – not dictate – their clinical decisions.”
The study had limitations. The researchers did not assess whether the cheaper alternative medications were appropriate in individual cases. Also, they did not take into account other factors, such as patient preferences, that affect how clinicians make prescription decisions.
Clinicians may also not know whether their patients worry about drug costs.
“There isn’t really good data on who wants to talk to their physician about costs, but it is definitely nowhere near 100%,” said health services researcher Alyna Chien, MD, a pediatrician at Boston Children’s Hospital. “For physicians, there is also good reason to keep cost out of the picture until asked so that patients don’t feel like they’re getting suboptimal choices.”
University of Washington, Seattle, graduate student Shiven Bhardwaj, PharmD, who studies health policy, said in an interview that the new study “suggests that physicians are not frequently selecting less costly agents suggested by the real-time benefit tool, and they may not even be considering these alternatives.”
According to Dr. Bhardwaj, previous research has found that physicians “are unable to estimate what their patients’ out-of-pocket costs may be, which is not surprising, given wide variation in health insurance benefit designs.”
Why aren’t more clinicians choosing cheaper alternatives, even when they’re directly told about them? Dr. Bhardwaj suggests that many health systems may be implementing electronic drug cost alerts in the absence of official notification or training.
“Health systems should be making providers aware of the system and its potential to reduce patients’ out-of-pocket costs.”
What’s next for research in this area?
Lead author Dr. Sinaiko said she and her team will interview clinicians and patients in practices at University of Colorado Health to understand how these price estimates are used in clinical encounters and how they affect clinician practice and patient experiences
“We are interested in learning about the cost-savings thresholds that are important to patients,” she said.
The researchers will also examine whether cost information helps to boost access to medications for chronic conditions among Black and Hispanic patients and patients who live in rural areas, she said.
The study was funded by the Harvard School of Public Health Dean’s Fund and the National Institute on Minority Health and Health Disparities. Dr. Sinaiko, Dr. Bhardwaj, and Dr. Chien have no relevant disclosures. Two study authors report having received a grant from the National Institute on Aging and consulting fees from Dispatch Health and Credo Health.
A version of this article first appeared on Medscape.com.
, according to findings from a study published in JAMA Internal Medicine.
The findings suggest that incorporating the alerts into electronic health record software could be useful for reducing patient expenses, said lead author Anna D. Sinaiko, PhD, assistant professor of health economics and policy at Harvard T. H. Chan School of Public Health, Boston. Showing clinicians the actual prices of medications their patient would pay led to changes in one in six orders when the potential cost savings to the patient was $20 or more, she said.
“This suggests that clinicians are taking medication out-of-pocket prices into account when they are most meaningful for patients.”
Such “real-time benefit tools” provide more meaningful information about patient drug prices in clinical settings than has previously been available, Dr. Sinaiko said. They provide out-of-pocket price estimates specific to individual patients and account for their health plans as opposed to symbols or colors indicating drugs that are more or less expensive, which has been the status quo.
Also, she said, Medicare has promoted the use of these tools by health systems and health plans.
Dr. Sinaiko and colleagues examined EHR data for 103,953 primary care clinic encounters with 72,420 patients in the University of Colorado Health system (81.5% White; 59.5% female; 51.4% aged 65 years or older; 51.9% on Medicare). The patients were treated from July 2019 to July 2022 by 889 clinicians (physicians, nurse practitioners, and physician assistants), who wrote nearly 1.9 million medication orders. Of those orders, 181,887 (9.7%) included a price estimate.
For each prescription, the EHR displayed out-of-pocket costs for patients and offered alternative drugs if those drugs were at least 15 cents cheaper or if they were available at an on-site pharmacy.
Clinicians changed prescriptions 12.3% of the time after they saw price information. The percentage went up to 14% when possible cost savings were $5 or more.
Researchers also found that, while there was the option for clinicians to click a button in the EHR and learn a patient’s specific medication price before ordering a drug, very few clinicians requested price estimates directly, Dr. Sinaiko said. Fewer than 1% (0.9%) did so. The other 99.1% did not, meaning they received information about prices via alerts only after ordering prescriptions.
Researchers also found that clinicians weren’t more likely to change psychiatric medications when the cost savings for the patient was higher. The demographics of patients – such as whether they were poorer or richer – didn’t affect the willingness of clinicians to change prescriptions after receiving price information.
In the big picture, Dr. Sinaiko said, “The fact that medication orders were changed more often when the potential cost savings for patients were larger suggests to me that clinicians were taking out-of-pocket cost into account when it was most salient for the patient.”
It’s not clear, however, why clinicians did not revise more prescriptions to help patients save money.
One theory is that they may ignore the alerts because of “alert fatigue,” she said. “I’d like to know if clinicians discount or ignore the price estimate because they don’t know where it comes from or whether it is accurate. It’s also possible that clinicians discuss the option to change a medication order with their patient, and for reasons other than cost, they decide to keep the original selection. This suggests that clinicians might be using price information to guide – not dictate – their clinical decisions.”
The study had limitations. The researchers did not assess whether the cheaper alternative medications were appropriate in individual cases. Also, they did not take into account other factors, such as patient preferences, that affect how clinicians make prescription decisions.
Clinicians may also not know whether their patients worry about drug costs.
“There isn’t really good data on who wants to talk to their physician about costs, but it is definitely nowhere near 100%,” said health services researcher Alyna Chien, MD, a pediatrician at Boston Children’s Hospital. “For physicians, there is also good reason to keep cost out of the picture until asked so that patients don’t feel like they’re getting suboptimal choices.”
University of Washington, Seattle, graduate student Shiven Bhardwaj, PharmD, who studies health policy, said in an interview that the new study “suggests that physicians are not frequently selecting less costly agents suggested by the real-time benefit tool, and they may not even be considering these alternatives.”
According to Dr. Bhardwaj, previous research has found that physicians “are unable to estimate what their patients’ out-of-pocket costs may be, which is not surprising, given wide variation in health insurance benefit designs.”
Why aren’t more clinicians choosing cheaper alternatives, even when they’re directly told about them? Dr. Bhardwaj suggests that many health systems may be implementing electronic drug cost alerts in the absence of official notification or training.
“Health systems should be making providers aware of the system and its potential to reduce patients’ out-of-pocket costs.”
What’s next for research in this area?
Lead author Dr. Sinaiko said she and her team will interview clinicians and patients in practices at University of Colorado Health to understand how these price estimates are used in clinical encounters and how they affect clinician practice and patient experiences
“We are interested in learning about the cost-savings thresholds that are important to patients,” she said.
The researchers will also examine whether cost information helps to boost access to medications for chronic conditions among Black and Hispanic patients and patients who live in rural areas, she said.
The study was funded by the Harvard School of Public Health Dean’s Fund and the National Institute on Minority Health and Health Disparities. Dr. Sinaiko, Dr. Bhardwaj, and Dr. Chien have no relevant disclosures. Two study authors report having received a grant from the National Institute on Aging and consulting fees from Dispatch Health and Credo Health.
A version of this article first appeared on Medscape.com.
, according to findings from a study published in JAMA Internal Medicine.
The findings suggest that incorporating the alerts into electronic health record software could be useful for reducing patient expenses, said lead author Anna D. Sinaiko, PhD, assistant professor of health economics and policy at Harvard T. H. Chan School of Public Health, Boston. Showing clinicians the actual prices of medications their patient would pay led to changes in one in six orders when the potential cost savings to the patient was $20 or more, she said.
“This suggests that clinicians are taking medication out-of-pocket prices into account when they are most meaningful for patients.”
Such “real-time benefit tools” provide more meaningful information about patient drug prices in clinical settings than has previously been available, Dr. Sinaiko said. They provide out-of-pocket price estimates specific to individual patients and account for their health plans as opposed to symbols or colors indicating drugs that are more or less expensive, which has been the status quo.
Also, she said, Medicare has promoted the use of these tools by health systems and health plans.
Dr. Sinaiko and colleagues examined EHR data for 103,953 primary care clinic encounters with 72,420 patients in the University of Colorado Health system (81.5% White; 59.5% female; 51.4% aged 65 years or older; 51.9% on Medicare). The patients were treated from July 2019 to July 2022 by 889 clinicians (physicians, nurse practitioners, and physician assistants), who wrote nearly 1.9 million medication orders. Of those orders, 181,887 (9.7%) included a price estimate.
For each prescription, the EHR displayed out-of-pocket costs for patients and offered alternative drugs if those drugs were at least 15 cents cheaper or if they were available at an on-site pharmacy.
Clinicians changed prescriptions 12.3% of the time after they saw price information. The percentage went up to 14% when possible cost savings were $5 or more.
Researchers also found that, while there was the option for clinicians to click a button in the EHR and learn a patient’s specific medication price before ordering a drug, very few clinicians requested price estimates directly, Dr. Sinaiko said. Fewer than 1% (0.9%) did so. The other 99.1% did not, meaning they received information about prices via alerts only after ordering prescriptions.
Researchers also found that clinicians weren’t more likely to change psychiatric medications when the cost savings for the patient was higher. The demographics of patients – such as whether they were poorer or richer – didn’t affect the willingness of clinicians to change prescriptions after receiving price information.
In the big picture, Dr. Sinaiko said, “The fact that medication orders were changed more often when the potential cost savings for patients were larger suggests to me that clinicians were taking out-of-pocket cost into account when it was most salient for the patient.”
It’s not clear, however, why clinicians did not revise more prescriptions to help patients save money.
One theory is that they may ignore the alerts because of “alert fatigue,” she said. “I’d like to know if clinicians discount or ignore the price estimate because they don’t know where it comes from or whether it is accurate. It’s also possible that clinicians discuss the option to change a medication order with their patient, and for reasons other than cost, they decide to keep the original selection. This suggests that clinicians might be using price information to guide – not dictate – their clinical decisions.”
The study had limitations. The researchers did not assess whether the cheaper alternative medications were appropriate in individual cases. Also, they did not take into account other factors, such as patient preferences, that affect how clinicians make prescription decisions.
Clinicians may also not know whether their patients worry about drug costs.
“There isn’t really good data on who wants to talk to their physician about costs, but it is definitely nowhere near 100%,” said health services researcher Alyna Chien, MD, a pediatrician at Boston Children’s Hospital. “For physicians, there is also good reason to keep cost out of the picture until asked so that patients don’t feel like they’re getting suboptimal choices.”
University of Washington, Seattle, graduate student Shiven Bhardwaj, PharmD, who studies health policy, said in an interview that the new study “suggests that physicians are not frequently selecting less costly agents suggested by the real-time benefit tool, and they may not even be considering these alternatives.”
According to Dr. Bhardwaj, previous research has found that physicians “are unable to estimate what their patients’ out-of-pocket costs may be, which is not surprising, given wide variation in health insurance benefit designs.”
Why aren’t more clinicians choosing cheaper alternatives, even when they’re directly told about them? Dr. Bhardwaj suggests that many health systems may be implementing electronic drug cost alerts in the absence of official notification or training.
“Health systems should be making providers aware of the system and its potential to reduce patients’ out-of-pocket costs.”
What’s next for research in this area?
Lead author Dr. Sinaiko said she and her team will interview clinicians and patients in practices at University of Colorado Health to understand how these price estimates are used in clinical encounters and how they affect clinician practice and patient experiences
“We are interested in learning about the cost-savings thresholds that are important to patients,” she said.
The researchers will also examine whether cost information helps to boost access to medications for chronic conditions among Black and Hispanic patients and patients who live in rural areas, she said.
The study was funded by the Harvard School of Public Health Dean’s Fund and the National Institute on Minority Health and Health Disparities. Dr. Sinaiko, Dr. Bhardwaj, and Dr. Chien have no relevant disclosures. Two study authors report having received a grant from the National Institute on Aging and consulting fees from Dispatch Health and Credo Health.
A version of this article first appeared on Medscape.com.
FROM JAMA INTERNAL MEDICINE
Your patient bequeathed money to you: Can you accept it?
Michael Victoroff, MD, described the phone call he received from an attorney asking a thorny ethics question involving a patient’s gift to another physician. Dr. Victoroff, a past member of the ethics committee of the American Academy of Family Physicians, had definite thoughts about it.
“The attorney was representing the daughters of an elderly gentleman who had moved from the East Coast to Colorado to be closer to them,” said Dr. Victoroff, who teaches bioethics in the MBA program at the University of Denver and also practices at the University of Colorado School of Medicine.
“The father visited his new primary care physician frequently because he had multiple health issues.”
The patient was happy with the doctor’s medical care and over time that they developed a friendship. Dr. Victoroff emphasized that no sexual or romantic impropriety ever took place between the patient and his physician.
“But the social relationship went beyond the ordinary doctor-patient boundaries. The patient ultimately named the doctor as his health care proxy in the event that he became unable to make decisions regarding his care. He also mentioned he was going to leave her $100,000 in his will,” says Dr. Victoroff.
The physician did accept the role of proxy, “which raises a whole host of ethical issues,” says Dr. Victoroff. As it happened, she was never called upon to exercise that decision-making authority, since the patient died suddenly and was mentally competent at the time.
for her to accept such a substantial bequest from a patient, and they hired an attorney to contest the will.
No law against it
Dennis Hursh, attorney and managing partner of Physician Agreements Health Law, a Pennsylvania-based law firm that represents physicians, noted in an interview that, “the problem isn’t legal per se. Rather, the problem is an ethical one.”
Legally speaking, there’s no prohibition against receiving a bequest or other form of gift from a patient. “People are free to dispose of their estates in whatever way they see fit, and no law technically precludes a physician from accepting a bequest,” says Dr. Victoroff. “But this presupposes there is nothing improper going on, such as extortion, deception, coercion, or exercising undue influence.”
The issue of bequeathing money to their physician gained attention in a recent case that took place in Australia. Peter Alexakis, MD, received a whopping bequest of $24 million from a patient. The elderly patient had changed his will to name Dr. Alexakis as the sole beneficiary – after Dr. Alexakis had visited him at home 92 times during the preceding months. The original heirs filed a lawsuit in Australia’s Supreme Court against Dr. Alexakis, contesting the will.
