Business of Medicine

This past June, during the search for the Titan submersible, and since then, we’ve had a not-entirely-unexpected development: Sick humor.

There was a lot of it. The Subway owner who got reprimanded for putting “Our subs don’t implode” on his sign was minor league compared with other things circulating on the Internet. One example that was sent to me showed the late Stockton Rush, OceanGate’s co-owner, as the new spokesman for Cap’n Crunch.

Of course, this is nothing new. People have made jokes about awful situations since to the dawn of civilization.

Why do we do this?

Humor is a remarkably human trait. There’s evidence other mammals have it, but not to the extent we do. We’ve created a multitude of forms that vary between cultures. But there isn’t a civilization or culture on Earth that doesn’t have humor.

Why we developed it I’ll leave to others, though I assume a key part is that it strengthens bonds between people, helping them stick together in the groups that keep society moving forward.

Sick humor is part of this, though having grown up watching Monty Python and reading National Lampoon magazine I’m certainly guilty of enjoying it. To this day I think “Eating Raoul” is one of the greatest comedies ever.

It’s also pretty common in medicine. I’ve been involved in plenty of hospital situations that were quite unfunny, yet there are always jokes about it flying as we work.

I assume it’s a defense mechanism. Helping us cope with a bad situation as we do our best to deal with it. Using humor to put a block between the obvious realization that someday this could happen to us. To help psychologically shield us from something tragic.

Years ago I was trying to describe the plot of “Eating Raoul” and said “if you read about this sort of crime spree in a newspaper you’d be horrified. But the way it’s handled in the movie it’s hysterical.” Perhaps that’s as close to understanding sick humor as I’ll ever get. It makes the unfunny funny.

Perhaps the better phrase is the more generic “it’s human nature.” We seek relief in humor, even (maybe especially) in bad situations of our own and others.

Whether or not it’s funny depends on the person. There were plenty of people horrified by the Subway sign, enough that the owner had to change it. But there were also those who admitted they found it tasteless, but still got a laugh out of it. I’m sure the families of those lost on the Titan were justifiably upset, but the closer you get to a personal tragedy the more serious it is.

There’s a fine line, as National Lampoon put it, between funny and sick. But it’s also part of who we are.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past June, during the search for the Titan submersible, and since then, we’ve had a not-entirely-unexpected development: Sick humor.

There was a lot of it. The Subway owner who got reprimanded for putting “Our subs don’t implode” on his sign was minor league compared with other things circulating on the Internet. One example that was sent to me showed the late Stockton Rush, OceanGate’s co-owner, as the new spokesman for Cap’n Crunch.

Of course, this is nothing new. People have made jokes about awful situations since to the dawn of civilization.

Why do we do this?

Humor is a remarkably human trait. There’s evidence other mammals have it, but not to the extent we do. We’ve created a multitude of forms that vary between cultures. But there isn’t a civilization or culture on Earth that doesn’t have humor.

Why we developed it I’ll leave to others, though I assume a key part is that it strengthens bonds between people, helping them stick together in the groups that keep society moving forward.

Sick humor is part of this, though having grown up watching Monty Python and reading National Lampoon magazine I’m certainly guilty of enjoying it. To this day I think “Eating Raoul” is one of the greatest comedies ever.

It’s also pretty common in medicine. I’ve been involved in plenty of hospital situations that were quite unfunny, yet there are always jokes about it flying as we work.

I assume it’s a defense mechanism. Helping us cope with a bad situation as we do our best to deal with it. Using humor to put a block between the obvious realization that someday this could happen to us. To help psychologically shield us from something tragic.

Years ago I was trying to describe the plot of “Eating Raoul” and said “if you read about this sort of crime spree in a newspaper you’d be horrified. But the way it’s handled in the movie it’s hysterical.” Perhaps that’s as close to understanding sick humor as I’ll ever get. It makes the unfunny funny.

Perhaps the better phrase is the more generic “it’s human nature.” We seek relief in humor, even (maybe especially) in bad situations of our own and others.

Whether or not it’s funny depends on the person. There were plenty of people horrified by the Subway sign, enough that the owner had to change it. But there were also those who admitted they found it tasteless, but still got a laugh out of it. I’m sure the families of those lost on the Titan were justifiably upset, but the closer you get to a personal tragedy the more serious it is.

There’s a fine line, as National Lampoon put it, between funny and sick. But it’s also part of who we are.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past June, during the search for the Titan submersible, and since then, we’ve had a not-entirely-unexpected development: Sick humor.

There was a lot of it. The Subway owner who got reprimanded for putting “Our subs don’t implode” on his sign was minor league compared with other things circulating on the Internet. One example that was sent to me showed the late Stockton Rush, OceanGate’s co-owner, as the new spokesman for Cap’n Crunch.

Of course, this is nothing new. People have made jokes about awful situations since to the dawn of civilization.

Why do we do this?

Humor is a remarkably human trait. There’s evidence other mammals have it, but not to the extent we do. We’ve created a multitude of forms that vary between cultures. But there isn’t a civilization or culture on Earth that doesn’t have humor.

Why we developed it I’ll leave to others, though I assume a key part is that it strengthens bonds between people, helping them stick together in the groups that keep society moving forward.

Sick humor is part of this, though having grown up watching Monty Python and reading National Lampoon magazine I’m certainly guilty of enjoying it. To this day I think “Eating Raoul” is one of the greatest comedies ever.

It’s also pretty common in medicine. I’ve been involved in plenty of hospital situations that were quite unfunny, yet there are always jokes about it flying as we work.

I assume it’s a defense mechanism. Helping us cope with a bad situation as we do our best to deal with it. Using humor to put a block between the obvious realization that someday this could happen to us. To help psychologically shield us from something tragic.

Years ago I was trying to describe the plot of “Eating Raoul” and said “if you read about this sort of crime spree in a newspaper you’d be horrified. But the way it’s handled in the movie it’s hysterical.” Perhaps that’s as close to understanding sick humor as I’ll ever get. It makes the unfunny funny.

Perhaps the better phrase is the more generic “it’s human nature.” We seek relief in humor, even (maybe especially) in bad situations of our own and others.

Whether or not it’s funny depends on the person. There were plenty of people horrified by the Subway sign, enough that the owner had to change it. But there were also those who admitted they found it tasteless, but still got a laugh out of it. I’m sure the families of those lost on the Titan were justifiably upset, but the closer you get to a personal tragedy the more serious it is.

There’s a fine line, as National Lampoon put it, between funny and sick. But it’s also part of who we are.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Despite my best efforts to cultivate acquaintances across a broader age group, my social circle still has the somewhat musty odor of septuagenarians. We try to talk about things beyond the weather and grandchildren but pain scenarios surface with unfortunate frequency. Arthritic joints ache, body parts wear out or become diseased and have to be removed or replaced. That stuff can hurt.

There are two pain-related themes that seem to crop up more frequently than you might expect. The first is the unfortunate side effects of opioid medication – most often gastric distress and vomiting, then of course there’s constipation. They seem so common that a good many of my acquaintances just plain refuse to take opioids when they have been prescribed postoperatively because of their vivid memories of the consequences or horror stories friends have told.

The second theme is the general annoyance with the damn “Please rate your pain from one to ten” request issued by every well-intentioned nurse. Do you mean the pain I am having right now, this second, or last night, or the average over the last day and a half? Or should I be comparing it with when I gave birth 70 years ago, or when I stubbed my toe getting out of the shower last week? And then what are you going to do with my guesstimated number?

It may surprise some of you that 40 years ago there wasn’t a pain scale fetish. But a few observant health care professionals realized that many of our patients were suffering because we weren’t adequately managing their pain. In postoperative situations this was slowing recovery and effecting outcomes. Like good pseudoscientists, they realized that we should first quantify the pain and the notion that no pain should go unrated came into being. Nor should pain go untreated, which is too frequently interpreted as meaning unmedicated.

Pain is a complex, multifaceted phenomenon. Distilling a person’s pain experience to a single number doesn’t make sense, nor does reflexly reaching for a prescription.

For example a systematic review of 61 studies of juvenile idiopathic arthritis (JIA) published in the journal Pediatric Rheumatology found that there was positive relationship between pain and a child’s belief that pain causes harm, disability, and lack of control. Not surprisingly, stress was also associated with pain intensity.

It is a long paper and touches on numerous other associations of varying degrees of strength between parental, social, and other external factors. But, in general, they were not as consistent as those related to a child’s beliefs.

Before, or at least at the same time, we treat a patient’s pain, we should learn more about that patient – his or her concerns, beliefs, and stressors. You and I may have exactly the same hernia operation, but if you have a better understanding of why you are going to feel uncomfortable after the surgery, and understand that not every pain is the result of a complication, I suspect you are more likely to complain of less pain.

The recent JIA study doesn’t claim to suggest therapeutic methods. However, one wonders what the result would be if we could somehow alter a patient’s belief system so that he or she no longer sees pain as always harmful, nor does the patient see himself or herself as powerless to do anything about the pain. To do this experiment we must follow up our robotic request to “rate your pain” with a dialogue in which we learn more about the patient. Which means probing believes, fears, and stressors.

You can tell me this exercise would be unrealistic and time consuming. But I bet in the long run it will save time. Even if it doesn’t it is the better way to manage pain.

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].

Despite my best efforts to cultivate acquaintances across a broader age group, my social circle still has the somewhat musty odor of septuagenarians. We try to talk about things beyond the weather and grandchildren but pain scenarios surface with unfortunate frequency. Arthritic joints ache, body parts wear out or become diseased and have to be removed or replaced. That stuff can hurt.

There are two pain-related themes that seem to crop up more frequently than you might expect. The first is the unfortunate side effects of opioid medication – most often gastric distress and vomiting, then of course there’s constipation. They seem so common that a good many of my acquaintances just plain refuse to take opioids when they have been prescribed postoperatively because of their vivid memories of the consequences or horror stories friends have told.

The second theme is the general annoyance with the damn “Please rate your pain from one to ten” request issued by every well-intentioned nurse. Do you mean the pain I am having right now, this second, or last night, or the average over the last day and a half? Or should I be comparing it with when I gave birth 70 years ago, or when I stubbed my toe getting out of the shower last week? And then what are you going to do with my guesstimated number?

It may surprise some of you that 40 years ago there wasn’t a pain scale fetish. But a few observant health care professionals realized that many of our patients were suffering because we weren’t adequately managing their pain. In postoperative situations this was slowing recovery and effecting outcomes. Like good pseudoscientists, they realized that we should first quantify the pain and the notion that no pain should go unrated came into being. Nor should pain go untreated, which is too frequently interpreted as meaning unmedicated.

Pain is a complex, multifaceted phenomenon. Distilling a person’s pain experience to a single number doesn’t make sense, nor does reflexly reaching for a prescription.

For example a systematic review of 61 studies of juvenile idiopathic arthritis (JIA) published in the journal Pediatric Rheumatology found that there was positive relationship between pain and a child’s belief that pain causes harm, disability, and lack of control. Not surprisingly, stress was also associated with pain intensity.

It is a long paper and touches on numerous other associations of varying degrees of strength between parental, social, and other external factors. But, in general, they were not as consistent as those related to a child’s beliefs.

Before, or at least at the same time, we treat a patient’s pain, we should learn more about that patient – his or her concerns, beliefs, and stressors. You and I may have exactly the same hernia operation, but if you have a better understanding of why you are going to feel uncomfortable after the surgery, and understand that not every pain is the result of a complication, I suspect you are more likely to complain of less pain.

The recent JIA study doesn’t claim to suggest therapeutic methods. However, one wonders what the result would be if we could somehow alter a patient’s belief system so that he or she no longer sees pain as always harmful, nor does the patient see himself or herself as powerless to do anything about the pain. To do this experiment we must follow up our robotic request to “rate your pain” with a dialogue in which we learn more about the patient. Which means probing believes, fears, and stressors.

You can tell me this exercise would be unrealistic and time consuming. But I bet in the long run it will save time. Even if it doesn’t it is the better way to manage pain.

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].

Despite my best efforts to cultivate acquaintances across a broader age group, my social circle still has the somewhat musty odor of septuagenarians. We try to talk about things beyond the weather and grandchildren but pain scenarios surface with unfortunate frequency. Arthritic joints ache, body parts wear out or become diseased and have to be removed or replaced. That stuff can hurt.

There are two pain-related themes that seem to crop up more frequently than you might expect. The first is the unfortunate side effects of opioid medication – most often gastric distress and vomiting, then of course there’s constipation. They seem so common that a good many of my acquaintances just plain refuse to take opioids when they have been prescribed postoperatively because of their vivid memories of the consequences or horror stories friends have told.

The second theme is the general annoyance with the damn “Please rate your pain from one to ten” request issued by every well-intentioned nurse. Do you mean the pain I am having right now, this second, or last night, or the average over the last day and a half? Or should I be comparing it with when I gave birth 70 years ago, or when I stubbed my toe getting out of the shower last week? And then what are you going to do with my guesstimated number?

It may surprise some of you that 40 years ago there wasn’t a pain scale fetish. But a few observant health care professionals realized that many of our patients were suffering because we weren’t adequately managing their pain. In postoperative situations this was slowing recovery and effecting outcomes. Like good pseudoscientists, they realized that we should first quantify the pain and the notion that no pain should go unrated came into being. Nor should pain go untreated, which is too frequently interpreted as meaning unmedicated.

Pain is a complex, multifaceted phenomenon. Distilling a person’s pain experience to a single number doesn’t make sense, nor does reflexly reaching for a prescription.

For example a systematic review of 61 studies of juvenile idiopathic arthritis (JIA) published in the journal Pediatric Rheumatology found that there was positive relationship between pain and a child’s belief that pain causes harm, disability, and lack of control. Not surprisingly, stress was also associated with pain intensity.

It is a long paper and touches on numerous other associations of varying degrees of strength between parental, social, and other external factors. But, in general, they were not as consistent as those related to a child’s beliefs.

Before, or at least at the same time, we treat a patient’s pain, we should learn more about that patient – his or her concerns, beliefs, and stressors. You and I may have exactly the same hernia operation, but if you have a better understanding of why you are going to feel uncomfortable after the surgery, and understand that not every pain is the result of a complication, I suspect you are more likely to complain of less pain.

The recent JIA study doesn’t claim to suggest therapeutic methods. However, one wonders what the result would be if we could somehow alter a patient’s belief system so that he or she no longer sees pain as always harmful, nor does the patient see himself or herself as powerless to do anything about the pain. To do this experiment we must follow up our robotic request to “rate your pain” with a dialogue in which we learn more about the patient. Which means probing believes, fears, and stressors.

You can tell me this exercise would be unrealistic and time consuming. But I bet in the long run it will save time. Even if it doesn’t it is the better way to manage pain.

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].

The former owner of a South Florida nursing school at the heart of a federal investigation into a multistate fraud scheme awarding at least 7,600 fake diplomas will have to serve nearly 2 years and repay millions.

U.S. District Judge Rodney Smith of the Southern District of Florida in Fort Lauderdale recently sentenced Johanah Napoleon, former president of the Palm Beach School of Nursing, to 21 months in prison, according to the Miami Herald . The judge also ordered Ms. Napoleon to pay about $3.5 million. She already paid $2.6 million of it, the Herald reports.

The sentence is “indicative of the seriousness of this crime,” shared Willa Fuller, BSN, RN, executive director of the Florida Nurses Association. “Hopefully, this decision will deter potential perpetrators in the future,” Ms. Fuller said in an email.

Ms. Napoleon was charged in 2021 along with two owners of nursing schools in Maryland and Virginia who worked with her. All pled guilty to selling fake degrees for $6,000-$18,000. The Florida Board of Nursing had previously shut down the Palm Beach school in 2017 as a result of its students’ low passing rate on the national licensing exam.

A tip related to the Maryland case led to federal charges in January against 25 owners, operators, and employees of the Palm Beach School of Nursing and two other Florida nursing schools for selling thousands of fake nursing degrees. Those who were charged operated in Delaware, New York, New Jersey, Texas, and Florida.

Five of those 25 defendants will be sentenced on July 27 in a federal district court in Fort Lauderdale after pleading guilty in May to wire fraud conspiracy, according to the U.S. Attorney for the Southern District of Florida. They each face up to 20 years in federal prison.

Purchasers of the fake associate or bachelor’s degrees received transcripts showing that they completed coursework. Some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses and licensed practice nurses/vocational nurses in hospitals, nursing homes, and Veterans Affairs medical centers around the country, according to The New York Times.

Ms. Napoleon’s attorney, Joel DeFabio, said in an interview that he requested a lower sentence than the 4 years recommended in sentencing guidelines because Ms. Napoleon pled guilty quickly and cooperated with the federal investigation.

Mr. DeFabio said that Ms. Napoleon will appear as the government’s witness in a trial in November against Gail Russ, who is one defendant, along with 13 others in the case involving the Palm Beach School of Nursing.

Meanwhile, state nursing boards have been trying to locate nurses who received the fake degrees. In March, the New York nursing board told 903 nurses to either surrender their licenses or prove they had the appropriate education. The board estimated that another 2,300 licensees from the Florida schools had pending applications.

Some nurses who received fake diplomas are pushing back. Attorneys for nurses in Georgia and Pennsylvania claim that their clients were either victims or in some cases, have legitimate credentials.

“The quality of nursing education as well as protection of applicants from these harmful schemes is essential to maintaining the strict standards of the nursing profession,” Ms. Fuller said.

A version of this article appeared on Medscape.com.

