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Introducing the ‘Ethics Corner’
In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.
In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.
Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.
We hope you enjoy these, and all the stories featured in our September issue.
Megan A. Adams, MD, JD, MSc
In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.
In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.
Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.
We hope you enjoy these, and all the stories featured in our September issue.
Megan A. Adams, MD, JD, MSc
In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.
In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.
Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.
We hope you enjoy these, and all the stories featured in our September issue.
Megan A. Adams, MD, JD, MSc
Coping with burnout and repetitive injuries
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
NPs, PAs, and physicians hope to join doctors’ union in rare alliance
Advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) have long been at odds with doctor groups over scope of practice issues. But in a rare alliance, in late September. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD.
The Allina health care providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.
Although doctors and APPs have said that they generally work well together, the relationship has been strained in recent years as APPs argue for greater scope of practice. Meanwhile, physician groups, such as the American Medical Association, believe that APPs need more oversight.
An Allina union organizer, Britta V. Kasmarik, CNP, acknowledges the tension between physicians and APPs. But she said in an interview that the union effort helped bond this group of health care providers. “We share common goals of providing high-quality care for patients in a safe way, and we see the same things day in and day out with our patients.”
Matt Hoffman, MD, a primary care physician at Allina, told this news organization that APPs in his specialty perform the same job as doctors “and the working conditions are really identical. In our view, that means we should be unionizing together.”
The decision to hold a union vote follows similar action by nearly 150 Allina Mercy Hospital physicians in March. Allina Health appealed the vote.
In response to a New York Times investigation, the Minnesota Attorney General’s office began reviewing reports of aggressive billing practices and denied care at Allina Health.
The Allina Health system, which reports $4 billion in annual revenue, cut off nonemergency services to patients, including children, if their medical debt exceeded $4,500, according to the New York Times article. For Allina’s physicians and APPs, that meant leaving patients’ illnesses untreated.
Less than a week after the attorney general announced its investigation, the health system ended this practice.
In a prepared statement to this news organization, Allina Health said that its providers are “critical members of our teams. … We deeply value and share their commitment to providing high-quality care to our patients.”
The health system said it planned to make operational improvements, implement new communication tools, and provide additional well-being resources and enhanced employee benefits “to improve the provider experience.” In addition, it hoped to continue to “foster a culture of collaboration with all our employees.”
Having a union will allow health care providers to advocate for their patients and give health care providers more decision-making power instead of corporate leaders maintaining full authority, Ms. Kasmarik told this news organization.
Union organizers are also concerned with changes to the daily practice of medicine. “We don’t want to be spending our time doing paperwork and calling insurance companies and filling out forms,” said Dr. Hoffman. “We want to be in the exam room with a patient.”
The Allina providers organized after multiple requests to corporate managers failed to address their concerns. Their demands include increased staffing and help with nonclinical work so that clinicians can spend more time with their patients.
“What I’m really excited about is that we will be able to work with the other unionized groups to make change ... by being involved in health care policy at a state or national level,” Dr. Hoffman said. For example, that involvement might include challenging insurance company decisions.
Doctors Council bills itself as the largest union for attending physicians in the country, with 3,500 members, according to Joe Crane, national organizing director.
Despite an increase in union efforts since the pandemic, health care workers – particularly doctors – have been slow to join unions. Mr. Crane estimated that only about 3% of U.S. physicians are currently union members. He cited union campaigns in Massachusetts, New York, and Washington, DC. For comparison, a minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape’s APRN compensation report last year.
Dr. Hoffman is confident the Allina health care providers will have enough votes to win the election to join the union. “We should have done this years ago.”
A version of this article appeared on Medscape.com.
Advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) have long been at odds with doctor groups over scope of practice issues. But in a rare alliance, in late September. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD.
The Allina health care providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.
Although doctors and APPs have said that they generally work well together, the relationship has been strained in recent years as APPs argue for greater scope of practice. Meanwhile, physician groups, such as the American Medical Association, believe that APPs need more oversight.
An Allina union organizer, Britta V. Kasmarik, CNP, acknowledges the tension between physicians and APPs. But she said in an interview that the union effort helped bond this group of health care providers. “We share common goals of providing high-quality care for patients in a safe way, and we see the same things day in and day out with our patients.”
Matt Hoffman, MD, a primary care physician at Allina, told this news organization that APPs in his specialty perform the same job as doctors “and the working conditions are really identical. In our view, that means we should be unionizing together.”
The decision to hold a union vote follows similar action by nearly 150 Allina Mercy Hospital physicians in March. Allina Health appealed the vote.
In response to a New York Times investigation, the Minnesota Attorney General’s office began reviewing reports of aggressive billing practices and denied care at Allina Health.
The Allina Health system, which reports $4 billion in annual revenue, cut off nonemergency services to patients, including children, if their medical debt exceeded $4,500, according to the New York Times article. For Allina’s physicians and APPs, that meant leaving patients’ illnesses untreated.
Less than a week after the attorney general announced its investigation, the health system ended this practice.
In a prepared statement to this news organization, Allina Health said that its providers are “critical members of our teams. … We deeply value and share their commitment to providing high-quality care to our patients.”
The health system said it planned to make operational improvements, implement new communication tools, and provide additional well-being resources and enhanced employee benefits “to improve the provider experience.” In addition, it hoped to continue to “foster a culture of collaboration with all our employees.”
Having a union will allow health care providers to advocate for their patients and give health care providers more decision-making power instead of corporate leaders maintaining full authority, Ms. Kasmarik told this news organization.
Union organizers are also concerned with changes to the daily practice of medicine. “We don’t want to be spending our time doing paperwork and calling insurance companies and filling out forms,” said Dr. Hoffman. “We want to be in the exam room with a patient.”
The Allina providers organized after multiple requests to corporate managers failed to address their concerns. Their demands include increased staffing and help with nonclinical work so that clinicians can spend more time with their patients.
“What I’m really excited about is that we will be able to work with the other unionized groups to make change ... by being involved in health care policy at a state or national level,” Dr. Hoffman said. For example, that involvement might include challenging insurance company decisions.
Doctors Council bills itself as the largest union for attending physicians in the country, with 3,500 members, according to Joe Crane, national organizing director.
Despite an increase in union efforts since the pandemic, health care workers – particularly doctors – have been slow to join unions. Mr. Crane estimated that only about 3% of U.S. physicians are currently union members. He cited union campaigns in Massachusetts, New York, and Washington, DC. For comparison, a minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape’s APRN compensation report last year.
Dr. Hoffman is confident the Allina health care providers will have enough votes to win the election to join the union. “We should have done this years ago.”
A version of this article appeared on Medscape.com.
Advanced practice providers (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) have long been at odds with doctor groups over scope of practice issues. But in a rare alliance, in late September. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD.
The Allina health care providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.
Although doctors and APPs have said that they generally work well together, the relationship has been strained in recent years as APPs argue for greater scope of practice. Meanwhile, physician groups, such as the American Medical Association, believe that APPs need more oversight.
An Allina union organizer, Britta V. Kasmarik, CNP, acknowledges the tension between physicians and APPs. But she said in an interview that the union effort helped bond this group of health care providers. “We share common goals of providing high-quality care for patients in a safe way, and we see the same things day in and day out with our patients.”
Matt Hoffman, MD, a primary care physician at Allina, told this news organization that APPs in his specialty perform the same job as doctors “and the working conditions are really identical. In our view, that means we should be unionizing together.”
The decision to hold a union vote follows similar action by nearly 150 Allina Mercy Hospital physicians in March. Allina Health appealed the vote.
In response to a New York Times investigation, the Minnesota Attorney General’s office began reviewing reports of aggressive billing practices and denied care at Allina Health.
The Allina Health system, which reports $4 billion in annual revenue, cut off nonemergency services to patients, including children, if their medical debt exceeded $4,500, according to the New York Times article. For Allina’s physicians and APPs, that meant leaving patients’ illnesses untreated.
Less than a week after the attorney general announced its investigation, the health system ended this practice.
In a prepared statement to this news organization, Allina Health said that its providers are “critical members of our teams. … We deeply value and share their commitment to providing high-quality care to our patients.”
The health system said it planned to make operational improvements, implement new communication tools, and provide additional well-being resources and enhanced employee benefits “to improve the provider experience.” In addition, it hoped to continue to “foster a culture of collaboration with all our employees.”
Having a union will allow health care providers to advocate for their patients and give health care providers more decision-making power instead of corporate leaders maintaining full authority, Ms. Kasmarik told this news organization.
Union organizers are also concerned with changes to the daily practice of medicine. “We don’t want to be spending our time doing paperwork and calling insurance companies and filling out forms,” said Dr. Hoffman. “We want to be in the exam room with a patient.”
The Allina providers organized after multiple requests to corporate managers failed to address their concerns. Their demands include increased staffing and help with nonclinical work so that clinicians can spend more time with their patients.
“What I’m really excited about is that we will be able to work with the other unionized groups to make change ... by being involved in health care policy at a state or national level,” Dr. Hoffman said. For example, that involvement might include challenging insurance company decisions.
Doctors Council bills itself as the largest union for attending physicians in the country, with 3,500 members, according to Joe Crane, national organizing director.
Despite an increase in union efforts since the pandemic, health care workers – particularly doctors – have been slow to join unions. Mr. Crane estimated that only about 3% of U.S. physicians are currently union members. He cited union campaigns in Massachusetts, New York, and Washington, DC. For comparison, a minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape’s APRN compensation report last year.
Dr. Hoffman is confident the Allina health care providers will have enough votes to win the election to join the union. “We should have done this years ago.”
A version of this article appeared on Medscape.com.
Medicare announces 10 drugs targeted for price cuts in 2026
People on Medicare may in 2026 see prices drop for 10 medicines, including pricey diabetes, cancer, blood clot, and arthritis treatments, if advocates for federal drug-price negotiations can implement their plans amid tough opposition.
It’s unclear at this time, though, how these negotiations will play out. The Chamber of Commerce has sided with pharmaceutical companies in bids to block direct Medicare negotiation of drug prices. Many influential Republicans in Congress oppose this plan, which has deep support from both Democrats and AARP.
While facing strong opposition to negotiations, the Centers for Medicare & Medicaid Services sought in its announcement to illustrate the high costs of the selected medicines.
CMS provided data on total Part D costs for selected medicines for the period from June 2022 to May 2023, along with tallies of the number of people taking these drugs. The 10 selected medicines are as follows:
- Eliquis (generic name: apixaban), used to prevent and treat serious blood clots. It is taken by about 3.7 million people through Part D plans. The estimated cost is $16.4 billion.
- Jardiance (generic name: empagliflozin), used for diabetes and heart failure. It is taken by almost 1.6 million people through Part D plans. The estimated cost is $7.06 billion.
- Xarelto (generic name: rivaroxaban), used for blood clots. It is taken by about 1.3 million people through Part D plans. The estimated cost is $6 billion.
- Januvia (generic name: sitagliptin), used for diabetes. It is taken by about 869,00 people through Part D plans. The estimated cost is $4.1 billion.
- Farxiga (generic name: dapagliflozin), used for diabetes, heart failure, and chronic kidney disease. It is taken by about 799,000 people through Part D plans. The estimated cost is almost $3.3 billion.
- Entresto (generic name: sacubitril/valsartan), used to treat heart failure. It is taken by 587,000 people through Part D plans. The estimated cost is $2.9 billion.
- Enbrel( generic name: etanercept), used for rheumatoid arthritis, psoriasis, and psoriatic arthritis. It is taken by 48,000 people through Part D plans. The estimated cost is $2.8 billion.
- Imbruvica (generic name: ibrutinib), used to treat some blood cancers. It is taken by about 20,000 people in Part D plans. The estimated cost is $2.7 billion.
- Stelara (generic name: ustekinumab), used to treat plaque psoriasis, psoriatic arthritis, or certain bowel conditions (Crohn’s disease, ulcerative colitis). It is used by about 22,000 people through Part D plans. The estimated cost is $2.6 billion.
- Fiasp; Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill. These are forms of insulin used to treat diabetes. They are used by about 777,000 people through Part D plans. The estimated cost is $2.6 billion.
A vocal critic of Medicare drug negotiations, Joel White, president of the Council for Affordable Health Coverage, called the announcement of the 10 drugs selected for negotiation “a hollow victory lap.” A former Republican staffer on the House Ways and Means Committee, Mr. White aided with the development of the Medicare Part D plans and has kept tabs on the pharmacy programs since its launch in 2006.
“No one’s costs will go down now or for years because of this announcement” about Part D negotiations, Mr. White said in a statement.
According to its website, CAHC includes among its members the American Academy of Ophthalmology as well as some patient groups, drugmakers, such as Johnson & Johnson, and insurers and industry groups, such as the National Association of Manufacturers.
Separately, the influential Chamber of Commerce is making a strong push to at least delay the implementation of the Medicare Part D drug negotiations. On Aug. 28, the chamber released a letter sent to the Biden administration, raising concerns about a “rush” to implement the provisions of the Inflation Reduction Act.
The chamber also has filed suit to challenge the drug negotiation provisions of the Inflation Reduction Act, requesting that the court issue a preliminary injunction by Oct. 1, 2023.
Other pending legal challenges to direct Medicare drug negotiations include suits filed by Merck, Bristol-Myers Squibb, Johnson & Johnson, Boehringer Ingelheim, and AstraZeneca, according to an email from Pharmaceutical Research and Manufacturers of America. PhRMA also said it is a party to a case.
In addition, the three congressional Republicans with most direct influence over Medicare policy issued on Aug. 29 a joint statement outlining their objections to the planned negotiations on drug prices.
This drug-negotiation proposal is “an unworkable, legally dubious scheme that will lead to higher prices for new drugs coming to market, stifle the development of new cures, and destroy jobs,” said House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.), House Ways and Means Committee Chair Jason Smith (R-Mo.), and Senate Finance Committee Ranking Member Mike Crapo (R-Idaho).
Democrats were equally firm and vocal in their support of the negotiations. Senate Finance Chairman Ron Wyden (D-Ore.) issued a statement on Aug. 29 that said the release of the list of the 10 drugs selected for Medicare drug negotiations is part of a “seismic shift in the relationship between Big Pharma, the federal government, and seniors who are counting on lower prices.
“I will be following the negotiation process closely and will fight any attempt by Big Pharma to undo or undermine the progress that’s been made,” Mr. Wyden said.
In addition, AARP issued a statement of its continued support for Medicare drug negotiations.