The lawsuit was unsuccessful in court, but Dr. Alexakis was found guilty of malpractice by Australia’s Health Care Complaints Commission after being reported to the HCCC by the palliative care physicians who were treating the patient. They alleged that Dr. Alexakis had interfered with their care of the patient. The more serious allegation was that the doctor had engaged in a deliberate strategy to exploit the relationship for financial gain.
Dr. Alexakis was chastised by the HCCC for engaging in “obtuse” and “suspicious” behavior and for “blurring the boundaries of the doctor-patient relationship.”
There are three domains – legal, ethical, and practical – when it comes to accepting bequests or any gifts from patients, says Dr. Victoroff.
“[In] the legal domain, for example, if you receive a bequest from anyone, patient or otherwise, you have to know your local laws about estates and taxes and so forth and obey them,” he said.
Attorney Hursh pointed out that the Australian doctor wasn’t found guilty of wrongdoing in a court of law but rather of unethical conduct by the Australian medical licensing entity.
Patients giving gifts is often a part of a physician’s life
When Ian Schorr, MD, first started out in practice, he was surprised that patients began bringing him gifts of food to express gratitude for his care.
“I thought it was unethical to accept their gifts, so I turned them down and wouldn’t accept so much as a cookie,” Dr. Schorr, a now-retired ophthalmologist, told this news organization. “But that changed because my office staff told me that some patients were feeling disappointed and insulted. I realized that some people want to express appreciation in ways that go beyond a monetary payment.”
The next time he received a gift from a patient, he “accepted it gracefully.” And he wrote a thank you note, which he continued to do any time he received a gift from a patient.
Kenneth Prager, MD, professor of clinical medicine, director of clinical ethics and chairman of the Medical Ethics Committee at Columbia University Medical Center, New York, says, “I have literally received hundreds of gifts, the vast majority being tokens of patients’ appreciation,” he said. “I’ll get boxes of chocolate or cakes, or sometimes articles of clothing.”
Occasionally, Dr. Prager receives a “somewhat larger gift” – for example, two tickets to a baseball game. “To reject these gifts would be a slap in the face to the patient,” he says, but “where it gets more ethically cloudy is when a gift is very substantial.”
Dr. Prager has never been offered a “substantial” gift or bequest personally. “But a patient whose brother I cared for has indicated that she has left instructions in her will to endow an associate chair of ethics in my honor, and I didn’t decline that,” he said.
The AMA Code of Ethics confirms that accepting gifts offered “as an expression of gratitude or a reflection of the patient’s cultural tradition” can “enhance the patient-physician relationship.” But sometimes gifts “may signal psychological needs that require the physician’s attention.” Accepting such gifts is “likely to damage the patient-physician relationship.”
Potential damage to the therapeutic relationship applies to all physicians but especially for psychiatrists and mental health professionals. “There are more stringent ethical requirements when it comes to these disciplines, where gift-giving gets into the territory of transference or may have particular psychological meaning, and accepting the gift may muddy the therapeutic waters,” Dr. Victoroff said.
Impact on the patient’s family and on other patients
The AMA statement encourages physicians to be “sensitive to the gift’s value, relative to the patient’s or physician’s means.” Physicians should decline gifts that are “disproportionately or inappropriately large, or when the physician would be uncomfortable to have colleagues know the gift had been accepted.”
They should also decline a bequest from a patient if they have reason to believe that to accept it “would present an emotional or financial hardship to the patient’s family.”
“If Bill Gates were leaving $100,000 to his doctor, I imagine Melinda would be just fine,” Mr. Hursh said. “But under ordinary circumstances, if the patient’s family might feel the impact of the bequest, it would be unethical to accept it and could be grounds for revocation of the doctor’s license.”
The AMA statement also warns physicians that by offering a gift, some patients may be seeking to “secure or influence care or to secure preferential treatment,” which can “undermine physicians’ obligation to provide services fairly to all patients.”
For this reason, bequests are “sticky,” said Laurel Lyckholm, MD, professor of hematology and oncology at West Virginia University School of Medicine. In the case of institutions where patients or community members donate money, “we know whose names are on the plaques that hang on the hospital walls, so it’s a delicate balance. What if there’s only one bed or one ventilator? Will the wife of the donor get preferential treatment?”
Follow institutional policy
A “very small gift, such as a fruitcake, is fine,” says Dr. Lyckholm, author of an essay on accepting gifts from patients. She said there’s a dollar amount ($15) that her institution mandates, above which a gift – even food – is considered too expensive to accept. “I was a nurse before I became a physician, and people always tried to give us gifts because we were so close to the minute-by-minute care of the patients,” she said. “We were not allowed to accept money or anything lavish.”
But in the case of small gifts, “the risk-benefit analysis is that there’s much more risk not to take it and to hurt the patient’s feelings.”
Gifts above $15 are given to charity. “I explain to patients that I’m not allowed to take such a large gift, but I’d love to give it to the hospital’s Rosenbaum Family House that provides patients and their relatives with lodging, or to the homeless shelter in Morgantown.”
Dr. Lyckholm, who serves on the ethics committee at J.W. Ruby Memorial Hospital, once was offered expensive tickets and said to the patient, “This is so incredibly thoughtful and kind, but I can’t accept them. I would like to give the tickets to a charity that can auction them off.”
She advises physicians to find out their institution’s policies. Many institutions have policies about what gifts their staff – whether physicians, nurses, or other health care professionals – can accept.
Passing the ‘smell test’
Accepting a large gift from a patient could potentially make it look like you might have exercised undue influence.
“That concern brings us to the third domain, which is very practical and all about appearances and perceptions,” Dr. Victoroff said.
He noted that there is “an inherent power differential between a physician and a patient. The very nature of the relationship can create a risk of ‘undue influence’ on the doctor’s part, even if it’s not apparent to the doctor.” For this reason, it’s necessary to be utterly transparent about how the bequest came about.
He suggests that if a patient informs you that he or she would like to leave money to you, it might be wise to suggest a meeting with the patient’s family, thus establishing some transparency.
It may not be possible to meet with the patient’s family for logistical reasons or because the patient would prefer not to involve their family in their estate planning. But in any case, it’s advisable to document any conversation in the patient’s chart, Dr. Victoroff advised.
“You should make a contemporaneous note that the patient initiated the suggestion and that you counseled them about the implications, no differently than you would with an interaction of a clinical nature,” he suggests. That way, if money has been left to you and is disputed, there’s a clear record that you didn’t solicit it or use any undue influence to bring it about.
He also recommended getting advice from a trusted colleague or a member of your institution’s ethics committee. “Taking time to get a second opinion about an ethical question is a safeguard, like having a chaperone in the room during an examination.”
Ultimately, “there is no human relationship without potential conflicts of interest. Our job is to manage those as best as we can, and sunlight is the best antidote to bad appearances,” Dr. Victoroff said.
A version of this article appeared on Medscape.com.
Michael Victoroff, MD, described the phone call he received from an attorney asking a thorny ethics question involving a patient’s gift to another physician. Dr. Victoroff, a past member of the ethics committee of the American Academy of Family Physicians, had definite thoughts about it.
“The attorney was representing the daughters of an elderly gentleman who had moved from the East Coast to Colorado to be closer to them,” said Dr. Victoroff, who teaches bioethics in the MBA program at the University of Denver and also practices at the University of Colorado School of Medicine.
“The father visited his new primary care physician frequently because he had multiple health issues.”
The patient was happy with the doctor’s medical care and over time that they developed a friendship. Dr. Victoroff emphasized that no sexual or romantic impropriety ever took place between the patient and his physician.
“But the social relationship went beyond the ordinary doctor-patient boundaries. The patient ultimately named the doctor as his health care proxy in the event that he became unable to make decisions regarding his care. He also mentioned he was going to leave her $100,000 in his will,” says Dr. Victoroff.
The physician did accept the role of proxy, “which raises a whole host of ethical issues,” says Dr. Victoroff. As it happened, she was never called upon to exercise that decision-making authority, since the patient died suddenly and was mentally competent at the time.
for her to accept such a substantial bequest from a patient, and they hired an attorney to contest the will.
No law against it
Dennis Hursh, attorney and managing partner of Physician Agreements Health Law, a Pennsylvania-based law firm that represents physicians, noted in an interview that, “the problem isn’t legal per se. Rather, the problem is an ethical one.”
Legally speaking, there’s no prohibition against receiving a bequest or other form of gift from a patient. “People are free to dispose of their estates in whatever way they see fit, and no law technically precludes a physician from accepting a bequest,” says Dr. Victoroff. “But this presupposes there is nothing improper going on, such as extortion, deception, coercion, or exercising undue influence.”
The issue of bequeathing money to their physician gained attention in a recent case that took place in Australia. Peter Alexakis, MD, received a whopping bequest of $24 million from a patient. The elderly patient had changed his will to name Dr. Alexakis as the sole beneficiary – after Dr. Alexakis had visited him at home 92 times during the preceding months. The original heirs filed a lawsuit in Australia’s Supreme Court against Dr. Alexakis, contesting the will.
The lawsuit was unsuccessful in court, but Dr. Alexakis was found guilty of malpractice by Australia’s Health Care Complaints Commission after being reported to the HCCC by the palliative care physicians who were treating the patient. They alleged that Dr. Alexakis had interfered with their care of the patient. The more serious allegation was that the doctor had engaged in a deliberate strategy to exploit the relationship for financial gain.
Dr. Alexakis was chastised by the HCCC for engaging in “obtuse” and “suspicious” behavior and for “blurring the boundaries of the doctor-patient relationship.”
There are three domains – legal, ethical, and practical – when it comes to accepting bequests or any gifts from patients, says Dr. Victoroff.
“[In] the legal domain, for example, if you receive a bequest from anyone, patient or otherwise, you have to know your local laws about estates and taxes and so forth and obey them,” he said.
Attorney Hursh pointed out that the Australian doctor wasn’t found guilty of wrongdoing in a court of law but rather of unethical conduct by the Australian medical licensing entity.
Patients giving gifts is often a part of a physician’s life
When Ian Schorr, MD, first started out in practice, he was surprised that patients began bringing him gifts of food to express gratitude for his care.
“I thought it was unethical to accept their gifts, so I turned them down and wouldn’t accept so much as a cookie,” Dr. Schorr, a now-retired ophthalmologist, told this news organization. “But that changed because my office staff told me that some patients were feeling disappointed and insulted. I realized that some people want to express appreciation in ways that go beyond a monetary payment.”
The next time he received a gift from a patient, he “accepted it gracefully.” And he wrote a thank you note, which he continued to do any time he received a gift from a patient.
Kenneth Prager, MD, professor of clinical medicine, director of clinical ethics and chairman of the Medical Ethics Committee at Columbia University Medical Center, New York, says, “I have literally received hundreds of gifts, the vast majority being tokens of patients’ appreciation,” he said. “I’ll get boxes of chocolate or cakes, or sometimes articles of clothing.”
Occasionally, Dr. Prager receives a “somewhat larger gift” – for example, two tickets to a baseball game. “To reject these gifts would be a slap in the face to the patient,” he says, but “where it gets more ethically cloudy is when a gift is very substantial.”
Dr. Prager has never been offered a “substantial” gift or bequest personally. “But a patient whose brother I cared for has indicated that she has left instructions in her will to endow an associate chair of ethics in my honor, and I didn’t decline that,” he said.
The AMA Code of Ethics confirms that accepting gifts offered “as an expression of gratitude or a reflection of the patient’s cultural tradition” can “enhance the patient-physician relationship.” But sometimes gifts “may signal psychological needs that require the physician’s attention.” Accepting such gifts is “likely to damage the patient-physician relationship.”
Potential damage to the therapeutic relationship applies to all physicians but especially for psychiatrists and mental health professionals. “There are more stringent ethical requirements when it comes to these disciplines, where gift-giving gets into the territory of transference or may have particular psychological meaning, and accepting the gift may muddy the therapeutic waters,” Dr. Victoroff said.
Impact on the patient’s family and on other patients
The AMA statement encourages physicians to be “sensitive to the gift’s value, relative to the patient’s or physician’s means.” Physicians should decline gifts that are “disproportionately or inappropriately large, or when the physician would be uncomfortable to have colleagues know the gift had been accepted.”
They should also decline a bequest from a patient if they have reason to believe that to accept it “would present an emotional or financial hardship to the patient’s family.”
“If Bill Gates were leaving $100,000 to his doctor, I imagine Melinda would be just fine,” Mr. Hursh said. “But under ordinary circumstances, if the patient’s family might feel the impact of the bequest, it would be unethical to accept it and could be grounds for revocation of the doctor’s license.”
The AMA statement also warns physicians that by offering a gift, some patients may be seeking to “secure or influence care or to secure preferential treatment,” which can “undermine physicians’ obligation to provide services fairly to all patients.”
For this reason, bequests are “sticky,” said Laurel Lyckholm, MD, professor of hematology and oncology at West Virginia University School of Medicine. In the case of institutions where patients or community members donate money, “we know whose names are on the plaques that hang on the hospital walls, so it’s a delicate balance. What if there’s only one bed or one ventilator? Will the wife of the donor get preferential treatment?”
Follow institutional policy
A “very small gift, such as a fruitcake, is fine,” says Dr. Lyckholm, author of an essay on accepting gifts from patients. She said there’s a dollar amount ($15) that her institution mandates, above which a gift – even food – is considered too expensive to accept. “I was a nurse before I became a physician, and people always tried to give us gifts because we were so close to the minute-by-minute care of the patients,” she said. “We were not allowed to accept money or anything lavish.”
But in the case of small gifts, “the risk-benefit analysis is that there’s much more risk not to take it and to hurt the patient’s feelings.”
Gifts above $15 are given to charity. “I explain to patients that I’m not allowed to take such a large gift, but I’d love to give it to the hospital’s Rosenbaum Family House that provides patients and their relatives with lodging, or to the homeless shelter in Morgantown.”
Dr. Lyckholm, who serves on the ethics committee at J.W. Ruby Memorial Hospital, once was offered expensive tickets and said to the patient, “This is so incredibly thoughtful and kind, but I can’t accept them. I would like to give the tickets to a charity that can auction them off.”
She advises physicians to find out their institution’s policies. Many institutions have policies about what gifts their staff – whether physicians, nurses, or other health care professionals – can accept.