The former owner of a South Florida nursing school at the heart of a federal investigation into a multistate fraud scheme awarding at least 7,600 fake diplomas will have to serve nearly 2 years and repay millions.

U.S. District Judge Rodney Smith of the Southern District of Florida in Fort Lauderdale recently sentenced Johanah Napoleon, former president of the Palm Beach School of Nursing, to 21 months in prison, according to the Miami Herald . The judge also ordered Ms. Napoleon to pay about $3.5 million. She already paid $2.6 million of it, the Herald reports.

The sentence is “indicative of the seriousness of this crime,” shared Willa Fuller, BSN, RN, executive director of the Florida Nurses Association. “Hopefully, this decision will deter potential perpetrators in the future,” Ms. Fuller said in an email.

Ms. Napoleon was charged in 2021 along with two owners of nursing schools in Maryland and Virginia who worked with her. All pled guilty to selling fake degrees for $6,000-$18,000. The Florida Board of Nursing had previously shut down the Palm Beach school in 2017 as a result of its students’ low passing rate on the national licensing exam.

A tip related to the Maryland case led to federal charges in January against 25 owners, operators, and employees of the Palm Beach School of Nursing and two other Florida nursing schools for selling thousands of fake nursing degrees. Those who were charged operated in Delaware, New York, New Jersey, Texas, and Florida.

Five of those 25 defendants will be sentenced on July 27 in a federal district court in Fort Lauderdale after pleading guilty in May to wire fraud conspiracy, according to the U.S. Attorney for the Southern District of Florida. They each face up to 20 years in federal prison.

Purchasers of the fake associate or bachelor’s degrees received transcripts showing that they completed coursework. Some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses and licensed practice nurses/vocational nurses in hospitals, nursing homes, and Veterans Affairs medical centers around the country, according to The New York Times.

Ms. Napoleon’s attorney, Joel DeFabio, said in an interview that he requested a lower sentence than the 4 years recommended in sentencing guidelines because Ms. Napoleon pled guilty quickly and cooperated with the federal investigation.

Mr. DeFabio said that Ms. Napoleon will appear as the government’s witness in a trial in November against Gail Russ, who is one defendant, along with 13 others in the case involving the Palm Beach School of Nursing.

Meanwhile, state nursing boards have been trying to locate nurses who received the fake degrees. In March, the New York nursing board told 903 nurses to either surrender their licenses or prove they had the appropriate education. The board estimated that another 2,300 licensees from the Florida schools had pending applications.

Some nurses who received fake diplomas are pushing back. Attorneys for nurses in Georgia and Pennsylvania claim that their clients were either victims or in some cases, have legitimate credentials.

“The quality of nursing education as well as protection of applicants from these harmful schemes is essential to maintaining the strict standards of the nursing profession,” Ms. Fuller said.

A version of this article appeared on Medscape.com.

The former owner of a South Florida nursing school at the heart of a federal investigation into a multistate fraud scheme awarding at least 7,600 fake diplomas will have to serve nearly 2 years and repay millions.

U.S. District Judge Rodney Smith of the Southern District of Florida in Fort Lauderdale recently sentenced Johanah Napoleon, former president of the Palm Beach School of Nursing, to 21 months in prison, according to the Miami Herald . The judge also ordered Ms. Napoleon to pay about $3.5 million. She already paid $2.6 million of it, the Herald reports.

The sentence is “indicative of the seriousness of this crime,” shared Willa Fuller, BSN, RN, executive director of the Florida Nurses Association. “Hopefully, this decision will deter potential perpetrators in the future,” Ms. Fuller said in an email.

Ms. Napoleon was charged in 2021 along with two owners of nursing schools in Maryland and Virginia who worked with her. All pled guilty to selling fake degrees for $6,000-$18,000. The Florida Board of Nursing had previously shut down the Palm Beach school in 2017 as a result of its students’ low passing rate on the national licensing exam.

A tip related to the Maryland case led to federal charges in January against 25 owners, operators, and employees of the Palm Beach School of Nursing and two other Florida nursing schools for selling thousands of fake nursing degrees. Those who were charged operated in Delaware, New York, New Jersey, Texas, and Florida.

Five of those 25 defendants will be sentenced on July 27 in a federal district court in Fort Lauderdale after pleading guilty in May to wire fraud conspiracy, according to the U.S. Attorney for the Southern District of Florida. They each face up to 20 years in federal prison.

Purchasers of the fake associate or bachelor’s degrees received transcripts showing that they completed coursework. Some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses and licensed practice nurses/vocational nurses in hospitals, nursing homes, and Veterans Affairs medical centers around the country, according to The New York Times.

Ms. Napoleon’s attorney, Joel DeFabio, said in an interview that he requested a lower sentence than the 4 years recommended in sentencing guidelines because Ms. Napoleon pled guilty quickly and cooperated with the federal investigation.

Mr. DeFabio said that Ms. Napoleon will appear as the government’s witness in a trial in November against Gail Russ, who is one defendant, along with 13 others in the case involving the Palm Beach School of Nursing.

Meanwhile, state nursing boards have been trying to locate nurses who received the fake degrees. In March, the New York nursing board told 903 nurses to either surrender their licenses or prove they had the appropriate education. The board estimated that another 2,300 licensees from the Florida schools had pending applications.

Some nurses who received fake diplomas are pushing back. Attorneys for nurses in Georgia and Pennsylvania claim that their clients were either victims or in some cases, have legitimate credentials.

“The quality of nursing education as well as protection of applicants from these harmful schemes is essential to maintaining the strict standards of the nursing profession,” Ms. Fuller said.

A version of this article appeared on Medscape.com.

“What if VA health care goes away?” That was the headline of a July 6, 2023, Disabled American Veterans news article to its members. The question was not hypothetical. Legislation currently under consideration by the US Congress may make it a strong probability.  

The US Senate Committee on Veterans’ Affairs recently held a hearing to discuss 2 bills that would drastically reshape the provision of private health care services through the Veterans Community Care Program. An unprecedented coalition of 10 organizations—made up of US Department of Veterans Affairs (VA) nurses, psychologists, physicians, dentists, social workers, optometrists, physician assistants, and nurse anesthetists, as well as the American Psychological Association, the Military and Veterans Committee of the Group for the Advancement of Psychiatry and the Veterans Healthcare Policy Institute—came together in a unified statement for the record highlighting how these proposed policies would open a Pandora’s box that could forever eliminate the Veterans Health Administration as we know it.

Over the past decade—and especially following the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act—there has been a surge of veterans gaining eligibility for private care if a VA medical facility is too far away, does not offer the needed care, or the wait time for an appointment is too long.

Courtesy: Rasmussen P, Farmer CM. The Promise and Challenges of VA Community Care: Veterans' Issues in Focus. Rand Health Q. 2023;10(3):9.

Testifying before the House Committee on Veterans’ Affairs hearing last year, Miguel LaPuz, MD, MBA, then the acting Deputy Under Secretary for Health at the VA, warned that “VA is rapidly approaching a point where half of all care available in both settings is provided through community care.” He cautioned that leaders were bracing for “the potential of a spiral effect.”

Care that is rendered to veterans in the community must, of course, be paid for. When those community costs began to soar at the start of the Community Care program, Congress bailed out the VA by allocating extra funds. Today, escalating costs are drawn from local VA facility budgets. And to guarantee that private sector care is paid for out of VA facility funds, legislators are introducing language, such as in the Veterans Healthcare Freedom Act, which states: “No additional funds are authorized to be appropriated to carry out this section and the amendments made by this section, and this section and the amendments made by this section shall be carried out using amounts otherwise made available to the Veterans Health Administration.” The anticipated vicious cycle looms. More money pouring into the private sector will force reductions and closures of in-house VA staff, programs, clinics, and units. This will cause more veterans to obtain care in the community, which will further drain more money out of VA facilities, leading to more reductions, etc. Rural areas will likely be hit hardest.

The VA is nearing the tipping point of this ever-descending spiral. And that is even without expanding eligibility further. Three provisions in this pair of bills could, on their own, drastically open eligibility, eliminate remaining guardrails, and push VA over the edge:

(1) Veteran preference. Tucked into the HEALTH Act, introduced by the ranking Republican Member, Jerry Moran of Kansas, is language which would require VA to consider a “veteran’s preference” for obtaining their health care in the private sector.

This stipulation violates the intent of the VA MISSION Act. When MISSION passed, there was bipartisan agreement that the Community Care Program was meant, in numerous Senators’ words, to “supplement, not supplant” VA health care. A veteran would be offered the option of receiving health care outside of the VA under 6 narrowly defined criteria. Legislators understood that veterans would get the option to choose whether to receive care in the private sector or the VA if, and only if, they qualified under the 6 eligibility rules. As a well-researched document coauthored by Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars stated, “veteran convenience or preference” should never be used as a sole reason for referral.

Explicitly adding preference for the first time will create the expectation among veterans and lawmakers of a new allowance. Were this to pass, every veteran—100%—would become eligible for referral to the private sector, kicking off an unstoppable drainage of VA budget resources and threatening its viability. Hopefully, the Senate will follow the lead of the US House Committee on Veterans’ Affairs which, last week, amended its its own community care bill by deleting “veteran preference” as a possible new eligibility criterion.

(2) Self-referral. Also being deliberated is the Making Community Care Work for Veterans Act, a draft bill authored by the US Senate Committee on Veterans’ Affairs Democratic Chairman Senator Jon Tester of Montana. It calls for allowing self-initiated routine vaccinations and routine vision/hearing services in the community.

On the surface, Tester’s bill focuses on only a tiny sliver of care. But once self-referral is permitted for a few services, private sector interests will, in no time, push the door wide open and add more services to which veterans can self-refer. Testimony at the hearing confirmed that prediction, as the Veterans of Foreign Wars and America’s Warrior Partnership stated there is no reason to limit self-referral to only eye and ear examinations. They proposed that self-referral should extend to mental health, substance use, podiatry, prosthetics, laboratory services, dermatology, and diabetes. Like other perilous sections of these bills, seemingly innocuous language would quickly lead to crippling impacts.

(3) Pilot program for unfettered access. The HEALTH Act contains another provision in which veterans would be allowed to receive outpatient care without VA referral, authorization, or oversight. An enrolled veteran could simply make an appointment with any Veterans Community Care Program mental health or substance use disorder practitioner for care for any duration of time. VA’s only role would be to pay the invoice. Private sector interests have been pressing this sort of program for years, and when it was carefully studied by the Commission on Care, the costs were estimated to be 2 to 3 times the existing system. That would come from a combination of fee-for-service reimbursement structures that abet overuse and higher overall costs in the private sector. Were the pilot to pass, VA would convert from its primary role as a system providing health care to an insurance carrier.

In the name of offering more choices, health care options will diminish for veterans. When VA programs/clinics/facilities close, veterans—especially service-connected veterans who depend on VA for high-quality care tailored to their needs—will lose those choices. Moreover, a downsized VA will make it nearly impossible for the VA to continue to research veterans’ complex health conditions, educate future health care professionals (the majority of whom train at VA medical centers), or fulfill its Fourth Mission as a backup for national emergencies.

Senate Committee members indicated their intention to combine provisions of the Moran and Tester bills into a larger compromise bill in September. Legislators must slow down, contemplate the ramifications, and set aside the stipulations noted above. What is needed first is a projection of future veterans’ authorizations for community care (under current eligibility criteria and also with these new allowances), how much money would that pull out of VA facilities, and what is the tipping point of a doom cycle.

In the meantime, there are smart solutions to ensure veterans can access high-quality care, as Disabled American Veterans testified at the hearing: By “investing in VA's health care infrastructure and staffing… this is particularly true for veterans who live in rural and remote areas where VA is most likely to be a stable, long-term health care option for veterans.”

The VA administers the most successful health care system in the country. As a recent summary of research confirmed yet again, the quality of care delivered by the VA is as good as or better than the care veterans receive from VA-paid community care or the general public obtains through private care. There will always be a supplemental role for the community to play when VA cannot provide care in a timely or convenient manner. But community care must be fixed in ways that never starves VA facilities of essential funding. If there ever were a time to stand up for the sake of our veterans and the long-term viability of the VA, it is now.

“What if VA health care goes away?” That was the headline of a July 6, 2023, Disabled American Veterans news article to its members. The question was not hypothetical. Legislation currently under consideration by the US Congress may make it a strong probability.  

The US Senate Committee on Veterans’ Affairs recently held a hearing to discuss 2 bills that would drastically reshape the provision of private health care services through the Veterans Community Care Program. An unprecedented coalition of 10 organizations—made up of US Department of Veterans Affairs (VA) nurses, psychologists, physicians, dentists, social workers, optometrists, physician assistants, and nurse anesthetists, as well as the American Psychological Association, the Military and Veterans Committee of the Group for the Advancement of Psychiatry and the Veterans Healthcare Policy Institute—came together in a unified statement for the record highlighting how these proposed policies would open a Pandora’s box that could forever eliminate the Veterans Health Administration as we know it.

Over the past decade—and especially following the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act—there has been a surge of veterans gaining eligibility for private care if a VA medical facility is too far away, does not offer the needed care, or the wait time for an appointment is too long.

Courtesy: Rasmussen P, Farmer CM. The Promise and Challenges of VA Community Care: Veterans' Issues in Focus. Rand Health Q. 2023;10(3):9.

Testifying before the House Committee on Veterans’ Affairs hearing last year, Miguel LaPuz, MD, MBA, then the acting Deputy Under Secretary for Health at the VA, warned that “VA is rapidly approaching a point where half of all care available in both settings is provided through community care.” He cautioned that leaders were bracing for “the potential of a spiral effect.”

Care that is rendered to veterans in the community must, of course, be paid for. When those community costs began to soar at the start of the Community Care program, Congress bailed out the VA by allocating extra funds. Today, escalating costs are drawn from local VA facility budgets. And to guarantee that private sector care is paid for out of VA facility funds, legislators are introducing language, such as in the Veterans Healthcare Freedom Act, which states: “No additional funds are authorized to be appropriated to carry out this section and the amendments made by this section, and this section and the amendments made by this section shall be carried out using amounts otherwise made available to the Veterans Health Administration.” The anticipated vicious cycle looms. More money pouring into the private sector will force reductions and closures of in-house VA staff, programs, clinics, and units. This will cause more veterans to obtain care in the community, which will further drain more money out of VA facilities, leading to more reductions, etc. Rural areas will likely be hit hardest.

The VA is nearing the tipping point of this ever-descending spiral. And that is even without expanding eligibility further. Three provisions in this pair of bills could, on their own, drastically open eligibility, eliminate remaining guardrails, and push VA over the edge:

(1) Veteran preference. Tucked into the HEALTH Act, introduced by the ranking Republican Member, Jerry Moran of Kansas, is language which would require VA to consider a “veteran’s preference” for obtaining their health care in the private sector.

This stipulation violates the intent of the VA MISSION Act. When MISSION passed, there was bipartisan agreement that the Community Care Program was meant, in numerous Senators’ words, to “supplement, not supplant” VA health care. A veteran would be offered the option of receiving health care outside of the VA under 6 narrowly defined criteria. Legislators understood that veterans would get the option to choose whether to receive care in the private sector or the VA if, and only if, they qualified under the 6 eligibility rules. As a well-researched document coauthored by Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars stated, “veteran convenience or preference” should never be used as a sole reason for referral.

Explicitly adding preference for the first time will create the expectation among veterans and lawmakers of a new allowance. Were this to pass, every veteran—100%—would become eligible for referral to the private sector, kicking off an unstoppable drainage of VA budget resources and threatening its viability. Hopefully, the Senate will follow the lead of the US House Committee on Veterans’ Affairs which, last week, amended its its own community care bill by deleting “veteran preference” as a possible new eligibility criterion.

(2) Self-referral. Also being deliberated is the Making Community Care Work for Veterans Act, a draft bill authored by the US Senate Committee on Veterans’ Affairs Democratic Chairman Senator Jon Tester of Montana. It calls for allowing self-initiated routine vaccinations and routine vision/hearing services in the community.

On the surface, Tester’s bill focuses on only a tiny sliver of care. But once self-referral is permitted for a few services, private sector interests will, in no time, push the door wide open and add more services to which veterans can self-refer. Testimony at the hearing confirmed that prediction, as the Veterans of Foreign Wars and America’s Warrior Partnership stated there is no reason to limit self-referral to only eye and ear examinations. They proposed that self-referral should extend to mental health, substance use, podiatry, prosthetics, laboratory services, dermatology, and diabetes. Like other perilous sections of these bills, seemingly innocuous language would quickly lead to crippling impacts.

(3) Pilot program for unfettered access. The HEALTH Act contains another provision in which veterans would be allowed to receive outpatient care without VA referral, authorization, or oversight. An enrolled veteran could simply make an appointment with any Veterans Community Care Program mental health or substance use disorder practitioner for care for any duration of time. VA’s only role would be to pay the invoice. Private sector interests have been pressing this sort of program for years, and when it was carefully studied by the Commission on Care, the costs were estimated to be 2 to 3 times the existing system. That would come from a combination of fee-for-service reimbursement structures that abet overuse and higher overall costs in the private sector. Were the pilot to pass, VA would convert from its primary role as a system providing health care to an insurance carrier.

In the name of offering more choices, health care options will diminish for veterans. When VA programs/clinics/facilities close, veterans—especially service-connected veterans who depend on VA for high-quality care tailored to their needs—will lose those choices. Moreover, a downsized VA will make it nearly impossible for the VA to continue to research veterans’ complex health conditions, educate future health care professionals (the majority of whom train at VA medical centers), or fulfill its Fourth Mission as a backup for national emergencies.