“The No. 1 reason seniors skip or ration their prescriptions is because they can’t afford them. This must stop,” said AARP executive vice president and chief advocacy and engagement officer Nancy LeaMond in the statement. “The big drug companies and their allies continue suing to overturn the Medicare drug price negotiation program to keep up their price gouging. We can’t allow seniors to be Big Pharma’s cash machine anymore.”
A version of this article first appeared on Medscape.com.
People on Medicare may in 2026 see prices drop for 10 medicines, including pricey diabetes, cancer, blood clot, and arthritis treatments, if advocates for federal drug-price negotiations can implement their plans amid tough opposition.
It’s unclear at this time, though, how these negotiations will play out. The Chamber of Commerce has sided with pharmaceutical companies in bids to block direct Medicare negotiation of drug prices. Many influential Republicans in Congress oppose this plan, which has deep support from both Democrats and AARP.
While facing strong opposition to negotiations, the Centers for Medicare & Medicaid Services sought in its announcement to illustrate the high costs of the selected medicines.
CMS provided data on total Part D costs for selected medicines for the period from June 2022 to May 2023, along with tallies of the number of people taking these drugs. The 10 selected medicines are as follows:
- Eliquis (generic name: apixaban), used to prevent and treat serious blood clots. It is taken by about 3.7 million people through Part D plans. The estimated cost is $16.4 billion.
- Jardiance (generic name: empagliflozin), used for diabetes and heart failure. It is taken by almost 1.6 million people through Part D plans. The estimated cost is $7.06 billion.
- Xarelto (generic name: rivaroxaban), used for blood clots. It is taken by about 1.3 million people through Part D plans. The estimated cost is $6 billion.
- Januvia (generic name: sitagliptin), used for diabetes. It is taken by about 869,00 people through Part D plans. The estimated cost is $4.1 billion.
- Farxiga (generic name: dapagliflozin), used for diabetes, heart failure, and chronic kidney disease. It is taken by about 799,000 people through Part D plans. The estimated cost is almost $3.3 billion.
- Entresto (generic name: sacubitril/valsartan), used to treat heart failure. It is taken by 587,000 people through Part D plans. The estimated cost is $2.9 billion.
- Enbrel( generic name: etanercept), used for rheumatoid arthritis, psoriasis, and psoriatic arthritis. It is taken by 48,000 people through Part D plans. The estimated cost is $2.8 billion.
- Imbruvica (generic name: ibrutinib), used to treat some blood cancers. It is taken by about 20,000 people in Part D plans. The estimated cost is $2.7 billion.
- Stelara (generic name: ustekinumab), used to treat plaque psoriasis, psoriatic arthritis, or certain bowel conditions (Crohn’s disease, ulcerative colitis). It is used by about 22,000 people through Part D plans. The estimated cost is $2.6 billion.
- Fiasp; Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill. These are forms of insulin used to treat diabetes. They are used by about 777,000 people through Part D plans. The estimated cost is $2.6 billion.
A vocal critic of Medicare drug negotiations, Joel White, president of the Council for Affordable Health Coverage, called the announcement of the 10 drugs selected for negotiation “a hollow victory lap.” A former Republican staffer on the House Ways and Means Committee, Mr. White aided with the development of the Medicare Part D plans and has kept tabs on the pharmacy programs since its launch in 2006.
“No one’s costs will go down now or for years because of this announcement” about Part D negotiations, Mr. White said in a statement.
According to its website, CAHC includes among its members the American Academy of Ophthalmology as well as some patient groups, drugmakers, such as Johnson & Johnson, and insurers and industry groups, such as the National Association of Manufacturers.
Separately, the influential Chamber of Commerce is making a strong push to at least delay the implementation of the Medicare Part D drug negotiations. On Aug. 28, the chamber released a letter sent to the Biden administration, raising concerns about a “rush” to implement the provisions of the Inflation Reduction Act.
The chamber also has filed suit to challenge the drug negotiation provisions of the Inflation Reduction Act, requesting that the court issue a preliminary injunction by Oct. 1, 2023.
Other pending legal challenges to direct Medicare drug negotiations include suits filed by Merck, Bristol-Myers Squibb, Johnson & Johnson, Boehringer Ingelheim, and AstraZeneca, according to an email from Pharmaceutical Research and Manufacturers of America. PhRMA also said it is a party to a case.
In addition, the three congressional Republicans with most direct influence over Medicare policy issued on Aug. 29 a joint statement outlining their objections to the planned negotiations on drug prices.
This drug-negotiation proposal is “an unworkable, legally dubious scheme that will lead to higher prices for new drugs coming to market, stifle the development of new cures, and destroy jobs,” said House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.), House Ways and Means Committee Chair Jason Smith (R-Mo.), and Senate Finance Committee Ranking Member Mike Crapo (R-Idaho).
Democrats were equally firm and vocal in their support of the negotiations. Senate Finance Chairman Ron Wyden (D-Ore.) issued a statement on Aug. 29 that said the release of the list of the 10 drugs selected for Medicare drug negotiations is part of a “seismic shift in the relationship between Big Pharma, the federal government, and seniors who are counting on lower prices.
“I will be following the negotiation process closely and will fight any attempt by Big Pharma to undo or undermine the progress that’s been made,” Mr. Wyden said.
In addition, AARP issued a statement of its continued support for Medicare drug negotiations.
“The No. 1 reason seniors skip or ration their prescriptions is because they can’t afford them. This must stop,” said AARP executive vice president and chief advocacy and engagement officer Nancy LeaMond in the statement. “The big drug companies and their allies continue suing to overturn the Medicare drug price negotiation program to keep up their price gouging. We can’t allow seniors to be Big Pharma’s cash machine anymore.”
A version of this article first appeared on Medscape.com.
People on Medicare may in 2026 see prices drop for 10 medicines, including pricey diabetes, cancer, blood clot, and arthritis treatments, if advocates for federal drug-price negotiations can implement their plans amid tough opposition.
It’s unclear at this time, though, how these negotiations will play out. The Chamber of Commerce has sided with pharmaceutical companies in bids to block direct Medicare negotiation of drug prices. Many influential Republicans in Congress oppose this plan, which has deep support from both Democrats and AARP.
While facing strong opposition to negotiations, the Centers for Medicare & Medicaid Services sought in its announcement to illustrate the high costs of the selected medicines.
CMS provided data on total Part D costs for selected medicines for the period from June 2022 to May 2023, along with tallies of the number of people taking these drugs. The 10 selected medicines are as follows:
- Eliquis (generic name: apixaban), used to prevent and treat serious blood clots. It is taken by about 3.7 million people through Part D plans. The estimated cost is $16.4 billion.
- Jardiance (generic name: empagliflozin), used for diabetes and heart failure. It is taken by almost 1.6 million people through Part D plans. The estimated cost is $7.06 billion.
- Xarelto (generic name: rivaroxaban), used for blood clots. It is taken by about 1.3 million people through Part D plans. The estimated cost is $6 billion.
- Januvia (generic name: sitagliptin), used for diabetes. It is taken by about 869,00 people through Part D plans. The estimated cost is $4.1 billion.
- Farxiga (generic name: dapagliflozin), used for diabetes, heart failure, and chronic kidney disease. It is taken by about 799,000 people through Part D plans. The estimated cost is almost $3.3 billion.
- Entresto (generic name: sacubitril/valsartan), used to treat heart failure. It is taken by 587,000 people through Part D plans. The estimated cost is $2.9 billion.
- Enbrel( generic name: etanercept), used for rheumatoid arthritis, psoriasis, and psoriatic arthritis. It is taken by 48,000 people through Part D plans. The estimated cost is $2.8 billion.
- Imbruvica (generic name: ibrutinib), used to treat some blood cancers. It is taken by about 20,000 people in Part D plans. The estimated cost is $2.7 billion.
- Stelara (generic name: ustekinumab), used to treat plaque psoriasis, psoriatic arthritis, or certain bowel conditions (Crohn’s disease, ulcerative colitis). It is used by about 22,000 people through Part D plans. The estimated cost is $2.6 billion.
- Fiasp; Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill. These are forms of insulin used to treat diabetes. They are used by about 777,000 people through Part D plans. The estimated cost is $2.6 billion.
A vocal critic of Medicare drug negotiations, Joel White, president of the Council for Affordable Health Coverage, called the announcement of the 10 drugs selected for negotiation “a hollow victory lap.” A former Republican staffer on the House Ways and Means Committee, Mr. White aided with the development of the Medicare Part D plans and has kept tabs on the pharmacy programs since its launch in 2006.
“No one’s costs will go down now or for years because of this announcement” about Part D negotiations, Mr. White said in a statement.
According to its website, CAHC includes among its members the American Academy of Ophthalmology as well as some patient groups, drugmakers, such as Johnson & Johnson, and insurers and industry groups, such as the National Association of Manufacturers.
Separately, the influential Chamber of Commerce is making a strong push to at least delay the implementation of the Medicare Part D drug negotiations. On Aug. 28, the chamber released a letter sent to the Biden administration, raising concerns about a “rush” to implement the provisions of the Inflation Reduction Act.
The chamber also has filed suit to challenge the drug negotiation provisions of the Inflation Reduction Act, requesting that the court issue a preliminary injunction by Oct. 1, 2023.
Other pending legal challenges to direct Medicare drug negotiations include suits filed by Merck, Bristol-Myers Squibb, Johnson & Johnson, Boehringer Ingelheim, and AstraZeneca, according to an email from Pharmaceutical Research and Manufacturers of America. PhRMA also said it is a party to a case.
In addition, the three congressional Republicans with most direct influence over Medicare policy issued on Aug. 29 a joint statement outlining their objections to the planned negotiations on drug prices.
This drug-negotiation proposal is “an unworkable, legally dubious scheme that will lead to higher prices for new drugs coming to market, stifle the development of new cures, and destroy jobs,” said House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.), House Ways and Means Committee Chair Jason Smith (R-Mo.), and Senate Finance Committee Ranking Member Mike Crapo (R-Idaho).
Democrats were equally firm and vocal in their support of the negotiations. Senate Finance Chairman Ron Wyden (D-Ore.) issued a statement on Aug. 29 that said the release of the list of the 10 drugs selected for Medicare drug negotiations is part of a “seismic shift in the relationship between Big Pharma, the federal government, and seniors who are counting on lower prices.
“I will be following the negotiation process closely and will fight any attempt by Big Pharma to undo or undermine the progress that’s been made,” Mr. Wyden said.
In addition, AARP issued a statement of its continued support for Medicare drug negotiations.
“The No. 1 reason seniors skip or ration their prescriptions is because they can’t afford them. This must stop,” said AARP executive vice president and chief advocacy and engagement officer Nancy LeaMond in the statement. “The big drug companies and their allies continue suing to overturn the Medicare drug price negotiation program to keep up their price gouging. We can’t allow seniors to be Big Pharma’s cash machine anymore.”
A version of this article first appeared on Medscape.com.
National Practitioner Data Bank should go public, group says
arguing that extra public scrutiny could pressure state medical boards to be more aggressive watchdogs.
Public Citizen’s report includes an analysis of how frequently medical boards sanctioned physicians in 2019, 2020, and 2021. These sanctions include license revocations, suspensions, voluntary surrenders of licenses, and limitations on practice while under investigation.
The report used data from the National Practitioner Data Bank (NPDB), a federal repository of reports about state licensure, discipline, and certification actions as well as medical malpractice payments. The database is closed to the public, but hospitals, malpractice insurers, and investigators can query it.
According to Public Citizen’s calculations, states most likely to take serious disciplinary action against physicians were:
- Michigan: 1.74 serious disciplinary actions per 1,000 physicians per year
- Ohio: 1.61
- North Dakota: 1.60
- Colorado: 1.55
- Arizona: 1.53
- The states least likely to do so were:
- Nevada: 0.24 serious disciplinary actions per 1,000 physicians per year
- New Hampshire: 0.25
- Georgia: 0.27
- Indiana: 0.28
- Nebraska: 0.32
- California, the largest U.S. state by both population and number of physicians, landed near the middle, ranking 27th with a rate of 0.83 serious actions per 1,000 physicians, Public Citizen said.
“There is no evidence that physicians in any state are, overall, more or less likely to be incompetent or miscreant than the physicians in any other state,” said Robert Oshel, PhD, a former NPDB associate director for research and an author of the report.
The differences instead reflect variations in boards’ enforcement of medical practice laws, domination of licensing boards by physicians, and inadequate budgets, he noted.
Public Citizen said Congress should change federal law to let members of the public get information from the NPDB to do a background check on physicians whom they are considering seeing or are already seeing. This would not only help individuals but also would spur state licensing boards to do their own checks with the NPDB, the group said.
“If licensing boards routinely queried the NPDB, they would not be faulted by the public and state legislators for not knowing about malpractice payments or disciplinary actions affecting their licensees and therefore not taking reasonable actions concerning their licensees found to have poor records,” the report said.
Questioning NPDB access for consumers
Michelle Mello, JD, PhD, a professor of law and health policy at Stanford (Calif.) University, has studied the current applications of the NPDB. In 2019, she published an article in The New England Journal of Medicine examining changes in practice patterns for clinicians who faced multiple malpractice claims.
Dr. Mello questioned what benefit consumers would get from direct access to the NPDB’s information.
“It provides almost no context for the information it reports, making it even harder for patients to make sense of what they see there,” Dr. Mello said in an interview.
Hospitals are already required to routinely query the NPDB. This legal requirement should be expanded to include licensing boards, which the report called “the last line of defense for the public from incompetent and miscreant physicians,” Public Citizen said.
“Ideally, this amendment should include free continuous query access by medical boards for all their licensees,” the report said. “In the absence of any action by Congress, individual state legislatures should require their licensing boards to query all their licensees or enroll in continuous query, as a few states already do.”
The Federation of State Medical Boards agreed with some of the other suggestions Public Citizen offered in the report. The two concur on the need for increased funding to state medical boards to ensure that they have adequate resources and staffing to fulfill their duties, FSMB said in a statement.
But FSMB disagreed with Public Citizens’ approach to ranking boards, saying it could mislead. The report lacks context about how boards’ funding and authority vary, Humayun Chaudhry, DO, FSMB’s chief executive officer, said. He also questioned the decision to focus only on serious disciplinary actions.
“The Public Citizen report does not take into account the wide range of disciplinary steps boards can take such as letters of reprimand or fines, which are often enough to stop problem behaviors – preempting further problems in the future,” Dr. Chaudhry said.
D.C. gets worst rating
The District of Columbia earned the worst mark in the Public Citizen ranking, holding the 51st spot, the same place it held in the group’s similar ranking on actions taken in the 2017-2019 period. There were 0.19 serious disciplinary actions per 1,000 physicians a year in Washington, Public Citizen said.