Passing the ‘smell test’
Accepting a large gift from a patient could potentially make it look like you might have exercised undue influence.
“That concern brings us to the third domain, which is very practical and all about appearances and perceptions,” Dr. Victoroff said.
He noted that there is “an inherent power differential between a physician and a patient. The very nature of the relationship can create a risk of ‘undue influence’ on the doctor’s part, even if it’s not apparent to the doctor.” For this reason, it’s necessary to be utterly transparent about how the bequest came about.
He suggests that if a patient informs you that he or she would like to leave money to you, it might be wise to suggest a meeting with the patient’s family, thus establishing some transparency.
It may not be possible to meet with the patient’s family for logistical reasons or because the patient would prefer not to involve their family in their estate planning. But in any case, it’s advisable to document any conversation in the patient’s chart, Dr. Victoroff advised.
“You should make a contemporaneous note that the patient initiated the suggestion and that you counseled them about the implications, no differently than you would with an interaction of a clinical nature,” he suggests. That way, if money has been left to you and is disputed, there’s a clear record that you didn’t solicit it or use any undue influence to bring it about.
He also recommended getting advice from a trusted colleague or a member of your institution’s ethics committee. “Taking time to get a second opinion about an ethical question is a safeguard, like having a chaperone in the room during an examination.”
Ultimately, “there is no human relationship without potential conflicts of interest. Our job is to manage those as best as we can, and sunlight is the best antidote to bad appearances,” Dr. Victoroff said.
A version of this article appeared on Medscape.com.
Michael Victoroff, MD, described the phone call he received from an attorney asking a thorny ethics question involving a patient’s gift to another physician. Dr. Victoroff, a past member of the ethics committee of the American Academy of Family Physicians, had definite thoughts about it.
“The attorney was representing the daughters of an elderly gentleman who had moved from the East Coast to Colorado to be closer to them,” said Dr. Victoroff, who teaches bioethics in the MBA program at the University of Denver and also practices at the University of Colorado School of Medicine.
“The father visited his new primary care physician frequently because he had multiple health issues.”
The patient was happy with the doctor’s medical care and over time that they developed a friendship. Dr. Victoroff emphasized that no sexual or romantic impropriety ever took place between the patient and his physician.
“But the social relationship went beyond the ordinary doctor-patient boundaries. The patient ultimately named the doctor as his health care proxy in the event that he became unable to make decisions regarding his care. He also mentioned he was going to leave her $100,000 in his will,” says Dr. Victoroff.
The physician did accept the role of proxy, “which raises a whole host of ethical issues,” says Dr. Victoroff. As it happened, she was never called upon to exercise that decision-making authority, since the patient died suddenly and was mentally competent at the time.
for her to accept such a substantial bequest from a patient, and they hired an attorney to contest the will.
No law against it
Dennis Hursh, attorney and managing partner of Physician Agreements Health Law, a Pennsylvania-based law firm that represents physicians, noted in an interview that, “the problem isn’t legal per se. Rather, the problem is an ethical one.”
Legally speaking, there’s no prohibition against receiving a bequest or other form of gift from a patient. “People are free to dispose of their estates in whatever way they see fit, and no law technically precludes a physician from accepting a bequest,” says Dr. Victoroff. “But this presupposes there is nothing improper going on, such as extortion, deception, coercion, or exercising undue influence.”
The issue of bequeathing money to their physician gained attention in a recent case that took place in Australia. Peter Alexakis, MD, received a whopping bequest of $24 million from a patient. The elderly patient had changed his will to name Dr. Alexakis as the sole beneficiary – after Dr. Alexakis had visited him at home 92 times during the preceding months. The original heirs filed a lawsuit in Australia’s Supreme Court against Dr. Alexakis, contesting the will.
The lawsuit was unsuccessful in court, but Dr. Alexakis was found guilty of malpractice by Australia’s Health Care Complaints Commission after being reported to the HCCC by the palliative care physicians who were treating the patient. They alleged that Dr. Alexakis had interfered with their care of the patient. The more serious allegation was that the doctor had engaged in a deliberate strategy to exploit the relationship for financial gain.
Dr. Alexakis was chastised by the HCCC for engaging in “obtuse” and “suspicious” behavior and for “blurring the boundaries of the doctor-patient relationship.”
There are three domains – legal, ethical, and practical – when it comes to accepting bequests or any gifts from patients, says Dr. Victoroff.
“[In] the legal domain, for example, if you receive a bequest from anyone, patient or otherwise, you have to know your local laws about estates and taxes and so forth and obey them,” he said.
Attorney Hursh pointed out that the Australian doctor wasn’t found guilty of wrongdoing in a court of law but rather of unethical conduct by the Australian medical licensing entity.
Patients giving gifts is often a part of a physician’s life
When Ian Schorr, MD, first started out in practice, he was surprised that patients began bringing him gifts of food to express gratitude for his care.
“I thought it was unethical to accept their gifts, so I turned them down and wouldn’t accept so much as a cookie,” Dr. Schorr, a now-retired ophthalmologist, told this news organization. “But that changed because my office staff told me that some patients were feeling disappointed and insulted. I realized that some people want to express appreciation in ways that go beyond a monetary payment.”
The next time he received a gift from a patient, he “accepted it gracefully.” And he wrote a thank you note, which he continued to do any time he received a gift from a patient.
Kenneth Prager, MD, professor of clinical medicine, director of clinical ethics and chairman of the Medical Ethics Committee at Columbia University Medical Center, New York, says, “I have literally received hundreds of gifts, the vast majority being tokens of patients’ appreciation,” he said. “I’ll get boxes of chocolate or cakes, or sometimes articles of clothing.”
Occasionally, Dr. Prager receives a “somewhat larger gift” – for example, two tickets to a baseball game. “To reject these gifts would be a slap in the face to the patient,” he says, but “where it gets more ethically cloudy is when a gift is very substantial.”
Dr. Prager has never been offered a “substantial” gift or bequest personally. “But a patient whose brother I cared for has indicated that she has left instructions in her will to endow an associate chair of ethics in my honor, and I didn’t decline that,” he said.
The AMA Code of Ethics confirms that accepting gifts offered “as an expression of gratitude or a reflection of the patient’s cultural tradition” can “enhance the patient-physician relationship.” But sometimes gifts “may signal psychological needs that require the physician’s attention.” Accepting such gifts is “likely to damage the patient-physician relationship.”
Potential damage to the therapeutic relationship applies to all physicians but especially for psychiatrists and mental health professionals. “There are more stringent ethical requirements when it comes to these disciplines, where gift-giving gets into the territory of transference or may have particular psychological meaning, and accepting the gift may muddy the therapeutic waters,” Dr. Victoroff said.
Impact on the patient’s family and on other patients
The AMA statement encourages physicians to be “sensitive to the gift’s value, relative to the patient’s or physician’s means.” Physicians should decline gifts that are “disproportionately or inappropriately large, or when the physician would be uncomfortable to have colleagues know the gift had been accepted.”
They should also decline a bequest from a patient if they have reason to believe that to accept it “would present an emotional or financial hardship to the patient’s family.”
“If Bill Gates were leaving $100,000 to his doctor, I imagine Melinda would be just fine,” Mr. Hursh said. “But under ordinary circumstances, if the patient’s family might feel the impact of the bequest, it would be unethical to accept it and could be grounds for revocation of the doctor’s license.”
The AMA statement also warns physicians that by offering a gift, some patients may be seeking to “secure or influence care or to secure preferential treatment,” which can “undermine physicians’ obligation to provide services fairly to all patients.”
For this reason, bequests are “sticky,” said Laurel Lyckholm, MD, professor of hematology and oncology at West Virginia University School of Medicine. In the case of institutions where patients or community members donate money, “we know whose names are on the plaques that hang on the hospital walls, so it’s a delicate balance. What if there’s only one bed or one ventilator? Will the wife of the donor get preferential treatment?”
Follow institutional policy
A “very small gift, such as a fruitcake, is fine,” says Dr. Lyckholm, author of an essay on accepting gifts from patients. She said there’s a dollar amount ($15) that her institution mandates, above which a gift – even food – is considered too expensive to accept. “I was a nurse before I became a physician, and people always tried to give us gifts because we were so close to the minute-by-minute care of the patients,” she said. “We were not allowed to accept money or anything lavish.”
But in the case of small gifts, “the risk-benefit analysis is that there’s much more risk not to take it and to hurt the patient’s feelings.”
Gifts above $15 are given to charity. “I explain to patients that I’m not allowed to take such a large gift, but I’d love to give it to the hospital’s Rosenbaum Family House that provides patients and their relatives with lodging, or to the homeless shelter in Morgantown.”
Dr. Lyckholm, who serves on the ethics committee at J.W. Ruby Memorial Hospital, once was offered expensive tickets and said to the patient, “This is so incredibly thoughtful and kind, but I can’t accept them. I would like to give the tickets to a charity that can auction them off.”
She advises physicians to find out their institution’s policies. Many institutions have policies about what gifts their staff – whether physicians, nurses, or other health care professionals – can accept.
Passing the ‘smell test’
Accepting a large gift from a patient could potentially make it look like you might have exercised undue influence.
“That concern brings us to the third domain, which is very practical and all about appearances and perceptions,” Dr. Victoroff said.
He noted that there is “an inherent power differential between a physician and a patient. The very nature of the relationship can create a risk of ‘undue influence’ on the doctor’s part, even if it’s not apparent to the doctor.” For this reason, it’s necessary to be utterly transparent about how the bequest came about.
He suggests that if a patient informs you that he or she would like to leave money to you, it might be wise to suggest a meeting with the patient’s family, thus establishing some transparency.
It may not be possible to meet with the patient’s family for logistical reasons or because the patient would prefer not to involve their family in their estate planning. But in any case, it’s advisable to document any conversation in the patient’s chart, Dr. Victoroff advised.
“You should make a contemporaneous note that the patient initiated the suggestion and that you counseled them about the implications, no differently than you would with an interaction of a clinical nature,” he suggests. That way, if money has been left to you and is disputed, there’s a clear record that you didn’t solicit it or use any undue influence to bring it about.
He also recommended getting advice from a trusted colleague or a member of your institution’s ethics committee. “Taking time to get a second opinion about an ethical question is a safeguard, like having a chaperone in the room during an examination.”
Ultimately, “there is no human relationship without potential conflicts of interest. Our job is to manage those as best as we can, and sunlight is the best antidote to bad appearances,” Dr. Victoroff said.
A version of this article appeared on Medscape.com.
The magic of music
I’m really going to miss Jimmy Buffett.
I’ve liked his music as far back as I can remember, and was lucky enough to see him in person in the mid-90s.
I’ve written about music before, but its affect on us never fails to amaze me. Songs can be background noise conducive to getting things done. They can also be in the foreground, serving as a mental vacation (or accompanying a real one). They can transport you to another place, briefly clearing your head from the daily goings-on around you. Even if it’s just during the drive home, it’s a welcome escape to a virtual beach and tropical drink.
Songs can bring back memories of certain events or people that we link them to. My dad loved anything by Neil Diamond, and nothing brings back thoughts of Dad more than when my iTunes randomly picks “I Am ... I Said.” Or John Williams’ Star Wars theme, taking me back to the summer of 1977 when I sat, spellbound, by this incredible movie whose magic is still going strong two generations later.
It’s amazing how our brain tries to make music out of nothing. Even in silence we have ear worms, the songs stuck in our head for hours to days (recently I’ve had “I Sing the Body Electric” from the 1980 movie Fame playing in there).
My office is over an MRI scanner, so I can always hear the chiller pumps softly running in the background. Sometimes my brain will turn their rhythmic chirping into a song, altering the pace of the song to fit them. The soft clicking of the ceiling fan, in my home office, does the same thing (for some reason my brain usually tries to fit “Yellow Submarine” to that one, no idea why).
Music is a part of that mysterious essence that makes us human. It touches all of us in some way, which varies between people, songs, and artists.
Jimmy Buffet’s music has a vacation vibe. Songs of the Caribbean & Keys, beaches, bars, boats, and tropical drinks. The 4:12 running time of his most well-known song, “Margaritaville,” gives a brief respite from my day when it comes on.
He passes into the beyond, to the sadness of his family, friends, and fans. But, unlike people, music can be immortal, and so he lives on through his creations. Like, Bach, Lennon, Bowie, Joplin, Sousa, and too many others to count, his work – and the enjoyment we get from it – are a gift left behind for the future.
Tight lines, Jimmy.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’m really going to miss Jimmy Buffett.
I’ve liked his music as far back as I can remember, and was lucky enough to see him in person in the mid-90s.
I’ve written about music before, but its affect on us never fails to amaze me. Songs can be background noise conducive to getting things done. They can also be in the foreground, serving as a mental vacation (or accompanying a real one). They can transport you to another place, briefly clearing your head from the daily goings-on around you. Even if it’s just during the drive home, it’s a welcome escape to a virtual beach and tropical drink.
Songs can bring back memories of certain events or people that we link them to. My dad loved anything by Neil Diamond, and nothing brings back thoughts of Dad more than when my iTunes randomly picks “I Am ... I Said.” Or John Williams’ Star Wars theme, taking me back to the summer of 1977 when I sat, spellbound, by this incredible movie whose magic is still going strong two generations later.
It’s amazing how our brain tries to make music out of nothing. Even in silence we have ear worms, the songs stuck in our head for hours to days (recently I’ve had “I Sing the Body Electric” from the 1980 movie Fame playing in there).
My office is over an MRI scanner, so I can always hear the chiller pumps softly running in the background. Sometimes my brain will turn their rhythmic chirping into a song, altering the pace of the song to fit them. The soft clicking of the ceiling fan, in my home office, does the same thing (for some reason my brain usually tries to fit “Yellow Submarine” to that one, no idea why).
Music is a part of that mysterious essence that makes us human. It touches all of us in some way, which varies between people, songs, and artists.
Jimmy Buffet’s music has a vacation vibe. Songs of the Caribbean & Keys, beaches, bars, boats, and tropical drinks. The 4:12 running time of his most well-known song, “Margaritaville,” gives a brief respite from my day when it comes on.
