Opinion

 

Gastroesophageal reflux (GER) is common in infants and often presents a challenge to doctors who try to balance changing evidence with concerns about complications and parents’ concerns about their infant’s discomfort. In a 2018 guideline, the writing committee defined GER as reflux of stomach contents to the esophagus. GER is considered pathologic and, therefore, gastroesophageal reflux disease (GERD) when it is associated with troublesome symptoms and/or complications that can include esophagitis and aspiration.

Infants

GERD is difficult to diagnose in infants. The symptoms of GERD, such as crying after feeds, regurgitation, and irritability, occur commonly in all infants and in any individual infant may not be reflective of GERD. Regurgitation is common, frequent and normal in infants up to 6 months of age. A common challenge occurs when families request treatment for infants with irritability, back arching, and/or regurgitation who are otherwise doing well. In this group of infants it is important to recognize that neither testing nor therapy is indicated unless there is difficulty with feeding, growth, acquisition of milestones, or red flag signs.

In infants with recurrent regurgitation history, physical exam is usually sufficient to distinguish uncomplicated GER from GERD and other more worrisome diagnoses. Red flag symptoms raise the possibility of a different diagnosis. Red flag symptoms include weight loss; lethargy; excessive irritability/pain; onset of vomiting for more than 6 months or persisting past 12-18 months of age; rapidly increasing head circumference; persistent forceful, nocturnal, bloody, or bilious vomiting; abdominal distention; rectal bleeding; and chronic diarrhea. GERD that starts after 6 months of age or which persists after 12 months of age warrants further evaluation, often with referral to a pediatric gastroenterologist.

When GERD is suspected, the first therapeutic steps are to institute behavioral changes. Caregivers should avoid overfeeding and modify the feeding pattern to more frequent feedings consisting of less volume at each feed. The addition of thickeners to feeds does reduce regurgitation, although it may not affect other GERD signs and symptoms. Formula can be thickened with rice cereal, which tends to be an affordable choice that doesn’t clog nipples. Enzymes present in breast milk digest cereal thickeners, so breast milk can be thickened with xanthum gum (after 1 year of age) or carob bean–based products (after 42 weeks gestation).

If these modifications do not improve symptoms, the next step is to change the type of feeds. Some infants in whom GERD is suspected actually have cow’s milk protein allergy (CMPA), so a trial of cow’s milk elimination is warranted. A breastfeeding mother can eliminate all dairy from her diet including casein and whey. Caregivers can switch to an extensively hydrolyzed formula or an amino acid–based formula. The guideline do not recommend soy-based formulas because they are not available in Europe and because a significant percentage of infants with CMPA also develop allergy to soy, and they do not recommend rice hydrolysate formula because of a lack of evidence. Dairy can be reintroduced at a later point. While positional changes including elevating the head of the crib or placing the infant in the left lateral position can help decrease GERD, the American Academy of Pediatrics strongly discourages these positions because of safety concerns, so the guidelines do not recommend positional change.

If a 2-4 week trial of nonpharmacologic interventions fails, the next step is referral to a pediatric gastroenterologist. If a pediatric gastroenterologist is not available, a 4-8 week trial of acid suppressive medication may be given. No trial has shown utility of a trial of acid suppression as a diagnostic test for GERD. Medication should only be used in infants with strongly suspected GERD and, per the guidelines, “should not be used for the treatment of visible regurgitation in otherwise healthy infants.” Medications to treat GER do not have evidence of efficacy, and there is evidence of an increased risk of infection with use of acid suppression, including an increased risk of necrotizing enterocolitis, pneumonia, upper respiratory tract infections, sepsis, urinary tract infections, and Clostridium difficile. If used, proton-pump inhibitors are preferred over histamine-2 receptor blockers. Antacids and alginates are not recommended.
 

 

Older children

In children with heartburn or regurgitation without red flag symptoms, a trial of lifestyle changes and dietary education may be initiated. If a child is overweight, it is important to inform the patient and parents that excess body weight is associated with GERD. The head of the bed can be elevated along with left lateral positioning. The guidelines do not support any probiotics or herbal medicines.

If bothersome symptoms persist, a trial of acid-suppressing medication for 4-8 weeks is reasonable. A PPI is preferred to a histamine-2 receptor blocker. PPI safety studies are lacking, but case studies suggest an increase in infections in children taking acid-suppressing medications. Therefore, as with infants, if medications are used they should be prescribed at the lowest dose and for the shortest period of time possible. If medications are not helping, or need to be used long term, referral to a pediatric gastroenterologist can be considered. Of note, the guidelines do support a 4-8 week trial of PPIs in older children as a diagnostic test; this differs from the recommendations for infants, in whom a trial for diagnostic purposes is discouraged.
 

Diagnostic testing

Refer to a gastroenterologist for endoscopy in cases of persistent symptoms despite PPI use or failure to wean off medication. If there are no erosions, pH monitoring with pH-impedance monitoring or pH-metry can help distinguish between nonerosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn. If it is performed when a child is off of PPIs, endoscopy can also diagnose PPI-responsive eosinophilic esophagitis. Barium contrast, abdominal ultrasonography, and manometry may be considered during the course of a search for an alternative diagnosis, but they should not be used to diagnose or confirm GERD.

The bottom line

Most GER is physiologic and does not need treatment. First-line treatment for GERD in infants and children is nonpharmacologic intervention.
 

Reference

Rosen R et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Mar;66(3):516-554.

Dr. Oh is a third year resident in the Family Medicine Residency at Abington-Jefferson Health. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington - Jefferson Health.

 

Gastroesophageal reflux (GER) is common in infants and often presents a challenge to doctors who try to balance changing evidence with concerns about complications and parents’ concerns about their infant’s discomfort. In a 2018 guideline, the writing committee defined GER as reflux of stomach contents to the esophagus. GER is considered pathologic and, therefore, gastroesophageal reflux disease (GERD) when it is associated with troublesome symptoms and/or complications that can include esophagitis and aspiration.

Infants

GERD is difficult to diagnose in infants. The symptoms of GERD, such as crying after feeds, regurgitation, and irritability, occur commonly in all infants and in any individual infant may not be reflective of GERD. Regurgitation is common, frequent and normal in infants up to 6 months of age. A common challenge occurs when families request treatment for infants with irritability, back arching, and/or regurgitation who are otherwise doing well. In this group of infants it is important to recognize that neither testing nor therapy is indicated unless there is difficulty with feeding, growth, acquisition of milestones, or red flag signs.

In infants with recurrent regurgitation history, physical exam is usually sufficient to distinguish uncomplicated GER from GERD and other more worrisome diagnoses. Red flag symptoms raise the possibility of a different diagnosis. Red flag symptoms include weight loss; lethargy; excessive irritability/pain; onset of vomiting for more than 6 months or persisting past 12-18 months of age; rapidly increasing head circumference; persistent forceful, nocturnal, bloody, or bilious vomiting; abdominal distention; rectal bleeding; and chronic diarrhea. GERD that starts after 6 months of age or which persists after 12 months of age warrants further evaluation, often with referral to a pediatric gastroenterologist.

When GERD is suspected, the first therapeutic steps are to institute behavioral changes. Caregivers should avoid overfeeding and modify the feeding pattern to more frequent feedings consisting of less volume at each feed. The addition of thickeners to feeds does reduce regurgitation, although it may not affect other GERD signs and symptoms. Formula can be thickened with rice cereal, which tends to be an affordable choice that doesn’t clog nipples. Enzymes present in breast milk digest cereal thickeners, so breast milk can be thickened with xanthum gum (after 1 year of age) or carob bean–based products (after 42 weeks gestation).