In an email to this news organization, Dr. Oshel said that the Public Citizen analysis focused on the number of licensed physicians in each state and D.C. that can be obtained and compared reliably. It avoided using the term “practicing physicians” owing in part to doubts about the reliability of these counts, he said.
As many as 20% of physicians nationwide are focused primarily on work outside of clinical care, Dr. Oshel estimated. In D.C., perhaps 40% of physicians may fall into this category. Of the more than 13,700 physicians licensed in D.C., there may be only about 8,126 actively practicing, according to Dr. Oshel.
But even using that lower estimate of practicing physicians would only raise D.C.’s ranking to 46, signaling a need for stepped-up enforcement, Dr. Oshel said.
“[Whether it’s] 46th or 51st, both are bad,” Dr. Oshel said.
A version of this article first appeared on Medscape.com.
arguing that extra public scrutiny could pressure state medical boards to be more aggressive watchdogs.
Public Citizen’s report includes an analysis of how frequently medical boards sanctioned physicians in 2019, 2020, and 2021. These sanctions include license revocations, suspensions, voluntary surrenders of licenses, and limitations on practice while under investigation.
The report used data from the National Practitioner Data Bank (NPDB), a federal repository of reports about state licensure, discipline, and certification actions as well as medical malpractice payments. The database is closed to the public, but hospitals, malpractice insurers, and investigators can query it.
According to Public Citizen’s calculations, states most likely to take serious disciplinary action against physicians were:
- Michigan: 1.74 serious disciplinary actions per 1,000 physicians per year
- Ohio: 1.61
- North Dakota: 1.60
- Colorado: 1.55
- Arizona: 1.53
- The states least likely to do so were:
- Nevada: 0.24 serious disciplinary actions per 1,000 physicians per year
- New Hampshire: 0.25
- Georgia: 0.27
- Indiana: 0.28
- Nebraska: 0.32
- California, the largest U.S. state by both population and number of physicians, landed near the middle, ranking 27th with a rate of 0.83 serious actions per 1,000 physicians, Public Citizen said.
“There is no evidence that physicians in any state are, overall, more or less likely to be incompetent or miscreant than the physicians in any other state,” said Robert Oshel, PhD, a former NPDB associate director for research and an author of the report.
The differences instead reflect variations in boards’ enforcement of medical practice laws, domination of licensing boards by physicians, and inadequate budgets, he noted.
Public Citizen said Congress should change federal law to let members of the public get information from the NPDB to do a background check on physicians whom they are considering seeing or are already seeing. This would not only help individuals but also would spur state licensing boards to do their own checks with the NPDB, the group said.
“If licensing boards routinely queried the NPDB, they would not be faulted by the public and state legislators for not knowing about malpractice payments or disciplinary actions affecting their licensees and therefore not taking reasonable actions concerning their licensees found to have poor records,” the report said.
Questioning NPDB access for consumers
Michelle Mello, JD, PhD, a professor of law and health policy at Stanford (Calif.) University, has studied the current applications of the NPDB. In 2019, she published an article in The New England Journal of Medicine examining changes in practice patterns for clinicians who faced multiple malpractice claims.
Dr. Mello questioned what benefit consumers would get from direct access to the NPDB’s information.
“It provides almost no context for the information it reports, making it even harder for patients to make sense of what they see there,” Dr. Mello said in an interview.
Hospitals are already required to routinely query the NPDB. This legal requirement should be expanded to include licensing boards, which the report called “the last line of defense for the public from incompetent and miscreant physicians,” Public Citizen said.
“Ideally, this amendment should include free continuous query access by medical boards for all their licensees,” the report said. “In the absence of any action by Congress, individual state legislatures should require their licensing boards to query all their licensees or enroll in continuous query, as a few states already do.”
The Federation of State Medical Boards agreed with some of the other suggestions Public Citizen offered in the report. The two concur on the need for increased funding to state medical boards to ensure that they have adequate resources and staffing to fulfill their duties, FSMB said in a statement.
But FSMB disagreed with Public Citizens’ approach to ranking boards, saying it could mislead. The report lacks context about how boards’ funding and authority vary, Humayun Chaudhry, DO, FSMB’s chief executive officer, said. He also questioned the decision to focus only on serious disciplinary actions.
“The Public Citizen report does not take into account the wide range of disciplinary steps boards can take such as letters of reprimand or fines, which are often enough to stop problem behaviors – preempting further problems in the future,” Dr. Chaudhry said.
D.C. gets worst rating
The District of Columbia earned the worst mark in the Public Citizen ranking, holding the 51st spot, the same place it held in the group’s similar ranking on actions taken in the 2017-2019 period. There were 0.19 serious disciplinary actions per 1,000 physicians a year in Washington, Public Citizen said.
In an email to this news organization, Dr. Oshel said that the Public Citizen analysis focused on the number of licensed physicians in each state and D.C. that can be obtained and compared reliably. It avoided using the term “practicing physicians” owing in part to doubts about the reliability of these counts, he said.
As many as 20% of physicians nationwide are focused primarily on work outside of clinical care, Dr. Oshel estimated. In D.C., perhaps 40% of physicians may fall into this category. Of the more than 13,700 physicians licensed in D.C., there may be only about 8,126 actively practicing, according to Dr. Oshel.
But even using that lower estimate of practicing physicians would only raise D.C.’s ranking to 46, signaling a need for stepped-up enforcement, Dr. Oshel said.
“[Whether it’s] 46th or 51st, both are bad,” Dr. Oshel said.
A version of this article first appeared on Medscape.com.
arguing that extra public scrutiny could pressure state medical boards to be more aggressive watchdogs.
Public Citizen’s report includes an analysis of how frequently medical boards sanctioned physicians in 2019, 2020, and 2021. These sanctions include license revocations, suspensions, voluntary surrenders of licenses, and limitations on practice while under investigation.
The report used data from the National Practitioner Data Bank (NPDB), a federal repository of reports about state licensure, discipline, and certification actions as well as medical malpractice payments. The database is closed to the public, but hospitals, malpractice insurers, and investigators can query it.
According to Public Citizen’s calculations, states most likely to take serious disciplinary action against physicians were:
- Michigan: 1.74 serious disciplinary actions per 1,000 physicians per year
- Ohio: 1.61
- North Dakota: 1.60
- Colorado: 1.55
- Arizona: 1.53
- The states least likely to do so were:
- Nevada: 0.24 serious disciplinary actions per 1,000 physicians per year
- New Hampshire: 0.25
- Georgia: 0.27
- Indiana: 0.28
- Nebraska: 0.32
- California, the largest U.S. state by both population and number of physicians, landed near the middle, ranking 27th with a rate of 0.83 serious actions per 1,000 physicians, Public Citizen said.
“There is no evidence that physicians in any state are, overall, more or less likely to be incompetent or miscreant than the physicians in any other state,” said Robert Oshel, PhD, a former NPDB associate director for research and an author of the report.
The differences instead reflect variations in boards’ enforcement of medical practice laws, domination of licensing boards by physicians, and inadequate budgets, he noted.
Public Citizen said Congress should change federal law to let members of the public get information from the NPDB to do a background check on physicians whom they are considering seeing or are already seeing. This would not only help individuals but also would spur state licensing boards to do their own checks with the NPDB, the group said.
“If licensing boards routinely queried the NPDB, they would not be faulted by the public and state legislators for not knowing about malpractice payments or disciplinary actions affecting their licensees and therefore not taking reasonable actions concerning their licensees found to have poor records,” the report said.
Questioning NPDB access for consumers
Michelle Mello, JD, PhD, a professor of law and health policy at Stanford (Calif.) University, has studied the current applications of the NPDB. In 2019, she published an article in The New England Journal of Medicine examining changes in practice patterns for clinicians who faced multiple malpractice claims.
Dr. Mello questioned what benefit consumers would get from direct access to the NPDB’s information.
“It provides almost no context for the information it reports, making it even harder for patients to make sense of what they see there,” Dr. Mello said in an interview.
Hospitals are already required to routinely query the NPDB. This legal requirement should be expanded to include licensing boards, which the report called “the last line of defense for the public from incompetent and miscreant physicians,” Public Citizen said.
“Ideally, this amendment should include free continuous query access by medical boards for all their licensees,” the report said. “In the absence of any action by Congress, individual state legislatures should require their licensing boards to query all their licensees or enroll in continuous query, as a few states already do.”
The Federation of State Medical Boards agreed with some of the other suggestions Public Citizen offered in the report. The two concur on the need for increased funding to state medical boards to ensure that they have adequate resources and staffing to fulfill their duties, FSMB said in a statement.
But FSMB disagreed with Public Citizens’ approach to ranking boards, saying it could mislead. The report lacks context about how boards’ funding and authority vary, Humayun Chaudhry, DO, FSMB’s chief executive officer, said. He also questioned the decision to focus only on serious disciplinary actions.
“The Public Citizen report does not take into account the wide range of disciplinary steps boards can take such as letters of reprimand or fines, which are often enough to stop problem behaviors – preempting further problems in the future,” Dr. Chaudhry said.
D.C. gets worst rating
The District of Columbia earned the worst mark in the Public Citizen ranking, holding the 51st spot, the same place it held in the group’s similar ranking on actions taken in the 2017-2019 period. There were 0.19 serious disciplinary actions per 1,000 physicians a year in Washington, Public Citizen said.
In an email to this news organization, Dr. Oshel said that the Public Citizen analysis focused on the number of licensed physicians in each state and D.C. that can be obtained and compared reliably. It avoided using the term “practicing physicians” owing in part to doubts about the reliability of these counts, he said.
As many as 20% of physicians nationwide are focused primarily on work outside of clinical care, Dr. Oshel estimated. In D.C., perhaps 40% of physicians may fall into this category. Of the more than 13,700 physicians licensed in D.C., there may be only about 8,126 actively practicing, according to Dr. Oshel.
But even using that lower estimate of practicing physicians would only raise D.C.’s ranking to 46, signaling a need for stepped-up enforcement, Dr. Oshel said.
“[Whether it’s] 46th or 51st, both are bad,” Dr. Oshel said.
A version of this article first appeared on Medscape.com.
ChatGPT in Dermatology Clinical Practice: Potential Uses and Pitfalls
Artificial intelligence (AI) technology has increasingly been incorporated in medicine. In dermatology, AI has been used to detect and diagnose skin lesions, including skin cancer.1 ChatGPT (OpenAI) is a novel, highly popular development in generative AI technology. A large language model released in 2022, ChatGPT is a chatbot designed to mimic human conversation and generate specific detailed information when prompted. Free and publicly available, it has been used by millions of people. ChatGPT’s application in the medical field currently is being evaluated across several specialties, including plastic surgery, radiology, and urology.2-4 ChatGPT has the potential to assist health care professionals, including dermatologists, though its use raises important ethical considerations. Herein, we focus on the potential benefits as well as the pitfalls of using ChatGPT in dermatology clinical practice.
Potential Uses of ChatGPT in Practice
A major benefit of ChatGPT is its ability to improve clinical efficiency. First, ChatGPT can provide quick access to general medical information, similar to a search engine but with more natural language processing and contextual understanding to synthesize information.5 This function is useful for rapid concise answers to specific and directed questions. ChatGPT also can interact with its user by asking follow-up questions to produce more precise and relevant responses; this feature may help dermatologists form more accurate differential diagnoses. Additionally, ChatGPT can increase efficiency in clinical practice by drafting generic medical documents,2 including templates for after-visit summaries, postprocedure instructions, referrals, prior authorization appeal letters, and educational handouts. Importantly, increased efficiency can reduce provider burnout and lead to improved patient care. Another useful feature of ChatGPT is its ability to output information modeling human conversation. Because of this feature, ChatGPT also could be employed in clinical practice to serve as an interpreter for patients during clinic visits. Currently, the use of virtual translators can be cumbersome and subject to technical constraints. ChatGPT can provide accurate and conversational translations for patients and dermatologists, improving the patient-provider relationship.
ChatGPT also can contribute to major advancements in the field of dermatology beyond the clinical setting. Because of its ability to draw from extensive data that have already been uploaded, there are some uses of ChatGPT in a research context: to assist in finding resources for research and reviews, formulating hypotheses, drafting study protocols, and collecting large amounts of data within seconds.6
ChatGPT also has potential in advancing medical education. It could be used by medical schools to model interactive patient encounters to help students practice taking a patient’s history and creating differential diagnoses.6 This application of ChatGPT may help medical students hone their clinical skills in a low-stress environment without the restrictions that can come with hiring and training standardized patients, especially when mimicking dermatologic clinical encounters.
Other possibilities for ChatGPT in dermatologic practice include survey administration, clinical trial recruitment, and even automatic high-risk medication monitoring. Despite the many potential applications of ChatGPT in clinical practice, the question raised in each scenario is the quality, accuracy, and safety of what it produces.
Potential Pitfalls of ChatGPT in Practice and Possible Mitigation Strategies
A main concern in using ChatGPT in clinical practice is its potential to produce inaccurate or biased information. When prompted to create a research abstract based on previously published research, ChatGPT drafted abstracts that were clear and digestible but supplemented with incorrect data.7 A group of medical researchers who reviewed these ChatGPT-generated abstracts mistook 32% of the abstracts as having been written by human researchers. The implications of this finding are worrisome. If inaccurate or false information is used by ChatGPT in documents sent to insurance companies or patients, the patient’s safety as well as the dermatologist’s license and credibility are at stake. Thus, dermatologists looking to use ChatGPT to draft generic medical documents should actively review the output to ensure that the information is accurate. Importantly, ChatGPT also is only currently programmed with information up to 2021, limiting its access to recently published research articles and updated International Classification of Diseases, Tenth Revision codes.5 The continued development of ChatGPT will lead to regular updates by OpenAI that resolve this shortcoming in the future. Further, AI models may encode and perpetuate harmful stereotypes and social biases that are present in training data.8
When considering its potential in clinical practice, ChatGPT itself states that it can aid in clinical decision-making by processing patient information, including history, current symptoms, and biopsy and test results. This is uncharted territory, and providers who use ChatGPT at this stage to aid in decision-making should regard it similarly to information retrieved from a search engine. The information produced by ChatGPT should be used to substantiate but not definitively confirm a diagnosis or dictate management. Clinical suspicion by the dermatologist should always trump ChatGPT output. If physicians recommend ChatGPT output over their own advice, it can become a liability, as the technology is not regulated to any degree. Patients also should be cautious when seeking and following medical advice from ChatGPT, as it could be misleading or incorrect and could undermine the patient-physician relationship.6
Additionally, the specific use of ChatGPT to evaluate patient health records raises concerns related to patient privacy and confidentiality. Providers should never enter patient information protected by the Health Insurance Portability and Accountability Act into ChatGPT or anywhere else on the internet. Mitigation of this risk is not currently possible; ChatGPT requires more development and further understanding to even consider its integration into current electronic health records without compromising patient confidentiality.