He passes into the beyond, to the sadness of his family, friends, and fans. But, unlike people, music can be immortal, and so he lives on through his creations. Like, Bach, Lennon, Bowie, Joplin, Sousa, and too many others to count, his work – and the enjoyment we get from it – are a gift left behind for the future.
Tight lines, Jimmy.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’m really going to miss Jimmy Buffett.
I’ve liked his music as far back as I can remember, and was lucky enough to see him in person in the mid-90s.
I’ve written about music before, but its affect on us never fails to amaze me. Songs can be background noise conducive to getting things done. They can also be in the foreground, serving as a mental vacation (or accompanying a real one). They can transport you to another place, briefly clearing your head from the daily goings-on around you. Even if it’s just during the drive home, it’s a welcome escape to a virtual beach and tropical drink.
Songs can bring back memories of certain events or people that we link them to. My dad loved anything by Neil Diamond, and nothing brings back thoughts of Dad more than when my iTunes randomly picks “I Am ... I Said.” Or John Williams’ Star Wars theme, taking me back to the summer of 1977 when I sat, spellbound, by this incredible movie whose magic is still going strong two generations later.
It’s amazing how our brain tries to make music out of nothing. Even in silence we have ear worms, the songs stuck in our head for hours to days (recently I’ve had “I Sing the Body Electric” from the 1980 movie Fame playing in there).
My office is over an MRI scanner, so I can always hear the chiller pumps softly running in the background. Sometimes my brain will turn their rhythmic chirping into a song, altering the pace of the song to fit them. The soft clicking of the ceiling fan, in my home office, does the same thing (for some reason my brain usually tries to fit “Yellow Submarine” to that one, no idea why).
Music is a part of that mysterious essence that makes us human. It touches all of us in some way, which varies between people, songs, and artists.
Jimmy Buffet’s music has a vacation vibe. Songs of the Caribbean & Keys, beaches, bars, boats, and tropical drinks. The 4:12 running time of his most well-known song, “Margaritaville,” gives a brief respite from my day when it comes on.
He passes into the beyond, to the sadness of his family, friends, and fans. But, unlike people, music can be immortal, and so he lives on through his creations. Like, Bach, Lennon, Bowie, Joplin, Sousa, and too many others to count, his work – and the enjoyment we get from it – are a gift left behind for the future.
Tight lines, Jimmy.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Targeted warnings
I was probably about 9 or 10 and I am assuming it was early winter when my mother took me aside and said in her usual quiet tone, “Willy, don’t ever stick your tongue on a metal pipe when it is cold outside.”
Putting my tongue on a frozen pipe was something that had never occurred to me even in my wildest preadolescent dreams. My mother’s caution only served to pique my interest and provide me with one more tempting scenario to consider.
Recently, a prank has gone viral on TikTok that shows an adult, usually the parent, cracking (not smashing) an egg on the child’s head and then emptying the egg contents into a bowl. Unlike the tongue-pipe disaster, it is hard to imagine how this stunt can be dangerous as long as the child is old enough to be walking around. But, at least one pediatrician has warned that there is a risk to the child from contracting salmonella.
There may be a few young children who are frightened by having an egg cracked on their head, but I can’t imagine that it would leave any lasting emotional scars. Given the minuscule theoretical risk of infection and the fact that the videos have accumulated more than 670 million views, this is another example of when we “experts” should keep a low profile and let the virus fade into Internet oblivion.
There is, however, a difference between harmless foolishness and stupidity, and one wonders when and in what manner we pediatricians should become involved. For example, in a recent study published in the journal Pediatrics, the investigators searched through a national emergency department database and found that
There were two peaks of distribution, one at less than 1 year of age and another at age 4. The older children were more often injured playing on furniture, most often bunk beds. The younger children were more likely to have been injured by being lifted or tossed in the air. No deaths were reported.
Is this a phenomenon that demands a response by pediatricians? Do we have time to ask every family if they have a ceiling fan? Should we be handing out brochures to every family? To whom should we target our message? This is a situation that seems to sort easily into two categories. One that involves stupidity and a second that is ignorance that may respond to education.
Tossing young children in the air is fun for the tosser and the child. I am sure there are a few children every year who slip out of the grasp of an adult and are injured. I have never seen a child brought in with this history. But it must happen. The result is likely to trigger a very tricky child protective investigation. But tossing a child underneath a ceiling fan is just plain stupid. I’m not sure our intervention is going to prevent it from happening. Bunk beds and ceiling fans are a different story. Posters in our offices and warnings and labels at the point of purchase of both fans and bunk beds makes some sense.
And while we are sticking labels on furniture, we should take a hard look at couches. Researchers have recently found that the accumulation of sedentary time in childhood can lead to early evidence of heart damage, which may portend heart disease in adulthood. Instead of those tags under the cushions, we need a big blaze orange sticker in prominent view that warns of the danger of becoming a couch potato.
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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
I was probably about 9 or 10 and I am assuming it was early winter when my mother took me aside and said in her usual quiet tone, “Willy, don’t ever stick your tongue on a metal pipe when it is cold outside.”
Putting my tongue on a frozen pipe was something that had never occurred to me even in my wildest preadolescent dreams. My mother’s caution only served to pique my interest and provide me with one more tempting scenario to consider.
Recently, a prank has gone viral on TikTok that shows an adult, usually the parent, cracking (not smashing) an egg on the child’s head and then emptying the egg contents into a bowl. Unlike the tongue-pipe disaster, it is hard to imagine how this stunt can be dangerous as long as the child is old enough to be walking around. But, at least one pediatrician has warned that there is a risk to the child from contracting salmonella.
There may be a few young children who are frightened by having an egg cracked on their head, but I can’t imagine that it would leave any lasting emotional scars. Given the minuscule theoretical risk of infection and the fact that the videos have accumulated more than 670 million views, this is another example of when we “experts” should keep a low profile and let the virus fade into Internet oblivion.
There is, however, a difference between harmless foolishness and stupidity, and one wonders when and in what manner we pediatricians should become involved. For example, in a recent study published in the journal Pediatrics, the investigators searched through a national emergency department database and found that
There were two peaks of distribution, one at less than 1 year of age and another at age 4. The older children were more often injured playing on furniture, most often bunk beds. The younger children were more likely to have been injured by being lifted or tossed in the air. No deaths were reported.
Is this a phenomenon that demands a response by pediatricians? Do we have time to ask every family if they have a ceiling fan? Should we be handing out brochures to every family? To whom should we target our message? This is a situation that seems to sort easily into two categories. One that involves stupidity and a second that is ignorance that may respond to education.
Tossing young children in the air is fun for the tosser and the child. I am sure there are a few children every year who slip out of the grasp of an adult and are injured. I have never seen a child brought in with this history. But it must happen. The result is likely to trigger a very tricky child protective investigation. But tossing a child underneath a ceiling fan is just plain stupid. I’m not sure our intervention is going to prevent it from happening. Bunk beds and ceiling fans are a different story. Posters in our offices and warnings and labels at the point of purchase of both fans and bunk beds makes some sense.
And while we are sticking labels on furniture, we should take a hard look at couches. Researchers have recently found that the accumulation of sedentary time in childhood can lead to early evidence of heart damage, which may portend heart disease in adulthood. Instead of those tags under the cushions, we need a big blaze orange sticker in prominent view that warns of the danger of becoming a couch potato.
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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
I was probably about 9 or 10 and I am assuming it was early winter when my mother took me aside and said in her usual quiet tone, “Willy, don’t ever stick your tongue on a metal pipe when it is cold outside.”
Putting my tongue on a frozen pipe was something that had never occurred to me even in my wildest preadolescent dreams. My mother’s caution only served to pique my interest and provide me with one more tempting scenario to consider.
Recently, a prank has gone viral on TikTok that shows an adult, usually the parent, cracking (not smashing) an egg on the child’s head and then emptying the egg contents into a bowl. Unlike the tongue-pipe disaster, it is hard to imagine how this stunt can be dangerous as long as the child is old enough to be walking around. But, at least one pediatrician has warned that there is a risk to the child from contracting salmonella.
There may be a few young children who are frightened by having an egg cracked on their head, but I can’t imagine that it would leave any lasting emotional scars. Given the minuscule theoretical risk of infection and the fact that the videos have accumulated more than 670 million views, this is another example of when we “experts” should keep a low profile and let the virus fade into Internet oblivion.
There is, however, a difference between harmless foolishness and stupidity, and one wonders when and in what manner we pediatricians should become involved. For example, in a recent study published in the journal Pediatrics, the investigators searched through a national emergency department database and found that
There were two peaks of distribution, one at less than 1 year of age and another at age 4. The older children were more often injured playing on furniture, most often bunk beds. The younger children were more likely to have been injured by being lifted or tossed in the air. No deaths were reported.
Is this a phenomenon that demands a response by pediatricians? Do we have time to ask every family if they have a ceiling fan? Should we be handing out brochures to every family? To whom should we target our message? This is a situation that seems to sort easily into two categories. One that involves stupidity and a second that is ignorance that may respond to education.
Tossing young children in the air is fun for the tosser and the child. I am sure there are a few children every year who slip out of the grasp of an adult and are injured. I have never seen a child brought in with this history. But it must happen. The result is likely to trigger a very tricky child protective investigation. But tossing a child underneath a ceiling fan is just plain stupid. I’m not sure our intervention is going to prevent it from happening. Bunk beds and ceiling fans are a different story. Posters in our offices and warnings and labels at the point of purchase of both fans and bunk beds makes some sense.
And while we are sticking labels on furniture, we should take a hard look at couches. Researchers have recently found that the accumulation of sedentary time in childhood can lead to early evidence of heart damage, which may portend heart disease in adulthood. Instead of those tags under the cushions, we need a big blaze orange sticker in prominent view that warns of the danger of becoming a couch potato.
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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Five ways to avert a malpractice lawsuit with better EHR techniques
Although most physicians have gotten used to working with EHRs, despite their irritations, the use of EHRs has contributed to a growing number of malpractice lawsuits. Defense attorneys say that
According to a study in the Journal of Patient Safety, more than 30% of all EHR-related malpractice cases are associated with medication errors; 28% with diagnosis; and 31% with a complication of treatment, such as entering wrong information, entering information in the wrong place, and overlooking EHR flags and warnings for interactions or contraindications.
The study gave these examples of EHR-related errors that led to patient harm and ultimately to malpractice lawsuits:
- A discharge order omitted a patient’s medication that prevented strokes; the patient had a stroke days later.
- An electronic order for morphine failed to state the upper dose limit; the patient died.
- A physician meant to click on “discontinue” for an anticoagulant but mistakenly clicked on “continue” for home use.
Catching potential issues such as drug interactions or critical medical history that should inform treatment is more important than ever. “We know from safety engineering principles that just relying on vigilance is not a long-term safety strategy,” says Aaron Zach Hettinger, MD, chief research information officer at MedStar Health Research Institute, Washington, D.C. “So, it’s critical that we design these safe systems and leverage the data that’s in them.”
Here are five smart EHR practices to help protect your patients’ health and your own liability.
1. Double-check dropdown boxes
When it comes to user error, it’s easy to click the wrong choice from a drop-down menu. Better to take the time to explain your answer in a box, even if it takes a few more minutes. Or if you are choosing from a menu, proofread any information it auto-fills in the chart.
Dr. Hettinger says you can strike a balance between these templated approaches to diagnosis and long-term care by working with third-party systems and your organization or vendor IT department to help with follow-up questions to keep populated data in check.
“Make sure you have a back-end system that can help monitor that structured data,” says Dr. Hettinger. Structured data are the patient’s demographic information, like name, address, age, height, weight, vital signs, and data elements like diagnosis, medications, and lab results. “Wherever you can leverage the underlying tools that are part of the electronic health record to make sure that we’re constantly checking the right results, that helps reduce the workload so that clinicians can focus on taking care of the patients and doing the right thing and not be as focused on entering data into the system.”
2. Supplement EHR notes with direct communication
The failure to diagnose cancer because one physician doesn’t know what another physician saw in an imaging report is one of the most common claims in the cases he tries, says Aaron Boeder, a plaintiff’s medical negligence lawyer in Chicago.
Physicians often assume that if they put a note in the electronic chart, others will look for it, but Mr. Boeder says it’s far more prudent to communicate directly.
“Let’s say a radiologist interprets a scan and sees what might be cancer,” he says. “If the ordering doctor is an orthopedist who’s ordered a CT scan for DVT, there’s going to be a report for that scan. It’s going to get auto-populated back into that physician’s note,” says Mr. Boeder.
The physician may or may not look at it, but it will be in their note, and they’re supposed to follow up on it because they ordered the scan. “But they may not follow up on it, and they may not get a call from the radiologist,” he says.
“Next thing you know, 2 or 3 years later, that patient is diagnosed with very advanced cancer.”
3. Tailor auto-fill information to your common practices
Suppose, as a physician, you find that you need to change a default setting time and time again. Dr. Hettinger says it’s worth your time to take an extra couple of minutes to work with your vendor or your health system to try and make changes to auto-population settings that align with your practices.
“Let’s say a default dose of 20 milligrams of a medication is what automatically pops up, but in reality, your practice is to use a smaller dose because it’s safer, even though they’re all within the acceptable realm of what you would order,” he says. “Rather than have the default to the higher dose, see if you can change the default to a lower dose. And that way, you don’t have to catch yourself every time.”
If your auto-fills are amounts that constantly need changing, an interruption could easily knock you off course before you make that correction.
“If there are ways to have the system defaults be safer or more in line with your clinical practice, and especially across a group, then you’re designing a safer system and not relying on vigilance or memory prone to interruptions,” says Dr. Hettinger.
4. Curb the copy and paste
It’s tempting to copy a note from a previous patient visit and make only minimal changes as needed, but you risk including outdated information if you do. Even if you’re repeating questions asked by the intake nurse, it is safer to not to rely on that information, says Beth Kanik, a defense medical malpractice attorney in Atlanta.
“If it later goes into litigation, the argument then becomes that it looks like you didn’t do your job,” says Ms. Kanik. “Instead, try to ask questions in a way that would elicit responses that may be a little different than what the nurse got, so that it’s clear you asked the questions and didn’t just simply rely upon someone else’s information.”