If these modifications do not improve symptoms, the next step is to change the type of feeds. Some infants in whom GERD is suspected actually have cow’s milk protein allergy (CMPA), so a trial of cow’s milk elimination is warranted. A breastfeeding mother can eliminate all dairy from her diet including casein and whey. Caregivers can switch to an extensively hydrolyzed formula or an amino acid–based formula. The guideline do not recommend soy-based formulas because they are not available in Europe and because a significant percentage of infants with CMPA also develop allergy to soy, and they do not recommend rice hydrolysate formula because of a lack of evidence. Dairy can be reintroduced at a later point. While positional changes including elevating the head of the crib or placing the infant in the left lateral position can help decrease GERD, the American Academy of Pediatrics strongly discourages these positions because of safety concerns, so the guidelines do not recommend positional change.

If a 2-4 week trial of nonpharmacologic interventions fails, the next step is referral to a pediatric gastroenterologist. If a pediatric gastroenterologist is not available, a 4-8 week trial of acid suppressive medication may be given. No trial has shown utility of a trial of acid suppression as a diagnostic test for GERD. Medication should only be used in infants with strongly suspected GERD and, per the guidelines, “should not be used for the treatment of visible regurgitation in otherwise healthy infants.” Medications to treat GER do not have evidence of efficacy, and there is evidence of an increased risk of infection with use of acid suppression, including an increased risk of necrotizing enterocolitis, pneumonia, upper respiratory tract infections, sepsis, urinary tract infections, and Clostridium difficile. If used, proton-pump inhibitors are preferred over histamine-2 receptor blockers. Antacids and alginates are not recommended.
 

 

Older children

In children with heartburn or regurgitation without red flag symptoms, a trial of lifestyle changes and dietary education may be initiated. If a child is overweight, it is important to inform the patient and parents that excess body weight is associated with GERD. The head of the bed can be elevated along with left lateral positioning. The guidelines do not support any probiotics or herbal medicines.

If bothersome symptoms persist, a trial of acid-suppressing medication for 4-8 weeks is reasonable. A PPI is preferred to a histamine-2 receptor blocker. PPI safety studies are lacking, but case studies suggest an increase in infections in children taking acid-suppressing medications. Therefore, as with infants, if medications are used they should be prescribed at the lowest dose and for the shortest period of time possible. If medications are not helping, or need to be used long term, referral to a pediatric gastroenterologist can be considered. Of note, the guidelines do support a 4-8 week trial of PPIs in older children as a diagnostic test; this differs from the recommendations for infants, in whom a trial for diagnostic purposes is discouraged.
 

Diagnostic testing

Refer to a gastroenterologist for endoscopy in cases of persistent symptoms despite PPI use or failure to wean off medication. If there are no erosions, pH monitoring with pH-impedance monitoring or pH-metry can help distinguish between nonerosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn. If it is performed when a child is off of PPIs, endoscopy can also diagnose PPI-responsive eosinophilic esophagitis. Barium contrast, abdominal ultrasonography, and manometry may be considered during the course of a search for an alternative diagnosis, but they should not be used to diagnose or confirm GERD.

The bottom line

Most GER is physiologic and does not need treatment. First-line treatment for GERD in infants and children is nonpharmacologic intervention.
 

Reference

Rosen R et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Mar;66(3):516-554.

Dr. Oh is a third year resident in the Family Medicine Residency at Abington-Jefferson Health. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington - Jefferson Health.

 

Gastroesophageal reflux (GER) is common in infants and often presents a challenge to doctors who try to balance changing evidence with concerns about complications and parents’ concerns about their infant’s discomfort. In a 2018 guideline, the writing committee defined GER as reflux of stomach contents to the esophagus. GER is considered pathologic and, therefore, gastroesophageal reflux disease (GERD) when it is associated with troublesome symptoms and/or complications that can include esophagitis and aspiration.

Infants

GERD is difficult to diagnose in infants. The symptoms of GERD, such as crying after feeds, regurgitation, and irritability, occur commonly in all infants and in any individual infant may not be reflective of GERD. Regurgitation is common, frequent and normal in infants up to 6 months of age. A common challenge occurs when families request treatment for infants with irritability, back arching, and/or regurgitation who are otherwise doing well. In this group of infants it is important to recognize that neither testing nor therapy is indicated unless there is difficulty with feeding, growth, acquisition of milestones, or red flag signs.

In infants with recurrent regurgitation history, physical exam is usually sufficient to distinguish uncomplicated GER from GERD and other more worrisome diagnoses. Red flag symptoms raise the possibility of a different diagnosis. Red flag symptoms include weight loss; lethargy; excessive irritability/pain; onset of vomiting for more than 6 months or persisting past 12-18 months of age; rapidly increasing head circumference; persistent forceful, nocturnal, bloody, or bilious vomiting; abdominal distention; rectal bleeding; and chronic diarrhea. GERD that starts after 6 months of age or which persists after 12 months of age warrants further evaluation, often with referral to a pediatric gastroenterologist.

When GERD is suspected, the first therapeutic steps are to institute behavioral changes. Caregivers should avoid overfeeding and modify the feeding pattern to more frequent feedings consisting of less volume at each feed. The addition of thickeners to feeds does reduce regurgitation, although it may not affect other GERD signs and symptoms. Formula can be thickened with rice cereal, which tends to be an affordable choice that doesn’t clog nipples. Enzymes present in breast milk digest cereal thickeners, so breast milk can be thickened with xanthum gum (after 1 year of age) or carob bean–based products (after 42 weeks gestation).

If these modifications do not improve symptoms, the next step is to change the type of feeds. Some infants in whom GERD is suspected actually have cow’s milk protein allergy (CMPA), so a trial of cow’s milk elimination is warranted. A breastfeeding mother can eliminate all dairy from her diet including casein and whey. Caregivers can switch to an extensively hydrolyzed formula or an amino acid–based formula. The guideline do not recommend soy-based formulas because they are not available in Europe and because a significant percentage of infants with CMPA also develop allergy to soy, and they do not recommend rice hydrolysate formula because of a lack of evidence. Dairy can be reintroduced at a later point. While positional changes including elevating the head of the crib or placing the infant in the left lateral position can help decrease GERD, the American Academy of Pediatrics strongly discourages these positions because of safety concerns, so the guidelines do not recommend positional change.

If a 2-4 week trial of nonpharmacologic interventions fails, the next step is referral to a pediatric gastroenterologist. If a pediatric gastroenterologist is not available, a 4-8 week trial of acid suppressive medication may be given. No trial has shown utility of a trial of acid suppression as a diagnostic test for GERD. Medication should only be used in infants with strongly suspected GERD and, per the guidelines, “should not be used for the treatment of visible regurgitation in otherwise healthy infants.” Medications to treat GER do not have evidence of efficacy, and there is evidence of an increased risk of infection with use of acid suppression, including an increased risk of necrotizing enterocolitis, pneumonia, upper respiratory tract infections, sepsis, urinary tract infections, and Clostridium difficile. If used, proton-pump inhibitors are preferred over histamine-2 receptor blockers. Antacids and alginates are not recommended.
 

 

Older children

In children with heartburn or regurgitation without red flag symptoms, a trial of lifestyle changes and dietary education may be initiated. If a child is overweight, it is important to inform the patient and parents that excess body weight is associated with GERD. The head of the bed can be elevated along with left lateral positioning. The guidelines do not support any probiotics or herbal medicines.

If bothersome symptoms persist, a trial of acid-suppressing medication for 4-8 weeks is reasonable. A PPI is preferred to a histamine-2 receptor blocker. PPI safety studies are lacking, but case studies suggest an increase in infections in children taking acid-suppressing medications. Therefore, as with infants, if medications are used they should be prescribed at the lowest dose and for the shortest period of time possible. If medications are not helping, or need to be used long term, referral to a pediatric gastroenterologist can be considered. Of note, the guidelines do support a 4-8 week trial of PPIs in older children as a diagnostic test; this differs from the recommendations for infants, in whom a trial for diagnostic purposes is discouraged.
 