Senate Committee members indicated their intention to combine provisions of the Moran and Tester bills into a larger compromise bill in September. Legislators must slow down, contemplate the ramifications, and set aside the stipulations noted above. What is needed first is a projection of future veterans’ authorizations for community care (under current eligibility criteria and also with these new allowances), how much money would that pull out of VA facilities, and what is the tipping point of a doom cycle.

In the meantime, there are smart solutions to ensure veterans can access high-quality care, as Disabled American Veterans testified at the hearing: By “investing in VA's health care infrastructure and staffing… this is particularly true for veterans who live in rural and remote areas where VA is most likely to be a stable, long-term health care option for veterans.”

The VA administers the most successful health care system in the country. As a recent summary of research confirmed yet again, the quality of care delivered by the VA is as good as or better than the care veterans receive from VA-paid community care or the general public obtains through private care. There will always be a supplemental role for the community to play when VA cannot provide care in a timely or convenient manner. But community care must be fixed in ways that never starves VA facilities of essential funding. If there ever were a time to stand up for the sake of our veterans and the long-term viability of the VA, it is now.

“What if VA health care goes away?” That was the headline of a July 6, 2023, Disabled American Veterans news article to its members. The question was not hypothetical. Legislation currently under consideration by the US Congress may make it a strong probability.  

The US Senate Committee on Veterans’ Affairs recently held a hearing to discuss 2 bills that would drastically reshape the provision of private health care services through the Veterans Community Care Program. An unprecedented coalition of 10 organizations—made up of US Department of Veterans Affairs (VA) nurses, psychologists, physicians, dentists, social workers, optometrists, physician assistants, and nurse anesthetists, as well as the American Psychological Association, the Military and Veterans Committee of the Group for the Advancement of Psychiatry and the Veterans Healthcare Policy Institute—came together in a unified statement for the record highlighting how these proposed policies would open a Pandora’s box that could forever eliminate the Veterans Health Administration as we know it.

Over the past decade—and especially following the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act—there has been a surge of veterans gaining eligibility for private care if a VA medical facility is too far away, does not offer the needed care, or the wait time for an appointment is too long.

Courtesy: Rasmussen P, Farmer CM. The Promise and Challenges of VA Community Care: Veterans' Issues in Focus. Rand Health Q. 2023;10(3):9.

Testifying before the House Committee on Veterans’ Affairs hearing last year, Miguel LaPuz, MD, MBA, then the acting Deputy Under Secretary for Health at the VA, warned that “VA is rapidly approaching a point where half of all care available in both settings is provided through community care.” He cautioned that leaders were bracing for “the potential of a spiral effect.”

Care that is rendered to veterans in the community must, of course, be paid for. When those community costs began to soar at the start of the Community Care program, Congress bailed out the VA by allocating extra funds. Today, escalating costs are drawn from local VA facility budgets. And to guarantee that private sector care is paid for out of VA facility funds, legislators are introducing language, such as in the Veterans Healthcare Freedom Act, which states: “No additional funds are authorized to be appropriated to carry out this section and the amendments made by this section, and this section and the amendments made by this section shall be carried out using amounts otherwise made available to the Veterans Health Administration.” The anticipated vicious cycle looms. More money pouring into the private sector will force reductions and closures of in-house VA staff, programs, clinics, and units. This will cause more veterans to obtain care in the community, which will further drain more money out of VA facilities, leading to more reductions, etc. Rural areas will likely be hit hardest.

The VA is nearing the tipping point of this ever-descending spiral. And that is even without expanding eligibility further. Three provisions in this pair of bills could, on their own, drastically open eligibility, eliminate remaining guardrails, and push VA over the edge:

(1) Veteran preference. Tucked into the HEALTH Act, introduced by the ranking Republican Member, Jerry Moran of Kansas, is language which would require VA to consider a “veteran’s preference” for obtaining their health care in the private sector.

This stipulation violates the intent of the VA MISSION Act. When MISSION passed, there was bipartisan agreement that the Community Care Program was meant, in numerous Senators’ words, to “supplement, not supplant” VA health care. A veteran would be offered the option of receiving health care outside of the VA under 6 narrowly defined criteria. Legislators understood that veterans would get the option to choose whether to receive care in the private sector or the VA if, and only if, they qualified under the 6 eligibility rules. As a well-researched document coauthored by Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars stated, “veteran convenience or preference” should never be used as a sole reason for referral.

Explicitly adding preference for the first time will create the expectation among veterans and lawmakers of a new allowance. Were this to pass, every veteran—100%—would become eligible for referral to the private sector, kicking off an unstoppable drainage of VA budget resources and threatening its viability. Hopefully, the Senate will follow the lead of the US House Committee on Veterans’ Affairs which, last week, amended its its own community care bill by deleting “veteran preference” as a possible new eligibility criterion.

(2) Self-referral. Also being deliberated is the Making Community Care Work for Veterans Act, a draft bill authored by the US Senate Committee on Veterans’ Affairs Democratic Chairman Senator Jon Tester of Montana. It calls for allowing self-initiated routine vaccinations and routine vision/hearing services in the community.

On the surface, Tester’s bill focuses on only a tiny sliver of care. But once self-referral is permitted for a few services, private sector interests will, in no time, push the door wide open and add more services to which veterans can self-refer. Testimony at the hearing confirmed that prediction, as the Veterans of Foreign Wars and America’s Warrior Partnership stated there is no reason to limit self-referral to only eye and ear examinations. They proposed that self-referral should extend to mental health, substance use, podiatry, prosthetics, laboratory services, dermatology, and diabetes. Like other perilous sections of these bills, seemingly innocuous language would quickly lead to crippling impacts.

(3) Pilot program for unfettered access. The HEALTH Act contains another provision in which veterans would be allowed to receive outpatient care without VA referral, authorization, or oversight. An enrolled veteran could simply make an appointment with any Veterans Community Care Program mental health or substance use disorder practitioner for care for any duration of time. VA’s only role would be to pay the invoice. Private sector interests have been pressing this sort of program for years, and when it was carefully studied by the Commission on Care, the costs were estimated to be 2 to 3 times the existing system. That would come from a combination of fee-for-service reimbursement structures that abet overuse and higher overall costs in the private sector. Were the pilot to pass, VA would convert from its primary role as a system providing health care to an insurance carrier.

In the name of offering more choices, health care options will diminish for veterans. When VA programs/clinics/facilities close, veterans—especially service-connected veterans who depend on VA for high-quality care tailored to their needs—will lose those choices. Moreover, a downsized VA will make it nearly impossible for the VA to continue to research veterans’ complex health conditions, educate future health care professionals (the majority of whom train at VA medical centers), or fulfill its Fourth Mission as a backup for national emergencies.

Senate Committee members indicated their intention to combine provisions of the Moran and Tester bills into a larger compromise bill in September. Legislators must slow down, contemplate the ramifications, and set aside the stipulations noted above. What is needed first is a projection of future veterans’ authorizations for community care (under current eligibility criteria and also with these new allowances), how much money would that pull out of VA facilities, and what is the tipping point of a doom cycle.

In the meantime, there are smart solutions to ensure veterans can access high-quality care, as Disabled American Veterans testified at the hearing: By “investing in VA's health care infrastructure and staffing… this is particularly true for veterans who live in rural and remote areas where VA is most likely to be a stable, long-term health care option for veterans.”

The VA administers the most successful health care system in the country. As a recent summary of research confirmed yet again, the quality of care delivered by the VA is as good as or better than the care veterans receive from VA-paid community care or the general public obtains through private care. There will always be a supplemental role for the community to play when VA cannot provide care in a timely or convenient manner. But community care must be fixed in ways that never starves VA facilities of essential funding. If there ever were a time to stand up for the sake of our veterans and the long-term viability of the VA, it is now.

California’s highest court has revived a high-profile lawsuit that could have a major impact on whether insurers can punish physicians who refer patients to out-of-network providers.

The case, which has bounced around courts in the Golden State since 2012, pits the nearly 50,000-member California Medical Association (CMA) against Aetna, one of the nation’s largest health insurers. The physician group alleges that Aetna illegally retaliated against physicians who sent patients to certain out-of-network clinics.

Out-of-network providers and clinics were involved in just 4.7% of professional medical claims in 2020, according to a federal report released July 6, 2023. Such claims are more likely than others to be denied, and they result in unexpected medical bills, which have led to the passage of state and federal laws that target “surprise billing.”

In a July 17 ruling, the California Supreme Court unanimously resurrected the CMA v. Aetna case after a judge and a state appeals court killed it on the grounds that the CMA - which is affiliated with the American Medical Association (AMA) - had no standing to sue Aetna. The high state court declared that the CMA could sue on its own behalf, but the justices noted that their ruling says nothing about the merits of the case.

The ruling appears to mean that CMA’s lawsuit will head back to Superior Court in Los Angeles County. The outcome of the case won’t have a direct national effect, since the case is in state court, not federal court. However, state rulings can influence the thinking of judges elsewhere.

The case, filed in 2012, alleges that Aetna harmed patient care by harassing and sacking contract physicians who referred patients to out-of-network ambulatory surgery centers.

According to the new ruling, Aetna responded by saying that “its policy, rather than interfering in medical judgments, was designed simply to encourage participating physicians, consistent with their judgment, to use in-network care providers, such as ambulatory surgery centers, and was adopted in part in response to physicians referring patients to facilities in which they had financial interests.”

In a 2012 letter to CMA, as reported by the Los Angeles Times, an Aetna attorney went further and claimed that “physicians and their business partners secure outsized and improper windfalls at the expense of Aetna’s plan members and employer plan sponsors.”

The CMA received support for its lawsuit via friend-of-the-court legal briefs from the California attorney general, city attorneys for several major California cities, the AMA, several major labor unions, the AIDS Healthcare Foundation, and the advocacy organization Consumer Watchdog. The U.S. Chamber of Commerce, the California Association of Health Plans, and the Association of California Life and Health Insurance Companies filed briefs supporting Aetna.

Aetna, now part of CVS Health, declined to comment about the new ruling.

The CMA released a statement from its president, internist/hospitalist Donaldo M. Hernandez, MD: “The practice of threatening physicians who refer patients to out-of-network providers is unlawful, and we are pleased that the court agrees that CMA has the right to challenge these practices in court.”

In an interview, research professor emeritus Jack Hoadley, PhD, of the Health Policy Institute at Georgetown University’s McCourt School of Public Policy, noted that many health plans don’t cover out-of-network care. Those that do – including PPOs and hybrid plans – often require that patients pay a larger share of the total cost or pay a separate or higher deductible, he said.

So why would an insurer punish doctors who refer patients to health care providers who are outside the insurer’s approved network? In some cases, patients may blame insurers when they’re forced to pay higher rates for out-of-network care, Dr. Hoadley said. Insurers may also be miffed when physicians send patients out of network, he said, because insurers contract with physicians to send a certain number of patients within the insurer’s network.

The federal No Surprises Act, passed by Congress in 2020, hasn’t decreased tension between providers and insurers over out-of-network fees, Dr. Hoadley said. As the effects of the law are hammered out in court, he said, there’s still an adversarial relationship.

In California, the out-of-network landscape changed 3 years before the No Surprises Act. In 2017, the state passed its own no-surprise-billing law, which “protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility and receive care from an out-of-network provider without their consent.” In these cases, the law says patients need to pay only in accordance with in-network cost sharing.

In 2019, a USC-Brookings Schaeffer Initiative for Health Policy report found signs that out-of-network care was fading in California other than in the emergency setting, possibly as a result of the law.

A version of this article first appeared on Medscape.com.

California’s highest court has revived a high-profile lawsuit that could have a major impact on whether insurers can punish physicians who refer patients to out-of-network providers.

The case, which has bounced around courts in the Golden State since 2012, pits the nearly 50,000-member California Medical Association (CMA) against Aetna, one of the nation’s largest health insurers. The physician group alleges that Aetna illegally retaliated against physicians who sent patients to certain out-of-network clinics.

Out-of-network providers and clinics were involved in just 4.7% of professional medical claims in 2020, according to a federal report released July 6, 2023. Such claims are more likely than others to be denied, and they result in unexpected medical bills, which have led to the passage of state and federal laws that target “surprise billing.”

In a July 17 ruling, the California Supreme Court unanimously resurrected the CMA v. Aetna case after a judge and a state appeals court killed it on the grounds that the CMA - which is affiliated with the American Medical Association (AMA) - had no standing to sue Aetna. The high state court declared that the CMA could sue on its own behalf, but the justices noted that their ruling says nothing about the merits of the case.

The ruling appears to mean that CMA’s lawsuit will head back to Superior Court in Los Angeles County. The outcome of the case won’t have a direct national effect, since the case is in state court, not federal court. However, state rulings can influence the thinking of judges elsewhere.

The case, filed in 2012, alleges that Aetna harmed patient care by harassing and sacking contract physicians who referred patients to out-of-network ambulatory surgery centers.

According to the new ruling, Aetna responded by saying that “its policy, rather than interfering in medical judgments, was designed simply to encourage participating physicians, consistent with their judgment, to use in-network care providers, such as ambulatory surgery centers, and was adopted in part in response to physicians referring patients to facilities in which they had financial interests.”

In a 2012 letter to CMA, as reported by the Los Angeles Times, an Aetna attorney went further and claimed that “physicians and their business partners secure outsized and improper windfalls at the expense of Aetna’s plan members and employer plan sponsors.”

The CMA received support for its lawsuit via friend-of-the-court legal briefs from the California attorney general, city attorneys for several major California cities, the AMA, several major labor unions, the AIDS Healthcare Foundation, and the advocacy organization Consumer Watchdog. The U.S. Chamber of Commerce, the California Association of Health Plans, and the Association of California Life and Health Insurance Companies filed briefs supporting Aetna.

Aetna, now part of CVS Health, declined to comment about the new ruling.

The CMA released a statement from its president, internist/hospitalist Donaldo M. Hernandez, MD: “The practice of threatening physicians who refer patients to out-of-network providers is unlawful, and we are pleased that the court agrees that CMA has the right to challenge these practices in court.”

In an interview, research professor emeritus Jack Hoadley, PhD, of the Health Policy Institute at Georgetown University’s McCourt School of Public Policy, noted that many health plans don’t cover out-of-network care. Those that do – including PPOs and hybrid plans – often require that patients pay a larger share of the total cost or pay a separate or higher deductible, he said.

So why would an insurer punish doctors who refer patients to health care providers who are outside the insurer’s approved network? In some cases, patients may blame insurers when they’re forced to pay higher rates for out-of-network care, Dr. Hoadley said. Insurers may also be miffed when physicians send patients out of network, he said, because insurers contract with physicians to send a certain number of patients within the insurer’s network.

The federal No Surprises Act, passed by Congress in 2020, hasn’t decreased tension between providers and insurers over out-of-network fees, Dr. Hoadley said. As the effects of the law are hammered out in court, he said, there’s still an adversarial relationship.

In California, the out-of-network landscape changed 3 years before the No Surprises Act. In 2017, the state passed its own no-surprise-billing law, which “protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility and receive care from an out-of-network provider without their consent.” In these cases, the law says patients need to pay only in accordance with in-network cost sharing.

In 2019, a USC-Brookings Schaeffer Initiative for Health Policy report found signs that out-of-network care was fading in California other than in the emergency setting, possibly as a result of the law.

A version of this article first appeared on Medscape.com.

California’s highest court has revived a high-profile lawsuit that could have a major impact on whether insurers can punish physicians who refer patients to out-of-network providers.

The case, which has bounced around courts in the Golden State since 2012, pits the nearly 50,000-member California Medical Association (CMA) against Aetna, one of the nation’s largest health insurers. The physician group alleges that Aetna illegally retaliated against physicians who sent patients to certain out-of-network clinics.

Out-of-network providers and clinics were involved in just 4.7% of professional medical claims in 2020, according to a federal report released July 6, 2023. Such claims are more likely than others to be denied, and they result in unexpected medical bills, which have led to the passage of state and federal laws that target “surprise billing.”

In a July 17 ruling, the California Supreme Court unanimously resurrected the CMA v. Aetna case after a judge and a state appeals court killed it on the grounds that the CMA - which is affiliated with the American Medical Association (AMA) - had no standing to sue Aetna. The high state court declared that the CMA could sue on its own behalf, but the justices noted that their ruling says nothing about the merits of the case.

The ruling appears to mean that CMA’s lawsuit will head back to Superior Court in Los Angeles County. The outcome of the case won’t have a direct national effect, since the case is in state court, not federal court. However, state rulings can influence the thinking of judges elsewhere.

The case, filed in 2012, alleges that Aetna harmed patient care by harassing and sacking contract physicians who referred patients to out-of-network ambulatory surgery centers.

According to the new ruling, Aetna responded by saying that “its policy, rather than interfering in medical judgments, was designed simply to encourage participating physicians, consistent with their judgment, to use in-network care providers, such as ambulatory surgery centers, and was adopted in part in response to physicians referring patients to facilities in which they had financial interests.”

In a 2012 letter to CMA, as reported by the Los Angeles Times, an Aetna attorney went further and claimed that “physicians and their business partners secure outsized and improper windfalls at the expense of Aetna’s plan members and employer plan sponsors.”

The CMA received support for its lawsuit via friend-of-the-court legal briefs from the California attorney general, city attorneys for several major California cities, the AMA, several major labor unions, the AIDS Healthcare Foundation, and the advocacy organization Consumer Watchdog. The U.S. Chamber of Commerce, the California Association of Health Plans, and the Association of California Life and Health Insurance Companies filed briefs supporting Aetna.