The Bottom Line
Overall, ChatGPT has the potential to improve efficiency in clinical practice by assisting with informational searches and document drafting. Importantly, increased efficiency can reduce provider burnout and lead to improved patient care. However, dermatologists should carefully weigh the ethical issues of nonmaleficence and justice in evaluating ChatGPT for accuracy, biases, and the protection of patient confidentiality.
Finally, we asked ChatGPT on February 28, 2023, what it thinks:
User: Should dermatologists use ChatGPT in clinical practice?
ChatGPT: As an AI language model, ChatGPT can be a useful tool in dermatology clinical practice, but it should be used with caution in conjunction with other sources of information and clinical judgement.
Dermatologists should be aware of the potential benefits and risks of using ChatGPT and make informed decisions about how to integrate it into their clinical practice. It’s important to remember that ChatGPT is not a substitute for clinical expertise or human interaction with patients, and it should only be used as a supplement to enhance the quality of patient care.
Dermatologists who choose to use ChatGPT should also be aware of its limitations and potential risks, such as limited accuracy, lack of context, and liability issues if it provides incorrect information or recommendations that lead to patient harm. Dermatologists should use their professional judgement and consult with other health care professionals when making important decisions regarding patient care.
- Thomsen K, Iversen L, Titlestad TL, et al. Systematic review of machine learning for diagnosis and prognosis in dermatology. J Dermatol Treat. 2020;31:496-510. doi:10.1080/09546634.2019.1682500
- Shen Y, Heacock L, Elias J, et al. ChatGPT and other large language models are double-edged swords. Radiology. 2023;307:E230163. doi:10.1148/radiol.230163
- Gupta R, Pande P, Herzog I, et al. Application of ChatGPT in cosmetic plastic surgery: ally or antagonist? Aesthet Surg J. 2023;43:NP587-NP590. doi: 10.1093/asj/sjad042
- Gabrielson AT, Odisho AY, Canes D. Harnessing generative artificial intelligence to improve efficiency among urologists: welcome ChatGPT. J Urol. 2023;209:827-829. doi:10.1097/JU.0000000000003383
- What is ChatGPT? OpenAI. Accessed August 10, 2023. https://help.openai.com/en/articles/6783457-chatgpt-general-faq
- Haupt CE, Marks M. AI-generated medical advice—GPT and beyond. JAMA. 2023;329:1349-1350. doi:10.1001/jama.2023.5321
- Gao CA, Howard FM, Markov NS, et al. Comparing Scientific Abstracts Generated by ChatGPT to Original Abstracts Using an Artificial Intelligence Output Detector, Plagiarism Detector, and Blinded Human Reviewers. Scientific Communication and Education; 2022. doi:10.1101/2022.12.23.521610
- Weidinger L, Mellor J, Rauh M, et al. Ethical and social risks of harm from language models. arXiv. Preprint posted online December 8, 2021. https://doi.org/10.48550/arXiv.2112.04359
Artificial intelligence (AI) technology has increasingly been incorporated in medicine. In dermatology, AI has been used to detect and diagnose skin lesions, including skin cancer.1 ChatGPT (OpenAI) is a novel, highly popular development in generative AI technology. A large language model released in 2022, ChatGPT is a chatbot designed to mimic human conversation and generate specific detailed information when prompted. Free and publicly available, it has been used by millions of people. ChatGPT’s application in the medical field currently is being evaluated across several specialties, including plastic surgery, radiology, and urology.2-4 ChatGPT has the potential to assist health care professionals, including dermatologists, though its use raises important ethical considerations. Herein, we focus on the potential benefits as well as the pitfalls of using ChatGPT in dermatology clinical practice.
Potential Uses of ChatGPT in Practice
A major benefit of ChatGPT is its ability to improve clinical efficiency. First, ChatGPT can provide quick access to general medical information, similar to a search engine but with more natural language processing and contextual understanding to synthesize information.5 This function is useful for rapid concise answers to specific and directed questions. ChatGPT also can interact with its user by asking follow-up questions to produce more precise and relevant responses; this feature may help dermatologists form more accurate differential diagnoses. Additionally, ChatGPT can increase efficiency in clinical practice by drafting generic medical documents,2 including templates for after-visit summaries, postprocedure instructions, referrals, prior authorization appeal letters, and educational handouts. Importantly, increased efficiency can reduce provider burnout and lead to improved patient care. Another useful feature of ChatGPT is its ability to output information modeling human conversation. Because of this feature, ChatGPT also could be employed in clinical practice to serve as an interpreter for patients during clinic visits. Currently, the use of virtual translators can be cumbersome and subject to technical constraints. ChatGPT can provide accurate and conversational translations for patients and dermatologists, improving the patient-provider relationship.
ChatGPT also can contribute to major advancements in the field of dermatology beyond the clinical setting. Because of its ability to draw from extensive data that have already been uploaded, there are some uses of ChatGPT in a research context: to assist in finding resources for research and reviews, formulating hypotheses, drafting study protocols, and collecting large amounts of data within seconds.6
ChatGPT also has potential in advancing medical education. It could be used by medical schools to model interactive patient encounters to help students practice taking a patient’s history and creating differential diagnoses.6 This application of ChatGPT may help medical students hone their clinical skills in a low-stress environment without the restrictions that can come with hiring and training standardized patients, especially when mimicking dermatologic clinical encounters.
Other possibilities for ChatGPT in dermatologic practice include survey administration, clinical trial recruitment, and even automatic high-risk medication monitoring. Despite the many potential applications of ChatGPT in clinical practice, the question raised in each scenario is the quality, accuracy, and safety of what it produces.
Potential Pitfalls of ChatGPT in Practice and Possible Mitigation Strategies
A main concern in using ChatGPT in clinical practice is its potential to produce inaccurate or biased information. When prompted to create a research abstract based on previously published research, ChatGPT drafted abstracts that were clear and digestible but supplemented with incorrect data.7 A group of medical researchers who reviewed these ChatGPT-generated abstracts mistook 32% of the abstracts as having been written by human researchers. The implications of this finding are worrisome. If inaccurate or false information is used by ChatGPT in documents sent to insurance companies or patients, the patient’s safety as well as the dermatologist’s license and credibility are at stake. Thus, dermatologists looking to use ChatGPT to draft generic medical documents should actively review the output to ensure that the information is accurate. Importantly, ChatGPT also is only currently programmed with information up to 2021, limiting its access to recently published research articles and updated International Classification of Diseases, Tenth Revision codes.5 The continued development of ChatGPT will lead to regular updates by OpenAI that resolve this shortcoming in the future. Further, AI models may encode and perpetuate harmful stereotypes and social biases that are present in training data.8
When considering its potential in clinical practice, ChatGPT itself states that it can aid in clinical decision-making by processing patient information, including history, current symptoms, and biopsy and test results. This is uncharted territory, and providers who use ChatGPT at this stage to aid in decision-making should regard it similarly to information retrieved from a search engine. The information produced by ChatGPT should be used to substantiate but not definitively confirm a diagnosis or dictate management. Clinical suspicion by the dermatologist should always trump ChatGPT output. If physicians recommend ChatGPT output over their own advice, it can become a liability, as the technology is not regulated to any degree. Patients also should be cautious when seeking and following medical advice from ChatGPT, as it could be misleading or incorrect and could undermine the patient-physician relationship.6
Additionally, the specific use of ChatGPT to evaluate patient health records raises concerns related to patient privacy and confidentiality. Providers should never enter patient information protected by the Health Insurance Portability and Accountability Act into ChatGPT or anywhere else on the internet. Mitigation of this risk is not currently possible; ChatGPT requires more development and further understanding to even consider its integration into current electronic health records without compromising patient confidentiality.
The Bottom Line
Overall, ChatGPT has the potential to improve efficiency in clinical practice by assisting with informational searches and document drafting. Importantly, increased efficiency can reduce provider burnout and lead to improved patient care. However, dermatologists should carefully weigh the ethical issues of nonmaleficence and justice in evaluating ChatGPT for accuracy, biases, and the protection of patient confidentiality.
Finally, we asked ChatGPT on February 28, 2023, what it thinks:
User: Should dermatologists use ChatGPT in clinical practice?
ChatGPT: As an AI language model, ChatGPT can be a useful tool in dermatology clinical practice, but it should be used with caution in conjunction with other sources of information and clinical judgement.
Dermatologists should be aware of the potential benefits and risks of using ChatGPT and make informed decisions about how to integrate it into their clinical practice. It’s important to remember that ChatGPT is not a substitute for clinical expertise or human interaction with patients, and it should only be used as a supplement to enhance the quality of patient care.
Dermatologists who choose to use ChatGPT should also be aware of its limitations and potential risks, such as limited accuracy, lack of context, and liability issues if it provides incorrect information or recommendations that lead to patient harm. Dermatologists should use their professional judgement and consult with other health care professionals when making important decisions regarding patient care.
Artificial intelligence (AI) technology has increasingly been incorporated in medicine. In dermatology, AI has been used to detect and diagnose skin lesions, including skin cancer.1 ChatGPT (OpenAI) is a novel, highly popular development in generative AI technology. A large language model released in 2022, ChatGPT is a chatbot designed to mimic human conversation and generate specific detailed information when prompted. Free and publicly available, it has been used by millions of people. ChatGPT’s application in the medical field currently is being evaluated across several specialties, including plastic surgery, radiology, and urology.2-4 ChatGPT has the potential to assist health care professionals, including dermatologists, though its use raises important ethical considerations. Herein, we focus on the potential benefits as well as the pitfalls of using ChatGPT in dermatology clinical practice.
Potential Uses of ChatGPT in Practice
A major benefit of ChatGPT is its ability to improve clinical efficiency. First, ChatGPT can provide quick access to general medical information, similar to a search engine but with more natural language processing and contextual understanding to synthesize information.5 This function is useful for rapid concise answers to specific and directed questions. ChatGPT also can interact with its user by asking follow-up questions to produce more precise and relevant responses; this feature may help dermatologists form more accurate differential diagnoses. Additionally, ChatGPT can increase efficiency in clinical practice by drafting generic medical documents,2 including templates for after-visit summaries, postprocedure instructions, referrals, prior authorization appeal letters, and educational handouts. Importantly, increased efficiency can reduce provider burnout and lead to improved patient care. Another useful feature of ChatGPT is its ability to output information modeling human conversation. Because of this feature, ChatGPT also could be employed in clinical practice to serve as an interpreter for patients during clinic visits. Currently, the use of virtual translators can be cumbersome and subject to technical constraints. ChatGPT can provide accurate and conversational translations for patients and dermatologists, improving the patient-provider relationship.
ChatGPT also can contribute to major advancements in the field of dermatology beyond the clinical setting. Because of its ability to draw from extensive data that have already been uploaded, there are some uses of ChatGPT in a research context: to assist in finding resources for research and reviews, formulating hypotheses, drafting study protocols, and collecting large amounts of data within seconds.6
ChatGPT also has potential in advancing medical education. It could be used by medical schools to model interactive patient encounters to help students practice taking a patient’s history and creating differential diagnoses.6 This application of ChatGPT may help medical students hone their clinical skills in a low-stress environment without the restrictions that can come with hiring and training standardized patients, especially when mimicking dermatologic clinical encounters.
Other possibilities for ChatGPT in dermatologic practice include survey administration, clinical trial recruitment, and even automatic high-risk medication monitoring. Despite the many potential applications of ChatGPT in clinical practice, the question raised in each scenario is the quality, accuracy, and safety of what it produces.
Potential Pitfalls of ChatGPT in Practice and Possible Mitigation Strategies
A main concern in using ChatGPT in clinical practice is its potential to produce inaccurate or biased information. When prompted to create a research abstract based on previously published research, ChatGPT drafted abstracts that were clear and digestible but supplemented with incorrect data.7 A group of medical researchers who reviewed these ChatGPT-generated abstracts mistook 32% of the abstracts as having been written by human researchers. The implications of this finding are worrisome. If inaccurate or false information is used by ChatGPT in documents sent to insurance companies or patients, the patient’s safety as well as the dermatologist’s license and credibility are at stake. Thus, dermatologists looking to use ChatGPT to draft generic medical documents should actively review the output to ensure that the information is accurate. Importantly, ChatGPT also is only currently programmed with information up to 2021, limiting its access to recently published research articles and updated International Classification of Diseases, Tenth Revision codes.5 The continued development of ChatGPT will lead to regular updates by OpenAI that resolve this shortcoming in the future. Further, AI models may encode and perpetuate harmful stereotypes and social biases that are present in training data.8
When considering its potential in clinical practice, ChatGPT itself states that it can aid in clinical decision-making by processing patient information, including history, current symptoms, and biopsy and test results. This is uncharted territory, and providers who use ChatGPT at this stage to aid in decision-making should regard it similarly to information retrieved from a search engine. The information produced by ChatGPT should be used to substantiate but not definitively confirm a diagnosis or dictate management. Clinical suspicion by the dermatologist should always trump ChatGPT output. If physicians recommend ChatGPT output over their own advice, it can become a liability, as the technology is not regulated to any degree. Patients also should be cautious when seeking and following medical advice from ChatGPT, as it could be misleading or incorrect and could undermine the patient-physician relationship.6
Additionally, the specific use of ChatGPT to evaluate patient health records raises concerns related to patient privacy and confidentiality. Providers should never enter patient information protected by the Health Insurance Portability and Accountability Act into ChatGPT or anywhere else on the internet. Mitigation of this risk is not currently possible; ChatGPT requires more development and further understanding to even consider its integration into current electronic health records without compromising patient confidentiality.
The Bottom Line
Overall, ChatGPT has the potential to improve efficiency in clinical practice by assisting with informational searches and document drafting. Importantly, increased efficiency can reduce provider burnout and lead to improved patient care. However, dermatologists should carefully weigh the ethical issues of nonmaleficence and justice in evaluating ChatGPT for accuracy, biases, and the protection of patient confidentiality.
Finally, we asked ChatGPT on February 28, 2023, what it thinks:
User: Should dermatologists use ChatGPT in clinical practice?