Diagnostic testing

Refer to a gastroenterologist for endoscopy in cases of persistent symptoms despite PPI use or failure to wean off medication. If there are no erosions, pH monitoring with pH-impedance monitoring or pH-metry can help distinguish between nonerosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn. If it is performed when a child is off of PPIs, endoscopy can also diagnose PPI-responsive eosinophilic esophagitis. Barium contrast, abdominal ultrasonography, and manometry may be considered during the course of a search for an alternative diagnosis, but they should not be used to diagnose or confirm GERD.

The bottom line

Most GER is physiologic and does not need treatment. First-line treatment for GERD in infants and children is nonpharmacologic intervention.
 

Reference

Rosen R et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Mar;66(3):516-554.

Dr. Oh is a third year resident in the Family Medicine Residency at Abington-Jefferson Health. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington - Jefferson Health.

Digestive Disease Week^® (DDW) 2019 is now history. This was the 50th anniversary of DDW and again, it lived up to its reputation as the world’s foremost meeting dedicated to digestive diseases. GI & Hepatology News will publish multiple articles highlighting the best of DDW in the coming months.

The AGA Presidential Plenary session is an annual DDW highlight. This year’s session did not disappoint and was attended by a large crowd. David Lieberman, MD, AGAF (outgoing AGA president) and Hashem B. El-Serag MD, MPH, AGAF (incoming AGA president) moderated the session. Outstanding presentations about management of obesity, new findings in IBD, the use of virtual reality in the treatment of functional abdominal pain, and findings from a long-term colorectal cancer screening trial were some of the key presentations.

Recent behind-the-scenes work by the AGA is paying off for its members and the larger GI community. The AGA was again awarded an NIH-funded grant to advance its education and training of under-represented minorities. This is the second NIH grant given to the AGA, who now has become a leader in diversity and inclusive education. The AGA has strengthened its close bond with the Crohn's and Colitis Foundation, adding to its portfolio of scientific and clinical offerings focused on IBD. The AGA Center for Gut Microbiome Research and Education has emerged as one of the best sources of education and research about the microbiome’s impact on digestive health.

On the business front, there are tectonic changes occurring. In 2018, three large GI practices were sold to private equity companies and each has completed multiple arbitrage plays (acquisition of smaller practices), growing to over 200 physicians. This year we will see 6-10 additional private equity acquisitions and will likely see one or more GI practices of 500-1000 providers. This consolidation will have profound implications for the practice of gastroenterology and will provide some interesting opportunities to conduct population-based research for physicians who can capture that potential through academic-community partnerships. 



John I. Allen, MD, MBA, AGAF
Editor in Chief

Digestive Disease Week^® (DDW) 2019 is now history. This was the 50th anniversary of DDW and again, it lived up to its reputation as the world’s foremost meeting dedicated to digestive diseases. GI & Hepatology News will publish multiple articles highlighting the best of DDW in the coming months.

The AGA Presidential Plenary session is an annual DDW highlight. This year’s session did not disappoint and was attended by a large crowd. David Lieberman, MD, AGAF (outgoing AGA president) and Hashem B. El-Serag MD, MPH, AGAF (incoming AGA president) moderated the session. Outstanding presentations about management of obesity, new findings in IBD, the use of virtual reality in the treatment of functional abdominal pain, and findings from a long-term colorectal cancer screening trial were some of the key presentations.

Recent behind-the-scenes work by the AGA is paying off for its members and the larger GI community. The AGA was again awarded an NIH-funded grant to advance its education and training of under-represented minorities. This is the second NIH grant given to the AGA, who now has become a leader in diversity and inclusive education. The AGA has strengthened its close bond with the Crohn's and Colitis Foundation, adding to its portfolio of scientific and clinical offerings focused on IBD. The AGA Center for Gut Microbiome Research and Education has emerged as one of the best sources of education and research about the microbiome’s impact on digestive health.

On the business front, there are tectonic changes occurring. In 2018, three large GI practices were sold to private equity companies and each has completed multiple arbitrage plays (acquisition of smaller practices), growing to over 200 physicians. This year we will see 6-10 additional private equity acquisitions and will likely see one or more GI practices of 500-1000 providers. This consolidation will have profound implications for the practice of gastroenterology and will provide some interesting opportunities to conduct population-based research for physicians who can capture that potential through academic-community partnerships. 



John I. Allen, MD, MBA, AGAF
Editor in Chief

Digestive Disease Week^® (DDW) 2019 is now history. This was the 50th anniversary of DDW and again, it lived up to its reputation as the world’s foremost meeting dedicated to digestive diseases. GI & Hepatology News will publish multiple articles highlighting the best of DDW in the coming months.

The AGA Presidential Plenary session is an annual DDW highlight. This year’s session did not disappoint and was attended by a large crowd. David Lieberman, MD, AGAF (outgoing AGA president) and Hashem B. El-Serag MD, MPH, AGAF (incoming AGA president) moderated the session. Outstanding presentations about management of obesity, new findings in IBD, the use of virtual reality in the treatment of functional abdominal pain, and findings from a long-term colorectal cancer screening trial were some of the key presentations.

Recent behind-the-scenes work by the AGA is paying off for its members and the larger GI community. The AGA was again awarded an NIH-funded grant to advance its education and training of under-represented minorities. This is the second NIH grant given to the AGA, who now has become a leader in diversity and inclusive education. The AGA has strengthened its close bond with the Crohn's and Colitis Foundation, adding to its portfolio of scientific and clinical offerings focused on IBD. The AGA Center for Gut Microbiome Research and Education has emerged as one of the best sources of education and research about the microbiome’s impact on digestive health.

On the business front, there are tectonic changes occurring. In 2018, three large GI practices were sold to private equity companies and each has completed multiple arbitrage plays (acquisition of smaller practices), growing to over 200 physicians. This year we will see 6-10 additional private equity acquisitions and will likely see one or more GI practices of 500-1000 providers. This consolidation will have profound implications for the practice of gastroenterology and will provide some interesting opportunities to conduct population-based research for physicians who can capture that potential through academic-community partnerships. 



John I. Allen, MD, MBA, AGAF
Editor in Chief

I know you don’t remember me. We met when you were just a baby. Now that you’re older, I want to tell you a story about your mom you may not know.

When your mom became pregnant with you, it was a joyous occasion. But strange things started to happen. Your mom noticed that she was bleeding into the toilet bowl. She was told pregnancy would make her gain weight, but the opposite was happening. By her second trimester, her maternity clothes were so baggy she had to exchange them.

She went to see a gastroenterologist and told him about the bleeding. He looked at her pregnant belly, ordered no additional tests, and said he would look into the bleeding if it persisted after her pregnancy.

But that was 5 months away. In the meantime, her symptoms got worse. As you probably know by now, your mom is proactive. She sought a second opinion and then a third. Three different gastroenterologists dismissed your mom. The visits were brief; as soon as each doctor noticed she was pregnant, each deferred dealing with her – even though rectal bleeding and weight loss are in no way explained by pregnancy. Even though a colonoscopy could absolutely be safely performed during pregnancy.

A few months later, she gave birth to you. You were a healthy baby and she and your dad cried. They were so happy to meet you.

The next day, your dad stayed with you while the doctors performed a colonoscopy on your mom. To everyone’s horror, the camera saw a huge colon tumor. While the gastroenterologists had been reassuring her during her pregnancy, the tumor was gnawing through the wall of her colon and invading nearby organs.

She was wheeled on a gurney from the maternity unit to oncology. That’s where I met her.

She asked a lot of good questions, none of which we could answer. Her heart rate was in the 140s, and she developed fevers. Her cancer put her at risk for a serious infection called an abscess, and it took the option of chemotherapy off the table.