5. Separate typing from listening
While EHR may be an excellent tool for data collection and safety checking, it’s not a stand-in for doctor-patient interaction. As technology practices push medicine toward more and more efficiency, Mr. Boeder says it’s most often listening over all else that makes the difference in the quality of care. And good listening requires full attention.
“A real concern for physicians is the number of visits they’re expected to accomplish in a set amount of time,” says Mr. Boeder. “Often this translates into a doctor talking to a patient while typing notes or while reading a note from the last time the patient was in.”
Taking the time to pause after entering data and briefly reviewing your understanding of what your patient has told you can be invaluable and may save you – and your patient – problems later.
“In so many cases, it comes down to people not being heard,” says Mr. Boeder. “So listen to what your patients are saying.”
A version of this article first appeared on Medscape.com.
Although most physicians have gotten used to working with EHRs, despite their irritations, the use of EHRs has contributed to a growing number of malpractice lawsuits. Defense attorneys say that
According to a study in the Journal of Patient Safety, more than 30% of all EHR-related malpractice cases are associated with medication errors; 28% with diagnosis; and 31% with a complication of treatment, such as entering wrong information, entering information in the wrong place, and overlooking EHR flags and warnings for interactions or contraindications.
The study gave these examples of EHR-related errors that led to patient harm and ultimately to malpractice lawsuits:
- A discharge order omitted a patient’s medication that prevented strokes; the patient had a stroke days later.
- An electronic order for morphine failed to state the upper dose limit; the patient died.
- A physician meant to click on “discontinue” for an anticoagulant but mistakenly clicked on “continue” for home use.
Catching potential issues such as drug interactions or critical medical history that should inform treatment is more important than ever. “We know from safety engineering principles that just relying on vigilance is not a long-term safety strategy,” says Aaron Zach Hettinger, MD, chief research information officer at MedStar Health Research Institute, Washington, D.C. “So, it’s critical that we design these safe systems and leverage the data that’s in them.”
Here are five smart EHR practices to help protect your patients’ health and your own liability.
1. Double-check dropdown boxes
When it comes to user error, it’s easy to click the wrong choice from a drop-down menu. Better to take the time to explain your answer in a box, even if it takes a few more minutes. Or if you are choosing from a menu, proofread any information it auto-fills in the chart.
Dr. Hettinger says you can strike a balance between these templated approaches to diagnosis and long-term care by working with third-party systems and your organization or vendor IT department to help with follow-up questions to keep populated data in check.
“Make sure you have a back-end system that can help monitor that structured data,” says Dr. Hettinger. Structured data are the patient’s demographic information, like name, address, age, height, weight, vital signs, and data elements like diagnosis, medications, and lab results. “Wherever you can leverage the underlying tools that are part of the electronic health record to make sure that we’re constantly checking the right results, that helps reduce the workload so that clinicians can focus on taking care of the patients and doing the right thing and not be as focused on entering data into the system.”
2. Supplement EHR notes with direct communication
The failure to diagnose cancer because one physician doesn’t know what another physician saw in an imaging report is one of the most common claims in the cases he tries, says Aaron Boeder, a plaintiff’s medical negligence lawyer in Chicago.
Physicians often assume that if they put a note in the electronic chart, others will look for it, but Mr. Boeder says it’s far more prudent to communicate directly.
“Let’s say a radiologist interprets a scan and sees what might be cancer,” he says. “If the ordering doctor is an orthopedist who’s ordered a CT scan for DVT, there’s going to be a report for that scan. It’s going to get auto-populated back into that physician’s note,” says Mr. Boeder.
The physician may or may not look at it, but it will be in their note, and they’re supposed to follow up on it because they ordered the scan. “But they may not follow up on it, and they may not get a call from the radiologist,” he says.
“Next thing you know, 2 or 3 years later, that patient is diagnosed with very advanced cancer.”
3. Tailor auto-fill information to your common practices
Suppose, as a physician, you find that you need to change a default setting time and time again. Dr. Hettinger says it’s worth your time to take an extra couple of minutes to work with your vendor or your health system to try and make changes to auto-population settings that align with your practices.
“Let’s say a default dose of 20 milligrams of a medication is what automatically pops up, but in reality, your practice is to use a smaller dose because it’s safer, even though they’re all within the acceptable realm of what you would order,” he says. “Rather than have the default to the higher dose, see if you can change the default to a lower dose. And that way, you don’t have to catch yourself every time.”
If your auto-fills are amounts that constantly need changing, an interruption could easily knock you off course before you make that correction.
“If there are ways to have the system defaults be safer or more in line with your clinical practice, and especially across a group, then you’re designing a safer system and not relying on vigilance or memory prone to interruptions,” says Dr. Hettinger.
4. Curb the copy and paste
It’s tempting to copy a note from a previous patient visit and make only minimal changes as needed, but you risk including outdated information if you do. Even if you’re repeating questions asked by the intake nurse, it is safer to not to rely on that information, says Beth Kanik, a defense medical malpractice attorney in Atlanta.
“If it later goes into litigation, the argument then becomes that it looks like you didn’t do your job,” says Ms. Kanik. “Instead, try to ask questions in a way that would elicit responses that may be a little different than what the nurse got, so that it’s clear you asked the questions and didn’t just simply rely upon someone else’s information.”
5. Separate typing from listening
While EHR may be an excellent tool for data collection and safety checking, it’s not a stand-in for doctor-patient interaction. As technology practices push medicine toward more and more efficiency, Mr. Boeder says it’s most often listening over all else that makes the difference in the quality of care. And good listening requires full attention.
“A real concern for physicians is the number of visits they’re expected to accomplish in a set amount of time,” says Mr. Boeder. “Often this translates into a doctor talking to a patient while typing notes or while reading a note from the last time the patient was in.”
Taking the time to pause after entering data and briefly reviewing your understanding of what your patient has told you can be invaluable and may save you – and your patient – problems later.
“In so many cases, it comes down to people not being heard,” says Mr. Boeder. “So listen to what your patients are saying.”
A version of this article first appeared on Medscape.com.
Although most physicians have gotten used to working with EHRs, despite their irritations, the use of EHRs has contributed to a growing number of malpractice lawsuits. Defense attorneys say that
According to a study in the Journal of Patient Safety, more than 30% of all EHR-related malpractice cases are associated with medication errors; 28% with diagnosis; and 31% with a complication of treatment, such as entering wrong information, entering information in the wrong place, and overlooking EHR flags and warnings for interactions or contraindications.
The study gave these examples of EHR-related errors that led to patient harm and ultimately to malpractice lawsuits:
- A discharge order omitted a patient’s medication that prevented strokes; the patient had a stroke days later.
- An electronic order for morphine failed to state the upper dose limit; the patient died.
- A physician meant to click on “discontinue” for an anticoagulant but mistakenly clicked on “continue” for home use.
Catching potential issues such as drug interactions or critical medical history that should inform treatment is more important than ever. “We know from safety engineering principles that just relying on vigilance is not a long-term safety strategy,” says Aaron Zach Hettinger, MD, chief research information officer at MedStar Health Research Institute, Washington, D.C. “So, it’s critical that we design these safe systems and leverage the data that’s in them.”
Here are five smart EHR practices to help protect your patients’ health and your own liability.
1. Double-check dropdown boxes
When it comes to user error, it’s easy to click the wrong choice from a drop-down menu. Better to take the time to explain your answer in a box, even if it takes a few more minutes. Or if you are choosing from a menu, proofread any information it auto-fills in the chart.
Dr. Hettinger says you can strike a balance between these templated approaches to diagnosis and long-term care by working with third-party systems and your organization or vendor IT department to help with follow-up questions to keep populated data in check.
“Make sure you have a back-end system that can help monitor that structured data,” says Dr. Hettinger. Structured data are the patient’s demographic information, like name, address, age, height, weight, vital signs, and data elements like diagnosis, medications, and lab results. “Wherever you can leverage the underlying tools that are part of the electronic health record to make sure that we’re constantly checking the right results, that helps reduce the workload so that clinicians can focus on taking care of the patients and doing the right thing and not be as focused on entering data into the system.”
2. Supplement EHR notes with direct communication
The failure to diagnose cancer because one physician doesn’t know what another physician saw in an imaging report is one of the most common claims in the cases he tries, says Aaron Boeder, a plaintiff’s medical negligence lawyer in Chicago.
Physicians often assume that if they put a note in the electronic chart, others will look for it, but Mr. Boeder says it’s far more prudent to communicate directly.
“Let’s say a radiologist interprets a scan and sees what might be cancer,” he says. “If the ordering doctor is an orthopedist who’s ordered a CT scan for DVT, there’s going to be a report for that scan. It’s going to get auto-populated back into that physician’s note,” says Mr. Boeder.
The physician may or may not look at it, but it will be in their note, and they’re supposed to follow up on it because they ordered the scan. “But they may not follow up on it, and they may not get a call from the radiologist,” he says.
“Next thing you know, 2 or 3 years later, that patient is diagnosed with very advanced cancer.”
3. Tailor auto-fill information to your common practices
Suppose, as a physician, you find that you need to change a default setting time and time again. Dr. Hettinger says it’s worth your time to take an extra couple of minutes to work with your vendor or your health system to try and make changes to auto-population settings that align with your practices.
“Let’s say a default dose of 20 milligrams of a medication is what automatically pops up, but in reality, your practice is to use a smaller dose because it’s safer, even though they’re all within the acceptable realm of what you would order,” he says. “Rather than have the default to the higher dose, see if you can change the default to a lower dose. And that way, you don’t have to catch yourself every time.”
If your auto-fills are amounts that constantly need changing, an interruption could easily knock you off course before you make that correction.
“If there are ways to have the system defaults be safer or more in line with your clinical practice, and especially across a group, then you’re designing a safer system and not relying on vigilance or memory prone to interruptions,” says Dr. Hettinger.
4. Curb the copy and paste
It’s tempting to copy a note from a previous patient visit and make only minimal changes as needed, but you risk including outdated information if you do. Even if you’re repeating questions asked by the intake nurse, it is safer to not to rely on that information, says Beth Kanik, a defense medical malpractice attorney in Atlanta.
“If it later goes into litigation, the argument then becomes that it looks like you didn’t do your job,” says Ms. Kanik. “Instead, try to ask questions in a way that would elicit responses that may be a little different than what the nurse got, so that it’s clear you asked the questions and didn’t just simply rely upon someone else’s information.”
5. Separate typing from listening
While EHR may be an excellent tool for data collection and safety checking, it’s not a stand-in for doctor-patient interaction. As technology practices push medicine toward more and more efficiency, Mr. Boeder says it’s most often listening over all else that makes the difference in the quality of care. And good listening requires full attention.
“A real concern for physicians is the number of visits they’re expected to accomplish in a set amount of time,” says Mr. Boeder. “Often this translates into a doctor talking to a patient while typing notes or while reading a note from the last time the patient was in.”
Taking the time to pause after entering data and briefly reviewing your understanding of what your patient has told you can be invaluable and may save you – and your patient – problems later.
“In so many cases, it comes down to people not being heard,” says Mr. Boeder. “So listen to what your patients are saying.”
A version of this article first appeared on Medscape.com.
Going into solo practice? An expert shares tips
SAN DIEGO – When the Boston-based cosmetic dermatology practice that employed Catherine M. DiGiorgio, MD, MS, was sold to a private equity firm a few years ago, she found herself at a crossroads: Stay and work for a large corporation, or open a solo practice?
She opted to start her own practice in Boston, “because I didn’t want to work for a large corporation, and I want to provide the best care for my patients in a more intimate manner,” Dr. DiGiorgio, a board-certified laser and cosmetic dermatologist, said at the annual Masters of Aesthetics Symposium.
The decision also tested her mettle. “I spoke to several colleagues and friends, and I was terrified,” she said. “I was like: ‘I don’t even know where to start.’ ”
On the heels of opening a new office in a matter of weeks, she offered the following tips and questions to consider when launching a solo dermatology practice:
Select a location. “That’s your first decision,” she said. “Where in the city are you going to open? Are you going to a new city, or are you moving back home? Don’t be afraid to start from scratch, and don’t be afraid to start a [solo] practice if you already have a patient base.”
Will you lease or purchase your space? After she secured a bank loan, Dr. DiGiorgio chose to lease the space for her new practice, “because you can kind of see where things go, get all the kinks out and figure out how to build things in a space that you don’t own. Then, when you’re ready and you have grown, you can invest more into your practice.”
Will you accept insurance? She built her practice around the direct specialty care model, which emphasizes the patient-physician relationship and removes third-party payors. “It’s not a concierge practice, but it’s a transparent, reasonable fee schedule for medical dermatology,” she explained. “I’ve done 100% cosmetics for about 5 years now, [but] I do medical dermatology for a fee. On my website I have a full price list on how much a full skin check is, [and] how much biopsies are. It’s completely transparent. Patients can submit to their insurance for reimbursement, but we don’t guarantee that they’re going to be reimbursed.”
Where will your patients come from? Will you advertise? Do you have physicians in the area who will refer to you if you’re a board-certified dermatologist? She emphasized the importance of “learning how to present yourself” on a website dedicated to your own practice. “Instagram, Facebook, and social media are great, but you don’t own those pages,” noted Dr. DiGiorgio, who served as the program cochair of the 2023 annual meeting of the American Society for Laser Medicine and Surgery and was recently elected to serve on the board of directors for the American Society for Dermatology Surgery. “You don’t own one of those pictures that are posted on your social media page. They can disappear in a second. If that happens, how are people going to find you?”
Are you going to hire more physicians in the future? That will influence the size of the new office and the floor plan.
Lawyer up. Hiring a health care attorney can “help you navigate transitioning from whatever position you’re in to opening up your own practice, as well as setting up the regulatory paperwork necessary for your new practice. You’ll also need a real estate attorney to help once you have selected a place, to help you navigate through that process,” she said, such as figuring out if the elevator in the building meets the Americans With Disabilities Act (ADA) requirements.
Create a mission statement. That way, “you know why you’re doing this, and it stays with you as you’re getting through the hard roadblocks.”
Find an architect, contractor, or designer. “If you’re building out a space from scratch, you’re going to need an architect,” she said. “Along with that architect will come a full-on contracting firm. I ended up hiring everyone individually, because I’m trying to spend as little money as possible.” She also hired a designer to help select furnishings and create the office atmosphere.