Aetna, now part of CVS Health, declined to comment about the new ruling.

The CMA released a statement from its president, internist/hospitalist Donaldo M. Hernandez, MD: “The practice of threatening physicians who refer patients to out-of-network providers is unlawful, and we are pleased that the court agrees that CMA has the right to challenge these practices in court.”

In an interview, research professor emeritus Jack Hoadley, PhD, of the Health Policy Institute at Georgetown University’s McCourt School of Public Policy, noted that many health plans don’t cover out-of-network care. Those that do – including PPOs and hybrid plans – often require that patients pay a larger share of the total cost or pay a separate or higher deductible, he said.

So why would an insurer punish doctors who refer patients to health care providers who are outside the insurer’s approved network? In some cases, patients may blame insurers when they’re forced to pay higher rates for out-of-network care, Dr. Hoadley said. Insurers may also be miffed when physicians send patients out of network, he said, because insurers contract with physicians to send a certain number of patients within the insurer’s network.

The federal No Surprises Act, passed by Congress in 2020, hasn’t decreased tension between providers and insurers over out-of-network fees, Dr. Hoadley said. As the effects of the law are hammered out in court, he said, there’s still an adversarial relationship.

In California, the out-of-network landscape changed 3 years before the No Surprises Act. In 2017, the state passed its own no-surprise-billing law, which “protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility and receive care from an out-of-network provider without their consent.” In these cases, the law says patients need to pay only in accordance with in-network cost sharing.

In 2019, a USC-Brookings Schaeffer Initiative for Health Policy report found signs that out-of-network care was fading in California other than in the emergency setting, possibly as a result of the law.

A version of this article first appeared on Medscape.com.

A Georgia doctor was cleared in June of having failed to diagnose and treat a child whose acute pancreatitis developed life-threatening complications, according to a report posted on the website of Courtroom View Network.

In 2018, the parents of the then 9-year-old child brought him to Wellstar Paulding Hospital in Hiram, Ga., because of his severe abdominal pain and distention, among other symptoms. Following their examination, medical personnel at the hospital suspected the child’s symptoms were the result of severe constipation.

That evening, he was transferred to Children’s Healthcare of Atlanta, where a pediatric gastroenterologist oversaw his care. (Neither the Atlanta hospital nor Wellstar Paulding were defendants in the subsequent lawsuit.)

Late the following day, the child went into hypovolemic shock, a condition that interrupted the blood supply to his body. Admitted to the pediatric ICU, he was diagnosed with a dangerous complication of acute pancreatitis, necrotizing pancreatitis.

Further complications of his original disease led to a 4-month hospital stay, multiple surgeries, and other interventions. To this point, his medical expenses totaled more than $2.5 million.

His parents then sued the pediatric gastroenterologist who had overseen their child’s care. At issue during the 4-day trial was whether the doctor had properly monitored and treated his patient before his hypovolemic shock set in.

Their attorney sketched the “timeline” of the child’s decline, including his rapid heart rate and repeated vomiting. Given these symptoms, he argued, the standard of care required that steps be taken – including the proper tests and other interventions – to prevent the child’s acute pancreatitis from progressing even further.

“We are not asking you to say, ‘Should [the doctor] have immediately diagnosed pancreatitis,’ “ the attorney told the jury. “But the totality here requires you to think, ‘This might be more than just a backed-up kid.’ ”

The defense pushed back strenuously, however. It argued that the pediatric gastroenterologist had acted appropriately given the prevailing consensus, namely that the child was suffering from extreme constipation. Doctors at Wellstar Paulding, the first hospital where he was seen, suspected this diagnosis – and so, based on his exam and the child’s “non-specific” symptoms, did their client, the pediatric gastroenterologist, who saw him subsequently. “The only clinicians who actually laid hands on [the child] all thought constipation,” the attorney said during his closing argument.

The jury agreed, finding that the pediatric gastroenterologist had acted appropriately, based on the available evidence. Following the jury verdict, the defense attorney noted: Absent the “classic” symptoms of pancreatitis, the jury saw that his client “was working with a reasonable diagnosis until [the child’s] clinical picture deteriorated.”
 

ED doctors can reduce system errors, study says

Emergency physicians are often blamed for system errors beyond their control, asserts a study in the June issue of Emergency Medicine News.

The study – conducted by Tom Belanger, MD, an emergency physician in Texas and chair-elect of the American College of Emergency Physicians Workforce Section – sought to understand to what extent doctors themselves were aware of systemic problems affecting their job. Dr. Belanger surveyed 99 doctors who were asked to comment on a series of ED–related adverse outcomes.

To mitigate response bias, he randomly manipulated the degree to which system error was a perceived factor in each of the adverse cases. In other words, in some cases, the system was represented as a major factor leading to error, while, in other cases, its role was diminished.

Dr. Belanger also divided his doctor/respondents into two groups: The first was asked about his or her personal experience with systemic issues before being presented with the adverse cases; the second group was queried about this experience after being presented with the cases.

The result confirmed Dr. Belanger’s suspicions: Physicians in the first group – that is, those asked about “system factors” before reading about the cases – “were 1.7 times more likely ... to attribute the adverse outcomes in the cases to system factors. (Other significant variables – including whether their shift was busy – also contributed to doctors’ perceptions of adverse outcomes.)

Concluded Dr. Belanger: Since doctors “can identify factors that increase their chances of making mistakes,” system designers should take heed and make efforts to reduce “the probability of error.” If they drag their heels or continue to point to individual doctor error, “they should be held medically and legally liable.”
 

A version of this article first appeared on Medscape.com.

A Georgia doctor was cleared in June of having failed to diagnose and treat a child whose acute pancreatitis developed life-threatening complications, according to a report posted on the website of Courtroom View Network.

In 2018, the parents of the then 9-year-old child brought him to Wellstar Paulding Hospital in Hiram, Ga., because of his severe abdominal pain and distention, among other symptoms. Following their examination, medical personnel at the hospital suspected the child’s symptoms were the result of severe constipation.

That evening, he was transferred to Children’s Healthcare of Atlanta, where a pediatric gastroenterologist oversaw his care. (Neither the Atlanta hospital nor Wellstar Paulding were defendants in the subsequent lawsuit.)

Late the following day, the child went into hypovolemic shock, a condition that interrupted the blood supply to his body. Admitted to the pediatric ICU, he was diagnosed with a dangerous complication of acute pancreatitis, necrotizing pancreatitis.

Further complications of his original disease led to a 4-month hospital stay, multiple surgeries, and other interventions. To this point, his medical expenses totaled more than $2.5 million.

His parents then sued the pediatric gastroenterologist who had overseen their child’s care. At issue during the 4-day trial was whether the doctor had properly monitored and treated his patient before his hypovolemic shock set in.

Their attorney sketched the “timeline” of the child’s decline, including his rapid heart rate and repeated vomiting. Given these symptoms, he argued, the standard of care required that steps be taken – including the proper tests and other interventions – to prevent the child’s acute pancreatitis from progressing even further.

“We are not asking you to say, ‘Should [the doctor] have immediately diagnosed pancreatitis,’ “ the attorney told the jury. “But the totality here requires you to think, ‘This might be more than just a backed-up kid.’ ”

The defense pushed back strenuously, however. It argued that the pediatric gastroenterologist had acted appropriately given the prevailing consensus, namely that the child was suffering from extreme constipation. Doctors at Wellstar Paulding, the first hospital where he was seen, suspected this diagnosis – and so, based on his exam and the child’s “non-specific” symptoms, did their client, the pediatric gastroenterologist, who saw him subsequently. “The only clinicians who actually laid hands on [the child] all thought constipation,” the attorney said during his closing argument.

The jury agreed, finding that the pediatric gastroenterologist had acted appropriately, based on the available evidence. Following the jury verdict, the defense attorney noted: Absent the “classic” symptoms of pancreatitis, the jury saw that his client “was working with a reasonable diagnosis until [the child’s] clinical picture deteriorated.”
 

ED doctors can reduce system errors, study says

Emergency physicians are often blamed for system errors beyond their control, asserts a study in the June issue of Emergency Medicine News.

The study – conducted by Tom Belanger, MD, an emergency physician in Texas and chair-elect of the American College of Emergency Physicians Workforce Section – sought to understand to what extent doctors themselves were aware of systemic problems affecting their job. Dr. Belanger surveyed 99 doctors who were asked to comment on a series of ED–related adverse outcomes.

To mitigate response bias, he randomly manipulated the degree to which system error was a perceived factor in each of the adverse cases. In other words, in some cases, the system was represented as a major factor leading to error, while, in other cases, its role was diminished.

Dr. Belanger also divided his doctor/respondents into two groups: The first was asked about his or her personal experience with systemic issues before being presented with the adverse cases; the second group was queried about this experience after being presented with the cases.

The result confirmed Dr. Belanger’s suspicions: Physicians in the first group – that is, those asked about “system factors” before reading about the cases – “were 1.7 times more likely ... to attribute the adverse outcomes in the cases to system factors. (Other significant variables – including whether their shift was busy – also contributed to doctors’ perceptions of adverse outcomes.)

Concluded Dr. Belanger: Since doctors “can identify factors that increase their chances of making mistakes,” system designers should take heed and make efforts to reduce “the probability of error.” If they drag their heels or continue to point to individual doctor error, “they should be held medically and legally liable.”
 

A version of this article first appeared on Medscape.com.

A Georgia doctor was cleared in June of having failed to diagnose and treat a child whose acute pancreatitis developed life-threatening complications, according to a report posted on the website of Courtroom View Network.

In 2018, the parents of the then 9-year-old child brought him to Wellstar Paulding Hospital in Hiram, Ga., because of his severe abdominal pain and distention, among other symptoms. Following their examination, medical personnel at the hospital suspected the child’s symptoms were the result of severe constipation.

That evening, he was transferred to Children’s Healthcare of Atlanta, where a pediatric gastroenterologist oversaw his care. (Neither the Atlanta hospital nor Wellstar Paulding were defendants in the subsequent lawsuit.)

Late the following day, the child went into hypovolemic shock, a condition that interrupted the blood supply to his body. Admitted to the pediatric ICU, he was diagnosed with a dangerous complication of acute pancreatitis, necrotizing pancreatitis.

Further complications of his original disease led to a 4-month hospital stay, multiple surgeries, and other interventions. To this point, his medical expenses totaled more than $2.5 million.

His parents then sued the pediatric gastroenterologist who had overseen their child’s care. At issue during the 4-day trial was whether the doctor had properly monitored and treated his patient before his hypovolemic shock set in.

Their attorney sketched the “timeline” of the child’s decline, including his rapid heart rate and repeated vomiting. Given these symptoms, he argued, the standard of care required that steps be taken – including the proper tests and other interventions – to prevent the child’s acute pancreatitis from progressing even further.

“We are not asking you to say, ‘Should [the doctor] have immediately diagnosed pancreatitis,’ “ the attorney told the jury. “But the totality here requires you to think, ‘This might be more than just a backed-up kid.’ ”

The defense pushed back strenuously, however. It argued that the pediatric gastroenterologist had acted appropriately given the prevailing consensus, namely that the child was suffering from extreme constipation. Doctors at Wellstar Paulding, the first hospital where he was seen, suspected this diagnosis – and so, based on his exam and the child’s “non-specific” symptoms, did their client, the pediatric gastroenterologist, who saw him subsequently. “The only clinicians who actually laid hands on [the child] all thought constipation,” the attorney said during his closing argument.

The jury agreed, finding that the pediatric gastroenterologist had acted appropriately, based on the available evidence. Following the jury verdict, the defense attorney noted: Absent the “classic” symptoms of pancreatitis, the jury saw that his client “was working with a reasonable diagnosis until [the child’s] clinical picture deteriorated.”
 

ED doctors can reduce system errors, study says

Emergency physicians are often blamed for system errors beyond their control, asserts a study in the June issue of Emergency Medicine News.

The study – conducted by Tom Belanger, MD, an emergency physician in Texas and chair-elect of the American College of Emergency Physicians Workforce Section – sought to understand to what extent doctors themselves were aware of systemic problems affecting their job. Dr. Belanger surveyed 99 doctors who were asked to comment on a series of ED–related adverse outcomes.

To mitigate response bias, he randomly manipulated the degree to which system error was a perceived factor in each of the adverse cases. In other words, in some cases, the system was represented as a major factor leading to error, while, in other cases, its role was diminished.

Dr. Belanger also divided his doctor/respondents into two groups: The first was asked about his or her personal experience with systemic issues before being presented with the adverse cases; the second group was queried about this experience after being presented with the cases.

The result confirmed Dr. Belanger’s suspicions: Physicians in the first group – that is, those asked about “system factors” before reading about the cases – “were 1.7 times more likely ... to attribute the adverse outcomes in the cases to system factors. (Other significant variables – including whether their shift was busy – also contributed to doctors’ perceptions of adverse outcomes.)

Concluded Dr. Belanger: Since doctors “can identify factors that increase their chances of making mistakes,” system designers should take heed and make efforts to reduce “the probability of error.” If they drag their heels or continue to point to individual doctor error, “they should be held medically and legally liable.”
 

A version of this article first appeared on Medscape.com.

ASHEVILLE, N.C. – TikTok, typical of several forms of social media, has been intentionally repositioned to rival Google as a primary source of information, meaning that health care professionals, including those who provide dermatologic care to children, should be thinking about how to get on board to counter myths, erroneous facts, and fake news, warned an expert at the annual meeting of the Society for Pediatric Dermatology.

“If we don’t get involved, we are basically letting misinformation win. We need to be there,” said Angelo Landriscina, MD, director of dermatology at a Mount Sinai Doctors Clinic in New York.

Most of the content currently available on medical topics, including dermatology and pediatric dermatology, is not created by health care professionals, Dr. Landriscina noted. Not surprisingly, given that much of the content is based on personal opinion from individuals who have no expertise in medical care, he described the information as being of “low quality” when not fully erroneous.

Dr. Landriscina has been active on social media, including TikTok, for several years. Most of his posts involve responses to misinformation. When he sets the record straight on the basis of existing evidence, he often supports his counterargument with references.

He acknowledged that when he became involved in social media he faced criticism from colleagues about participating on an entertainment platform that many considered unworthy of providing objective information. If that was ever true, he argued, it is no longer the case.

“TikTok has adopted a new strategy. The goal is to unseat Google as a search tool, and it’s working,” he said. He explained that many people now use TikTok and other social media sites as their primary source of information on essentially every topic, from where to eat to whether to be screened for cancer.

The particular problem with TikTok – one of the most popular social media outlets – is that there is no mechanism for vetting the source of information. YouTube, by contrast, now requires some sort of validation for anyone who claims to have a medical degree or any other verifiable qualification, according to Dr. Landriscina. TikTok, like many other platforms, has no such requirement.

“Anyone can buy a pair of scrubs [implying expertise] and then post a video,” Dr. Landriscina said.

Even if information from one content provider is more valid than information from others, the TikTok algorithm is specifically designed to emphasize content that has the potential for going viral, which means it favors videos that are provocative over those that are not.

“The algorithm favors any content that is more controversial, more surprising, and keeps viewers engaged,” Dr. Landriscina pointed out.

This does not mean that objective and factual information is ignored, but the algorithm is indifferent to the validity of information, meaning that it allows videos to be posted without regard to whether the content is true, untrue, purposefully misleading, or utter nonsense. For that reason, it is often easier to attract attention by responding to a post that has already gone viral. Information that is clear and digestible can attract viewers and therefore is distributed more widely with the TikTok algorithm.
 

Parents are on Tiktok too

There is a misperception that the TikTok audience is younger, according to Dr. Landriscina. While peak use in the United States fell among people between the ages of 25 and 34 years in 2022, he said the number of users falls off relatively slowly with subsequent 10-year increments in age. In 2022, there were nearly 20 million users in the peak 10-year age range, but 7.5 million users were 55 years of age or older.

“Pediatric dermatologists should recognize that it is not just kids who are looking for information about their skin diseases, but also their parents,” Dr. Landriscina said.

The top three dermatology topics searched on TikTok in a recent period were acne, alopecia, and cysts. But top searches are very fluid and are extremely hard to quantify, because the basis of the algorithm, which is a proprietary secret, is not only unknown but produces different results for every user.

“The second you touch the app, it changes,” Dr. Landriscina said. He explained that an inquiry about any subject, including those that are medically related, yields content that is different, or at least ordered differently, “depending on how you behaved on the app in the past.”

The phenomenon that drives social media predates this technology. Dr. Landriscina cited a study in 1956 that described the “parasocial interaction theory.” The theory was based on the observation that those who consume media, such as television, which was relatively new in 1956, believed that they had a personal relationship with media figures.

“The users begin to trust influencers as a source, like a friend providing them advice,” Dr. Landriscina said. As an example, he suggested that a fan of the television show Friends who follows actor Jennifer Aniston on social media platforms may begin to think of her as a trusted source of information on any topic, including those for which she may not have expertise.

The reason that he urges medical professionals to become active on TikTok and other social media platforms is that they have a potentially critical role in responding to information that is not just wrong but harmful.

On TikTok and other social media platforms, “there is a lot of interest in content about dermatologic conditions in children. There is a real need for accurate information,” he said,

In the question-and-answer session following his presentation, Dr. Landriscina’s message was not uniformly embraced. One risk, according to an audience member, is that medical professionals will begin to express their own personal opinions rather than rely on evidence, with the result that they will “just add to the sea of misinformation.”