We went back and forth on what to do. We got lots of experts involved, and we went through the possibilities. We realized something terrible. There was no cure anymore. There were only trade-offs.

I will never forget the meeting between all of these doctors, your mom, and a Spanish interpreter. We gave your mom a best case scenario: 1 year.

Holding her necklace cross in one hand and your dad’s hand in the other, she repeated something over and over. The interpreter couldn’t hold back tears as she translated in a soft voice: “Please don’t let me die. Please don’t let me die. Please don’t let me die.”

We were all working so hard, doing our best to find a way out for her. Meanwhile, you stayed in the newborn nursery near the maternity ward. Every day your mom would go back and forth between oncology and the nursery to hold you.

Finally, we proceeded with surgery. It was an enormous, delicate, risky operation that took more than 10 hours. There were colorectal surgeons, urologists, and gynecologic oncologists. They scooped out not only the tumor but also your mom’s uterus, her ovaries, her bladder, and part of the abdominal wall. There was just so much cancer.

But your mom made it through the operation. Two days later, she married your dad in her hospital room while a nurse held you. She called it the best day of her life.

But we were still so worried. Everyone in the oncology unit had grown to love your mom, and we knew this was not a permanent fix. She was discharged from the hospital to rehab to get stronger. The plan was to see her in clinic and consider chemotherapy.

I usually keep a list of patients I want to follow even after I’m no longer their doctor. With your mom, I couldn’t put her on any list. It was too personal; I was too invested. I knew what the outcome would be, and I couldn’t bear to see it.

I never forgot your mom though. I decided to become an oncologist, and I thought about her when I met patients, especially young women, who had been dismissed by other doctors. I vowed to be the change as I listened to them and diagnosed them and treated them. I vowed to be a part of the system that would do better.

One day, 3 years after I met your mom, I was rotating in a colon cancer clinic and looked at the schedule. I recognized a name. Was it possible? It had to be someone with the same name. Could it really be your mom?

It was. By this time, she had finished chemotherapy. The goal was to keep the cancer from growing, but it somehow did more than that. Throughout your mom’s entire body, the cancer was gone. Her stoma was reversed, and she had gained back all the weight she lost. You were there too, defying instructions telling you not to touch the medical equipment. You hugged your mom’s leg as she made plans for a routine follow-up in 6 months.

I want you to know this story about your mom because, for the rest of your life, people will tell you what to think and how to feel. They will think it’s their business to tell you when to be worried, they will talk like they know better, and they will try to make you feel small for speaking up. I don’t have a perfect solution for all of this, except to say: Don’t let them.

But I’m not worried about you. If you grow up to be anything like your mom, you will be okay.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

I know you don’t remember me. We met when you were just a baby. Now that you’re older, I want to tell you a story about your mom you may not know.

When your mom became pregnant with you, it was a joyous occasion. But strange things started to happen. Your mom noticed that she was bleeding into the toilet bowl. She was told pregnancy would make her gain weight, but the opposite was happening. By her second trimester, her maternity clothes were so baggy she had to exchange them.

She went to see a gastroenterologist and told him about the bleeding. He looked at her pregnant belly, ordered no additional tests, and said he would look into the bleeding if it persisted after her pregnancy.

But that was 5 months away. In the meantime, her symptoms got worse. As you probably know by now, your mom is proactive. She sought a second opinion and then a third. Three different gastroenterologists dismissed your mom. The visits were brief; as soon as each doctor noticed she was pregnant, each deferred dealing with her – even though rectal bleeding and weight loss are in no way explained by pregnancy. Even though a colonoscopy could absolutely be safely performed during pregnancy.

A few months later, she gave birth to you. You were a healthy baby and she and your dad cried. They were so happy to meet you.

The next day, your dad stayed with you while the doctors performed a colonoscopy on your mom. To everyone’s horror, the camera saw a huge colon tumor. While the gastroenterologists had been reassuring her during her pregnancy, the tumor was gnawing through the wall of her colon and invading nearby organs.

She was wheeled on a gurney from the maternity unit to oncology. That’s where I met her.

She asked a lot of good questions, none of which we could answer. Her heart rate was in the 140s, and she developed fevers. Her cancer put her at risk for a serious infection called an abscess, and it took the option of chemotherapy off the table.

We went back and forth on what to do. We got lots of experts involved, and we went through the possibilities. We realized something terrible. There was no cure anymore. There were only trade-offs.

I will never forget the meeting between all of these doctors, your mom, and a Spanish interpreter. We gave your mom a best case scenario: 1 year.

Holding her necklace cross in one hand and your dad’s hand in the other, she repeated something over and over. The interpreter couldn’t hold back tears as she translated in a soft voice: “Please don’t let me die. Please don’t let me die. Please don’t let me die.”

We were all working so hard, doing our best to find a way out for her. Meanwhile, you stayed in the newborn nursery near the maternity ward. Every day your mom would go back and forth between oncology and the nursery to hold you.

Finally, we proceeded with surgery. It was an enormous, delicate, risky operation that took more than 10 hours. There were colorectal surgeons, urologists, and gynecologic oncologists. They scooped out not only the tumor but also your mom’s uterus, her ovaries, her bladder, and part of the abdominal wall. There was just so much cancer.

But your mom made it through the operation. Two days later, she married your dad in her hospital room while a nurse held you. She called it the best day of her life.

But we were still so worried. Everyone in the oncology unit had grown to love your mom, and we knew this was not a permanent fix. She was discharged from the hospital to rehab to get stronger. The plan was to see her in clinic and consider chemotherapy.

I usually keep a list of patients I want to follow even after I’m no longer their doctor. With your mom, I couldn’t put her on any list. It was too personal; I was too invested. I knew what the outcome would be, and I couldn’t bear to see it.

I never forgot your mom though. I decided to become an oncologist, and I thought about her when I met patients, especially young women, who had been dismissed by other doctors. I vowed to be the change as I listened to them and diagnosed them and treated them. I vowed to be a part of the system that would do better.

One day, 3 years after I met your mom, I was rotating in a colon cancer clinic and looked at the schedule. I recognized a name. Was it possible? It had to be someone with the same name. Could it really be your mom?

It was. By this time, she had finished chemotherapy. The goal was to keep the cancer from growing, but it somehow did more than that. Throughout your mom’s entire body, the cancer was gone. Her stoma was reversed, and she had gained back all the weight she lost. You were there too, defying instructions telling you not to touch the medical equipment. You hugged your mom’s leg as she made plans for a routine follow-up in 6 months.

I want you to know this story about your mom because, for the rest of your life, people will tell you what to think and how to feel. They will think it’s their business to tell you when to be worried, they will talk like they know better, and they will try to make you feel small for speaking up. I don’t have a perfect solution for all of this, except to say: Don’t let them.

But I’m not worried about you. If you grow up to be anything like your mom, you will be okay.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

I know you don’t remember me. We met when you were just a baby. Now that you’re older, I want to tell you a story about your mom you may not know.

When your mom became pregnant with you, it was a joyous occasion. But strange things started to happen. Your mom noticed that she was bleeding into the toilet bowl. She was told pregnancy would make her gain weight, but the opposite was happening. By her second trimester, her maternity clothes were so baggy she had to exchange them.

She went to see a gastroenterologist and told him about the bleeding. He looked at her pregnant belly, ordered no additional tests, and said he would look into the bleeding if it persisted after her pregnancy.

But that was 5 months away. In the meantime, her symptoms got worse. As you probably know by now, your mom is proactive. She sought a second opinion and then a third. Three different gastroenterologists dismissed your mom. The visits were brief; as soon as each doctor noticed she was pregnant, each deferred dealing with her – even though rectal bleeding and weight loss are in no way explained by pregnancy. Even though a colonoscopy could absolutely be safely performed during pregnancy.