Secure a building permit ASAP. “It’s almost better to have the city permit before you sign the lease, because the permits can take a year, and you don’t want to pay rent on an empty space for a year if you don’t have a permit or if there are other hoops to go through,” Dr. DiGiorgio said.
Find an agent to help you set up medical malpractice insurance, liability insurance, and worker’s compensation insurance. “Make sure you read all the paperwork, because it can be very intricate,” she said.
Find an accountant. That person can help set up a bookkeeping process.
What equipment and devices will you need? That depends largely on the patient population a physician serves. Dr. DiGiorgio noted that eligible small businesses may take a tax credit of up to $5,000 per year for accommodations made to comply with the ADA. “That’s a nice feature, so that you can purchase ADA compliant items like a larger exam chair and custom reception areas.”
Dr. DiGiorgio reported having no relevant disclosures.
SAN DIEGO – When the Boston-based cosmetic dermatology practice that employed Catherine M. DiGiorgio, MD, MS, was sold to a private equity firm a few years ago, she found herself at a crossroads: Stay and work for a large corporation, or open a solo practice?
She opted to start her own practice in Boston, “because I didn’t want to work for a large corporation, and I want to provide the best care for my patients in a more intimate manner,” Dr. DiGiorgio, a board-certified laser and cosmetic dermatologist, said at the annual Masters of Aesthetics Symposium.
The decision also tested her mettle. “I spoke to several colleagues and friends, and I was terrified,” she said. “I was like: ‘I don’t even know where to start.’ ”
On the heels of opening a new office in a matter of weeks, she offered the following tips and questions to consider when launching a solo dermatology practice:
Select a location. “That’s your first decision,” she said. “Where in the city are you going to open? Are you going to a new city, or are you moving back home? Don’t be afraid to start from scratch, and don’t be afraid to start a [solo] practice if you already have a patient base.”
Will you lease or purchase your space? After she secured a bank loan, Dr. DiGiorgio chose to lease the space for her new practice, “because you can kind of see where things go, get all the kinks out and figure out how to build things in a space that you don’t own. Then, when you’re ready and you have grown, you can invest more into your practice.”
Will you accept insurance? She built her practice around the direct specialty care model, which emphasizes the patient-physician relationship and removes third-party payors. “It’s not a concierge practice, but it’s a transparent, reasonable fee schedule for medical dermatology,” she explained. “I’ve done 100% cosmetics for about 5 years now, [but] I do medical dermatology for a fee. On my website I have a full price list on how much a full skin check is, [and] how much biopsies are. It’s completely transparent. Patients can submit to their insurance for reimbursement, but we don’t guarantee that they’re going to be reimbursed.”
Where will your patients come from? Will you advertise? Do you have physicians in the area who will refer to you if you’re a board-certified dermatologist? She emphasized the importance of “learning how to present yourself” on a website dedicated to your own practice. “Instagram, Facebook, and social media are great, but you don’t own those pages,” noted Dr. DiGiorgio, who served as the program cochair of the 2023 annual meeting of the American Society for Laser Medicine and Surgery and was recently elected to serve on the board of directors for the American Society for Dermatology Surgery. “You don’t own one of those pictures that are posted on your social media page. They can disappear in a second. If that happens, how are people going to find you?”
Are you going to hire more physicians in the future? That will influence the size of the new office and the floor plan.
Lawyer up. Hiring a health care attorney can “help you navigate transitioning from whatever position you’re in to opening up your own practice, as well as setting up the regulatory paperwork necessary for your new practice. You’ll also need a real estate attorney to help once you have selected a place, to help you navigate through that process,” she said, such as figuring out if the elevator in the building meets the Americans With Disabilities Act (ADA) requirements.
Create a mission statement. That way, “you know why you’re doing this, and it stays with you as you’re getting through the hard roadblocks.”
Find an architect, contractor, or designer. “If you’re building out a space from scratch, you’re going to need an architect,” she said. “Along with that architect will come a full-on contracting firm. I ended up hiring everyone individually, because I’m trying to spend as little money as possible.” She also hired a designer to help select furnishings and create the office atmosphere.
Secure a building permit ASAP. “It’s almost better to have the city permit before you sign the lease, because the permits can take a year, and you don’t want to pay rent on an empty space for a year if you don’t have a permit or if there are other hoops to go through,” Dr. DiGiorgio said.
Find an agent to help you set up medical malpractice insurance, liability insurance, and worker’s compensation insurance. “Make sure you read all the paperwork, because it can be very intricate,” she said.
Find an accountant. That person can help set up a bookkeeping process.
What equipment and devices will you need? That depends largely on the patient population a physician serves. Dr. DiGiorgio noted that eligible small businesses may take a tax credit of up to $5,000 per year for accommodations made to comply with the ADA. “That’s a nice feature, so that you can purchase ADA compliant items like a larger exam chair and custom reception areas.”
Dr. DiGiorgio reported having no relevant disclosures.
SAN DIEGO – When the Boston-based cosmetic dermatology practice that employed Catherine M. DiGiorgio, MD, MS, was sold to a private equity firm a few years ago, she found herself at a crossroads: Stay and work for a large corporation, or open a solo practice?
She opted to start her own practice in Boston, “because I didn’t want to work for a large corporation, and I want to provide the best care for my patients in a more intimate manner,” Dr. DiGiorgio, a board-certified laser and cosmetic dermatologist, said at the annual Masters of Aesthetics Symposium.
The decision also tested her mettle. “I spoke to several colleagues and friends, and I was terrified,” she said. “I was like: ‘I don’t even know where to start.’ ”
On the heels of opening a new office in a matter of weeks, she offered the following tips and questions to consider when launching a solo dermatology practice:
Select a location. “That’s your first decision,” she said. “Where in the city are you going to open? Are you going to a new city, or are you moving back home? Don’t be afraid to start from scratch, and don’t be afraid to start a [solo] practice if you already have a patient base.”
Will you lease or purchase your space? After she secured a bank loan, Dr. DiGiorgio chose to lease the space for her new practice, “because you can kind of see where things go, get all the kinks out and figure out how to build things in a space that you don’t own. Then, when you’re ready and you have grown, you can invest more into your practice.”
Will you accept insurance? She built her practice around the direct specialty care model, which emphasizes the patient-physician relationship and removes third-party payors. “It’s not a concierge practice, but it’s a transparent, reasonable fee schedule for medical dermatology,” she explained. “I’ve done 100% cosmetics for about 5 years now, [but] I do medical dermatology for a fee. On my website I have a full price list on how much a full skin check is, [and] how much biopsies are. It’s completely transparent. Patients can submit to their insurance for reimbursement, but we don’t guarantee that they’re going to be reimbursed.”
Where will your patients come from? Will you advertise? Do you have physicians in the area who will refer to you if you’re a board-certified dermatologist? She emphasized the importance of “learning how to present yourself” on a website dedicated to your own practice. “Instagram, Facebook, and social media are great, but you don’t own those pages,” noted Dr. DiGiorgio, who served as the program cochair of the 2023 annual meeting of the American Society for Laser Medicine and Surgery and was recently elected to serve on the board of directors for the American Society for Dermatology Surgery. “You don’t own one of those pictures that are posted on your social media page. They can disappear in a second. If that happens, how are people going to find you?”
Are you going to hire more physicians in the future? That will influence the size of the new office and the floor plan.
Lawyer up. Hiring a health care attorney can “help you navigate transitioning from whatever position you’re in to opening up your own practice, as well as setting up the regulatory paperwork necessary for your new practice. You’ll also need a real estate attorney to help once you have selected a place, to help you navigate through that process,” she said, such as figuring out if the elevator in the building meets the Americans With Disabilities Act (ADA) requirements.
Create a mission statement. That way, “you know why you’re doing this, and it stays with you as you’re getting through the hard roadblocks.”
Find an architect, contractor, or designer. “If you’re building out a space from scratch, you’re going to need an architect,” she said. “Along with that architect will come a full-on contracting firm. I ended up hiring everyone individually, because I’m trying to spend as little money as possible.” She also hired a designer to help select furnishings and create the office atmosphere.
Secure a building permit ASAP. “It’s almost better to have the city permit before you sign the lease, because the permits can take a year, and you don’t want to pay rent on an empty space for a year if you don’t have a permit or if there are other hoops to go through,” Dr. DiGiorgio said.
Find an agent to help you set up medical malpractice insurance, liability insurance, and worker’s compensation insurance. “Make sure you read all the paperwork, because it can be very intricate,” she said.
Find an accountant. That person can help set up a bookkeeping process.
What equipment and devices will you need? That depends largely on the patient population a physician serves. Dr. DiGiorgio noted that eligible small businesses may take a tax credit of up to $5,000 per year for accommodations made to comply with the ADA. “That’s a nice feature, so that you can purchase ADA compliant items like a larger exam chair and custom reception areas.”
Dr. DiGiorgio reported having no relevant disclosures.
AT MOAS 2023
ACR: Rheumatologists help reduce ED, hospitalization costs
Rheumatology care can save health systems more than $2,700 per patient per year, according to a new report from the American College of Rheumatology.
In a white paper and corresponding position statement, the organization outlined how rheumatology care delivers financial benefits for health systems.
The work also highlighted prior research on the positive outcomes associated with rheumatology care, including a decline in hip and knee replacements for patients with rheumatoid arthritis after the introduction of biologics, while the total number of hip and knee replacements for patients with osteoarthritis increased, as well as lower 30-day readmission rates among patients with systemic lupus erythematosus with access to a rheumatology clinic post discharge.
“Many rheumatologists can attest to the value they bring to the care team at a health care system,” said Christina Downey, MD, an assistant professor of medicine at Loma Linda (Calif.) University, in a press release. She is the lead author of the white paper and chair of the ACR’s Government Affairs Committee. “Our goal with the paper and position statement is to emphasize what that value looks like from a preventive and financial perspective. A rheumatologist on the care team benefits patients, practices, and the economy.”
The analysis used adjusted claims insurance data to compare markets with a high vs. low supply of rheumatologists. A high supply was defined as at least 1.5 rheumatologists per 100,000 population, whereas a low supply was less than this amount. On average, markets with a high supply of rheumatologists had lower emergency department (ED) and hospitalization costs per patient per year.
Added together, high-supply rheumatology markets save on average $2,762 in ED visit and hospitalization costs per patient per year.
Dr. Downey and colleagues also tallied the direct and downstream billings associated with rheumatologists, including office visits, consultations, lab testing, and radiology services. The average revenue generated per rheumatologist was $3.5 million per year.
“Emphasizing the impact rheumatologists have on the entire medical community is more important than ever, especially as we contend with an impending rheumatology workforce shortage coupled with an expected increase in patient demand for rheumatologic care,” Dr. Downey said. “This paper supports our recruitment and sustainability efforts for the specialty by spotlighting the significant contributions we make every day and every year to patient outcomes, hospitals, and other health care practices.”
A version of this article first appeared on Medscape.com.
Rheumatology care can save health systems more than $2,700 per patient per year, according to a new report from the American College of Rheumatology.
In a white paper and corresponding position statement, the organization outlined how rheumatology care delivers financial benefits for health systems.
The work also highlighted prior research on the positive outcomes associated with rheumatology care, including a decline in hip and knee replacements for patients with rheumatoid arthritis after the introduction of biologics, while the total number of hip and knee replacements for patients with osteoarthritis increased, as well as lower 30-day readmission rates among patients with systemic lupus erythematosus with access to a rheumatology clinic post discharge.
“Many rheumatologists can attest to the value they bring to the care team at a health care system,” said Christina Downey, MD, an assistant professor of medicine at Loma Linda (Calif.) University, in a press release. She is the lead author of the white paper and chair of the ACR’s Government Affairs Committee. “Our goal with the paper and position statement is to emphasize what that value looks like from a preventive and financial perspective. A rheumatologist on the care team benefits patients, practices, and the economy.”
The analysis used adjusted claims insurance data to compare markets with a high vs. low supply of rheumatologists. A high supply was defined as at least 1.5 rheumatologists per 100,000 population, whereas a low supply was less than this amount. On average, markets with a high supply of rheumatologists had lower emergency department (ED) and hospitalization costs per patient per year.
Added together, high-supply rheumatology markets save on average $2,762 in ED visit and hospitalization costs per patient per year.
Dr. Downey and colleagues also tallied the direct and downstream billings associated with rheumatologists, including office visits, consultations, lab testing, and radiology services. The average revenue generated per rheumatologist was $3.5 million per year.
“Emphasizing the impact rheumatologists have on the entire medical community is more important than ever, especially as we contend with an impending rheumatology workforce shortage coupled with an expected increase in patient demand for rheumatologic care,” Dr. Downey said. “This paper supports our recruitment and sustainability efforts for the specialty by spotlighting the significant contributions we make every day and every year to patient outcomes, hospitals, and other health care practices.”
A version of this article first appeared on Medscape.com.
Rheumatology care can save health systems more than $2,700 per patient per year, according to a new report from the American College of Rheumatology.
In a white paper and corresponding position statement, the organization outlined how rheumatology care delivers financial benefits for health systems.
The work also highlighted prior research on the positive outcomes associated with rheumatology care, including a decline in hip and knee replacements for patients with rheumatoid arthritis after the introduction of biologics, while the total number of hip and knee replacements for patients with osteoarthritis increased, as well as lower 30-day readmission rates among patients with systemic lupus erythematosus with access to a rheumatology clinic post discharge.
“Many rheumatologists can attest to the value they bring to the care team at a health care system,” said Christina Downey, MD, an assistant professor of medicine at Loma Linda (Calif.) University, in a press release. She is the lead author of the white paper and chair of the ACR’s Government Affairs Committee. “Our goal with the paper and position statement is to emphasize what that value looks like from a preventive and financial perspective. A rheumatologist on the care team benefits patients, practices, and the economy.”
The analysis used adjusted claims insurance data to compare markets with a high vs. low supply of rheumatologists. A high supply was defined as at least 1.5 rheumatologists per 100,000 population, whereas a low supply was less than this amount. On average, markets with a high supply of rheumatologists had lower emergency department (ED) and hospitalization costs per patient per year.
Added together, high-supply rheumatology markets save on average $2,762 in ED visit and hospitalization costs per patient per year.