However, this opinion appeared to be the minority view. Most of those who commented took a “that-ship-has-sailed” stance, recognizing the irreversible ascendancy of social media.

“Whether you like it or not, social media is here to stay. We cannot fight it. Rather, we need to embrace it in a responsible way,” said Dakara R. Wright, MD, a dermatologist at the Mid-Atlantic Kaiser Permanente Group, Halethorpe, Md. She, like others, reported that she has come to recognize that social media is a major source of medical information for her patients.

“We need to be a presence on these platforms for the benefit of our patients and their parents,” she said. She acknowledged that she has not been active in posting on social media in the past but said that she has been speaking with administrators in her organization about how to become involved in a responsible way that can be useful to patients.

Candrice R. Heath, MD, assistant professor of dermatology at Temple University, Philadelphia, has been active on social media for several years, posting content on her own account, which is not related to her academic affiliation. She posts for many reasons, not least of which is drawing attention to her expertise.

Like Dr. Landriscina, she recognizes that users of these platforms are guided by the content to make decisions about health care. She also agreed that physicians should not ignore this phenomenon.

Tips on providing content

Given the fact that the algorithm is intended to produce posts that go viral, Dr. Landriscina urged clinicians to make their content easy to watch. He said it is not necessary to overthink content beyond providing accurate information, but he advised that videos be made with attention to adequate lighting and other simple factors to promote visual quality. He said that accurate information is not necessarily dull.

“Some facts can actually be surprising to patients,” he said. He noted that a calm, coherent video can be particularly effective in attracting an audience when it is in reaction to information that has gone viral but is misleading or patently incorrect.

Dr. Landriscina has been an influencer associated with multiple social media platforms, including TikTok. He has in the past been paid for consulting work for TikTok. Dr. Wright and Dr. Heath reported no potential conflicts of interest.

A version of this article first appeared on Medscape.com.

ASHEVILLE, N.C. – TikTok, typical of several forms of social media, has been intentionally repositioned to rival Google as a primary source of information, meaning that health care professionals, including those who provide dermatologic care to children, should be thinking about how to get on board to counter myths, erroneous facts, and fake news, warned an expert at the annual meeting of the Society for Pediatric Dermatology.

“If we don’t get involved, we are basically letting misinformation win. We need to be there,” said Angelo Landriscina, MD, director of dermatology at a Mount Sinai Doctors Clinic in New York.

Most of the content currently available on medical topics, including dermatology and pediatric dermatology, is not created by health care professionals, Dr. Landriscina noted. Not surprisingly, given that much of the content is based on personal opinion from individuals who have no expertise in medical care, he described the information as being of “low quality” when not fully erroneous.

Dr. Landriscina has been active on social media, including TikTok, for several years. Most of his posts involve responses to misinformation. When he sets the record straight on the basis of existing evidence, he often supports his counterargument with references.

He acknowledged that when he became involved in social media he faced criticism from colleagues about participating on an entertainment platform that many considered unworthy of providing objective information. If that was ever true, he argued, it is no longer the case.

“TikTok has adopted a new strategy. The goal is to unseat Google as a search tool, and it’s working,” he said. He explained that many people now use TikTok and other social media sites as their primary source of information on essentially every topic, from where to eat to whether to be screened for cancer.

The particular problem with TikTok – one of the most popular social media outlets – is that there is no mechanism for vetting the source of information. YouTube, by contrast, now requires some sort of validation for anyone who claims to have a medical degree or any other verifiable qualification, according to Dr. Landriscina. TikTok, like many other platforms, has no such requirement.

“Anyone can buy a pair of scrubs [implying expertise] and then post a video,” Dr. Landriscina said.

Even if information from one content provider is more valid than information from others, the TikTok algorithm is specifically designed to emphasize content that has the potential for going viral, which means it favors videos that are provocative over those that are not.

“The algorithm favors any content that is more controversial, more surprising, and keeps viewers engaged,” Dr. Landriscina pointed out.

This does not mean that objective and factual information is ignored, but the algorithm is indifferent to the validity of information, meaning that it allows videos to be posted without regard to whether the content is true, untrue, purposefully misleading, or utter nonsense. For that reason, it is often easier to attract attention by responding to a post that has already gone viral. Information that is clear and digestible can attract viewers and therefore is distributed more widely with the TikTok algorithm.
 

Parents are on Tiktok too

There is a misperception that the TikTok audience is younger, according to Dr. Landriscina. While peak use in the United States fell among people between the ages of 25 and 34 years in 2022, he said the number of users falls off relatively slowly with subsequent 10-year increments in age. In 2022, there were nearly 20 million users in the peak 10-year age range, but 7.5 million users were 55 years of age or older.

“Pediatric dermatologists should recognize that it is not just kids who are looking for information about their skin diseases, but also their parents,” Dr. Landriscina said.

The top three dermatology topics searched on TikTok in a recent period were acne, alopecia, and cysts. But top searches are very fluid and are extremely hard to quantify, because the basis of the algorithm, which is a proprietary secret, is not only unknown but produces different results for every user.

“The second you touch the app, it changes,” Dr. Landriscina said. He explained that an inquiry about any subject, including those that are medically related, yields content that is different, or at least ordered differently, “depending on how you behaved on the app in the past.”

The phenomenon that drives social media predates this technology. Dr. Landriscina cited a study in 1956 that described the “parasocial interaction theory.” The theory was based on the observation that those who consume media, such as television, which was relatively new in 1956, believed that they had a personal relationship with media figures.

“The users begin to trust influencers as a source, like a friend providing them advice,” Dr. Landriscina said. As an example, he suggested that a fan of the television show Friends who follows actor Jennifer Aniston on social media platforms may begin to think of her as a trusted source of information on any topic, including those for which she may not have expertise.

The reason that he urges medical professionals to become active on TikTok and other social media platforms is that they have a potentially critical role in responding to information that is not just wrong but harmful.

On TikTok and other social media platforms, “there is a lot of interest in content about dermatologic conditions in children. There is a real need for accurate information,” he said,

In the question-and-answer session following his presentation, Dr. Landriscina’s message was not uniformly embraced. One risk, according to an audience member, is that medical professionals will begin to express their own personal opinions rather than rely on evidence, with the result that they will “just add to the sea of misinformation.”

However, this opinion appeared to be the minority view. Most of those who commented took a “that-ship-has-sailed” stance, recognizing the irreversible ascendancy of social media.

“Whether you like it or not, social media is here to stay. We cannot fight it. Rather, we need to embrace it in a responsible way,” said Dakara R. Wright, MD, a dermatologist at the Mid-Atlantic Kaiser Permanente Group, Halethorpe, Md. She, like others, reported that she has come to recognize that social media is a major source of medical information for her patients.

“We need to be a presence on these platforms for the benefit of our patients and their parents,” she said. She acknowledged that she has not been active in posting on social media in the past but said that she has been speaking with administrators in her organization about how to become involved in a responsible way that can be useful to patients.

Candrice R. Heath, MD, assistant professor of dermatology at Temple University, Philadelphia, has been active on social media for several years, posting content on her own account, which is not related to her academic affiliation. She posts for many reasons, not least of which is drawing attention to her expertise.

Like Dr. Landriscina, she recognizes that users of these platforms are guided by the content to make decisions about health care. She also agreed that physicians should not ignore this phenomenon.

Tips on providing content

Given the fact that the algorithm is intended to produce posts that go viral, Dr. Landriscina urged clinicians to make their content easy to watch. He said it is not necessary to overthink content beyond providing accurate information, but he advised that videos be made with attention to adequate lighting and other simple factors to promote visual quality. He said that accurate information is not necessarily dull.

“Some facts can actually be surprising to patients,” he said. He noted that a calm, coherent video can be particularly effective in attracting an audience when it is in reaction to information that has gone viral but is misleading or patently incorrect.

Dr. Landriscina has been an influencer associated with multiple social media platforms, including TikTok. He has in the past been paid for consulting work for TikTok. Dr. Wright and Dr. Heath reported no potential conflicts of interest.

A version of this article first appeared on Medscape.com.

ASHEVILLE, N.C. – TikTok, typical of several forms of social media, has been intentionally repositioned to rival Google as a primary source of information, meaning that health care professionals, including those who provide dermatologic care to children, should be thinking about how to get on board to counter myths, erroneous facts, and fake news, warned an expert at the annual meeting of the Society for Pediatric Dermatology.

“If we don’t get involved, we are basically letting misinformation win. We need to be there,” said Angelo Landriscina, MD, director of dermatology at a Mount Sinai Doctors Clinic in New York.

Most of the content currently available on medical topics, including dermatology and pediatric dermatology, is not created by health care professionals, Dr. Landriscina noted. Not surprisingly, given that much of the content is based on personal opinion from individuals who have no expertise in medical care, he described the information as being of “low quality” when not fully erroneous.

Dr. Landriscina has been active on social media, including TikTok, for several years. Most of his posts involve responses to misinformation. When he sets the record straight on the basis of existing evidence, he often supports his counterargument with references.

He acknowledged that when he became involved in social media he faced criticism from colleagues about participating on an entertainment platform that many considered unworthy of providing objective information. If that was ever true, he argued, it is no longer the case.

“TikTok has adopted a new strategy. The goal is to unseat Google as a search tool, and it’s working,” he said. He explained that many people now use TikTok and other social media sites as their primary source of information on essentially every topic, from where to eat to whether to be screened for cancer.

The particular problem with TikTok – one of the most popular social media outlets – is that there is no mechanism for vetting the source of information. YouTube, by contrast, now requires some sort of validation for anyone who claims to have a medical degree or any other verifiable qualification, according to Dr. Landriscina. TikTok, like many other platforms, has no such requirement.

“Anyone can buy a pair of scrubs [implying expertise] and then post a video,” Dr. Landriscina said.

Even if information from one content provider is more valid than information from others, the TikTok algorithm is specifically designed to emphasize content that has the potential for going viral, which means it favors videos that are provocative over those that are not.

“The algorithm favors any content that is more controversial, more surprising, and keeps viewers engaged,” Dr. Landriscina pointed out.

This does not mean that objective and factual information is ignored, but the algorithm is indifferent to the validity of information, meaning that it allows videos to be posted without regard to whether the content is true, untrue, purposefully misleading, or utter nonsense. For that reason, it is often easier to attract attention by responding to a post that has already gone viral. Information that is clear and digestible can attract viewers and therefore is distributed more widely with the TikTok algorithm.
 

Parents are on Tiktok too

There is a misperception that the TikTok audience is younger, according to Dr. Landriscina. While peak use in the United States fell among people between the ages of 25 and 34 years in 2022, he said the number of users falls off relatively slowly with subsequent 10-year increments in age. In 2022, there were nearly 20 million users in the peak 10-year age range, but 7.5 million users were 55 years of age or older.

“Pediatric dermatologists should recognize that it is not just kids who are looking for information about their skin diseases, but also their parents,” Dr. Landriscina said.

The top three dermatology topics searched on TikTok in a recent period were acne, alopecia, and cysts. But top searches are very fluid and are extremely hard to quantify, because the basis of the algorithm, which is a proprietary secret, is not only unknown but produces different results for every user.

“The second you touch the app, it changes,” Dr. Landriscina said. He explained that an inquiry about any subject, including those that are medically related, yields content that is different, or at least ordered differently, “depending on how you behaved on the app in the past.”

The phenomenon that drives social media predates this technology. Dr. Landriscina cited a study in 1956 that described the “parasocial interaction theory.” The theory was based on the observation that those who consume media, such as television, which was relatively new in 1956, believed that they had a personal relationship with media figures.

“The users begin to trust influencers as a source, like a friend providing them advice,” Dr. Landriscina said. As an example, he suggested that a fan of the television show Friends who follows actor Jennifer Aniston on social media platforms may begin to think of her as a trusted source of information on any topic, including those for which she may not have expertise.

The reason that he urges medical professionals to become active on TikTok and other social media platforms is that they have a potentially critical role in responding to information that is not just wrong but harmful.

On TikTok and other social media platforms, “there is a lot of interest in content about dermatologic conditions in children. There is a real need for accurate information,” he said,

In the question-and-answer session following his presentation, Dr. Landriscina’s message was not uniformly embraced. One risk, according to an audience member, is that medical professionals will begin to express their own personal opinions rather than rely on evidence, with the result that they will “just add to the sea of misinformation.”

However, this opinion appeared to be the minority view. Most of those who commented took a “that-ship-has-sailed” stance, recognizing the irreversible ascendancy of social media.

“Whether you like it or not, social media is here to stay. We cannot fight it. Rather, we need to embrace it in a responsible way,” said Dakara R. Wright, MD, a dermatologist at the Mid-Atlantic Kaiser Permanente Group, Halethorpe, Md. She, like others, reported that she has come to recognize that social media is a major source of medical information for her patients.

“We need to be a presence on these platforms for the benefit of our patients and their parents,” she said. She acknowledged that she has not been active in posting on social media in the past but said that she has been speaking with administrators in her organization about how to become involved in a responsible way that can be useful to patients.

Candrice R. Heath, MD, assistant professor of dermatology at Temple University, Philadelphia, has been active on social media for several years, posting content on her own account, which is not related to her academic affiliation. She posts for many reasons, not least of which is drawing attention to her expertise.

Like Dr. Landriscina, she recognizes that users of these platforms are guided by the content to make decisions about health care. She also agreed that physicians should not ignore this phenomenon.

Tips on providing content

Given the fact that the algorithm is intended to produce posts that go viral, Dr. Landriscina urged clinicians to make their content easy to watch. He said it is not necessary to overthink content beyond providing accurate information, but he advised that videos be made with attention to adequate lighting and other simple factors to promote visual quality. He said that accurate information is not necessarily dull.

“Some facts can actually be surprising to patients,” he said. He noted that a calm, coherent video can be particularly effective in attracting an audience when it is in reaction to information that has gone viral but is misleading or patently incorrect.

Dr. Landriscina has been an influencer associated with multiple social media platforms, including TikTok. He has in the past been paid for consulting work for TikTok. Dr. Wright and Dr. Heath reported no potential conflicts of interest.

A version of this article first appeared on Medscape.com.

One has to be living off the grid to not be bombarded with direct-to-consumer (DTC) pharmaceutical advertising. Since 1997, when the Food and Drug Administration eased restrictions on this prohibition and allowed pharmaceutical companies to promote prescription-only medications to the public, there has been a deluge of ads in magazines, on the Internet, and, most annoying, on commercial television.

These television ads are quite formulaic:

We are initially introduced to a number of highly functioning patients (typically actors) who are engaged in rewarding pursuits. A voiceover narration then presents the pharmaceutical to be promoted, suggesting (not so subtly) to consumers that taking the advertised drug will improve one’s disease outlook or quality of life such that they too, just like the actors in the minidrama, can lead such highly productive lives.

The potential best-case scenarios of these new treatments may be stated. There then follows a litany of side effects – some of them life threatening – warnings, and contraindications. We’re again treated to another 5 or 10 seconds of patients leading “the good life,” and almost all of the ads end with the narrator concluding: “Ask your doctor (sometimes ‘provider’) if _____ is right for you.”

Big pharma spends nearly $10 billion on DTC advertising, with television ads accounting for the vast majority of these dollars. Is this type of advertising appropriate? Or even ethical?

Americans spend more money on their prescriptions than do citizens of any other highly developed nation. I have personally heard from patients who get their prescriptions from other countries, where they are more affordable. These patients will also cut their pills in half or take a medication every other day instead of every day, to economize on drug costs.

Another “trick” they use to save money – and I have heard pharmacists and pharmaceutical reps themselves recommend this – is to ask for a higher dose of a medication, usually double, and then use a pill cutter to divide a tablet in half, thus making their prescription last twice as long. Why do Americans have to resort to such “workarounds”?

Many of the medications advertised are for relatively rare conditions, such as thyroid eye disease or myasthenia gravis (which affects up to about 60,000 patients in the United States). Why not spend these advertising dollars on programs to make drugs taken by the millions of Americans with common conditions (for example, hypertension, diabetes, heart failure) more affordable?

Very often the television ads contain medical jargon, such as: “If you have the EGFR mutation, or if your cancer is HER2 negative ...”

Do most patients truly understand what these terms mean? And what happens when a patient’s physician doesn’t prescribe a medication that a patient has seen on TV and asks for, or when the physician believes that a generic (nonadvertised) medication might work just as well? This creates conflict and potential discord, adversely affecting the doctor-patient relationship.

An oncologist colleague related to me that he often has to spend time correcting patients’ misperceptions of potential miracle cures offered by these ads, and that several patients have left his practice because he would not prescribe a drug they saw advertised.

Further, while these ads urge patients to try expensive “newest and latest” treatments, pharmacy benefit plans are working with health care insurance conglomerates to reduce costs of pharmaceuticals.

How does this juxtaposition of opposing forces make any sense?

It is time for us to put an end to DTC advertising, at least on television. It will require legislative action by our federal government to end this practice (legal, by the way, only in the United States and New Zealand), and hence the willingness of our politicians to get behind legislation to do so.

Just as a law was passed to prohibit tobacco advertising on television, so should a law be passed to regulate DTC pharmaceutical advertising.

The time to end DTC advertising has come!
 

Lloyd Alterman, MD, is a retired physician and chairman of the New Jersey Universal Healthcare Coalition. He disclosed having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

One has to be living off the grid to not be bombarded with direct-to-consumer (DTC) pharmaceutical advertising. Since 1997, when the Food and Drug Administration eased restrictions on this prohibition and allowed pharmaceutical companies to promote prescription-only medications to the public, there has been a deluge of ads in magazines, on the Internet, and, most annoying, on commercial television.