A few months later, she gave birth to you. You were a healthy baby and she and your dad cried. They were so happy to meet you.

The next day, your dad stayed with you while the doctors performed a colonoscopy on your mom. To everyone’s horror, the camera saw a huge colon tumor. While the gastroenterologists had been reassuring her during her pregnancy, the tumor was gnawing through the wall of her colon and invading nearby organs.

She was wheeled on a gurney from the maternity unit to oncology. That’s where I met her.

She asked a lot of good questions, none of which we could answer. Her heart rate was in the 140s, and she developed fevers. Her cancer put her at risk for a serious infection called an abscess, and it took the option of chemotherapy off the table.

We went back and forth on what to do. We got lots of experts involved, and we went through the possibilities. We realized something terrible. There was no cure anymore. There were only trade-offs.

I will never forget the meeting between all of these doctors, your mom, and a Spanish interpreter. We gave your mom a best case scenario: 1 year.

Holding her necklace cross in one hand and your dad’s hand in the other, she repeated something over and over. The interpreter couldn’t hold back tears as she translated in a soft voice: “Please don’t let me die. Please don’t let me die. Please don’t let me die.”

We were all working so hard, doing our best to find a way out for her. Meanwhile, you stayed in the newborn nursery near the maternity ward. Every day your mom would go back and forth between oncology and the nursery to hold you.

Finally, we proceeded with surgery. It was an enormous, delicate, risky operation that took more than 10 hours. There were colorectal surgeons, urologists, and gynecologic oncologists. They scooped out not only the tumor but also your mom’s uterus, her ovaries, her bladder, and part of the abdominal wall. There was just so much cancer.

But your mom made it through the operation. Two days later, she married your dad in her hospital room while a nurse held you. She called it the best day of her life.

But we were still so worried. Everyone in the oncology unit had grown to love your mom, and we knew this was not a permanent fix. She was discharged from the hospital to rehab to get stronger. The plan was to see her in clinic and consider chemotherapy.

I usually keep a list of patients I want to follow even after I’m no longer their doctor. With your mom, I couldn’t put her on any list. It was too personal; I was too invested. I knew what the outcome would be, and I couldn’t bear to see it.

I never forgot your mom though. I decided to become an oncologist, and I thought about her when I met patients, especially young women, who had been dismissed by other doctors. I vowed to be the change as I listened to them and diagnosed them and treated them. I vowed to be a part of the system that would do better.

One day, 3 years after I met your mom, I was rotating in a colon cancer clinic and looked at the schedule. I recognized a name. Was it possible? It had to be someone with the same name. Could it really be your mom?

It was. By this time, she had finished chemotherapy. The goal was to keep the cancer from growing, but it somehow did more than that. Throughout your mom’s entire body, the cancer was gone. Her stoma was reversed, and she had gained back all the weight she lost. You were there too, defying instructions telling you not to touch the medical equipment. You hugged your mom’s leg as she made plans for a routine follow-up in 6 months.

I want you to know this story about your mom because, for the rest of your life, people will tell you what to think and how to feel. They will think it’s their business to tell you when to be worried, they will talk like they know better, and they will try to make you feel small for speaking up. I don’t have a perfect solution for all of this, except to say: Don’t let them.

But I’m not worried about you. If you grow up to be anything like your mom, you will be okay.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

 

When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.

As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.

As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.

This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.

My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.

Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.

However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.

We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).

These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.

Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.

Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.

Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.

The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?

If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.

We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.

 

When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.

As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.

As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.

This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.

My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.

Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.

However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.

We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).

These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.

Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.

Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.

Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.

The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?

If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.

We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.

 

When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.

As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.

As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.

This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.

My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.

Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.

However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.

We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).

These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.

Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.

Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.

Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.

The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?

If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.

We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.

 

As I watched my grandson and his team warm up for their Saturday morning lacrosse game, a long parade of mostly purple-shirted adults and children of all ages began to weave its way around the periphery of the athletic field complex. A quick reading of the hand-lettered and machine-printed shirts made it clear that I was watching a charity walk for cystic fibrosis. There must have been several hundred walkers strolling by, laughing and chatting with one another. It lent a festive atmosphere to the park. I suspect that for most of the participants this was not their first fundraising event for cystic fibrosis.

Salima Senyavskaya/iStock Unreleased

The motley mix of marchers probably included several handfuls of parents of children with cystic fibrosis. I wonder how many of those parents realized how fortunate they were. Cystic fibrosis isn’t a great diagnosis. But at least it is a diagnosis, and with the diagnosis comes a community.

Reading a front-page article on DNA testing in a recent Wall Street Journal issue had primed me to reconsider how even an unfortunate diagnosis can be extremely valuable for a family (“The Unfulfilled Promise of DNA Testing,” by Amy Dockser Marcus, May 18, 2019).The focus of the article was on the confusion and disappointment that are the predictable consequences of our current inability to accurately correlate genetic code “mistakes” with phenotypic abnormalities. Of course there have been a few successes, but we aren’t even close to the promise that many have predicted in the wake of sequencing the human genome. The family featured in the article has a ridden roller coaster ride through two failed attributions of genetic syndromes that appeared to provide their now 8-year-old daughter with a diagnosis for her epilepsy and developmental delay.

In each case, the mother had searched out other families with children who shared the same genetic code errors. She formed support groups and created foundations to promote research for these rare disorders only to learn that her daughter didn’t really fit into the phenotype exhibited by the other children. As the article indicates this mother had “found a genetic home, only to feel that she no longer belonged.” She had made “intense friendships” and for “2 years, the community was her main emotional support.” Since the second diagnosis has evaporated, she has struggled with whether to remain with that community, having already left one behind. She has been encouraged to stay involved by another mother whose son does have the diagnosis. Understandably, she is still seeking the correct diagnosis, and I suspect will form or join a new community when she finds it.

We all want to belong to a community. Having a diagnosis, even if there is no reasonable hope for cure in the near future, is the ticket into that community. And with that ticket comes the opportunity to share the frustrations and difficulties unique to children with that diagnosis, and the comfort that there are other people who look, behave, and feel the way we do. We hear repeatedly about the value of diversity and how wonderful it is to be all inclusive. And certainly we should continue to be as accepting as we can of people who are different. But the truth is that we will always fall short because we seem to be hardwired to notice what is different. And the power of the longing to belong is often stronger than our will to be inclusive.

The revolution that resulted in the disappearance of the label “mental retardation” and the widespread adoption of the diagnosis of autism are examples of how a community can form around a diagnosis. But not every child who is labeled as autistic will actually fit the diagnosis. Yet even a less-than-perfect attribution can provide a place where a family and a patient can feel that they belong.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

 

As I watched my grandson and his team warm up for their Saturday morning lacrosse game, a long parade of mostly purple-shirted adults and children of all ages began to weave its way around the periphery of the athletic field complex. A quick reading of the hand-lettered and machine-printed shirts made it clear that I was watching a charity walk for cystic fibrosis. There must have been several hundred walkers strolling by, laughing and chatting with one another. It lent a festive atmosphere to the park. I suspect that for most of the participants this was not their first fundraising event for cystic fibrosis.

Salima Senyavskaya/iStock Unreleased

The motley mix of marchers probably included several handfuls of parents of children with cystic fibrosis. I wonder how many of those parents realized how fortunate they were. Cystic fibrosis isn’t a great diagnosis. But at least it is a diagnosis, and with the diagnosis comes a community.