Dr. Downey and colleagues also tallied the direct and downstream billings associated with rheumatologists, including office visits, consultations, lab testing, and radiology services. The average revenue generated per rheumatologist was $3.5 million per year.
“Emphasizing the impact rheumatologists have on the entire medical community is more important than ever, especially as we contend with an impending rheumatology workforce shortage coupled with an expected increase in patient demand for rheumatologic care,” Dr. Downey said. “This paper supports our recruitment and sustainability efforts for the specialty by spotlighting the significant contributions we make every day and every year to patient outcomes, hospitals, and other health care practices.”
A version of this article first appeared on Medscape.com.
NPs, PAs, and physicians hope to join doctors’ union in rare alliance
Advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) have long been at odds with doctor groups over scope of practice issues. But in a rare alliance, in late September. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD.
The Allina health care providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.
Although doctors and APPs have said that they generally work well together, the relationship has been strained in recent years as APPs argue for greater scope of practice. Meanwhile, physician groups, such as the American Medical Association, believe that APPs need more oversight.
An Allina union organizer, Britta V. Kasmarik, CNP, acknowledges the tension between physicians and APPs. But she said in an interview that the union effort helped bond this group of health care providers. “We share common goals of providing high-quality care for patients in a safe way, and we see the same things day in and day out with our patients.”
Matt Hoffman, MD, a primary care physician at Allina, told this news organization that APPs in his specialty perform the same job as doctors “and the working conditions are really identical. In our view, that means we should be unionizing together.”
The decision to hold a union vote follows similar action by nearly 150 Allina Mercy Hospital physicians in March. Allina Health appealed the vote.
In response to a New York Times investigation, the Minnesota Attorney General’s office began reviewing reports of aggressive billing practices and denied care at Allina Health.
The Allina Health system, which reports $4 billion in annual revenue, cut off nonemergency services to patients, including children, if their medical debt exceeded $4,500, according to the New York Times article. For Allina’s physicians and APPs, that meant leaving patients’ illnesses untreated.
Less than a week after the attorney general announced its investigation, the health system ended this practice.
In a prepared statement to this news organization, Allina Health said that its providers are “critical members of our teams. … We deeply value and share their commitment to providing high-quality care to our patients.”
The health system said it planned to make operational improvements, implement new communication tools, and provide additional well-being resources and enhanced employee benefits “to improve the provider experience.” In addition, it hoped to continue to “foster a culture of collaboration with all our employees.”
Having a union will allow health care providers to advocate for their patients and give health care providers more decision-making power instead of corporate leaders maintaining full authority, Ms. Kasmarik told this news organization.
Union organizers are also concerned with changes to the daily practice of medicine. “We don’t want to be spending our time doing paperwork and calling insurance companies and filling out forms,” said Dr. Hoffman. “We want to be in the exam room with a patient.”
The Allina providers organized after multiple requests to corporate managers failed to address their concerns. Their demands include increased staffing and help with nonclinical work so that clinicians can spend more time with their patients.
“What I’m really excited about is that we will be able to work with the other unionized groups to make change ... by being involved in health care policy at a state or national level,” Dr. Hoffman said. For example, that involvement might include challenging insurance company decisions.
Doctors Council bills itself as the largest union for attending physicians in the country, with 3,500 members, according to Joe Crane, national organizing director.
Despite an increase in union efforts since the pandemic, health care workers – particularly doctors – have been slow to join unions. Mr. Crane estimated that only about 3% of U.S. physicians are currently union members. He cited union campaigns in Massachusetts, New York, and Washington, DC. For comparison, a minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape’s APRN compensation report last year.
Dr. Hoffman is confident the Allina health care providers will have enough votes to win the election to join the union. “We should have done this years ago.”
A version of this article appeared on Medscape.com.
Advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) have long been at odds with doctor groups over scope of practice issues. But in a rare alliance, in late September. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD.
The Allina health care providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.
Although doctors and APPs have said that they generally work well together, the relationship has been strained in recent years as APPs argue for greater scope of practice. Meanwhile, physician groups, such as the American Medical Association, believe that APPs need more oversight.
An Allina union organizer, Britta V. Kasmarik, CNP, acknowledges the tension between physicians and APPs. But she said in an interview that the union effort helped bond this group of health care providers. “We share common goals of providing high-quality care for patients in a safe way, and we see the same things day in and day out with our patients.”
Matt Hoffman, MD, a primary care physician at Allina, told this news organization that APPs in his specialty perform the same job as doctors “and the working conditions are really identical. In our view, that means we should be unionizing together.”
The decision to hold a union vote follows similar action by nearly 150 Allina Mercy Hospital physicians in March. Allina Health appealed the vote.
In response to a New York Times investigation, the Minnesota Attorney General’s office began reviewing reports of aggressive billing practices and denied care at Allina Health.
The Allina Health system, which reports $4 billion in annual revenue, cut off nonemergency services to patients, including children, if their medical debt exceeded $4,500, according to the New York Times article. For Allina’s physicians and APPs, that meant leaving patients’ illnesses untreated.
Less than a week after the attorney general announced its investigation, the health system ended this practice.
In a prepared statement to this news organization, Allina Health said that its providers are “critical members of our teams. … We deeply value and share their commitment to providing high-quality care to our patients.”
The health system said it planned to make operational improvements, implement new communication tools, and provide additional well-being resources and enhanced employee benefits “to improve the provider experience.” In addition, it hoped to continue to “foster a culture of collaboration with all our employees.”
Having a union will allow health care providers to advocate for their patients and give health care providers more decision-making power instead of corporate leaders maintaining full authority, Ms. Kasmarik told this news organization.
Union organizers are also concerned with changes to the daily practice of medicine. “We don’t want to be spending our time doing paperwork and calling insurance companies and filling out forms,” said Dr. Hoffman. “We want to be in the exam room with a patient.”
The Allina providers organized after multiple requests to corporate managers failed to address their concerns. Their demands include increased staffing and help with nonclinical work so that clinicians can spend more time with their patients.
“What I’m really excited about is that we will be able to work with the other unionized groups to make change ... by being involved in health care policy at a state or national level,” Dr. Hoffman said. For example, that involvement might include challenging insurance company decisions.
Doctors Council bills itself as the largest union for attending physicians in the country, with 3,500 members, according to Joe Crane, national organizing director.
Despite an increase in union efforts since the pandemic, health care workers – particularly doctors – have been slow to join unions. Mr. Crane estimated that only about 3% of U.S. physicians are currently union members. He cited union campaigns in Massachusetts, New York, and Washington, DC. For comparison, a minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape’s APRN compensation report last year.
Dr. Hoffman is confident the Allina health care providers will have enough votes to win the election to join the union. “We should have done this years ago.”
A version of this article appeared on Medscape.com.
Advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) have long been at odds with doctor groups over scope of practice issues. But in a rare alliance, in late September. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD.
The Allina health care providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.
Although doctors and APPs have said that they generally work well together, the relationship has been strained in recent years as APPs argue for greater scope of practice. Meanwhile, physician groups, such as the American Medical Association, believe that APPs need more oversight.
An Allina union organizer, Britta V. Kasmarik, CNP, acknowledges the tension between physicians and APPs. But she said in an interview that the union effort helped bond this group of health care providers. “We share common goals of providing high-quality care for patients in a safe way, and we see the same things day in and day out with our patients.”
Matt Hoffman, MD, a primary care physician at Allina, told this news organization that APPs in his specialty perform the same job as doctors “and the working conditions are really identical. In our view, that means we should be unionizing together.”
The decision to hold a union vote follows similar action by nearly 150 Allina Mercy Hospital physicians in March. Allina Health appealed the vote.
In response to a New York Times investigation, the Minnesota Attorney General’s office began reviewing reports of aggressive billing practices and denied care at Allina Health.
The Allina Health system, which reports $4 billion in annual revenue, cut off nonemergency services to patients, including children, if their medical debt exceeded $4,500, according to the New York Times article. For Allina’s physicians and APPs, that meant leaving patients’ illnesses untreated.
Less than a week after the attorney general announced its investigation, the health system ended this practice.
In a prepared statement to this news organization, Allina Health said that its providers are “critical members of our teams. … We deeply value and share their commitment to providing high-quality care to our patients.”
The health system said it planned to make operational improvements, implement new communication tools, and provide additional well-being resources and enhanced employee benefits “to improve the provider experience.” In addition, it hoped to continue to “foster a culture of collaboration with all our employees.”
Having a union will allow health care providers to advocate for their patients and give health care providers more decision-making power instead of corporate leaders maintaining full authority, Ms. Kasmarik told this news organization.
Union organizers are also concerned with changes to the daily practice of medicine. “We don’t want to be spending our time doing paperwork and calling insurance companies and filling out forms,” said Dr. Hoffman. “We want to be in the exam room with a patient.”
The Allina providers organized after multiple requests to corporate managers failed to address their concerns. Their demands include increased staffing and help with nonclinical work so that clinicians can spend more time with their patients.
“What I’m really excited about is that we will be able to work with the other unionized groups to make change ... by being involved in health care policy at a state or national level,” Dr. Hoffman said. For example, that involvement might include challenging insurance company decisions.
Doctors Council bills itself as the largest union for attending physicians in the country, with 3,500 members, according to Joe Crane, national organizing director.
Despite an increase in union efforts since the pandemic, health care workers – particularly doctors – have been slow to join unions. Mr. Crane estimated that only about 3% of U.S. physicians are currently union members. He cited union campaigns in Massachusetts, New York, and Washington, DC. For comparison, a minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape’s APRN compensation report last year.
Dr. Hoffman is confident the Allina health care providers will have enough votes to win the election to join the union. “We should have done this years ago.”
A version of this article appeared on Medscape.com.
Making one key connection may increase HPV vax uptake
The understanding that human papillomavirus (HPV) causes oropharyngeal squamous cell carcinoma (OPSCC) has been linked with increased likelihood of adults having been vaccinated for HPV, new research indicates.
In a study published online in JAMA Otolaryngology–Head and Neck Surgery, most of the 288 adults surveyed with validated questions were not aware that HPV causes OPSCC and had not been told of the relationship by their health care provider.
Researchers found that when participants knew about the relationship between HPV infection and OPSCC they were more than three times as likely to be vaccinated (odds ratio, 3.7; 95% confidence interval, 1.8-7.6) as those without the knowledge.
The survey was paired with a novel point-of-care adult vaccination program within an otolaryngology clinic.
“Targeted education aimed at unvaccinated adults establishing the relationship between HPV infection and OPSCC, paired with point-of-care vaccination, may be an innovative strategy for increasing HPV vaccination rates in adults,” write the authors, led by Jacob C. Bloom, MD, with the department of otolaryngology–head and neck surgery at Boston Medical Center.
Current HPV vaccination recommendations include three parts:
- Routine vaccination at age 11 or 12 years
- Catch-up vaccination at ages 13-26 years if not adequately vaccinated
- Shared clinical decision-making in adults aged 27-45 years if the vaccine series has not been completed.
Despite proven efficacy and safety of the HPV vaccine, vaccination rates are low for adults. Although 75% of adolescents aged 13-17 years have initiated the HPV vaccine, recent studies show only 16% of U.S. men aged 18-21 years have received at least 1 dose of the HPV vaccine, the authors write.
Christiana Zhang, MD, with the division of internal medicine at Johns Hopkins University in Baltimore, who was not part of the study, said she was not surprised by the lack of knowledge about the HPV-OPSCC link.
Patients are often counseled on the relationship between HPV and genital warts or anogenital cancers like cervical cancer, she says, but there is less patient education surrounding the relationship between HPV and oropharyngeal cancers.
She says she does counsel patients on the link with OPSCC, but not all providers do and provider knowledge in general surrounding HPV is low.
“Research has shown that knowledge and confidence among health care providers surrounding HPV vaccination is generally low, and this corresponds with a low vaccination recommendation rate,” she says.
She adds, “Patient education on HPV infection and its relationship with OPSCC, paired with point-of-care vaccination for qualifying patients, is a great approach.”
But the education needs to go beyond patients, she says.
“Given the important role that health care providers play in vaccine uptake, I think further efforts are needed to educate providers on HPV vaccination as well,” she says.
The study included patients aged 18-45 years who sought routine outpatient care at the otolaryngology clinic at Boston Medical Center from Sept. 1, 2020, to May 19, 2021.
Limitations of this study include studying a population from a single otolaryngology clinic in an urban, academic medical center. The population was more racially and ethnically diverse than the U.S. population with 60.3% identifying as racial and ethnic minorities. Gender and educational levels were also not reflective of U.S. demographics as half (50.8%) of the participants had a college degree or higher and 58.3% were women.
Dr. Bloom reports grants from the American Head and Neck Cancer Society during the conduct of the study. Coauthor Dr. Faden reports personal fees from Merck, Neotic, Focus, BMS, Chrystalis Biomedical Advisors, and Guidepoint; receiving nonfinancial support from BostonGene and Predicine; and receiving grants from Calico outside the submitted work. Dr. Zhang reports no relevant financial relationships.
The understanding that human papillomavirus (HPV) causes oropharyngeal squamous cell carcinoma (OPSCC) has been linked with increased likelihood of adults having been vaccinated for HPV, new research indicates.
In a study published online in JAMA Otolaryngology–Head and Neck Surgery, most of the 288 adults surveyed with validated questions were not aware that HPV causes OPSCC and had not been told of the relationship by their health care provider.
Researchers found that when participants knew about the relationship between HPV infection and OPSCC they were more than three times as likely to be vaccinated (odds ratio, 3.7; 95% confidence interval, 1.8-7.6) as those without the knowledge.
The survey was paired with a novel point-of-care adult vaccination program within an otolaryngology clinic.
“Targeted education aimed at unvaccinated adults establishing the relationship between HPV infection and OPSCC, paired with point-of-care vaccination, may be an innovative strategy for increasing HPV vaccination rates in adults,” write the authors, led by Jacob C. Bloom, MD, with the department of otolaryngology–head and neck surgery at Boston Medical Center.
Current HPV vaccination recommendations include three parts:
- Routine vaccination at age 11 or 12 years
- Catch-up vaccination at ages 13-26 years if not adequately vaccinated
- Shared clinical decision-making in adults aged 27-45 years if the vaccine series has not been completed.