ChatGPT: As an AI language model, ChatGPT can be a useful tool in dermatology clinical practice, but it should be used with caution in conjunction with other sources of information and clinical judgement.
Dermatologists should be aware of the potential benefits and risks of using ChatGPT and make informed decisions about how to integrate it into their clinical practice. It’s important to remember that ChatGPT is not a substitute for clinical expertise or human interaction with patients, and it should only be used as a supplement to enhance the quality of patient care.
Dermatologists who choose to use ChatGPT should also be aware of its limitations and potential risks, such as limited accuracy, lack of context, and liability issues if it provides incorrect information or recommendations that lead to patient harm. Dermatologists should use their professional judgement and consult with other health care professionals when making important decisions regarding patient care.
- Thomsen K, Iversen L, Titlestad TL, et al. Systematic review of machine learning for diagnosis and prognosis in dermatology. J Dermatol Treat. 2020;31:496-510. doi:10.1080/09546634.2019.1682500
- Shen Y, Heacock L, Elias J, et al. ChatGPT and other large language models are double-edged swords. Radiology. 2023;307:E230163. doi:10.1148/radiol.230163
- Gupta R, Pande P, Herzog I, et al. Application of ChatGPT in cosmetic plastic surgery: ally or antagonist? Aesthet Surg J. 2023;43:NP587-NP590. doi: 10.1093/asj/sjad042
- Gabrielson AT, Odisho AY, Canes D. Harnessing generative artificial intelligence to improve efficiency among urologists: welcome ChatGPT. J Urol. 2023;209:827-829. doi:10.1097/JU.0000000000003383
- What is ChatGPT? OpenAI. Accessed August 10, 2023. https://help.openai.com/en/articles/6783457-chatgpt-general-faq
- Haupt CE, Marks M. AI-generated medical advice—GPT and beyond. JAMA. 2023;329:1349-1350. doi:10.1001/jama.2023.5321
- Gao CA, Howard FM, Markov NS, et al. Comparing Scientific Abstracts Generated by ChatGPT to Original Abstracts Using an Artificial Intelligence Output Detector, Plagiarism Detector, and Blinded Human Reviewers. Scientific Communication and Education; 2022. doi:10.1101/2022.12.23.521610
- Weidinger L, Mellor J, Rauh M, et al. Ethical and social risks of harm from language models. arXiv. Preprint posted online December 8, 2021. https://doi.org/10.48550/arXiv.2112.04359
- Thomsen K, Iversen L, Titlestad TL, et al. Systematic review of machine learning for diagnosis and prognosis in dermatology. J Dermatol Treat. 2020;31:496-510. doi:10.1080/09546634.2019.1682500
- Shen Y, Heacock L, Elias J, et al. ChatGPT and other large language models are double-edged swords. Radiology. 2023;307:E230163. doi:10.1148/radiol.230163
- Gupta R, Pande P, Herzog I, et al. Application of ChatGPT in cosmetic plastic surgery: ally or antagonist? Aesthet Surg J. 2023;43:NP587-NP590. doi: 10.1093/asj/sjad042
- Gabrielson AT, Odisho AY, Canes D. Harnessing generative artificial intelligence to improve efficiency among urologists: welcome ChatGPT. J Urol. 2023;209:827-829. doi:10.1097/JU.0000000000003383
- What is ChatGPT? OpenAI. Accessed August 10, 2023. https://help.openai.com/en/articles/6783457-chatgpt-general-faq
- Haupt CE, Marks M. AI-generated medical advice—GPT and beyond. JAMA. 2023;329:1349-1350. doi:10.1001/jama.2023.5321
- Gao CA, Howard FM, Markov NS, et al. Comparing Scientific Abstracts Generated by ChatGPT to Original Abstracts Using an Artificial Intelligence Output Detector, Plagiarism Detector, and Blinded Human Reviewers. Scientific Communication and Education; 2022. doi:10.1101/2022.12.23.521610
- Weidinger L, Mellor J, Rauh M, et al. Ethical and social risks of harm from language models. arXiv. Preprint posted online December 8, 2021. https://doi.org/10.48550/arXiv.2112.04359
Practice Points
- ChatGPT potentially can play a beneficial role in dermatologic practice by quickly accessing and synthesizing information, drafting generic medical documents, interpreting visits, advancing medical education, and more.
- Dermatologists using ChatGPT should be extremely cautious, as it can produce false or biased information, perpetuate harmful stereotypes, and present information that is not up-to-date.
Big geographic access gaps for oncofertility services in U.S.
TOPLINE:
, a study shows.
METHODOLOGY:
- In this cross-sectional analysis, researchers identified 370 fertility centers in the United States (361 in the continental U.S.) that provide oncofertility services and that met criteria for an oncofertility center.
- Clinics were considered oncofertility centers if they offered oocyte cryopreservation, had performed at least one fertility preservation cycle in 2018, reported serving people without partners, and had an embryology laboratory that was accredited per Centers for Disease Control and Prevention guidelines.
- Researchers then quantified the number of young women potentially eligible for oncofertility services who lived farther than 2 hours from an oncofertility center.
- In a secondary analysis, the team assessed the association between geographic access and state fertility preservation insurance mandates.
TAKEAWAY:
- Overall, 3.63 million (5.7%) young women of reproductive age in the United States (aged 15-4) live more than 2 hours from an oncofertility center.
- The greatest gaps in access are in the Mountain West, West North Central, and Southwest regions; for instance, in Montana, North Dakota, and Wyoming fewer than half of the at-risk population has geographic access to an oncofertility center.
- Among the 11 states with fertility preservation insurance mandates, 98.5% of at-risk women have geographic access to an oncofertility center; in the 17 states without fertility preservation legislation, 79.6% of at-risk women have access to an oncofertility center.
IN PRACTICE:
Just over 3.6 million “reproductive-age female individuals lack geographic access to oncofertility services, especially in the Mountain West and West North Central regions,” the authors concluded. “Significant geographic disparities in access to fertility preservation in the U.S. require strategic expansion of care, especially given the growing demand for oncofertility services.”
SOURCE:
The study, led by Benjamin Peipert, MD, with Duke University, Durham, N.C., was published online in JAMA Oncology.
LIMITATIONS:
The authors relied on clinic data reported to the CDC, made assumptions about reasonable travel time, and may have underestimated access in some areas.
DISCLOSURES:
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
TOPLINE:
, a study shows.
METHODOLOGY:
- In this cross-sectional analysis, researchers identified 370 fertility centers in the United States (361 in the continental U.S.) that provide oncofertility services and that met criteria for an oncofertility center.
- Clinics were considered oncofertility centers if they offered oocyte cryopreservation, had performed at least one fertility preservation cycle in 2018, reported serving people without partners, and had an embryology laboratory that was accredited per Centers for Disease Control and Prevention guidelines.
- Researchers then quantified the number of young women potentially eligible for oncofertility services who lived farther than 2 hours from an oncofertility center.
- In a secondary analysis, the team assessed the association between geographic access and state fertility preservation insurance mandates.
TAKEAWAY:
- Overall, 3.63 million (5.7%) young women of reproductive age in the United States (aged 15-4) live more than 2 hours from an oncofertility center.
- The greatest gaps in access are in the Mountain West, West North Central, and Southwest regions; for instance, in Montana, North Dakota, and Wyoming fewer than half of the at-risk population has geographic access to an oncofertility center.
- Among the 11 states with fertility preservation insurance mandates, 98.5% of at-risk women have geographic access to an oncofertility center; in the 17 states without fertility preservation legislation, 79.6% of at-risk women have access to an oncofertility center.
IN PRACTICE:
Just over 3.6 million “reproductive-age female individuals lack geographic access to oncofertility services, especially in the Mountain West and West North Central regions,” the authors concluded. “Significant geographic disparities in access to fertility preservation in the U.S. require strategic expansion of care, especially given the growing demand for oncofertility services.”
SOURCE:
The study, led by Benjamin Peipert, MD, with Duke University, Durham, N.C., was published online in JAMA Oncology.
LIMITATIONS:
The authors relied on clinic data reported to the CDC, made assumptions about reasonable travel time, and may have underestimated access in some areas.
DISCLOSURES:
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
TOPLINE:
, a study shows.
METHODOLOGY:
- In this cross-sectional analysis, researchers identified 370 fertility centers in the United States (361 in the continental U.S.) that provide oncofertility services and that met criteria for an oncofertility center.
- Clinics were considered oncofertility centers if they offered oocyte cryopreservation, had performed at least one fertility preservation cycle in 2018, reported serving people without partners, and had an embryology laboratory that was accredited per Centers for Disease Control and Prevention guidelines.
- Researchers then quantified the number of young women potentially eligible for oncofertility services who lived farther than 2 hours from an oncofertility center.
- In a secondary analysis, the team assessed the association between geographic access and state fertility preservation insurance mandates.
TAKEAWAY:
- Overall, 3.63 million (5.7%) young women of reproductive age in the United States (aged 15-4) live more than 2 hours from an oncofertility center.
- The greatest gaps in access are in the Mountain West, West North Central, and Southwest regions; for instance, in Montana, North Dakota, and Wyoming fewer than half of the at-risk population has geographic access to an oncofertility center.
- Among the 11 states with fertility preservation insurance mandates, 98.5% of at-risk women have geographic access to an oncofertility center; in the 17 states without fertility preservation legislation, 79.6% of at-risk women have access to an oncofertility center.
IN PRACTICE:
Just over 3.6 million “reproductive-age female individuals lack geographic access to oncofertility services, especially in the Mountain West and West North Central regions,” the authors concluded. “Significant geographic disparities in access to fertility preservation in the U.S. require strategic expansion of care, especially given the growing demand for oncofertility services.”
SOURCE:
The study, led by Benjamin Peipert, MD, with Duke University, Durham, N.C., was published online in JAMA Oncology.
LIMITATIONS:
The authors relied on clinic data reported to the CDC, made assumptions about reasonable travel time, and may have underestimated access in some areas.
DISCLOSURES:
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA ONCOLOGY
Lobbying allowed insurers to charge physicians fees to receive payments online: Report
, according to a new investigation by the nonprofit news organization ProPublica.
The Affordable Care Act requires that health plans give providers the option of being paid electronically to improve efficiency and save money. In 2017, the Centers for Medicare & Medicaid Services issued guidance that prohibited insurers and their payment processing vendors from “engaging in unfair business practices that do not support an efficient healthcare system,” according to a recent Medical Group Management Association position paper.
But that guidance, which appeared to forbid requiring fees to receive payments online, disappeared from the CMS site 6 months later.
According to ProPublica’s reporting, the change was the result of a quiet insurance industry lobbying campaign led by Matthew Albright, a former CMS employee who left government service to work for Zelis, a payment processing company co-owned by private equity giant Bain Capital.
The details of the lobbying effort were discovered by Alex Shteynshlyuger, a New York urologist, who through public records requests received the email correspondence between Mr. Albright and CMS and shared that material with ProPublica.
Mr. Albright had been able to influence CMS policy to protect what ProPublica called a “crucial revenue stream” for payment processors. The fee notice was removed just 3 days after Mr. Albright requested the change, ProPublica found.
When CMS resisted further changes, including eliminating guidance forbidding insurers and payment processors from charging excess fees for online payments, Mr. Albright brought in a law firm. The threat of a lawsuit by deep-pocketed Zelis was enough to bring CMS in line, ProPublica reported. Today, these fees can cost larger medical practices more than $1 million a year, according to the MGMA report.
“It took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in,” writes Cezary Podkul, the author of the ProPublica report.
Predatory practices
It might seem that avoiding the fees would be as simple as requesting to be paid by check. However, a 2021 poll by the MGMA found that 57% of doctors were being charged these fees when they hadn’t agreed to them. According to the ProPublica report, physicians who have requested to be paid by check often find themselves being bounced back to electronic fund transfer (EFT) payments, where they are again charged fees.
In October 2021, more than 90 physician organizations, including the American Medical Association and the MGMA, signed a letter calling on the Biden administration to reinstate guidance to protect physicians’ right to receive EFT payments without paying fees. The letter describes the practice as “outrageous” and analogous to “an employee being required to enroll in a program that would deduct a percentage of each paycheck to receive direct deposit payments from an employer.”
So far, however, the situation remains unchanged. The language on the CMS site has changed, though. In 2022, the guidelines were adjusted to clarify that EFT fees are allowed.
A version of this article first appeared on Medscape.com.
, according to a new investigation by the nonprofit news organization ProPublica.
The Affordable Care Act requires that health plans give providers the option of being paid electronically to improve efficiency and save money. In 2017, the Centers for Medicare & Medicaid Services issued guidance that prohibited insurers and their payment processing vendors from “engaging in unfair business practices that do not support an efficient healthcare system,” according to a recent Medical Group Management Association position paper.
But that guidance, which appeared to forbid requiring fees to receive payments online, disappeared from the CMS site 6 months later.
According to ProPublica’s reporting, the change was the result of a quiet insurance industry lobbying campaign led by Matthew Albright, a former CMS employee who left government service to work for Zelis, a payment processing company co-owned by private equity giant Bain Capital.
The details of the lobbying effort were discovered by Alex Shteynshlyuger, a New York urologist, who through public records requests received the email correspondence between Mr. Albright and CMS and shared that material with ProPublica.
Mr. Albright had been able to influence CMS policy to protect what ProPublica called a “crucial revenue stream” for payment processors. The fee notice was removed just 3 days after Mr. Albright requested the change, ProPublica found.
When CMS resisted further changes, including eliminating guidance forbidding insurers and payment processors from charging excess fees for online payments, Mr. Albright brought in a law firm. The threat of a lawsuit by deep-pocketed Zelis was enough to bring CMS in line, ProPublica reported. Today, these fees can cost larger medical practices more than $1 million a year, according to the MGMA report.
“It took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in,” writes Cezary Podkul, the author of the ProPublica report.
Predatory practices
It might seem that avoiding the fees would be as simple as requesting to be paid by check. However, a 2021 poll by the MGMA found that 57% of doctors were being charged these fees when they hadn’t agreed to them. According to the ProPublica report, physicians who have requested to be paid by check often find themselves being bounced back to electronic fund transfer (EFT) payments, where they are again charged fees.
In October 2021, more than 90 physician organizations, including the American Medical Association and the MGMA, signed a letter calling on the Biden administration to reinstate guidance to protect physicians’ right to receive EFT payments without paying fees. The letter describes the practice as “outrageous” and analogous to “an employee being required to enroll in a program that would deduct a percentage of each paycheck to receive direct deposit payments from an employer.”