Reading a front-page article on DNA testing in a recent Wall Street Journal issue had primed me to reconsider how even an unfortunate diagnosis can be extremely valuable for a family (“The Unfulfilled Promise of DNA Testing,” by Amy Dockser Marcus, May 18, 2019).The focus of the article was on the confusion and disappointment that are the predictable consequences of our current inability to accurately correlate genetic code “mistakes” with phenotypic abnormalities. Of course there have been a few successes, but we aren’t even close to the promise that many have predicted in the wake of sequencing the human genome. The family featured in the article has a ridden roller coaster ride through two failed attributions of genetic syndromes that appeared to provide their now 8-year-old daughter with a diagnosis for her epilepsy and developmental delay.

In each case, the mother had searched out other families with children who shared the same genetic code errors. She formed support groups and created foundations to promote research for these rare disorders only to learn that her daughter didn’t really fit into the phenotype exhibited by the other children. As the article indicates this mother had “found a genetic home, only to feel that she no longer belonged.” She had made “intense friendships” and for “2 years, the community was her main emotional support.” Since the second diagnosis has evaporated, she has struggled with whether to remain with that community, having already left one behind. She has been encouraged to stay involved by another mother whose son does have the diagnosis. Understandably, she is still seeking the correct diagnosis, and I suspect will form or join a new community when she finds it.

We all want to belong to a community. Having a diagnosis, even if there is no reasonable hope for cure in the near future, is the ticket into that community. And with that ticket comes the opportunity to share the frustrations and difficulties unique to children with that diagnosis, and the comfort that there are other people who look, behave, and feel the way we do. We hear repeatedly about the value of diversity and how wonderful it is to be all inclusive. And certainly we should continue to be as accepting as we can of people who are different. But the truth is that we will always fall short because we seem to be hardwired to notice what is different. And the power of the longing to belong is often stronger than our will to be inclusive.

The revolution that resulted in the disappearance of the label “mental retardation” and the widespread adoption of the diagnosis of autism are examples of how a community can form around a diagnosis. But not every child who is labeled as autistic will actually fit the diagnosis. Yet even a less-than-perfect attribution can provide a place where a family and a patient can feel that they belong.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

 

As I watched my grandson and his team warm up for their Saturday morning lacrosse game, a long parade of mostly purple-shirted adults and children of all ages began to weave its way around the periphery of the athletic field complex. A quick reading of the hand-lettered and machine-printed shirts made it clear that I was watching a charity walk for cystic fibrosis. There must have been several hundred walkers strolling by, laughing and chatting with one another. It lent a festive atmosphere to the park. I suspect that for most of the participants this was not their first fundraising event for cystic fibrosis.

Salima Senyavskaya/iStock Unreleased

The motley mix of marchers probably included several handfuls of parents of children with cystic fibrosis. I wonder how many of those parents realized how fortunate they were. Cystic fibrosis isn’t a great diagnosis. But at least it is a diagnosis, and with the diagnosis comes a community.

Reading a front-page article on DNA testing in a recent Wall Street Journal issue had primed me to reconsider how even an unfortunate diagnosis can be extremely valuable for a family (“The Unfulfilled Promise of DNA Testing,” by Amy Dockser Marcus, May 18, 2019).The focus of the article was on the confusion and disappointment that are the predictable consequences of our current inability to accurately correlate genetic code “mistakes” with phenotypic abnormalities. Of course there have been a few successes, but we aren’t even close to the promise that many have predicted in the wake of sequencing the human genome. The family featured in the article has a ridden roller coaster ride through two failed attributions of genetic syndromes that appeared to provide their now 8-year-old daughter with a diagnosis for her epilepsy and developmental delay.

In each case, the mother had searched out other families with children who shared the same genetic code errors. She formed support groups and created foundations to promote research for these rare disorders only to learn that her daughter didn’t really fit into the phenotype exhibited by the other children. As the article indicates this mother had “found a genetic home, only to feel that she no longer belonged.” She had made “intense friendships” and for “2 years, the community was her main emotional support.” Since the second diagnosis has evaporated, she has struggled with whether to remain with that community, having already left one behind. She has been encouraged to stay involved by another mother whose son does have the diagnosis. Understandably, she is still seeking the correct diagnosis, and I suspect will form or join a new community when she finds it.

We all want to belong to a community. Having a diagnosis, even if there is no reasonable hope for cure in the near future, is the ticket into that community. And with that ticket comes the opportunity to share the frustrations and difficulties unique to children with that diagnosis, and the comfort that there are other people who look, behave, and feel the way we do. We hear repeatedly about the value of diversity and how wonderful it is to be all inclusive. And certainly we should continue to be as accepting as we can of people who are different. But the truth is that we will always fall short because we seem to be hardwired to notice what is different. And the power of the longing to belong is often stronger than our will to be inclusive.

The revolution that resulted in the disappearance of the label “mental retardation” and the widespread adoption of the diagnosis of autism are examples of how a community can form around a diagnosis. But not every child who is labeled as autistic will actually fit the diagnosis. Yet even a less-than-perfect attribution can provide a place where a family and a patient can feel that they belong.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

 

I have no idea what the standard of care in cardiology is. Or nephrology, endocrinology, or pulmonary medicine.

tomloel/ThinkStock

Nor do I think anyone in those fields tries to keep up to date on the latest in epilepsy, migraines, or Parkinson’s disease. They have their fields, I have mine. That’s the whole point of being a specialist: Medicine is too vast a subject for one person to know everything about it. Even my own field is further divided into subspecialties like vascular disease, neuromuscular disorders, and dementia, so I imagine other fields are, too.

Yet, there are still states where a physician of a different specialty can testify as to the standard of care in others for malpractice cases.

Think about that. An orthopedist testifying as to the competence of an ob.gyn. An adult neurologist claiming to be up to date on pediatric allergies. A family practice doctor stating what a neurosurgeon should be doing. All in a court of law, the most dreaded scenario for most of us.

Fortunately, there are several states that require an expert witness to be an actively-practicing, board-certified, specialist in the same field as the person they’re testifying against.

However, some states have little to no regulation of this, so an “expert witness” can be anyone with an MD/DO degree and a pulse. While a good defense attorney can hopefully pick this apart, the average jury is not composed of people with medical training. To many lay people, “a doctor is a doctor,” and it’s very hard to emphasize the degree of specialty differences to them.

This difference is one (but certainly not the only) factor that drives the different malpractice costs between states. You’d think requiring own-field standard of care would be one of the least contentious malpractice reforms to make, but these days people fight tooth and nail about everything. The result of these battles is that states with the lowest malpractice rates tend to attract more physicians, and states with the highest can have trouble finding qualified people. In the long run, that only hurts those who need medical care.
 

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

 

I have no idea what the standard of care in cardiology is. Or nephrology, endocrinology, or pulmonary medicine.

tomloel/ThinkStock

Nor do I think anyone in those fields tries to keep up to date on the latest in epilepsy, migraines, or Parkinson’s disease. They have their fields, I have mine. That’s the whole point of being a specialist: Medicine is too vast a subject for one person to know everything about it. Even my own field is further divided into subspecialties like vascular disease, neuromuscular disorders, and dementia, so I imagine other fields are, too.

Yet, there are still states where a physician of a different specialty can testify as to the standard of care in others for malpractice cases.

Think about that. An orthopedist testifying as to the competence of an ob.gyn. An adult neurologist claiming to be up to date on pediatric allergies. A family practice doctor stating what a neurosurgeon should be doing. All in a court of law, the most dreaded scenario for most of us.

Fortunately, there are several states that require an expert witness to be an actively-practicing, board-certified, specialist in the same field as the person they’re testifying against.

However, some states have little to no regulation of this, so an “expert witness” can be anyone with an MD/DO degree and a pulse. While a good defense attorney can hopefully pick this apart, the average jury is not composed of people with medical training. To many lay people, “a doctor is a doctor,” and it’s very hard to emphasize the degree of specialty differences to them.