These television ads are quite formulaic:

We are initially introduced to a number of highly functioning patients (typically actors) who are engaged in rewarding pursuits. A voiceover narration then presents the pharmaceutical to be promoted, suggesting (not so subtly) to consumers that taking the advertised drug will improve one’s disease outlook or quality of life such that they too, just like the actors in the minidrama, can lead such highly productive lives.

The potential best-case scenarios of these new treatments may be stated. There then follows a litany of side effects – some of them life threatening – warnings, and contraindications. We’re again treated to another 5 or 10 seconds of patients leading “the good life,” and almost all of the ads end with the narrator concluding: “Ask your doctor (sometimes ‘provider’) if _____ is right for you.”

Big pharma spends nearly $10 billion on DTC advertising, with television ads accounting for the vast majority of these dollars. Is this type of advertising appropriate? Or even ethical?

Americans spend more money on their prescriptions than do citizens of any other highly developed nation. I have personally heard from patients who get their prescriptions from other countries, where they are more affordable. These patients will also cut their pills in half or take a medication every other day instead of every day, to economize on drug costs.

Another “trick” they use to save money – and I have heard pharmacists and pharmaceutical reps themselves recommend this – is to ask for a higher dose of a medication, usually double, and then use a pill cutter to divide a tablet in half, thus making their prescription last twice as long. Why do Americans have to resort to such “workarounds”?

Many of the medications advertised are for relatively rare conditions, such as thyroid eye disease or myasthenia gravis (which affects up to about 60,000 patients in the United States). Why not spend these advertising dollars on programs to make drugs taken by the millions of Americans with common conditions (for example, hypertension, diabetes, heart failure) more affordable?

Very often the television ads contain medical jargon, such as: “If you have the EGFR mutation, or if your cancer is HER2 negative ...”

Do most patients truly understand what these terms mean? And what happens when a patient’s physician doesn’t prescribe a medication that a patient has seen on TV and asks for, or when the physician believes that a generic (nonadvertised) medication might work just as well? This creates conflict and potential discord, adversely affecting the doctor-patient relationship.

An oncologist colleague related to me that he often has to spend time correcting patients’ misperceptions of potential miracle cures offered by these ads, and that several patients have left his practice because he would not prescribe a drug they saw advertised.

Further, while these ads urge patients to try expensive “newest and latest” treatments, pharmacy benefit plans are working with health care insurance conglomerates to reduce costs of pharmaceuticals.

How does this juxtaposition of opposing forces make any sense?

It is time for us to put an end to DTC advertising, at least on television. It will require legislative action by our federal government to end this practice (legal, by the way, only in the United States and New Zealand), and hence the willingness of our politicians to get behind legislation to do so.

Just as a law was passed to prohibit tobacco advertising on television, so should a law be passed to regulate DTC pharmaceutical advertising.

The time to end DTC advertising has come!
 

Lloyd Alterman, MD, is a retired physician and chairman of the New Jersey Universal Healthcare Coalition. He disclosed having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

One has to be living off the grid to not be bombarded with direct-to-consumer (DTC) pharmaceutical advertising. Since 1997, when the Food and Drug Administration eased restrictions on this prohibition and allowed pharmaceutical companies to promote prescription-only medications to the public, there has been a deluge of ads in magazines, on the Internet, and, most annoying, on commercial television.

These television ads are quite formulaic:

We are initially introduced to a number of highly functioning patients (typically actors) who are engaged in rewarding pursuits. A voiceover narration then presents the pharmaceutical to be promoted, suggesting (not so subtly) to consumers that taking the advertised drug will improve one’s disease outlook or quality of life such that they too, just like the actors in the minidrama, can lead such highly productive lives.

The potential best-case scenarios of these new treatments may be stated. There then follows a litany of side effects – some of them life threatening – warnings, and contraindications. We’re again treated to another 5 or 10 seconds of patients leading “the good life,” and almost all of the ads end with the narrator concluding: “Ask your doctor (sometimes ‘provider’) if _____ is right for you.”

Big pharma spends nearly $10 billion on DTC advertising, with television ads accounting for the vast majority of these dollars. Is this type of advertising appropriate? Or even ethical?

Americans spend more money on their prescriptions than do citizens of any other highly developed nation. I have personally heard from patients who get their prescriptions from other countries, where they are more affordable. These patients will also cut their pills in half or take a medication every other day instead of every day, to economize on drug costs.

Another “trick” they use to save money – and I have heard pharmacists and pharmaceutical reps themselves recommend this – is to ask for a higher dose of a medication, usually double, and then use a pill cutter to divide a tablet in half, thus making their prescription last twice as long. Why do Americans have to resort to such “workarounds”?

Many of the medications advertised are for relatively rare conditions, such as thyroid eye disease or myasthenia gravis (which affects up to about 60,000 patients in the United States). Why not spend these advertising dollars on programs to make drugs taken by the millions of Americans with common conditions (for example, hypertension, diabetes, heart failure) more affordable?

Very often the television ads contain medical jargon, such as: “If you have the EGFR mutation, or if your cancer is HER2 negative ...”

Do most patients truly understand what these terms mean? And what happens when a patient’s physician doesn’t prescribe a medication that a patient has seen on TV and asks for, or when the physician believes that a generic (nonadvertised) medication might work just as well? This creates conflict and potential discord, adversely affecting the doctor-patient relationship.

An oncologist colleague related to me that he often has to spend time correcting patients’ misperceptions of potential miracle cures offered by these ads, and that several patients have left his practice because he would not prescribe a drug they saw advertised.

Further, while these ads urge patients to try expensive “newest and latest” treatments, pharmacy benefit plans are working with health care insurance conglomerates to reduce costs of pharmaceuticals.

How does this juxtaposition of opposing forces make any sense?

It is time for us to put an end to DTC advertising, at least on television. It will require legislative action by our federal government to end this practice (legal, by the way, only in the United States and New Zealand), and hence the willingness of our politicians to get behind legislation to do so.

Just as a law was passed to prohibit tobacco advertising on television, so should a law be passed to regulate DTC pharmaceutical advertising.

The time to end DTC advertising has come!
 

Lloyd Alterman, MD, is a retired physician and chairman of the New Jersey Universal Healthcare Coalition. He disclosed having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In March 2023, four “medical tourists” from South Carolina who were seeking health care in Mexico were kidnapped by a drug cartel. Two were killed when they were trapped in a shootout. One of them was scheduled for tummy-tuck surgery, and others were seeking cheaper prescription drugs.

The news reached Bruce Hermann, MD, a plastic surgeon in Denton, Tex., who brought up the incident in a segment of his podcast, “Nip Talk,” in which he talked about the risks of medical tourism. But violence in foreign countries isn’t Dr. Hermann’s primary concern.

“Being the victim of a crime is lower down the risk strata,” Dr. Hermann said in an interview. “A bigger concern is the lack of regulations of doctors and facilities in countries like Mexico.”

The savings from medical tourism may be tempting, but the unpredictable clinical risks are daunting. Some employers pay for treatment at certain foreign clinics, and Blue Shield of California’s HMO plan, Access Baja, covers care in certain clinics in Mexico’s Baja peninsula. But U.S. health insurance generally does not cover medical tourism.

Despite its popularity, medical tourism is not siphoning off a significant number of patients from U.S. doctors, with the possible exception of plastic surgery. One study found that medical tourism accounts for less than 2% of U.S. spending on noncosmetic health care.

Still, as many as 1.2 million Americans travel to Mexico each year seeking health care at lower costs, particularly dental care, bariatric surgery, and cosmetic procedures.

Physicians such as Dr. Hermann see the results when things go awry. Dr. Hermann said when he takes calls at a nearby level II trauma center, he sees, on average, one patient a month with complications from plastic surgeries performed abroad.

Patients tell Dr. Hermann they often had little preoperative time with the surgeons, and some may not even see their surgeon. They have to fly back home just days after their procedures, so complications that typically arise later are missed, he said.
 

Who opts for medical tourism?

There are few statistics on the number of medical tourists or the clinical problems they have. Josef Woodman, CEO of Patients Beyond Borders, a medical tourism consultancy in Chapel Hill, N.C., has developed a profile of medical tourism that is based on his close contacts within the industry.

Mr. Woodman said the vast majority of U.S. medical tourists go to Mexico, which accounts for an estimated 1 million to 1.2 million medical visitors a year. He said Costa Rica is another popular destination, followed by other Latin American countries and some in the Far East, the Middle East, and Eastern Europe.

Mr. Woodman estimates that dental treatments make up 65% of all medical tourism. Cosmetic procedures come in a distant second, at 15%. Cosmetic procedures can be expensive and are rarely covered by insurance. They can be performed at half the price abroad, he said.

According to Mr. Woodman, other significant fields for medical tourism are orthopedics, which accounts for 5% of all visits, and bariatrics, with 3%-5%. Hip and knee replacements are expensive, and in the case of bariatrics, U.S. insurers often deny coverage, he said.

People also go abroad for fertility care and organ transplants, and one Jamaica company even offered dialysis vacations for U.S. tourists.

On the other hand, medical tourism does not work well for cancer treatments, because cancer care involves long periods of treatment and cannot be completed in a trip or two, Mr. Woodman said. “The media also plays up major procedures like open heart surgery, but they are in fact very rare,” he added.
 

What patients are looking for

Medical tourists typically pay 50%-70% of what they would pay in the United States for the same procedure, Mr. Woodman said. Prices are lower because patients pay in cash, foreign wages are lower, and expenses such as malpractice insurance are much lower.

“Many medical tourists don’t have a choice,” Mr. Woodman said. “They cannot afford the U.S. price for the procedure, even if they have health insurance, because they often have a high deductible.” In one study, the majority of medical tourists to Mexico reported an income of $25,000-$50,000 a year.

That same study also found that the average age of medical tourists was just under 65. These older patients often come for a vacation. “A sizable number of medical tourists are looking for surgery plus a vacation, a tummy-tuck and a stay at an all-inclusive resort,” said Steven P. Davison, MD, DDS, a plastic surgeon in Washington, who has written on the phenomenon.

Another large group of medical tourists are immigrants to the United States who want surgery in their country of origin, such as Brazil or Iran, Dr. Davison said, perhaps because they feel more comfortable or have family members who can act as caregivers. He said some go to places that have expertise in a certain procedure.

“For instance, they get their hair transplantation done in Turkey because surgeons there have the expertise and it’s cheaper than in the United States,” Dr. Davison said.
 

Arranging the trip

Patients often find foreign providers through online brokers who can arrange the flight, hotel, clinic, and physician. Brokers are not unbiased because they are usually paid by the clinic. Mr. Woodman said this arrangement works when the broker can offer a wide variety of options but not when the broker represents just a few clinics.

Mr. Woodman said patients could conceivably make their own arrangements without a broker, and some do so. “All the tools are on the Internet,” he said. “However, many people don’t trust themselves to do this work.”

Even for patients who depend on brokers, Mr. Woodman advises verifying the quality of the clinic and its doctors before signing on. Most countries have online lists of registered doctors, and patients seeking health care can research complaints against a doctor.

There is no insurance that patients can have to guard against the risks of medical tourism, Mr. Woodman said. “When you could get it, it was prohibitively expensive,” he said. “You can get travel insurance, but that just covers peripheral problems, such as flight cancellations, accidental injury, and emergency care. It has nothing to do with problems stemming from planned procedures.

“Some clinics and hospitals serving medical tourists provide warranties on their work,” he added. “However, plastic surgery clinics are less likely to offer warranties, because patients are so frequently dissatisfied.”
 

How things can go wrong

Mr. Woodman said medical tourists may often receive substandard care when they select a provider who offers unusually large savings, such as 80% off the U.S. price. “Those providers are likely cutting corners to get that kind of savings, and you should stay away from them,” he said.

Even when receiving care at an excellent clinic, patients can get infections if postoperative requirements are not followed, according to Darrick E. Antell, MD, a plastic surgeon in New York, who has treated medical tourists upon their return to the United States.

Typically, patients are told to stay in their rooms for several days after the operation, but friends may push them to go out and have fun, he said. Sometimes patients choose exotic arrangements that place them at risk for infection. As an example, Dr. Antell mentioned a broker who offered a safari in combination with plastic surgery.

Dr. Hermann said tummy tucks are riskier because they involve large incisions, and many such patients are overweight, which impairs healing. “Tummy-tuck patients need a longer recovery, and they often have more discomfort than other plastic surgery,” he said.

When things go wrong, medical tourists have few legal protections. “They usually don’t go to an accredited facility, there is no credentialing of physicians, and their ability to sue is extremely limited,” Dr. Davison said. Patients would have to return to the foreign country and hire a lawyer there, and even then, it is harder to win a case and to receive an award as high as in the United States, he added.
 

Dealing with follow-ups

An inherent flaw with medical tourism, Dr. Antell said, is that patients typically go back home before postoperative care is fully completed. “They may stay just a few days after surgery, and then fly back home,” he said.

“Patients who have complex operations abroad should stay for 8-10 days to have a proper follow-up,” he said. “But they fly back early, which can also lead to getting pulmonary embolisms on the flight.

“A checkup right after surgery doesn’t uncover many complications, because these tend to occur 7-12 days after surgery,” Dr. Hermann said.

“If they come to me within 3 months after surgery, I charge an upfront fee just to see them, because it takes an hour of my time,” Dr. Davison said. “Then I will take care of acute emergency, such as taking out an infected implant.”

Hermann said many patients wait too long to have their complications treated in the United States. “They may first try calling their doctor in Mexico, who tells them to take some antibiotics or something,” he said. “So when they finally do seek care, the infection is pretty far along.”
 

What U.S. doctors can do

Patients rarely tell their U.S. doctors that they are planning a trip to a foreign country to undergo medical treatment, even though they have to request a copy of their medical records for the foreign doctor, Mr. Woodman said.

Dr. Hermann said only one of his patients told him she was planning to go aboard for plastic surgery. “She was a young mom, and I tried to talk her out of it,” he said. “I don’t know what happened because she didn’t come back.”

Dr. Hermann said doctors should assume that they won’t be able to change their patients’ minds, and they should try to help their patients make the best of it.

“They should insist on seeing the doctor ahead of time and make sure they get along with them,” he said. “Ask for credentialing of the doctor and the facility, and stay there several weeks post op. But they’re probably not going to do all of this.”

A version of this article first appeared on Medscape.com.

In March 2023, four “medical tourists” from South Carolina who were seeking health care in Mexico were kidnapped by a drug cartel. Two were killed when they were trapped in a shootout. One of them was scheduled for tummy-tuck surgery, and others were seeking cheaper prescription drugs.

The news reached Bruce Hermann, MD, a plastic surgeon in Denton, Tex., who brought up the incident in a segment of his podcast, “Nip Talk,” in which he talked about the risks of medical tourism. But violence in foreign countries isn’t Dr. Hermann’s primary concern.

“Being the victim of a crime is lower down the risk strata,” Dr. Hermann said in an interview. “A bigger concern is the lack of regulations of doctors and facilities in countries like Mexico.”

The savings from medical tourism may be tempting, but the unpredictable clinical risks are daunting. Some employers pay for treatment at certain foreign clinics, and Blue Shield of California’s HMO plan, Access Baja, covers care in certain clinics in Mexico’s Baja peninsula. But U.S. health insurance generally does not cover medical tourism.

Despite its popularity, medical tourism is not siphoning off a significant number of patients from U.S. doctors, with the possible exception of plastic surgery. One study found that medical tourism accounts for less than 2% of U.S. spending on noncosmetic health care.

Still, as many as 1.2 million Americans travel to Mexico each year seeking health care at lower costs, particularly dental care, bariatric surgery, and cosmetic procedures.

Physicians such as Dr. Hermann see the results when things go awry. Dr. Hermann said when he takes calls at a nearby level II trauma center, he sees, on average, one patient a month with complications from plastic surgeries performed abroad.

Patients tell Dr. Hermann they often had little preoperative time with the surgeons, and some may not even see their surgeon. They have to fly back home just days after their procedures, so complications that typically arise later are missed, he said.
 

Who opts for medical tourism?

There are few statistics on the number of medical tourists or the clinical problems they have. Josef Woodman, CEO of Patients Beyond Borders, a medical tourism consultancy in Chapel Hill, N.C., has developed a profile of medical tourism that is based on his close contacts within the industry.

Mr. Woodman said the vast majority of U.S. medical tourists go to Mexico, which accounts for an estimated 1 million to 1.2 million medical visitors a year. He said Costa Rica is another popular destination, followed by other Latin American countries and some in the Far East, the Middle East, and Eastern Europe.

Mr. Woodman estimates that dental treatments make up 65% of all medical tourism. Cosmetic procedures come in a distant second, at 15%. Cosmetic procedures can be expensive and are rarely covered by insurance. They can be performed at half the price abroad, he said.

According to Mr. Woodman, other significant fields for medical tourism are orthopedics, which accounts for 5% of all visits, and bariatrics, with 3%-5%. Hip and knee replacements are expensive, and in the case of bariatrics, U.S. insurers often deny coverage, he said.

People also go abroad for fertility care and organ transplants, and one Jamaica company even offered dialysis vacations for U.S. tourists.

On the other hand, medical tourism does not work well for cancer treatments, because cancer care involves long periods of treatment and cannot be completed in a trip or two, Mr. Woodman said. “The media also plays up major procedures like open heart surgery, but they are in fact very rare,” he added.
 