So far, however, the situation remains unchanged. The language on the CMS site has changed, though. In 2022, the guidelines were adjusted to clarify that EFT fees are allowed.
A version of this article first appeared on Medscape.com.
, according to a new investigation by the nonprofit news organization ProPublica.
The Affordable Care Act requires that health plans give providers the option of being paid electronically to improve efficiency and save money. In 2017, the Centers for Medicare & Medicaid Services issued guidance that prohibited insurers and their payment processing vendors from “engaging in unfair business practices that do not support an efficient healthcare system,” according to a recent Medical Group Management Association position paper.
But that guidance, which appeared to forbid requiring fees to receive payments online, disappeared from the CMS site 6 months later.
According to ProPublica’s reporting, the change was the result of a quiet insurance industry lobbying campaign led by Matthew Albright, a former CMS employee who left government service to work for Zelis, a payment processing company co-owned by private equity giant Bain Capital.
The details of the lobbying effort were discovered by Alex Shteynshlyuger, a New York urologist, who through public records requests received the email correspondence between Mr. Albright and CMS and shared that material with ProPublica.
Mr. Albright had been able to influence CMS policy to protect what ProPublica called a “crucial revenue stream” for payment processors. The fee notice was removed just 3 days after Mr. Albright requested the change, ProPublica found.
When CMS resisted further changes, including eliminating guidance forbidding insurers and payment processors from charging excess fees for online payments, Mr. Albright brought in a law firm. The threat of a lawsuit by deep-pocketed Zelis was enough to bring CMS in line, ProPublica reported. Today, these fees can cost larger medical practices more than $1 million a year, according to the MGMA report.
“It took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in,” writes Cezary Podkul, the author of the ProPublica report.
Predatory practices
It might seem that avoiding the fees would be as simple as requesting to be paid by check. However, a 2021 poll by the MGMA found that 57% of doctors were being charged these fees when they hadn’t agreed to them. According to the ProPublica report, physicians who have requested to be paid by check often find themselves being bounced back to electronic fund transfer (EFT) payments, where they are again charged fees.
In October 2021, more than 90 physician organizations, including the American Medical Association and the MGMA, signed a letter calling on the Biden administration to reinstate guidance to protect physicians’ right to receive EFT payments without paying fees. The letter describes the practice as “outrageous” and analogous to “an employee being required to enroll in a program that would deduct a percentage of each paycheck to receive direct deposit payments from an employer.”
So far, however, the situation remains unchanged. The language on the CMS site has changed, though. In 2022, the guidelines were adjusted to clarify that EFT fees are allowed.
A version of this article first appeared on Medscape.com.
Could a malpractice insurer drop you when you need it most?
You’ve practiced medicine for years without issues, but now you are facing a medical malpractice case. No worries – you’ve had professional liability insurance all this time, so surely there’s nothing to be concerned about. Undoubtedly, your medical malpractice insurer will cover the costs of defending you. Or will they? One case casts questions on just this issue.
Professional liability insurance
According to the American Medical Association, almost one in three physicians (31%) have had a medical malpractice lawsuit filed against them at some point in their careers. These numbers only increase the longer a physician practices; almost half of doctors 55 and over have been sued, compared with less than 10% of physicians under 40.
And while the majority of cases are dropped or dismissed, and the small minority of cases that do go to trial are mostly won by the defense, the cost of defending these cases can be extremely high. Physicians have medical malpractice insurance to defray these costs.
Malpractice insurance generally covers the costs of attorney fees, court costs, arbitration, compensatory damages, and settlements related to patient injury or death. Insurance sometimes, but not always, pays for the costs of malpractice lawsuits arising out of Health Insurance Portability and Accountability Act (HIPAA) violations.
But it is what the policies don’t pay for that should be of most interest to practitioners.
Exclusions to medical malpractice insurance
All professional liability insurance policies contain exclusions, and it is essential that you know what they are. While the exclusions may vary by policy, most malpractice insurance policies exclude claims stemming from:
- Reckless or intentional acts.
- Illegal/criminal activities, including theft.
- Misrepresentation, including dishonesty, fraudulent activity, falsification, and misrepresentation on forms.
- Practicing under the influence of alcohol or drugs.
- Altering patient or hospital records.
- Sexual misconduct.
- Cyber security issues, which typically require a separate cyber liability policy to protect against cyber attacks and data breaches affecting patient medical records.
It’s essential to know what your specific policy’s exclusions are, or you may be surprised to find that your malpractice liability insurance doesn’t cover you when you expected that it would. Such was the situation in a recently decided case.
Also essential is knowing what type of coverage your policy provides – claims-made or occurrence-based. Occurrence policies offer lifetime coverage for incidents that occurred during the policy period, no matter when the claim is made. Claims-made policies cover only incidents that occur and are reported within the policy’s time period (unless a “tail” policy is purchased to extend the reporting period).
The case
Dr. P was a neurologist specializing in pain management. He had a professional liability insurance policy with an insurance company. In 2012, Dr. P’s insurance agent saw a television news story about the physician being accused by the state medical board for overprescribing opioids, resulting in the deaths of 17 patients. The next day, the agent obtained copies of documents from the state medical board, including a summary suspension order and a notice of contemplated action.
The notice of contemplated action specified that Dr. P had deviated from the standard of care through injudicious prescribing, leading to approximately 17 patient deaths due to drug toxicity. Because the agent realized that lawsuits could be filed against Dr. P for the deaths, she sent the insurance company the paperwork from the medical board so the insurer would be aware of the potential claims.
However, when the insurer received the information, it did not investigate or seek more information as it was required to do. The insurer failed to get medical records, or specific patient names, and none of the 17 deaths were recorded in the insurance company’s claims system (a failure to follow company procedure). Instead, the insurance company decided to cancel Dr. P’s policy effective the following month.
The company sent Dr. P a cancellation letter advising him that his policy was being terminated due to “license suspension, nature of allegations, and practice profile,” and offered him a tail policy to purchase.
The insurance company did not advise Dr. P that he should ensure all potential claims were reported, including the 17 deaths, before his policy expired. The company also did not advise him that he had a claims-made policy and what that meant regarding future lawsuits that might be filed after his policy period expired.
A year later, Dr. P was sued in two wrongful death lawsuits by the families of two of the 17 opioid-related deaths. When he was served with the papers, he promptly notified the insurance company. The insurance company issued a denial letter, incorrectly asserting that the 17 drug-toxicity deaths that they were aware of did not qualify as claims under Dr. P’s policy.
After his insurance company failed to represent him, Dr. P divorced his wife of 35 years and filed for bankruptcy. The only creditors with claims were the two families who had sued him. The bankruptcy trustee filed a lawsuit against the insurance company on behalf of Dr. P for the insurer’s failure to defend and indemnify Dr. P against the wrongful death lawsuits. In 2017, the bankruptcy trustee settled the two wrongful death cases by paying the families a certain amount of cash and assigning the insurance bad faith lawsuit to them.
Court and jury decide
In 2020, the case against the insurance company ended up in court. By 2022, the court had decided some of the issues and left some for the jury to determine.
The court found that the insurance company had breached its obligation to defend and indemnify Dr. P, committed unfair insurance claims practices, and committed bad faith in failing to defend the physician. The court limited the compensation to the amount of cash that had been paid to settle the two cases, and any fees and costs that Dr. P had incurred defending himself.
However, this still left the jury to decide whether the insurance company had committed bad faith in failing to indemnify (secure a person against legal liability for his/her actions) Dr. P, whether it had violated the state’s Unfair Insurance Practices Act, and whether punitive damages should be levied against the insurer.
The jury trial ended in a stunning $52 million verdict against the insurance company after less than 2 hours of deliberation. The jury found that the insurance company had acted in bad faith and willfully violated the Unfair Insurances Practices Act.
While the jury ultimately decided against the insurance company and sent it a strong message with a large verdict, Dr. P’s career was still over. He had stopped practicing medicine, was bankrupt, and his personal life was in shambles. The litigation had taken about a decade. Sometimes a win isn’t a victory.
Protecting yourself
The best way to protect yourself from a situation in which your insurer will not defend you is to really know and understand your insurance policy. Is it occurrence-based or claims-made insurance? What exactly does it cover? How are claims supposed to be made? Your professional liability insurance can be extremely important if you get sued, so it is equally important to choose it carefully and to really understand what is being covered.
Other ways to protect yourself:
- Know your agent. Your agent is key to explaining your policy as well as helping in the event that you need to make a claim. Dr. P’s agent saw a news story about him on television, which is why she submitted the information to the insurance company. Dr. P would have been far better off calling the agent directly when he was being investigated by the state medical board to explain the situation and seek advice.
- Be aware of exclusions to your policy. Many – such as criminal acts, reckless or intentional acts, or practicing under the influence – were mentioned earlier in this article. Some may be unexpected, so it is extremely important that you understand the specific exclusions to your particular policy.
- Be aware of your state law, and how changes might affect you. For example, in states that have outlawed or criminalized abortion, an insurance company would probably not have to represent a policy holder who was sued for malpractice involving an abortion. On the other hand, be aware that not treating a patient who needs life-saving care because you are afraid of running afoul of the law can also get you in trouble if the patient is harmed by not being treated. (For example, the Centers for Medicare & Medicaid Services is currently investigating two hospitals that failed to provide necessary stabilizing abortion care to a patient with an emergency medication condition resulting from a miscarriage.)
- Know how your policy defines ‘intentional’ acts (which are typically excluded from coverage). This is important. In some jurisdictions, the insured clinician has to merely intend to commit the acts in order for the claim to be excluded. In other jurisdictions, the insured doctor has to intend to cause the resulting damage. This can result in a very different outcome.
- The best thing doctors can do is to really understand what the policy covers and be prepared to make some noise if the company is not covering something that it should. Don’t be afraid to ask questions if you think your insurer is doing something wrong, and if the answers don’t satisfy you, consult an attorney.
The future
In the fall of 2022, at least partially in response to the Dobbs v. Jackson Women’s Health Organization decision regarding abortion, one professional liability company (Physician’s Insurance) launched criminal defense reimbursement coverage for physicians and hospitals to pay for defense costs incurred in responding to criminal allegations arising directly from patient care.
The add-on Criminal Defense Reimbursement Endorsement was made available in Washington State in January 2023, and will be offered in other states pending regulatory approval. It reimburses defense costs up to $250,000 when criminal actions have arisen from direct patient care.
In a press release announcing the new coverage, Physician’s Insurance CEO Bill Cotter explained the company’s reasoning in providing it: “The already challenging environment for physicians and hospitals has been made even more difficult as they now navigate the legal ramifications of increased criminal medical negligence claims as seen in the case of the Nashville nurse at the Vanderbilt University Medical Center, the potential for criminal state claims arising out of the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, and the subsequent state criminalization of healthcare practices that have long been the professionally accepted standard of care.”
Expect to see more insurance companies offering new coverage options for physicians in the future as they recognize that physicians may be facing more than just medical malpractice lawsuits arising out of patient care.
A version of this article first appeared on Medscape.com.
You’ve practiced medicine for years without issues, but now you are facing a medical malpractice case. No worries – you’ve had professional liability insurance all this time, so surely there’s nothing to be concerned about. Undoubtedly, your medical malpractice insurer will cover the costs of defending you. Or will they? One case casts questions on just this issue.
Professional liability insurance
According to the American Medical Association, almost one in three physicians (31%) have had a medical malpractice lawsuit filed against them at some point in their careers. These numbers only increase the longer a physician practices; almost half of doctors 55 and over have been sued, compared with less than 10% of physicians under 40.
And while the majority of cases are dropped or dismissed, and the small minority of cases that do go to trial are mostly won by the defense, the cost of defending these cases can be extremely high. Physicians have medical malpractice insurance to defray these costs.
Malpractice insurance generally covers the costs of attorney fees, court costs, arbitration, compensatory damages, and settlements related to patient injury or death. Insurance sometimes, but not always, pays for the costs of malpractice lawsuits arising out of Health Insurance Portability and Accountability Act (HIPAA) violations.
But it is what the policies don’t pay for that should be of most interest to practitioners.
Exclusions to medical malpractice insurance
All professional liability insurance policies contain exclusions, and it is essential that you know what they are. While the exclusions may vary by policy, most malpractice insurance policies exclude claims stemming from:
- Reckless or intentional acts.
- Illegal/criminal activities, including theft.
- Misrepresentation, including dishonesty, fraudulent activity, falsification, and misrepresentation on forms.
- Practicing under the influence of alcohol or drugs.
- Altering patient or hospital records.
- Sexual misconduct.
- Cyber security issues, which typically require a separate cyber liability policy to protect against cyber attacks and data breaches affecting patient medical records.
It’s essential to know what your specific policy’s exclusions are, or you may be surprised to find that your malpractice liability insurance doesn’t cover you when you expected that it would. Such was the situation in a recently decided case.
Also essential is knowing what type of coverage your policy provides – claims-made or occurrence-based. Occurrence policies offer lifetime coverage for incidents that occurred during the policy period, no matter when the claim is made. Claims-made policies cover only incidents that occur and are reported within the policy’s time period (unless a “tail” policy is purchased to extend the reporting period).
The case
Dr. P was a neurologist specializing in pain management. He had a professional liability insurance policy with an insurance company. In 2012, Dr. P’s insurance agent saw a television news story about the physician being accused by the state medical board for overprescribing opioids, resulting in the deaths of 17 patients. The next day, the agent obtained copies of documents from the state medical board, including a summary suspension order and a notice of contemplated action.
The notice of contemplated action specified that Dr. P had deviated from the standard of care through injudicious prescribing, leading to approximately 17 patient deaths due to drug toxicity. Because the agent realized that lawsuits could be filed against Dr. P for the deaths, she sent the insurance company the paperwork from the medical board so the insurer would be aware of the potential claims.
However, when the insurer received the information, it did not investigate or seek more information as it was required to do. The insurer failed to get medical records, or specific patient names, and none of the 17 deaths were recorded in the insurance company’s claims system (a failure to follow company procedure). Instead, the insurance company decided to cancel Dr. P’s policy effective the following month.
The company sent Dr. P a cancellation letter advising him that his policy was being terminated due to “license suspension, nature of allegations, and practice profile,” and offered him a tail policy to purchase.
The insurance company did not advise Dr. P that he should ensure all potential claims were reported, including the 17 deaths, before his policy expired. The company also did not advise him that he had a claims-made policy and what that meant regarding future lawsuits that might be filed after his policy period expired.