This difference is one (but certainly not the only) factor that drives the different malpractice costs between states. You’d think requiring own-field standard of care would be one of the least contentious malpractice reforms to make, but these days people fight tooth and nail about everything. The result of these battles is that states with the lowest malpractice rates tend to attract more physicians, and states with the highest can have trouble finding qualified people. In the long run, that only hurts those who need medical care.
 

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

 

I have no idea what the standard of care in cardiology is. Or nephrology, endocrinology, or pulmonary medicine.

tomloel/ThinkStock

Nor do I think anyone in those fields tries to keep up to date on the latest in epilepsy, migraines, or Parkinson’s disease. They have their fields, I have mine. That’s the whole point of being a specialist: Medicine is too vast a subject for one person to know everything about it. Even my own field is further divided into subspecialties like vascular disease, neuromuscular disorders, and dementia, so I imagine other fields are, too.

Yet, there are still states where a physician of a different specialty can testify as to the standard of care in others for malpractice cases.

Think about that. An orthopedist testifying as to the competence of an ob.gyn. An adult neurologist claiming to be up to date on pediatric allergies. A family practice doctor stating what a neurosurgeon should be doing. All in a court of law, the most dreaded scenario for most of us.

Fortunately, there are several states that require an expert witness to be an actively-practicing, board-certified, specialist in the same field as the person they’re testifying against.

However, some states have little to no regulation of this, so an “expert witness” can be anyone with an MD/DO degree and a pulse. While a good defense attorney can hopefully pick this apart, the average jury is not composed of people with medical training. To many lay people, “a doctor is a doctor,” and it’s very hard to emphasize the degree of specialty differences to them.

This difference is one (but certainly not the only) factor that drives the different malpractice costs between states. You’d think requiring own-field standard of care would be one of the least contentious malpractice reforms to make, but these days people fight tooth and nail about everything. The result of these battles is that states with the lowest malpractice rates tend to attract more physicians, and states with the highest can have trouble finding qualified people. In the long run, that only hurts those who need medical care.
 

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

 

Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.

kevron2001/Getty Images

Boris has a spot on his nose. I call with test results.

“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”

“Skin cancer?”

“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”

“Will I have to stay in the hospital?”

“No, it’s done under local anesthesia. You get it done and go home.”

“Is it urgent?”

“It can wait a few weeks. Just call for an appointment.”

“Will it be done in the hospital itself, or in another building?”

One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”

It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.

Stella is more perplexing than Boris, not to mention more challenging.

“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”

“Taken care of?”

“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”

“A healer?”

“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”

“With due respect, I don’t think she did.”

“Why do you say that?”

“Because it’s still there on your forehead. I can see it.”

Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.

The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.

I call Stella.

“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”

“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”

“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”

Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”

“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”

Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...

“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”

“Of course,” says Stella, “that goes without saying.”

“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”

 

We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.

Stella’s faith in her remote healer seems like one way of abetting denial and addressing fear, one step beyond just pretending the symptom or sign simply isn’t there. How much more obvious can a problem be than a black spot on your forehead?

Fear can be annoying, confounding, insulting. It can present as whining, as interrogation, as aggression. Dealing with it may be wearying, or impossible. But it’s part of our job, because it’s always there.

Besides, we should be able to relate. Doctors know fear too, don’t we?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.

 

Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.

kevron2001/Getty Images

Boris has a spot on his nose. I call with test results.

“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”

“Skin cancer?”

“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”

“Will I have to stay in the hospital?”

“No, it’s done under local anesthesia. You get it done and go home.”

“Is it urgent?”

“It can wait a few weeks. Just call for an appointment.”

“Will it be done in the hospital itself, or in another building?”

One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”

It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.

Stella is more perplexing than Boris, not to mention more challenging.

“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”

“Taken care of?”

“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”

“A healer?”

“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”

“With due respect, I don’t think she did.”

“Why do you say that?”

“Because it’s still there on your forehead. I can see it.”

Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.

The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.

I call Stella.

“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”

“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”

“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”

Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”

“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”

Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...

“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”

“Of course,” says Stella, “that goes without saying.”

“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”

 

We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.

Stella’s faith in her remote healer seems like one way of abetting denial and addressing fear, one step beyond just pretending the symptom or sign simply isn’t there. How much more obvious can a problem be than a black spot on your forehead?

Fear can be annoying, confounding, insulting. It can present as whining, as interrogation, as aggression. Dealing with it may be wearying, or impossible. But it’s part of our job, because it’s always there.

Besides, we should be able to relate. Doctors know fear too, don’t we?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.

 

Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.

kevron2001/Getty Images

Boris has a spot on his nose. I call with test results.

“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”

“Skin cancer?”

“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”

“Will I have to stay in the hospital?”

“No, it’s done under local anesthesia. You get it done and go home.”

“Is it urgent?”

“It can wait a few weeks. Just call for an appointment.”

“Will it be done in the hospital itself, or in another building?”

One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”

It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.

Stella is more perplexing than Boris, not to mention more challenging.

“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”

“Taken care of?”

“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”

“A healer?”

“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”

“With due respect, I don’t think she did.”

“Why do you say that?”

“Because it’s still there on your forehead. I can see it.”

Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.

The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.

I call Stella.

“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”

“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”

“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”

Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”

“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”

Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...

“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”

“Of course,” says Stella, “that goes without saying.”

“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”

 

We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.

Stella’s faith in her remote healer seems like one way of abetting denial and addressing fear, one step beyond just pretending the symptom or sign simply isn’t there. How much more obvious can a problem be than a black spot on your forehead?

Fear can be annoying, confounding, insulting. It can present as whining, as interrogation, as aggression. Dealing with it may be wearying, or impossible. But it’s part of our job, because it’s always there.

Besides, we should be able to relate. Doctors know fear too, don’t we?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.

According to the World Health Organization, there were about 219 million cases of malaria and an estimated 660,000 deaths in 2010. Although huge, this was a 26% decrease from the rates in 2000. Six countries in Africa account for 47% of malaria cases: Cote d’Ivoire, Democratic Republic of the Congo, Mozambique, Nigeria, Uganda, and the United Republic of Tanzania. The second-most affected region in the world is Southeast Asia, which includes Myanmar, India, and Indonesia. In comparison, about 1,500 malaria cases and 5 deaths are reported annually in the United States, mostly from returned travelers.

Courtesy NIAID

It is extremely important for any woman that is or might be pregnant or breastfeeding to take an antimalarial drug for protection if they will be traveling in any of the above regions. Malaria during pregnancy increases the risk for adverse pregnancy outcomes, including maternal anemia, prematurity, spontaneous abortion, and stillbirth.

As stated by the Centers for Disease Control and Prevention, no antimalarial agent is 100% protective. Therefore, whatever agent is used must be combined with personal protective measures such as wearing insect repellent, long sleeves, and long pants; sleeping in a mosquito-free setting; or using an insecticide-treated bed net.

There are nine antimalarial drugs available in the United States.

Atovaquone/Proguanil Hcl (Malarone and as generic)

This agent is good for last-minute travelers because the drug is started 1-2 days before traveling to areas where malaria transmission occurs. The combination can be classified as compatible in pregnancy. No reports in breastfeeding with atovaquone or the combination have been found. Proguanil is not available in the United States as a single agent.

Chloroquine (generic)

This is the drug of choice to prevent and treat sensitive malaria species during pregnancy. The drug crosses the placenta producing fetal concentrations that are similar to those in the mother. The drug appears to be low risk for embryo-fetal harm.

It is compatible in breastfeeding.

Dapsone (generic)

This agent does not appear to represent a major risk of harm to the fetus. Although it has been used in combination with pyrimethamine (an antiparasitic) or trimethoprim (an antibiotic) to prevent malaria, the efficacy of the combination has not been confirmed.

In breastfeeding, there is one case of mild hemolytic anemia in the mother and her breastfeeding infant that may have been caused by the drug.