What patients are looking for

Medical tourists typically pay 50%-70% of what they would pay in the United States for the same procedure, Mr. Woodman said. Prices are lower because patients pay in cash, foreign wages are lower, and expenses such as malpractice insurance are much lower.

“Many medical tourists don’t have a choice,” Mr. Woodman said. “They cannot afford the U.S. price for the procedure, even if they have health insurance, because they often have a high deductible.” In one study, the majority of medical tourists to Mexico reported an income of $25,000-$50,000 a year.

That same study also found that the average age of medical tourists was just under 65. These older patients often come for a vacation. “A sizable number of medical tourists are looking for surgery plus a vacation, a tummy-tuck and a stay at an all-inclusive resort,” said Steven P. Davison, MD, DDS, a plastic surgeon in Washington, who has written on the phenomenon.

Another large group of medical tourists are immigrants to the United States who want surgery in their country of origin, such as Brazil or Iran, Dr. Davison said, perhaps because they feel more comfortable or have family members who can act as caregivers. He said some go to places that have expertise in a certain procedure.

“For instance, they get their hair transplantation done in Turkey because surgeons there have the expertise and it’s cheaper than in the United States,” Dr. Davison said.
 

Arranging the trip

Patients often find foreign providers through online brokers who can arrange the flight, hotel, clinic, and physician. Brokers are not unbiased because they are usually paid by the clinic. Mr. Woodman said this arrangement works when the broker can offer a wide variety of options but not when the broker represents just a few clinics.

Mr. Woodman said patients could conceivably make their own arrangements without a broker, and some do so. “All the tools are on the Internet,” he said. “However, many people don’t trust themselves to do this work.”

Even for patients who depend on brokers, Mr. Woodman advises verifying the quality of the clinic and its doctors before signing on. Most countries have online lists of registered doctors, and patients seeking health care can research complaints against a doctor.

There is no insurance that patients can have to guard against the risks of medical tourism, Mr. Woodman said. “When you could get it, it was prohibitively expensive,” he said. “You can get travel insurance, but that just covers peripheral problems, such as flight cancellations, accidental injury, and emergency care. It has nothing to do with problems stemming from planned procedures.

“Some clinics and hospitals serving medical tourists provide warranties on their work,” he added. “However, plastic surgery clinics are less likely to offer warranties, because patients are so frequently dissatisfied.”
 

How things can go wrong

Mr. Woodman said medical tourists may often receive substandard care when they select a provider who offers unusually large savings, such as 80% off the U.S. price. “Those providers are likely cutting corners to get that kind of savings, and you should stay away from them,” he said.

Even when receiving care at an excellent clinic, patients can get infections if postoperative requirements are not followed, according to Darrick E. Antell, MD, a plastic surgeon in New York, who has treated medical tourists upon their return to the United States.

Typically, patients are told to stay in their rooms for several days after the operation, but friends may push them to go out and have fun, he said. Sometimes patients choose exotic arrangements that place them at risk for infection. As an example, Dr. Antell mentioned a broker who offered a safari in combination with plastic surgery.

Dr. Hermann said tummy tucks are riskier because they involve large incisions, and many such patients are overweight, which impairs healing. “Tummy-tuck patients need a longer recovery, and they often have more discomfort than other plastic surgery,” he said.

When things go wrong, medical tourists have few legal protections. “They usually don’t go to an accredited facility, there is no credentialing of physicians, and their ability to sue is extremely limited,” Dr. Davison said. Patients would have to return to the foreign country and hire a lawyer there, and even then, it is harder to win a case and to receive an award as high as in the United States, he added.
 

Dealing with follow-ups

An inherent flaw with medical tourism, Dr. Antell said, is that patients typically go back home before postoperative care is fully completed. “They may stay just a few days after surgery, and then fly back home,” he said.

“Patients who have complex operations abroad should stay for 8-10 days to have a proper follow-up,” he said. “But they fly back early, which can also lead to getting pulmonary embolisms on the flight.

“A checkup right after surgery doesn’t uncover many complications, because these tend to occur 7-12 days after surgery,” Dr. Hermann said.

“If they come to me within 3 months after surgery, I charge an upfront fee just to see them, because it takes an hour of my time,” Dr. Davison said. “Then I will take care of acute emergency, such as taking out an infected implant.”

Hermann said many patients wait too long to have their complications treated in the United States. “They may first try calling their doctor in Mexico, who tells them to take some antibiotics or something,” he said. “So when they finally do seek care, the infection is pretty far along.”
 

What U.S. doctors can do

Patients rarely tell their U.S. doctors that they are planning a trip to a foreign country to undergo medical treatment, even though they have to request a copy of their medical records for the foreign doctor, Mr. Woodman said.

Dr. Hermann said only one of his patients told him she was planning to go aboard for plastic surgery. “She was a young mom, and I tried to talk her out of it,” he said. “I don’t know what happened because she didn’t come back.”

Dr. Hermann said doctors should assume that they won’t be able to change their patients’ minds, and they should try to help their patients make the best of it.

“They should insist on seeing the doctor ahead of time and make sure they get along with them,” he said. “Ask for credentialing of the doctor and the facility, and stay there several weeks post op. But they’re probably not going to do all of this.”

A version of this article first appeared on Medscape.com.

In March 2023, four “medical tourists” from South Carolina who were seeking health care in Mexico were kidnapped by a drug cartel. Two were killed when they were trapped in a shootout. One of them was scheduled for tummy-tuck surgery, and others were seeking cheaper prescription drugs.

The news reached Bruce Hermann, MD, a plastic surgeon in Denton, Tex., who brought up the incident in a segment of his podcast, “Nip Talk,” in which he talked about the risks of medical tourism. But violence in foreign countries isn’t Dr. Hermann’s primary concern.

“Being the victim of a crime is lower down the risk strata,” Dr. Hermann said in an interview. “A bigger concern is the lack of regulations of doctors and facilities in countries like Mexico.”

The savings from medical tourism may be tempting, but the unpredictable clinical risks are daunting. Some employers pay for treatment at certain foreign clinics, and Blue Shield of California’s HMO plan, Access Baja, covers care in certain clinics in Mexico’s Baja peninsula. But U.S. health insurance generally does not cover medical tourism.

Despite its popularity, medical tourism is not siphoning off a significant number of patients from U.S. doctors, with the possible exception of plastic surgery. One study found that medical tourism accounts for less than 2% of U.S. spending on noncosmetic health care.

Still, as many as 1.2 million Americans travel to Mexico each year seeking health care at lower costs, particularly dental care, bariatric surgery, and cosmetic procedures.

Physicians such as Dr. Hermann see the results when things go awry. Dr. Hermann said when he takes calls at a nearby level II trauma center, he sees, on average, one patient a month with complications from plastic surgeries performed abroad.

Patients tell Dr. Hermann they often had little preoperative time with the surgeons, and some may not even see their surgeon. They have to fly back home just days after their procedures, so complications that typically arise later are missed, he said.
 

Who opts for medical tourism?

There are few statistics on the number of medical tourists or the clinical problems they have. Josef Woodman, CEO of Patients Beyond Borders, a medical tourism consultancy in Chapel Hill, N.C., has developed a profile of medical tourism that is based on his close contacts within the industry.

Mr. Woodman said the vast majority of U.S. medical tourists go to Mexico, which accounts for an estimated 1 million to 1.2 million medical visitors a year. He said Costa Rica is another popular destination, followed by other Latin American countries and some in the Far East, the Middle East, and Eastern Europe.

Mr. Woodman estimates that dental treatments make up 65% of all medical tourism. Cosmetic procedures come in a distant second, at 15%. Cosmetic procedures can be expensive and are rarely covered by insurance. They can be performed at half the price abroad, he said.

According to Mr. Woodman, other significant fields for medical tourism are orthopedics, which accounts for 5% of all visits, and bariatrics, with 3%-5%. Hip and knee replacements are expensive, and in the case of bariatrics, U.S. insurers often deny coverage, he said.

People also go abroad for fertility care and organ transplants, and one Jamaica company even offered dialysis vacations for U.S. tourists.

On the other hand, medical tourism does not work well for cancer treatments, because cancer care involves long periods of treatment and cannot be completed in a trip or two, Mr. Woodman said. “The media also plays up major procedures like open heart surgery, but they are in fact very rare,” he added.
 

What patients are looking for

Medical tourists typically pay 50%-70% of what they would pay in the United States for the same procedure, Mr. Woodman said. Prices are lower because patients pay in cash, foreign wages are lower, and expenses such as malpractice insurance are much lower.

“Many medical tourists don’t have a choice,” Mr. Woodman said. “They cannot afford the U.S. price for the procedure, even if they have health insurance, because they often have a high deductible.” In one study, the majority of medical tourists to Mexico reported an income of $25,000-$50,000 a year.

That same study also found that the average age of medical tourists was just under 65. These older patients often come for a vacation. “A sizable number of medical tourists are looking for surgery plus a vacation, a tummy-tuck and a stay at an all-inclusive resort,” said Steven P. Davison, MD, DDS, a plastic surgeon in Washington, who has written on the phenomenon.

Another large group of medical tourists are immigrants to the United States who want surgery in their country of origin, such as Brazil or Iran, Dr. Davison said, perhaps because they feel more comfortable or have family members who can act as caregivers. He said some go to places that have expertise in a certain procedure.

“For instance, they get their hair transplantation done in Turkey because surgeons there have the expertise and it’s cheaper than in the United States,” Dr. Davison said.
 

Arranging the trip

Patients often find foreign providers through online brokers who can arrange the flight, hotel, clinic, and physician. Brokers are not unbiased because they are usually paid by the clinic. Mr. Woodman said this arrangement works when the broker can offer a wide variety of options but not when the broker represents just a few clinics.

Mr. Woodman said patients could conceivably make their own arrangements without a broker, and some do so. “All the tools are on the Internet,” he said. “However, many people don’t trust themselves to do this work.”

Even for patients who depend on brokers, Mr. Woodman advises verifying the quality of the clinic and its doctors before signing on. Most countries have online lists of registered doctors, and patients seeking health care can research complaints against a doctor.

There is no insurance that patients can have to guard against the risks of medical tourism, Mr. Woodman said. “When you could get it, it was prohibitively expensive,” he said. “You can get travel insurance, but that just covers peripheral problems, such as flight cancellations, accidental injury, and emergency care. It has nothing to do with problems stemming from planned procedures.

“Some clinics and hospitals serving medical tourists provide warranties on their work,” he added. “However, plastic surgery clinics are less likely to offer warranties, because patients are so frequently dissatisfied.”
 

How things can go wrong

Mr. Woodman said medical tourists may often receive substandard care when they select a provider who offers unusually large savings, such as 80% off the U.S. price. “Those providers are likely cutting corners to get that kind of savings, and you should stay away from them,” he said.

Even when receiving care at an excellent clinic, patients can get infections if postoperative requirements are not followed, according to Darrick E. Antell, MD, a plastic surgeon in New York, who has treated medical tourists upon their return to the United States.

Typically, patients are told to stay in their rooms for several days after the operation, but friends may push them to go out and have fun, he said. Sometimes patients choose exotic arrangements that place them at risk for infection. As an example, Dr. Antell mentioned a broker who offered a safari in combination with plastic surgery.

Dr. Hermann said tummy tucks are riskier because they involve large incisions, and many such patients are overweight, which impairs healing. “Tummy-tuck patients need a longer recovery, and they often have more discomfort than other plastic surgery,” he said.

When things go wrong, medical tourists have few legal protections. “They usually don’t go to an accredited facility, there is no credentialing of physicians, and their ability to sue is extremely limited,” Dr. Davison said. Patients would have to return to the foreign country and hire a lawyer there, and even then, it is harder to win a case and to receive an award as high as in the United States, he added.
 

Dealing with follow-ups

An inherent flaw with medical tourism, Dr. Antell said, is that patients typically go back home before postoperative care is fully completed. “They may stay just a few days after surgery, and then fly back home,” he said.

“Patients who have complex operations abroad should stay for 8-10 days to have a proper follow-up,” he said. “But they fly back early, which can also lead to getting pulmonary embolisms on the flight.

“A checkup right after surgery doesn’t uncover many complications, because these tend to occur 7-12 days after surgery,” Dr. Hermann said.

“If they come to me within 3 months after surgery, I charge an upfront fee just to see them, because it takes an hour of my time,” Dr. Davison said. “Then I will take care of acute emergency, such as taking out an infected implant.”

Hermann said many patients wait too long to have their complications treated in the United States. “They may first try calling their doctor in Mexico, who tells them to take some antibiotics or something,” he said. “So when they finally do seek care, the infection is pretty far along.”
 

What U.S. doctors can do

Patients rarely tell their U.S. doctors that they are planning a trip to a foreign country to undergo medical treatment, even though they have to request a copy of their medical records for the foreign doctor, Mr. Woodman said.

Dr. Hermann said only one of his patients told him she was planning to go aboard for plastic surgery. “She was a young mom, and I tried to talk her out of it,” he said. “I don’t know what happened because she didn’t come back.”

Dr. Hermann said doctors should assume that they won’t be able to change their patients’ minds, and they should try to help their patients make the best of it.

“They should insist on seeing the doctor ahead of time and make sure they get along with them,” he said. “Ask for credentialing of the doctor and the facility, and stay there several weeks post op. But they’re probably not going to do all of this.”

A version of this article first appeared on Medscape.com.

News of physicians accused or convicted of sexually inappropriate behavior toward patients during medical exams has been frequent recently. And patient advocates have brought up the fact that many patients are uncomfortable during sensitive exams.

As a result, more doctors and medical organizations are using chaperones to protect the patient and the physician.

For some institutions, the movement has been toward mandating chaperones. Chaperones can be present for any examination of what are often referred to as sensitive areas, such as breasts, genitalia, and the perianal area. For example, Yale University Health requires patients to use a medical staff member as a chaperone for all sensitive exams except in emergency situations. UCLA Health, on the other hand, allows any adult or child aged 12 years or older to decline a chaperone if they wish to do so. Michigan Medicine provides a chaperone on request, although a patient can opt out.

Many physicians fully support the concept. “If a patient requests a chaperone I think we all, as practitioners, should honor that request respectfully,” said Shieva Ghofrany, MD, an ob.gyn. practicing in Stamford, Conn., and cofounder of tribecalledv, a women’s health knowledge platform. “It’s a clear sign a patient wants to ensure that they feel safe and comfortable.”

However, using a chaperone can be challenging for many primary care physicians and specialists in terms of logistics. Should a chaperone’s job be purely observational? Or should the chaperone also be a medical professional who assists during the procedure? How, specifically, should a chaperone perform their duty during an exam? Where should the chaperone stand? What about legal and ethical ramifications?
 

Who should be a chaperone?

The role of a chaperone is sometimes vaguely defined. It’s logical that a chaperone should have sufficient medical knowledge. Could it be a medical student? Should it be a nurse or another doctor? Would a patient representative suffice even if they aren’t a direct-care clinician?

There are no set standards about who can assume the role. However, the American Medical Association recommends that a patient chaperone be an authorized member of a health care team. For many patients, this is vital.

“As a survivor of sexual assault by an ob.gyn. while I was pregnant, I can assure you that the heinous crime committed against me and hundreds of other women would have been prevented had there been another medical professional in the room,” said Laurie Kanyok, founder of a dance company in New York City, whose former doctor was recently convicted of federal sex abuse charges and is scheduled to be sentenced in July 2023. “The chaperone should be a physician assistant, nurse or medical professional. Qualified professionals better understand the nature and protocols of an exam.”

For children and adolescents, allowing a parent to be a chaperone might be a logical and comforting choice. However, a new British study found that it’s not appropriate.

Study authors Rebecca Jane Moon and Justin Huw Davies looked at pubertal staging–related exams and contend that a chaperone should always be impartial, and a parent’s presence could conceivably open up a physician to false charges of misconduct.

The solution: A parent should have the option be present during any physical exam of their child, with a medical professional additionally acting as chaperone. This can also work for any patient who wishes to bring a trusted friend or family member to their medical appointments.
 

How does a chaperoned exam work?

A research team from the Medical College of Wisconsin and Louisiana State University Health conducted a recent systematic review of patient and clinician perspectives on carrying out a chaperoned urology exam. The review found that the protocol could use improvement. For example, it was reported that over one-quarter of patients didn’t feel comfortable asking for a chaperone if they were not offered one. “Patients should not have to request this,” said Diana Londoño, MD, a board-certified urologist and assistant clinical professor at City of Hope National Medical Center in Duarte, Calif.

The researchers also found that 93% of female patients preferred a chaperone of the same gender, whereas male patients were split on this issue. Key duties of a chaperone should be to ensure privacy, help interpret instructions from doctor to patient, and continually clarify that consent is being requested as a sensitive exam proceeds, the researchers report. Although clinical practice standards for chaperones aren’t uniform, keeping these important points in mind can easily be adopted by any health care provider.

Many doctors do follow their own set guidelines. “Often, we have our medical assistants be our chaperones,” explained Dr. Ghofrany. “Ideally they ‘room’ the patient – take vitals and ask the patient what specific concerns they would like to address. This helps with exam set-up.

“For example, if a patient has a breast concern versus a concern about their genital area, this would change what drapes are used. The medical assistant would then stand near me if they are helping with a Pap smear or cultures, or they may stand by the patient’s head at the bedside and offer support if needed. Some patients want to hold someone’s hand during an uncomfortable exam.”