Despite proven efficacy and safety of the HPV vaccine, vaccination rates are low for adults. Although 75% of adolescents aged 13-17 years have initiated the HPV vaccine, recent studies show only 16% of U.S. men aged 18-21 years have received at least 1 dose of the HPV vaccine, the authors write.
Christiana Zhang, MD, with the division of internal medicine at Johns Hopkins University in Baltimore, who was not part of the study, said she was not surprised by the lack of knowledge about the HPV-OPSCC link.
Patients are often counseled on the relationship between HPV and genital warts or anogenital cancers like cervical cancer, she says, but there is less patient education surrounding the relationship between HPV and oropharyngeal cancers.
She says she does counsel patients on the link with OPSCC, but not all providers do and provider knowledge in general surrounding HPV is low.
“Research has shown that knowledge and confidence among health care providers surrounding HPV vaccination is generally low, and this corresponds with a low vaccination recommendation rate,” she says.
She adds, “Patient education on HPV infection and its relationship with OPSCC, paired with point-of-care vaccination for qualifying patients, is a great approach.”
But the education needs to go beyond patients, she says.
“Given the important role that health care providers play in vaccine uptake, I think further efforts are needed to educate providers on HPV vaccination as well,” she says.
The study included patients aged 18-45 years who sought routine outpatient care at the otolaryngology clinic at Boston Medical Center from Sept. 1, 2020, to May 19, 2021.
Limitations of this study include studying a population from a single otolaryngology clinic in an urban, academic medical center. The population was more racially and ethnically diverse than the U.S. population with 60.3% identifying as racial and ethnic minorities. Gender and educational levels were also not reflective of U.S. demographics as half (50.8%) of the participants had a college degree or higher and 58.3% were women.
Dr. Bloom reports grants from the American Head and Neck Cancer Society during the conduct of the study. Coauthor Dr. Faden reports personal fees from Merck, Neotic, Focus, BMS, Chrystalis Biomedical Advisors, and Guidepoint; receiving nonfinancial support from BostonGene and Predicine; and receiving grants from Calico outside the submitted work. Dr. Zhang reports no relevant financial relationships.
The understanding that human papillomavirus (HPV) causes oropharyngeal squamous cell carcinoma (OPSCC) has been linked with increased likelihood of adults having been vaccinated for HPV, new research indicates.
In a study published online in JAMA Otolaryngology–Head and Neck Surgery, most of the 288 adults surveyed with validated questions were not aware that HPV causes OPSCC and had not been told of the relationship by their health care provider.
Researchers found that when participants knew about the relationship between HPV infection and OPSCC they were more than three times as likely to be vaccinated (odds ratio, 3.7; 95% confidence interval, 1.8-7.6) as those without the knowledge.
The survey was paired with a novel point-of-care adult vaccination program within an otolaryngology clinic.
“Targeted education aimed at unvaccinated adults establishing the relationship between HPV infection and OPSCC, paired with point-of-care vaccination, may be an innovative strategy for increasing HPV vaccination rates in adults,” write the authors, led by Jacob C. Bloom, MD, with the department of otolaryngology–head and neck surgery at Boston Medical Center.
Current HPV vaccination recommendations include three parts:
- Routine vaccination at age 11 or 12 years
- Catch-up vaccination at ages 13-26 years if not adequately vaccinated
- Shared clinical decision-making in adults aged 27-45 years if the vaccine series has not been completed.
Despite proven efficacy and safety of the HPV vaccine, vaccination rates are low for adults. Although 75% of adolescents aged 13-17 years have initiated the HPV vaccine, recent studies show only 16% of U.S. men aged 18-21 years have received at least 1 dose of the HPV vaccine, the authors write.
Christiana Zhang, MD, with the division of internal medicine at Johns Hopkins University in Baltimore, who was not part of the study, said she was not surprised by the lack of knowledge about the HPV-OPSCC link.
Patients are often counseled on the relationship between HPV and genital warts or anogenital cancers like cervical cancer, she says, but there is less patient education surrounding the relationship between HPV and oropharyngeal cancers.
She says she does counsel patients on the link with OPSCC, but not all providers do and provider knowledge in general surrounding HPV is low.
“Research has shown that knowledge and confidence among health care providers surrounding HPV vaccination is generally low, and this corresponds with a low vaccination recommendation rate,” she says.
She adds, “Patient education on HPV infection and its relationship with OPSCC, paired with point-of-care vaccination for qualifying patients, is a great approach.”
But the education needs to go beyond patients, she says.
“Given the important role that health care providers play in vaccine uptake, I think further efforts are needed to educate providers on HPV vaccination as well,” she says.
The study included patients aged 18-45 years who sought routine outpatient care at the otolaryngology clinic at Boston Medical Center from Sept. 1, 2020, to May 19, 2021.
Limitations of this study include studying a population from a single otolaryngology clinic in an urban, academic medical center. The population was more racially and ethnically diverse than the U.S. population with 60.3% identifying as racial and ethnic minorities. Gender and educational levels were also not reflective of U.S. demographics as half (50.8%) of the participants had a college degree or higher and 58.3% were women.
Dr. Bloom reports grants from the American Head and Neck Cancer Society during the conduct of the study. Coauthor Dr. Faden reports personal fees from Merck, Neotic, Focus, BMS, Chrystalis Biomedical Advisors, and Guidepoint; receiving nonfinancial support from BostonGene and Predicine; and receiving grants from Calico outside the submitted work. Dr. Zhang reports no relevant financial relationships.
FROM JAMA OTOLARYNGOLOGY–HEAD AND NECK SURGERY
Industry funding falls for rheumatology research
Industry-sponsored research funding has fallen by more than 20% from 2014 to 2022, according to a new analysis.
“Despite the growing partnerships and networks between rheumatologists, the public sector, and the health care industry to optimize research funding allocations, the declining trend in industry-sponsored research payments is a concerning sign for all rheumatologists,” writes study author Anju Murayama, an undergraduate medical student at the Tohoku University School of Medicine in Sendai City, Japan. The data suggest that “more and more rheumatologists are facing difficulties in obtaining research funding from the health care industry.”
Dr. Murayama used the Open Payments Database, which contains records of payments made by drug and pharmaceutical companies to health care providers. The analysis included research payments provided directly to rheumatologists (direct-research payments) and payments given to clinicians or health care organizations related to research whose principal investigator was a rheumatologist (associated-research payments). These associated payments included costs for study enrollment and screening, safety monitoring committees, research publication, and more.
The research was published August 15 in The Journal of Rheumatology .
In 2014, the total direct payments to rheumatologists from industry were $1.4 million. These payments jumped to nearly $4.6 million in 2016 but have declined since. In 2022, there were $976,481 in total payments, a 31% drop from 9 years before.
This decline comes after an observed drop in research funding from the public sector. From 2014 to 2017, public-sector research funding to members of the American College of Rheumatology fell by 7.5%. Timothy Niewold, MD, a rheumatologist and vice chair for research in the department of medicine at Hospital for Special Surgery, New York, said that he and colleagues have felt the funding squeeze from both public and industry sectors. “The budgets for trials have seemed tight,” he told this news organization. With the overhead and cost of doing a trial at an academic institution like HSS, “sometimes you can’t make the budget work,” and researchers must pass on industry-funded trials.
The analysis also found a larger discrepancy between average and median associated-research payments. Of the $1.4 billion in associated-research payments combined over the 9-year period, the median payments per physician ($173,022) were much smaller than the mean payments ($989,753), which indicates that “only a very small number of rheumatologists received substantial amounts of research funding from the industry,” Dr. Murayama wrote in an email to this news organization. “This finding might support statements published by Scher and Schett in Nature Review Rheumatology suggesting that many industry-initiated clinical trials are conducted and authored by a small number of influential rheumatologists, often referred to as key opinion leaders.”
The analysis also found that of all associated payments, less than 3% ($39.2 million) went to funding preclinical research, which is “more disappointing than surprising,” Dr. Niewold said. Though clinical trials are expensive and require larger amounts of investment, industry partnerships at preclinical phases of research are important for devising novel solutions for these complex rheumatic diseases, he noted. “The clinical trials are one piece,” he added, “but you need the whole [research] continuum.”
Dr. Niewold reports receiving research grants from EMD Serono and Zenas Biopharma and consulting for Thermo Fisher Scientific, Progentec Diagnostics, Roivant Sciences, Ventus, S3 Connected Health, AstraZeneca, and Inova. Dr. Murayama reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Industry-sponsored research funding has fallen by more than 20% from 2014 to 2022, according to a new analysis.
“Despite the growing partnerships and networks between rheumatologists, the public sector, and the health care industry to optimize research funding allocations, the declining trend in industry-sponsored research payments is a concerning sign for all rheumatologists,” writes study author Anju Murayama, an undergraduate medical student at the Tohoku University School of Medicine in Sendai City, Japan. The data suggest that “more and more rheumatologists are facing difficulties in obtaining research funding from the health care industry.”
Dr. Murayama used the Open Payments Database, which contains records of payments made by drug and pharmaceutical companies to health care providers. The analysis included research payments provided directly to rheumatologists (direct-research payments) and payments given to clinicians or health care organizations related to research whose principal investigator was a rheumatologist (associated-research payments). These associated payments included costs for study enrollment and screening, safety monitoring committees, research publication, and more.
The research was published August 15 in The Journal of Rheumatology .
In 2014, the total direct payments to rheumatologists from industry were $1.4 million. These payments jumped to nearly $4.6 million in 2016 but have declined since. In 2022, there were $976,481 in total payments, a 31% drop from 9 years before.
This decline comes after an observed drop in research funding from the public sector. From 2014 to 2017, public-sector research funding to members of the American College of Rheumatology fell by 7.5%. Timothy Niewold, MD, a rheumatologist and vice chair for research in the department of medicine at Hospital for Special Surgery, New York, said that he and colleagues have felt the funding squeeze from both public and industry sectors. “The budgets for trials have seemed tight,” he told this news organization. With the overhead and cost of doing a trial at an academic institution like HSS, “sometimes you can’t make the budget work,” and researchers must pass on industry-funded trials.
The analysis also found a larger discrepancy between average and median associated-research payments. Of the $1.4 billion in associated-research payments combined over the 9-year period, the median payments per physician ($173,022) were much smaller than the mean payments ($989,753), which indicates that “only a very small number of rheumatologists received substantial amounts of research funding from the industry,” Dr. Murayama wrote in an email to this news organization. “This finding might support statements published by Scher and Schett in Nature Review Rheumatology suggesting that many industry-initiated clinical trials are conducted and authored by a small number of influential rheumatologists, often referred to as key opinion leaders.”
The analysis also found that of all associated payments, less than 3% ($39.2 million) went to funding preclinical research, which is “more disappointing than surprising,” Dr. Niewold said. Though clinical trials are expensive and require larger amounts of investment, industry partnerships at preclinical phases of research are important for devising novel solutions for these complex rheumatic diseases, he noted. “The clinical trials are one piece,” he added, “but you need the whole [research] continuum.”
Dr. Niewold reports receiving research grants from EMD Serono and Zenas Biopharma and consulting for Thermo Fisher Scientific, Progentec Diagnostics, Roivant Sciences, Ventus, S3 Connected Health, AstraZeneca, and Inova. Dr. Murayama reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Industry-sponsored research funding has fallen by more than 20% from 2014 to 2022, according to a new analysis.
“Despite the growing partnerships and networks between rheumatologists, the public sector, and the health care industry to optimize research funding allocations, the declining trend in industry-sponsored research payments is a concerning sign for all rheumatologists,” writes study author Anju Murayama, an undergraduate medical student at the Tohoku University School of Medicine in Sendai City, Japan. The data suggest that “more and more rheumatologists are facing difficulties in obtaining research funding from the health care industry.”
Dr. Murayama used the Open Payments Database, which contains records of payments made by drug and pharmaceutical companies to health care providers. The analysis included research payments provided directly to rheumatologists (direct-research payments) and payments given to clinicians or health care organizations related to research whose principal investigator was a rheumatologist (associated-research payments). These associated payments included costs for study enrollment and screening, safety monitoring committees, research publication, and more.
The research was published August 15 in The Journal of Rheumatology .
In 2014, the total direct payments to rheumatologists from industry were $1.4 million. These payments jumped to nearly $4.6 million in 2016 but have declined since. In 2022, there were $976,481 in total payments, a 31% drop from 9 years before.
This decline comes after an observed drop in research funding from the public sector. From 2014 to 2017, public-sector research funding to members of the American College of Rheumatology fell by 7.5%. Timothy Niewold, MD, a rheumatologist and vice chair for research in the department of medicine at Hospital for Special Surgery, New York, said that he and colleagues have felt the funding squeeze from both public and industry sectors. “The budgets for trials have seemed tight,” he told this news organization. With the overhead and cost of doing a trial at an academic institution like HSS, “sometimes you can’t make the budget work,” and researchers must pass on industry-funded trials.
The analysis also found a larger discrepancy between average and median associated-research payments. Of the $1.4 billion in associated-research payments combined over the 9-year period, the median payments per physician ($173,022) were much smaller than the mean payments ($989,753), which indicates that “only a very small number of rheumatologists received substantial amounts of research funding from the industry,” Dr. Murayama wrote in an email to this news organization. “This finding might support statements published by Scher and Schett in Nature Review Rheumatology suggesting that many industry-initiated clinical trials are conducted and authored by a small number of influential rheumatologists, often referred to as key opinion leaders.”
The analysis also found that of all associated payments, less than 3% ($39.2 million) went to funding preclinical research, which is “more disappointing than surprising,” Dr. Niewold said. Though clinical trials are expensive and require larger amounts of investment, industry partnerships at preclinical phases of research are important for devising novel solutions for these complex rheumatic diseases, he noted. “The clinical trials are one piece,” he added, “but you need the whole [research] continuum.”
Dr. Niewold reports receiving research grants from EMD Serono and Zenas Biopharma and consulting for Thermo Fisher Scientific, Progentec Diagnostics, Roivant Sciences, Ventus, S3 Connected Health, AstraZeneca, and Inova. Dr. Murayama reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF RHEUMATOLOGY