A year later, Dr. P was sued in two wrongful death lawsuits by the families of two of the 17 opioid-related deaths. When he was served with the papers, he promptly notified the insurance company. The insurance company issued a denial letter, incorrectly asserting that the 17 drug-toxicity deaths that they were aware of did not qualify as claims under Dr. P’s policy.
After his insurance company failed to represent him, Dr. P divorced his wife of 35 years and filed for bankruptcy. The only creditors with claims were the two families who had sued him. The bankruptcy trustee filed a lawsuit against the insurance company on behalf of Dr. P for the insurer’s failure to defend and indemnify Dr. P against the wrongful death lawsuits. In 2017, the bankruptcy trustee settled the two wrongful death cases by paying the families a certain amount of cash and assigning the insurance bad faith lawsuit to them.
Court and jury decide
In 2020, the case against the insurance company ended up in court. By 2022, the court had decided some of the issues and left some for the jury to determine.
The court found that the insurance company had breached its obligation to defend and indemnify Dr. P, committed unfair insurance claims practices, and committed bad faith in failing to defend the physician. The court limited the compensation to the amount of cash that had been paid to settle the two cases, and any fees and costs that Dr. P had incurred defending himself.
However, this still left the jury to decide whether the insurance company had committed bad faith in failing to indemnify (secure a person against legal liability for his/her actions) Dr. P, whether it had violated the state’s Unfair Insurance Practices Act, and whether punitive damages should be levied against the insurer.
The jury trial ended in a stunning $52 million verdict against the insurance company after less than 2 hours of deliberation. The jury found that the insurance company had acted in bad faith and willfully violated the Unfair Insurances Practices Act.
While the jury ultimately decided against the insurance company and sent it a strong message with a large verdict, Dr. P’s career was still over. He had stopped practicing medicine, was bankrupt, and his personal life was in shambles. The litigation had taken about a decade. Sometimes a win isn’t a victory.
Protecting yourself
The best way to protect yourself from a situation in which your insurer will not defend you is to really know and understand your insurance policy. Is it occurrence-based or claims-made insurance? What exactly does it cover? How are claims supposed to be made? Your professional liability insurance can be extremely important if you get sued, so it is equally important to choose it carefully and to really understand what is being covered.
Other ways to protect yourself:
- Know your agent. Your agent is key to explaining your policy as well as helping in the event that you need to make a claim. Dr. P’s agent saw a news story about him on television, which is why she submitted the information to the insurance company. Dr. P would have been far better off calling the agent directly when he was being investigated by the state medical board to explain the situation and seek advice.
- Be aware of exclusions to your policy. Many – such as criminal acts, reckless or intentional acts, or practicing under the influence – were mentioned earlier in this article. Some may be unexpected, so it is extremely important that you understand the specific exclusions to your particular policy.
- Be aware of your state law, and how changes might affect you. For example, in states that have outlawed or criminalized abortion, an insurance company would probably not have to represent a policy holder who was sued for malpractice involving an abortion. On the other hand, be aware that not treating a patient who needs life-saving care because you are afraid of running afoul of the law can also get you in trouble if the patient is harmed by not being treated. (For example, the Centers for Medicare & Medicaid Services is currently investigating two hospitals that failed to provide necessary stabilizing abortion care to a patient with an emergency medication condition resulting from a miscarriage.)
- Know how your policy defines ‘intentional’ acts (which are typically excluded from coverage). This is important. In some jurisdictions, the insured clinician has to merely intend to commit the acts in order for the claim to be excluded. In other jurisdictions, the insured doctor has to intend to cause the resulting damage. This can result in a very different outcome.
- The best thing doctors can do is to really understand what the policy covers and be prepared to make some noise if the company is not covering something that it should. Don’t be afraid to ask questions if you think your insurer is doing something wrong, and if the answers don’t satisfy you, consult an attorney.
The future
In the fall of 2022, at least partially in response to the Dobbs v. Jackson Women’s Health Organization decision regarding abortion, one professional liability company (Physician’s Insurance) launched criminal defense reimbursement coverage for physicians and hospitals to pay for defense costs incurred in responding to criminal allegations arising directly from patient care.
The add-on Criminal Defense Reimbursement Endorsement was made available in Washington State in January 2023, and will be offered in other states pending regulatory approval. It reimburses defense costs up to $250,000 when criminal actions have arisen from direct patient care.
In a press release announcing the new coverage, Physician’s Insurance CEO Bill Cotter explained the company’s reasoning in providing it: “The already challenging environment for physicians and hospitals has been made even more difficult as they now navigate the legal ramifications of increased criminal medical negligence claims as seen in the case of the Nashville nurse at the Vanderbilt University Medical Center, the potential for criminal state claims arising out of the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, and the subsequent state criminalization of healthcare practices that have long been the professionally accepted standard of care.”
Expect to see more insurance companies offering new coverage options for physicians in the future as they recognize that physicians may be facing more than just medical malpractice lawsuits arising out of patient care.
A version of this article first appeared on Medscape.com.
You’ve practiced medicine for years without issues, but now you are facing a medical malpractice case. No worries – you’ve had professional liability insurance all this time, so surely there’s nothing to be concerned about. Undoubtedly, your medical malpractice insurer will cover the costs of defending you. Or will they? One case casts questions on just this issue.
Professional liability insurance
According to the American Medical Association, almost one in three physicians (31%) have had a medical malpractice lawsuit filed against them at some point in their careers. These numbers only increase the longer a physician practices; almost half of doctors 55 and over have been sued, compared with less than 10% of physicians under 40.
And while the majority of cases are dropped or dismissed, and the small minority of cases that do go to trial are mostly won by the defense, the cost of defending these cases can be extremely high. Physicians have medical malpractice insurance to defray these costs.
Malpractice insurance generally covers the costs of attorney fees, court costs, arbitration, compensatory damages, and settlements related to patient injury or death. Insurance sometimes, but not always, pays for the costs of malpractice lawsuits arising out of Health Insurance Portability and Accountability Act (HIPAA) violations.
But it is what the policies don’t pay for that should be of most interest to practitioners.
Exclusions to medical malpractice insurance
All professional liability insurance policies contain exclusions, and it is essential that you know what they are. While the exclusions may vary by policy, most malpractice insurance policies exclude claims stemming from:
- Reckless or intentional acts.
- Illegal/criminal activities, including theft.
- Misrepresentation, including dishonesty, fraudulent activity, falsification, and misrepresentation on forms.
- Practicing under the influence of alcohol or drugs.
- Altering patient or hospital records.
- Sexual misconduct.
- Cyber security issues, which typically require a separate cyber liability policy to protect against cyber attacks and data breaches affecting patient medical records.
It’s essential to know what your specific policy’s exclusions are, or you may be surprised to find that your malpractice liability insurance doesn’t cover you when you expected that it would. Such was the situation in a recently decided case.
Also essential is knowing what type of coverage your policy provides – claims-made or occurrence-based. Occurrence policies offer lifetime coverage for incidents that occurred during the policy period, no matter when the claim is made. Claims-made policies cover only incidents that occur and are reported within the policy’s time period (unless a “tail” policy is purchased to extend the reporting period).
The case
Dr. P was a neurologist specializing in pain management. He had a professional liability insurance policy with an insurance company. In 2012, Dr. P’s insurance agent saw a television news story about the physician being accused by the state medical board for overprescribing opioids, resulting in the deaths of 17 patients. The next day, the agent obtained copies of documents from the state medical board, including a summary suspension order and a notice of contemplated action.
The notice of contemplated action specified that Dr. P had deviated from the standard of care through injudicious prescribing, leading to approximately 17 patient deaths due to drug toxicity. Because the agent realized that lawsuits could be filed against Dr. P for the deaths, she sent the insurance company the paperwork from the medical board so the insurer would be aware of the potential claims.
However, when the insurer received the information, it did not investigate or seek more information as it was required to do. The insurer failed to get medical records, or specific patient names, and none of the 17 deaths were recorded in the insurance company’s claims system (a failure to follow company procedure). Instead, the insurance company decided to cancel Dr. P’s policy effective the following month.
The company sent Dr. P a cancellation letter advising him that his policy was being terminated due to “license suspension, nature of allegations, and practice profile,” and offered him a tail policy to purchase.
The insurance company did not advise Dr. P that he should ensure all potential claims were reported, including the 17 deaths, before his policy expired. The company also did not advise him that he had a claims-made policy and what that meant regarding future lawsuits that might be filed after his policy period expired.
A year later, Dr. P was sued in two wrongful death lawsuits by the families of two of the 17 opioid-related deaths. When he was served with the papers, he promptly notified the insurance company. The insurance company issued a denial letter, incorrectly asserting that the 17 drug-toxicity deaths that they were aware of did not qualify as claims under Dr. P’s policy.
After his insurance company failed to represent him, Dr. P divorced his wife of 35 years and filed for bankruptcy. The only creditors with claims were the two families who had sued him. The bankruptcy trustee filed a lawsuit against the insurance company on behalf of Dr. P for the insurer’s failure to defend and indemnify Dr. P against the wrongful death lawsuits. In 2017, the bankruptcy trustee settled the two wrongful death cases by paying the families a certain amount of cash and assigning the insurance bad faith lawsuit to them.
Court and jury decide
In 2020, the case against the insurance company ended up in court. By 2022, the court had decided some of the issues and left some for the jury to determine.
The court found that the insurance company had breached its obligation to defend and indemnify Dr. P, committed unfair insurance claims practices, and committed bad faith in failing to defend the physician. The court limited the compensation to the amount of cash that had been paid to settle the two cases, and any fees and costs that Dr. P had incurred defending himself.
However, this still left the jury to decide whether the insurance company had committed bad faith in failing to indemnify (secure a person against legal liability for his/her actions) Dr. P, whether it had violated the state’s Unfair Insurance Practices Act, and whether punitive damages should be levied against the insurer.
The jury trial ended in a stunning $52 million verdict against the insurance company after less than 2 hours of deliberation. The jury found that the insurance company had acted in bad faith and willfully violated the Unfair Insurances Practices Act.
While the jury ultimately decided against the insurance company and sent it a strong message with a large verdict, Dr. P’s career was still over. He had stopped practicing medicine, was bankrupt, and his personal life was in shambles. The litigation had taken about a decade. Sometimes a win isn’t a victory.
Protecting yourself
The best way to protect yourself from a situation in which your insurer will not defend you is to really know and understand your insurance policy. Is it occurrence-based or claims-made insurance? What exactly does it cover? How are claims supposed to be made? Your professional liability insurance can be extremely important if you get sued, so it is equally important to choose it carefully and to really understand what is being covered.
Other ways to protect yourself:
- Know your agent. Your agent is key to explaining your policy as well as helping in the event that you need to make a claim. Dr. P’s agent saw a news story about him on television, which is why she submitted the information to the insurance company. Dr. P would have been far better off calling the agent directly when he was being investigated by the state medical board to explain the situation and seek advice.
- Be aware of exclusions to your policy. Many – such as criminal acts, reckless or intentional acts, or practicing under the influence – were mentioned earlier in this article. Some may be unexpected, so it is extremely important that you understand the specific exclusions to your particular policy.
- Be aware of your state law, and how changes might affect you. For example, in states that have outlawed or criminalized abortion, an insurance company would probably not have to represent a policy holder who was sued for malpractice involving an abortion. On the other hand, be aware that not treating a patient who needs life-saving care because you are afraid of running afoul of the law can also get you in trouble if the patient is harmed by not being treated. (For example, the Centers for Medicare & Medicaid Services is currently investigating two hospitals that failed to provide necessary stabilizing abortion care to a patient with an emergency medication condition resulting from a miscarriage.)
- Know how your policy defines ‘intentional’ acts (which are typically excluded from coverage). This is important. In some jurisdictions, the insured clinician has to merely intend to commit the acts in order for the claim to be excluded. In other jurisdictions, the insured doctor has to intend to cause the resulting damage. This can result in a very different outcome.
- The best thing doctors can do is to really understand what the policy covers and be prepared to make some noise if the company is not covering something that it should. Don’t be afraid to ask questions if you think your insurer is doing something wrong, and if the answers don’t satisfy you, consult an attorney.
The future
In the fall of 2022, at least partially in response to the Dobbs v. Jackson Women’s Health Organization decision regarding abortion, one professional liability company (Physician’s Insurance) launched criminal defense reimbursement coverage for physicians and hospitals to pay for defense costs incurred in responding to criminal allegations arising directly from patient care.
The add-on Criminal Defense Reimbursement Endorsement was made available in Washington State in January 2023, and will be offered in other states pending regulatory approval. It reimburses defense costs up to $250,000 when criminal actions have arisen from direct patient care.
In a press release announcing the new coverage, Physician’s Insurance CEO Bill Cotter explained the company’s reasoning in providing it: “The already challenging environment for physicians and hospitals has been made even more difficult as they now navigate the legal ramifications of increased criminal medical negligence claims as seen in the case of the Nashville nurse at the Vanderbilt University Medical Center, the potential for criminal state claims arising out of the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, and the subsequent state criminalization of healthcare practices that have long been the professionally accepted standard of care.”
Expect to see more insurance companies offering new coverage options for physicians in the future as they recognize that physicians may be facing more than just medical malpractice lawsuits arising out of patient care.
A version of this article first appeared on Medscape.com.
Docs using AI? Some love it, most remain wary
When OpenAI released ChatGPT-3 publicly last November, some doctors decided to try out the free AI tool that learns language and writes human-like text. Some physicians found the chatbot made mistakes and stopped using it, while others were happy with the results and plan to use it more often.
“We’ve played around with it. It was very early on in AI and we noticed it gave us incorrect information with regards to clinical guidance,” said Monalisa Tailor, MD, an internal medicine physician at Norton Health Care in Louisville, Ky. “We decided not to pursue it further,” she said.
Orthopedic spine surgeon Daniel Choi, MD, who owns a small medical/surgical practice in Long Island, New York, tested the chatbot’s performance with a few administrative tasks, including writing a job listing for an administrator and prior authorization letters.
He was enthusiastic. “A well-polished job posting that would usually take me 2-3 hours to write was done in 5 minutes,” Dr. Choi said. “I was blown away by the writing – it was much better than anything I could write.”
The chatbot can also automate administrative tasks in doctors’ practices from appointment scheduling and billing to clinical documentation, saving doctors time and money, experts say.
Most physicians are proceeding cautiously. About 10% of more than 500 medical group leaders, responding to a March poll by the Medical Group Management Association, said their practices regularly use AI tools.
More than half of the respondents not using AI said they first want more evidence that the technology works as intended.
“None of them work as advertised,” said one respondent.