The issue of positioning is important. A patient may feel very uneasy if it appears that the chaperone is looking at their body from the doctor’s angle, negating the point of reassurance. The key is to explain before an exam exactly how a chaperone is needed during the exam itself and whether the chaperone is a medical assistant or nurse.

“Chaperones usually stand next to me on either side or on the side of the patient facing me, depending on if they are immediately assisting me or helping the patient,” said Dr. Londoño. If a chaperone will be moving back and forth during the exam, that should be conveyed as well. For virtual visits, a chaperone can act as a third party and be present on a split screen, a process Michigan Medicine uses.

It’s also important to inform patients that a chaperone can step in and stop an exam at any point, both at the patient’s request or because of any observation of inappropriate physician behavior. Understanding this can help reluctant patients feel less worry.

When Christian Miller was diagnosed with a sleep disorder, his doctor suggested having a chaperone present during his physical exams. At first, he was apprehensive but then found the experience to be very positive. “Having someone there with me gave me an extra measure of assurance that nothing untoward would happen,” he said. “I found that having a chaperone was reassuring. The chaperone was not intrusive but stood close enough to ensure everything went smoothly and respectfully.”
 

Do chaperones help protect physicians legally?

Some states mandate that chaperones be present by patient request during sensitive exams, such as Texas and Oregon. For the most part, though, physicians have no legal obligation to offer chaperones, although it could be in their best interest to do so.

Ob.gyn. is one of the most litigated specialties, for example, so these physicians may find chaperones can play a key role in averting lawsuits. According to data from Physicians’ Insurance, having a reliable witness in an exam room can mitigate claims, and doctors should follow a clear practice policy regarding chaperones for all patients to further reduce liability.

Another advantage to having a chaperone present: protection for a doctor against a problematic patient. The risk for assault or aggression during an exam can of course go both ways. It’s important to be able to prove any patient misconduct through a witness, and a chaperone can lessen the prospect of violence in any form. “Having a chaperone in an exam room is about protecting the doctors as well as the patient,” said Ms. Kanyok.

A chaperone can also defuse ethical dilemmas. Consider a patient who refuses to allow a chaperone in an exam, but a chaperone is required by the physician’s health care organization. Asking a patient to state their reasons for wanting privacy with the chaperone present before the actual exam can help document the patient’s wish respectfully as well as protect a physician and organization from any potential liability if the patient refuses the exam altogether or if an exception for the patient is made.
 

Making a chaperone policy work best

• Have your staff inform patients of a medical chaperone policy at the time an appointment is made. Have fact sheets available for the patient before appointments fully outlining your policy.
• Inform the chaperone fully about the details of the exam and the patient’s case prior to the exam, in accordance with HIPAA.
• The chaperone can introduce themselves to the patient in the waiting room or exam room before you enter the room. The chaperone can go over the policy again verbally and answer any questions the patient may have initially. You can then clarify whether the patient understands your chaperone policy when you come in.
• Document, document, document. Write down who the chaperone was for each exam in patient notes and note the details of any interactions that are significant, such as patient questions or conflicts.
• Practice respect, above all. “A patient’s safety and level of comfort should be prioritized,” said Ms. Kanyok.

A version of this article first appeared on Medscape.com.

News of physicians accused or convicted of sexually inappropriate behavior toward patients during medical exams has been frequent recently. And patient advocates have brought up the fact that many patients are uncomfortable during sensitive exams.

As a result, more doctors and medical organizations are using chaperones to protect the patient and the physician.

For some institutions, the movement has been toward mandating chaperones. Chaperones can be present for any examination of what are often referred to as sensitive areas, such as breasts, genitalia, and the perianal area. For example, Yale University Health requires patients to use a medical staff member as a chaperone for all sensitive exams except in emergency situations. UCLA Health, on the other hand, allows any adult or child aged 12 years or older to decline a chaperone if they wish to do so. Michigan Medicine provides a chaperone on request, although a patient can opt out.

Many physicians fully support the concept. “If a patient requests a chaperone I think we all, as practitioners, should honor that request respectfully,” said Shieva Ghofrany, MD, an ob.gyn. practicing in Stamford, Conn., and cofounder of tribecalledv, a women’s health knowledge platform. “It’s a clear sign a patient wants to ensure that they feel safe and comfortable.”

However, using a chaperone can be challenging for many primary care physicians and specialists in terms of logistics. Should a chaperone’s job be purely observational? Or should the chaperone also be a medical professional who assists during the procedure? How, specifically, should a chaperone perform their duty during an exam? Where should the chaperone stand? What about legal and ethical ramifications?
 

Who should be a chaperone?

The role of a chaperone is sometimes vaguely defined. It’s logical that a chaperone should have sufficient medical knowledge. Could it be a medical student? Should it be a nurse or another doctor? Would a patient representative suffice even if they aren’t a direct-care clinician?

There are no set standards about who can assume the role. However, the American Medical Association recommends that a patient chaperone be an authorized member of a health care team. For many patients, this is vital.

“As a survivor of sexual assault by an ob.gyn. while I was pregnant, I can assure you that the heinous crime committed against me and hundreds of other women would have been prevented had there been another medical professional in the room,” said Laurie Kanyok, founder of a dance company in New York City, whose former doctor was recently convicted of federal sex abuse charges and is scheduled to be sentenced in July 2023. “The chaperone should be a physician assistant, nurse or medical professional. Qualified professionals better understand the nature and protocols of an exam.”

For children and adolescents, allowing a parent to be a chaperone might be a logical and comforting choice. However, a new British study found that it’s not appropriate.

Study authors Rebecca Jane Moon and Justin Huw Davies looked at pubertal staging–related exams and contend that a chaperone should always be impartial, and a parent’s presence could conceivably open up a physician to false charges of misconduct.

The solution: A parent should have the option be present during any physical exam of their child, with a medical professional additionally acting as chaperone. This can also work for any patient who wishes to bring a trusted friend or family member to their medical appointments.
 

How does a chaperoned exam work?

A research team from the Medical College of Wisconsin and Louisiana State University Health conducted a recent systematic review of patient and clinician perspectives on carrying out a chaperoned urology exam. The review found that the protocol could use improvement. For example, it was reported that over one-quarter of patients didn’t feel comfortable asking for a chaperone if they were not offered one. “Patients should not have to request this,” said Diana Londoño, MD, a board-certified urologist and assistant clinical professor at City of Hope National Medical Center in Duarte, Calif.

The researchers also found that 93% of female patients preferred a chaperone of the same gender, whereas male patients were split on this issue. Key duties of a chaperone should be to ensure privacy, help interpret instructions from doctor to patient, and continually clarify that consent is being requested as a sensitive exam proceeds, the researchers report. Although clinical practice standards for chaperones aren’t uniform, keeping these important points in mind can easily be adopted by any health care provider.

Many doctors do follow their own set guidelines. “Often, we have our medical assistants be our chaperones,” explained Dr. Ghofrany. “Ideally they ‘room’ the patient – take vitals and ask the patient what specific concerns they would like to address. This helps with exam set-up.

“For example, if a patient has a breast concern versus a concern about their genital area, this would change what drapes are used. The medical assistant would then stand near me if they are helping with a Pap smear or cultures, or they may stand by the patient’s head at the bedside and offer support if needed. Some patients want to hold someone’s hand during an uncomfortable exam.”

The issue of positioning is important. A patient may feel very uneasy if it appears that the chaperone is looking at their body from the doctor’s angle, negating the point of reassurance. The key is to explain before an exam exactly how a chaperone is needed during the exam itself and whether the chaperone is a medical assistant or nurse.

“Chaperones usually stand next to me on either side or on the side of the patient facing me, depending on if they are immediately assisting me or helping the patient,” said Dr. Londoño. If a chaperone will be moving back and forth during the exam, that should be conveyed as well. For virtual visits, a chaperone can act as a third party and be present on a split screen, a process Michigan Medicine uses.

It’s also important to inform patients that a chaperone can step in and stop an exam at any point, both at the patient’s request or because of any observation of inappropriate physician behavior. Understanding this can help reluctant patients feel less worry.

When Christian Miller was diagnosed with a sleep disorder, his doctor suggested having a chaperone present during his physical exams. At first, he was apprehensive but then found the experience to be very positive. “Having someone there with me gave me an extra measure of assurance that nothing untoward would happen,” he said. “I found that having a chaperone was reassuring. The chaperone was not intrusive but stood close enough to ensure everything went smoothly and respectfully.”
 

Do chaperones help protect physicians legally?

Some states mandate that chaperones be present by patient request during sensitive exams, such as Texas and Oregon. For the most part, though, physicians have no legal obligation to offer chaperones, although it could be in their best interest to do so.

Ob.gyn. is one of the most litigated specialties, for example, so these physicians may find chaperones can play a key role in averting lawsuits. According to data from Physicians’ Insurance, having a reliable witness in an exam room can mitigate claims, and doctors should follow a clear practice policy regarding chaperones for all patients to further reduce liability.

Another advantage to having a chaperone present: protection for a doctor against a problematic patient. The risk for assault or aggression during an exam can of course go both ways. It’s important to be able to prove any patient misconduct through a witness, and a chaperone can lessen the prospect of violence in any form. “Having a chaperone in an exam room is about protecting the doctors as well as the patient,” said Ms. Kanyok.

A chaperone can also defuse ethical dilemmas. Consider a patient who refuses to allow a chaperone in an exam, but a chaperone is required by the physician’s health care organization. Asking a patient to state their reasons for wanting privacy with the chaperone present before the actual exam can help document the patient’s wish respectfully as well as protect a physician and organization from any potential liability if the patient refuses the exam altogether or if an exception for the patient is made.
 

Making a chaperone policy work best

• Have your staff inform patients of a medical chaperone policy at the time an appointment is made. Have fact sheets available for the patient before appointments fully outlining your policy.
• Inform the chaperone fully about the details of the exam and the patient’s case prior to the exam, in accordance with HIPAA.
• The chaperone can introduce themselves to the patient in the waiting room or exam room before you enter the room. The chaperone can go over the policy again verbally and answer any questions the patient may have initially. You can then clarify whether the patient understands your chaperone policy when you come in.
• Document, document, document. Write down who the chaperone was for each exam in patient notes and note the details of any interactions that are significant, such as patient questions or conflicts.
• Practice respect, above all. “A patient’s safety and level of comfort should be prioritized,” said Ms. Kanyok.

A version of this article first appeared on Medscape.com.

News of physicians accused or convicted of sexually inappropriate behavior toward patients during medical exams has been frequent recently. And patient advocates have brought up the fact that many patients are uncomfortable during sensitive exams.

As a result, more doctors and medical organizations are using chaperones to protect the patient and the physician.

For some institutions, the movement has been toward mandating chaperones. Chaperones can be present for any examination of what are often referred to as sensitive areas, such as breasts, genitalia, and the perianal area. For example, Yale University Health requires patients to use a medical staff member as a chaperone for all sensitive exams except in emergency situations. UCLA Health, on the other hand, allows any adult or child aged 12 years or older to decline a chaperone if they wish to do so. Michigan Medicine provides a chaperone on request, although a patient can opt out.

Many physicians fully support the concept. “If a patient requests a chaperone I think we all, as practitioners, should honor that request respectfully,” said Shieva Ghofrany, MD, an ob.gyn. practicing in Stamford, Conn., and cofounder of tribecalledv, a women’s health knowledge platform. “It’s a clear sign a patient wants to ensure that they feel safe and comfortable.”

However, using a chaperone can be challenging for many primary care physicians and specialists in terms of logistics. Should a chaperone’s job be purely observational? Or should the chaperone also be a medical professional who assists during the procedure? How, specifically, should a chaperone perform their duty during an exam? Where should the chaperone stand? What about legal and ethical ramifications?
 

Who should be a chaperone?

The role of a chaperone is sometimes vaguely defined. It’s logical that a chaperone should have sufficient medical knowledge. Could it be a medical student? Should it be a nurse or another doctor? Would a patient representative suffice even if they aren’t a direct-care clinician?

There are no set standards about who can assume the role. However, the American Medical Association recommends that a patient chaperone be an authorized member of a health care team. For many patients, this is vital.

“As a survivor of sexual assault by an ob.gyn. while I was pregnant, I can assure you that the heinous crime committed against me and hundreds of other women would have been prevented had there been another medical professional in the room,” said Laurie Kanyok, founder of a dance company in New York City, whose former doctor was recently convicted of federal sex abuse charges and is scheduled to be sentenced in July 2023. “The chaperone should be a physician assistant, nurse or medical professional. Qualified professionals better understand the nature and protocols of an exam.”

For children and adolescents, allowing a parent to be a chaperone might be a logical and comforting choice. However, a new British study found that it’s not appropriate.

Study authors Rebecca Jane Moon and Justin Huw Davies looked at pubertal staging–related exams and contend that a chaperone should always be impartial, and a parent’s presence could conceivably open up a physician to false charges of misconduct.

The solution: A parent should have the option be present during any physical exam of their child, with a medical professional additionally acting as chaperone. This can also work for any patient who wishes to bring a trusted friend or family member to their medical appointments.
 

How does a chaperoned exam work?

A research team from the Medical College of Wisconsin and Louisiana State University Health conducted a recent systematic review of patient and clinician perspectives on carrying out a chaperoned urology exam. The review found that the protocol could use improvement. For example, it was reported that over one-quarter of patients didn’t feel comfortable asking for a chaperone if they were not offered one. “Patients should not have to request this,” said Diana Londoño, MD, a board-certified urologist and assistant clinical professor at City of Hope National Medical Center in Duarte, Calif.

The researchers also found that 93% of female patients preferred a chaperone of the same gender, whereas male patients were split on this issue. Key duties of a chaperone should be to ensure privacy, help interpret instructions from doctor to patient, and continually clarify that consent is being requested as a sensitive exam proceeds, the researchers report. Although clinical practice standards for chaperones aren’t uniform, keeping these important points in mind can easily be adopted by any health care provider.

Many doctors do follow their own set guidelines. “Often, we have our medical assistants be our chaperones,” explained Dr. Ghofrany. “Ideally they ‘room’ the patient – take vitals and ask the patient what specific concerns they would like to address. This helps with exam set-up.

“For example, if a patient has a breast concern versus a concern about their genital area, this would change what drapes are used. The medical assistant would then stand near me if they are helping with a Pap smear or cultures, or they may stand by the patient’s head at the bedside and offer support if needed. Some patients want to hold someone’s hand during an uncomfortable exam.”

The issue of positioning is important. A patient may feel very uneasy if it appears that the chaperone is looking at their body from the doctor’s angle, negating the point of reassurance. The key is to explain before an exam exactly how a chaperone is needed during the exam itself and whether the chaperone is a medical assistant or nurse.

“Chaperones usually stand next to me on either side or on the side of the patient facing me, depending on if they are immediately assisting me or helping the patient,” said Dr. Londoño. If a chaperone will be moving back and forth during the exam, that should be conveyed as well. For virtual visits, a chaperone can act as a third party and be present on a split screen, a process Michigan Medicine uses.

It’s also important to inform patients that a chaperone can step in and stop an exam at any point, both at the patient’s request or because of any observation of inappropriate physician behavior. Understanding this can help reluctant patients feel less worry.

When Christian Miller was diagnosed with a sleep disorder, his doctor suggested having a chaperone present during his physical exams. At first, he was apprehensive but then found the experience to be very positive. “Having someone there with me gave me an extra measure of assurance that nothing untoward would happen,” he said. “I found that having a chaperone was reassuring. The chaperone was not intrusive but stood close enough to ensure everything went smoothly and respectfully.”
 

Do chaperones help protect physicians legally?

Some states mandate that chaperones be present by patient request during sensitive exams, such as Texas and Oregon. For the most part, though, physicians have no legal obligation to offer chaperones, although it could be in their best interest to do so.

Ob.gyn. is one of the most litigated specialties, for example, so these physicians may find chaperones can play a key role in averting lawsuits. According to data from Physicians’ Insurance, having a reliable witness in an exam room can mitigate claims, and doctors should follow a clear practice policy regarding chaperones for all patients to further reduce liability.

Another advantage to having a chaperone present: protection for a doctor against a problematic patient. The risk for assault or aggression during an exam can of course go both ways. It’s important to be able to prove any patient misconduct through a witness, and a chaperone can lessen the prospect of violence in any form. “Having a chaperone in an exam room is about protecting the doctors as well as the patient,” said Ms. Kanyok.

A chaperone can also defuse ethical dilemmas. Consider a patient who refuses to allow a chaperone in an exam, but a chaperone is required by the physician’s health care organization. Asking a patient to state their reasons for wanting privacy with the chaperone present before the actual exam can help document the patient’s wish respectfully as well as protect a physician and organization from any potential liability if the patient refuses the exam altogether or if an exception for the patient is made.
 

Making a chaperone policy work best

• Have your staff inform patients of a medical chaperone policy at the time an appointment is made. Have fact sheets available for the patient before appointments fully outlining your policy.
• Inform the chaperone fully about the details of the exam and the patient’s case prior to the exam, in accordance with HIPAA.
• The chaperone can introduce themselves to the patient in the waiting room or exam room before you enter the room. The chaperone can go over the policy again verbally and answer any questions the patient may have initially. You can then clarify whether the patient understands your chaperone policy when you come in.
• Document, document, document. Write down who the chaperone was for each exam in patient notes and note the details of any interactions that are significant, such as patient questions or conflicts.
• Practice respect, above all. “A patient’s safety and level of comfort should be prioritized,” said Ms. Kanyok.

A version of this article first appeared on Medscape.com.