MGMA practice management consultant Dawn Plested acknowledges that many of the physician practices she’s worked with are still wary. “I have yet to encounter a practice that is using any AI tool, even something as low-risk as appointment scheduling,” she said.
Physician groups may be concerned about the costs and logistics of integrating ChatGPT with their electronic health record systems (EHRs) and how that would work, said Ms. Plested.
Doctors may also be skeptical of AI based on their experience with EHRs, she said.
“They were promoted as a panacea to many problems; they were supposed to automate business practice, reduce staff and clinician’s work, and improve billing/coding/documentation. Unfortunately, they have become a major source of frustration for doctors,” said Ms. Plested.
Drawing the line at patient care
Patients are worried about their doctors relying on AI for their care, according to a Pew Research Center poll released in February. About 60% of U.S. adults say they would feel uncomfortable if their own health care professional relied on artificial intelligence to do things like diagnose disease and recommend treatments; about 40% say they would feel comfortable with this.
“We have not yet gone into using ChatGPT for clinical purposes and will be very cautious with these types of applications due to concerns about inaccuracies,” Dr. Choi said.
Practice leaders reported in the MGMA poll that the most common uses of AI were nonclinical, such as:
- Patient communications, including call center answering service to help triage calls, to sort/distribute incoming fax messages, and outreach such as appointment reminders and marketing materials.
- Capturing clinical documentation, often with natural language processing or speech recognition platforms to help virtually scribe.
- Improving billing operations and predictive analytics.
Some doctors told The New York Times that ChatGPT helped them communicate with patients in a more compassionate way.
They used chatbots “to find words to break bad news and express concerns about a patient’s suffering, or to just more clearly explain medical recommendations,” the story noted.
Is regulation needed?
Some legal scholars and medical groups say that AI should be regulated to protect patients and doctors from risks, including medical errors, that could harm patients.
“It’s very important to evaluate the accuracy, safety, and privacy of language learning models (LLMs) before integrating them into the medical system. The same should be true of any new medical tool,” said Mason Marks, MD, JD, a health law professor at the Florida State University College of Law in Tallahassee.
In mid-June, the American Medical Association approved two resolutions calling for greater government oversight of AI. The AMA will develop proposed state and federal regulations and work with the federal government and other organizations to protect patients from false or misleading AI-generated medical advice.
Dr. Marks pointed to existing federal rules that apply to AI. “The Federal Trade Commission already has regulation that can potentially be used to combat unfair or deceptive trade practices associated with chatbots,” he said.
In addition, “the U.S. Food and Drug Administration can also regulate these tools, but it needs to update how it approaches risk when it comes to AI. The FDA has an outdated view of risk as physical harm, for instance, from traditional medical devices. That view of risk needs to be updated and expanded to encompass the unique harms of AI,” Dr. Marks said.
There should also be more transparency about how LLM software is used in medicine, he said. “That could be a norm implemented by the LLM developers and it could also be enforced by federal agencies. For instance, the FDA could require developers to be more transparent regarding training data and methods, and the FTC could require greater transparency regarding how consumer data might be used and opportunities to opt out of certain uses,” said Dr. Marks.
What should doctors do?
Dr. Marks advised doctors to be cautious when using ChatGPT and other LLMs, especially for medical advice. “The same would apply to any new medical tool, but we know that the current generation of LLMs [is] particularly prone to making things up, which could lead to medical errors if relied on in clinical settings,” he said.
There is also potential for breaches of patient confidentiality if doctors input clinical information. ChatGPT and OpenAI-enabled tools may not be compliant with the Health Insurance Portability and Accountability Act, which set national standards to protect individuals’ medical records and individually identifiable health information.
“The best approach is to use chatbots cautiously and with skepticism. Don’t input patient information, confirm the accuracy of information produced, and don’t use them as replacements for professional judgment,” Dr. Marks recommended.
Ms. Plested suggested that doctors who want to experiment with AI start with a low-risk tool such as appointment reminders that could save staff time and money. “I never recommend they start with something as high-stakes as coding/billing,” she said.
A version of this article appeared on Medscape.com.
When OpenAI released ChatGPT-3 publicly last November, some doctors decided to try out the free AI tool that learns language and writes human-like text. Some physicians found the chatbot made mistakes and stopped using it, while others were happy with the results and plan to use it more often.
“We’ve played around with it. It was very early on in AI and we noticed it gave us incorrect information with regards to clinical guidance,” said Monalisa Tailor, MD, an internal medicine physician at Norton Health Care in Louisville, Ky. “We decided not to pursue it further,” she said.
Orthopedic spine surgeon Daniel Choi, MD, who owns a small medical/surgical practice in Long Island, New York, tested the chatbot’s performance with a few administrative tasks, including writing a job listing for an administrator and prior authorization letters.
He was enthusiastic. “A well-polished job posting that would usually take me 2-3 hours to write was done in 5 minutes,” Dr. Choi said. “I was blown away by the writing – it was much better than anything I could write.”
The chatbot can also automate administrative tasks in doctors’ practices from appointment scheduling and billing to clinical documentation, saving doctors time and money, experts say.
Most physicians are proceeding cautiously. About 10% of more than 500 medical group leaders, responding to a March poll by the Medical Group Management Association, said their practices regularly use AI tools.
More than half of the respondents not using AI said they first want more evidence that the technology works as intended.
“None of them work as advertised,” said one respondent.
MGMA practice management consultant Dawn Plested acknowledges that many of the physician practices she’s worked with are still wary. “I have yet to encounter a practice that is using any AI tool, even something as low-risk as appointment scheduling,” she said.
Physician groups may be concerned about the costs and logistics of integrating ChatGPT with their electronic health record systems (EHRs) and how that would work, said Ms. Plested.
Doctors may also be skeptical of AI based on their experience with EHRs, she said.
“They were promoted as a panacea to many problems; they were supposed to automate business practice, reduce staff and clinician’s work, and improve billing/coding/documentation. Unfortunately, they have become a major source of frustration for doctors,” said Ms. Plested.
Drawing the line at patient care
Patients are worried about their doctors relying on AI for their care, according to a Pew Research Center poll released in February. About 60% of U.S. adults say they would feel uncomfortable if their own health care professional relied on artificial intelligence to do things like diagnose disease and recommend treatments; about 40% say they would feel comfortable with this.
“We have not yet gone into using ChatGPT for clinical purposes and will be very cautious with these types of applications due to concerns about inaccuracies,” Dr. Choi said.
Practice leaders reported in the MGMA poll that the most common uses of AI were nonclinical, such as:
- Patient communications, including call center answering service to help triage calls, to sort/distribute incoming fax messages, and outreach such as appointment reminders and marketing materials.
- Capturing clinical documentation, often with natural language processing or speech recognition platforms to help virtually scribe.
- Improving billing operations and predictive analytics.
Some doctors told The New York Times that ChatGPT helped them communicate with patients in a more compassionate way.
They used chatbots “to find words to break bad news and express concerns about a patient’s suffering, or to just more clearly explain medical recommendations,” the story noted.
Is regulation needed?
Some legal scholars and medical groups say that AI should be regulated to protect patients and doctors from risks, including medical errors, that could harm patients.
“It’s very important to evaluate the accuracy, safety, and privacy of language learning models (LLMs) before integrating them into the medical system. The same should be true of any new medical tool,” said Mason Marks, MD, JD, a health law professor at the Florida State University College of Law in Tallahassee.
In mid-June, the American Medical Association approved two resolutions calling for greater government oversight of AI. The AMA will develop proposed state and federal regulations and work with the federal government and other organizations to protect patients from false or misleading AI-generated medical advice.
Dr. Marks pointed to existing federal rules that apply to AI. “The Federal Trade Commission already has regulation that can potentially be used to combat unfair or deceptive trade practices associated with chatbots,” he said.
In addition, “the U.S. Food and Drug Administration can also regulate these tools, but it needs to update how it approaches risk when it comes to AI. The FDA has an outdated view of risk as physical harm, for instance, from traditional medical devices. That view of risk needs to be updated and expanded to encompass the unique harms of AI,” Dr. Marks said.
There should also be more transparency about how LLM software is used in medicine, he said. “That could be a norm implemented by the LLM developers and it could also be enforced by federal agencies. For instance, the FDA could require developers to be more transparent regarding training data and methods, and the FTC could require greater transparency regarding how consumer data might be used and opportunities to opt out of certain uses,” said Dr. Marks.
What should doctors do?
Dr. Marks advised doctors to be cautious when using ChatGPT and other LLMs, especially for medical advice. “The same would apply to any new medical tool, but we know that the current generation of LLMs [is] particularly prone to making things up, which could lead to medical errors if relied on in clinical settings,” he said.
There is also potential for breaches of patient confidentiality if doctors input clinical information. ChatGPT and OpenAI-enabled tools may not be compliant with the Health Insurance Portability and Accountability Act, which set national standards to protect individuals’ medical records and individually identifiable health information.
“The best approach is to use chatbots cautiously and with skepticism. Don’t input patient information, confirm the accuracy of information produced, and don’t use them as replacements for professional judgment,” Dr. Marks recommended.
Ms. Plested suggested that doctors who want to experiment with AI start with a low-risk tool such as appointment reminders that could save staff time and money. “I never recommend they start with something as high-stakes as coding/billing,” she said.
A version of this article appeared on Medscape.com.
When OpenAI released ChatGPT-3 publicly last November, some doctors decided to try out the free AI tool that learns language and writes human-like text. Some physicians found the chatbot made mistakes and stopped using it, while others were happy with the results and plan to use it more often.
“We’ve played around with it. It was very early on in AI and we noticed it gave us incorrect information with regards to clinical guidance,” said Monalisa Tailor, MD, an internal medicine physician at Norton Health Care in Louisville, Ky. “We decided not to pursue it further,” she said.
Orthopedic spine surgeon Daniel Choi, MD, who owns a small medical/surgical practice in Long Island, New York, tested the chatbot’s performance with a few administrative tasks, including writing a job listing for an administrator and prior authorization letters.
He was enthusiastic. “A well-polished job posting that would usually take me 2-3 hours to write was done in 5 minutes,” Dr. Choi said. “I was blown away by the writing – it was much better than anything I could write.”
The chatbot can also automate administrative tasks in doctors’ practices from appointment scheduling and billing to clinical documentation, saving doctors time and money, experts say.
Most physicians are proceeding cautiously. About 10% of more than 500 medical group leaders, responding to a March poll by the Medical Group Management Association, said their practices regularly use AI tools.
More than half of the respondents not using AI said they first want more evidence that the technology works as intended.
“None of them work as advertised,” said one respondent.
MGMA practice management consultant Dawn Plested acknowledges that many of the physician practices she’s worked with are still wary. “I have yet to encounter a practice that is using any AI tool, even something as low-risk as appointment scheduling,” she said.
Physician groups may be concerned about the costs and logistics of integrating ChatGPT with their electronic health record systems (EHRs) and how that would work, said Ms. Plested.
Doctors may also be skeptical of AI based on their experience with EHRs, she said.
“They were promoted as a panacea to many problems; they were supposed to automate business practice, reduce staff and clinician’s work, and improve billing/coding/documentation. Unfortunately, they have become a major source of frustration for doctors,” said Ms. Plested.
Drawing the line at patient care
Patients are worried about their doctors relying on AI for their care, according to a Pew Research Center poll released in February. About 60% of U.S. adults say they would feel uncomfortable if their own health care professional relied on artificial intelligence to do things like diagnose disease and recommend treatments; about 40% say they would feel comfortable with this.
“We have not yet gone into using ChatGPT for clinical purposes and will be very cautious with these types of applications due to concerns about inaccuracies,” Dr. Choi said.
Practice leaders reported in the MGMA poll that the most common uses of AI were nonclinical, such as:
- Patient communications, including call center answering service to help triage calls, to sort/distribute incoming fax messages, and outreach such as appointment reminders and marketing materials.
- Capturing clinical documentation, often with natural language processing or speech recognition platforms to help virtually scribe.
- Improving billing operations and predictive analytics.
Some doctors told The New York Times that ChatGPT helped them communicate with patients in a more compassionate way.
They used chatbots “to find words to break bad news and express concerns about a patient’s suffering, or to just more clearly explain medical recommendations,” the story noted.
Is regulation needed?
Some legal scholars and medical groups say that AI should be regulated to protect patients and doctors from risks, including medical errors, that could harm patients.
“It’s very important to evaluate the accuracy, safety, and privacy of language learning models (LLMs) before integrating them into the medical system. The same should be true of any new medical tool,” said Mason Marks, MD, JD, a health law professor at the Florida State University College of Law in Tallahassee.
In mid-June, the American Medical Association approved two resolutions calling for greater government oversight of AI. The AMA will develop proposed state and federal regulations and work with the federal government and other organizations to protect patients from false or misleading AI-generated medical advice.
Dr. Marks pointed to existing federal rules that apply to AI. “The Federal Trade Commission already has regulation that can potentially be used to combat unfair or deceptive trade practices associated with chatbots,” he said.
In addition, “the U.S. Food and Drug Administration can also regulate these tools, but it needs to update how it approaches risk when it comes to AI. The FDA has an outdated view of risk as physical harm, for instance, from traditional medical devices. That view of risk needs to be updated and expanded to encompass the unique harms of AI,” Dr. Marks said.
There should also be more transparency about how LLM software is used in medicine, he said. “That could be a norm implemented by the LLM developers and it could also be enforced by federal agencies. For instance, the FDA could require developers to be more transparent regarding training data and methods, and the FTC could require greater transparency regarding how consumer data might be used and opportunities to opt out of certain uses,” said Dr. Marks.
What should doctors do?
Dr. Marks advised doctors to be cautious when using ChatGPT and other LLMs, especially for medical advice. “The same would apply to any new medical tool, but we know that the current generation of LLMs [is] particularly prone to making things up, which could lead to medical errors if relied on in clinical settings,” he said.
There is also potential for breaches of patient confidentiality if doctors input clinical information. ChatGPT and OpenAI-enabled tools may not be compliant with the Health Insurance Portability and Accountability Act, which set national standards to protect individuals’ medical records and individually identifiable health information.
“The best approach is to use chatbots cautiously and with skepticism. Don’t input patient information, confirm the accuracy of information produced, and don’t use them as replacements for professional judgment,” Dr. Marks recommended.
Ms. Plested suggested that doctors who want to experiment with AI start with a low-risk tool such as appointment reminders that could save staff time and money. “I never recommend they start with something as high-stakes as coding/billing,” she said.
A version of this article appeared on Medscape.com.