Hydroxychloroquine (generic)

This agent is used for the treatment of malaria, systemic erythematosus, and rheumatoid arthritis. For antimalarial prophylaxis, 400 mg/week appears to be low risk for embryo-fetal harm. Doses used to treat malaria have been 200-400 mg/day.

Because very low concentrations of the drug have been found in breast milk, breastfeeding is probably compatible.

Mefloquine (generic)

This agent is a quinoline-methanol agent that does not appear to cause embryo-fetal harm based on a large number of pregnancy exposures.

There are no reports of its use while breastfeeding.

 

Primaquine (generic)

This agent is best avoided in pregnancy. There is no human pregnancy data, but it may cause hemolytic anemia in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD). Because the fetus is relatively G6PD deficient, it is best avoided in pregnancy regardless of the mother’s status.

There are no reports describing the use of the drug during lactation. Both the mother and baby should be tested for G6PD deficiency before the drug is used during breastfeeding.

Pyrimethamine (generic)

This agent has been used for the treatment or prophylaxis of malaria. Most studies have found this agent to be relatively safe and effective.

It is excreted into breast milk and has been effective in eliminating malaria parasites from breastfeeding infants.

Quinidine (generic)

Reports linking the use of this agent with congenital defects have not been found. Although the drug has data on its use as an antiarrhythmic, its published use to treat malaria is limited.

The drug is excreted into breast milk, but there are no reports of its during breastfeeding.

Quinine (generic)

This agent has a large amount of human pregnancy data (more than 1,000 exposures) that found no increased risk of birth defects. The drug has been replaced by newer agents but still may be used for chloroquine-resistant malaria.

The drug appears to be compatible during breastfeeding.

Mr. Briggs is clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at obnews@mdedge.com.

According to the World Health Organization, there were about 219 million cases of malaria and an estimated 660,000 deaths in 2010. Although huge, this was a 26% decrease from the rates in 2000. Six countries in Africa account for 47% of malaria cases: Cote d’Ivoire, Democratic Republic of the Congo, Mozambique, Nigeria, Uganda, and the United Republic of Tanzania. The second-most affected region in the world is Southeast Asia, which includes Myanmar, India, and Indonesia. In comparison, about 1,500 malaria cases and 5 deaths are reported annually in the United States, mostly from returned travelers.

Courtesy NIAID

It is extremely important for any woman that is or might be pregnant or breastfeeding to take an antimalarial drug for protection if they will be traveling in any of the above regions. Malaria during pregnancy increases the risk for adverse pregnancy outcomes, including maternal anemia, prematurity, spontaneous abortion, and stillbirth.

As stated by the Centers for Disease Control and Prevention, no antimalarial agent is 100% protective. Therefore, whatever agent is used must be combined with personal protective measures such as wearing insect repellent, long sleeves, and long pants; sleeping in a mosquito-free setting; or using an insecticide-treated bed net.

There are nine antimalarial drugs available in the United States.

Atovaquone/Proguanil Hcl (Malarone and as generic)

This agent is good for last-minute travelers because the drug is started 1-2 days before traveling to areas where malaria transmission occurs. The combination can be classified as compatible in pregnancy. No reports in breastfeeding with atovaquone or the combination have been found. Proguanil is not available in the United States as a single agent.

Chloroquine (generic)

This is the drug of choice to prevent and treat sensitive malaria species during pregnancy. The drug crosses the placenta producing fetal concentrations that are similar to those in the mother. The drug appears to be low risk for embryo-fetal harm.

It is compatible in breastfeeding.

Dapsone (generic)

This agent does not appear to represent a major risk of harm to the fetus. Although it has been used in combination with pyrimethamine (an antiparasitic) or trimethoprim (an antibiotic) to prevent malaria, the efficacy of the combination has not been confirmed.

In breastfeeding, there is one case of mild hemolytic anemia in the mother and her breastfeeding infant that may have been caused by the drug.

Hydroxychloroquine (generic)

This agent is used for the treatment of malaria, systemic erythematosus, and rheumatoid arthritis. For antimalarial prophylaxis, 400 mg/week appears to be low risk for embryo-fetal harm. Doses used to treat malaria have been 200-400 mg/day.

Because very low concentrations of the drug have been found in breast milk, breastfeeding is probably compatible.

Mefloquine (generic)

This agent is a quinoline-methanol agent that does not appear to cause embryo-fetal harm based on a large number of pregnancy exposures.

There are no reports of its use while breastfeeding.

 

Primaquine (generic)

This agent is best avoided in pregnancy. There is no human pregnancy data, but it may cause hemolytic anemia in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD). Because the fetus is relatively G6PD deficient, it is best avoided in pregnancy regardless of the mother’s status.

There are no reports describing the use of the drug during lactation. Both the mother and baby should be tested for G6PD deficiency before the drug is used during breastfeeding.

Pyrimethamine (generic)

This agent has been used for the treatment or prophylaxis of malaria. Most studies have found this agent to be relatively safe and effective.

It is excreted into breast milk and has been effective in eliminating malaria parasites from breastfeeding infants.

Quinidine (generic)

Reports linking the use of this agent with congenital defects have not been found. Although the drug has data on its use as an antiarrhythmic, its published use to treat malaria is limited.

The drug is excreted into breast milk, but there are no reports of its during breastfeeding.

Quinine (generic)

This agent has a large amount of human pregnancy data (more than 1,000 exposures) that found no increased risk of birth defects. The drug has been replaced by newer agents but still may be used for chloroquine-resistant malaria.

The drug appears to be compatible during breastfeeding.

Mr. Briggs is clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at obnews@mdedge.com.

According to the World Health Organization, there were about 219 million cases of malaria and an estimated 660,000 deaths in 2010. Although huge, this was a 26% decrease from the rates in 2000. Six countries in Africa account for 47% of malaria cases: Cote d’Ivoire, Democratic Republic of the Congo, Mozambique, Nigeria, Uganda, and the United Republic of Tanzania. The second-most affected region in the world is Southeast Asia, which includes Myanmar, India, and Indonesia. In comparison, about 1,500 malaria cases and 5 deaths are reported annually in the United States, mostly from returned travelers.

Courtesy NIAID

It is extremely important for any woman that is or might be pregnant or breastfeeding to take an antimalarial drug for protection if they will be traveling in any of the above regions. Malaria during pregnancy increases the risk for adverse pregnancy outcomes, including maternal anemia, prematurity, spontaneous abortion, and stillbirth.

As stated by the Centers for Disease Control and Prevention, no antimalarial agent is 100% protective. Therefore, whatever agent is used must be combined with personal protective measures such as wearing insect repellent, long sleeves, and long pants; sleeping in a mosquito-free setting; or using an insecticide-treated bed net.

There are nine antimalarial drugs available in the United States.

Atovaquone/Proguanil Hcl (Malarone and as generic)

This agent is good for last-minute travelers because the drug is started 1-2 days before traveling to areas where malaria transmission occurs. The combination can be classified as compatible in pregnancy. No reports in breastfeeding with atovaquone or the combination have been found. Proguanil is not available in the United States as a single agent.

Chloroquine (generic)

This is the drug of choice to prevent and treat sensitive malaria species during pregnancy. The drug crosses the placenta producing fetal concentrations that are similar to those in the mother. The drug appears to be low risk for embryo-fetal harm.

It is compatible in breastfeeding.

Dapsone (generic)

This agent does not appear to represent a major risk of harm to the fetus. Although it has been used in combination with pyrimethamine (an antiparasitic) or trimethoprim (an antibiotic) to prevent malaria, the efficacy of the combination has not been confirmed.

In breastfeeding, there is one case of mild hemolytic anemia in the mother and her breastfeeding infant that may have been caused by the drug.

Hydroxychloroquine (generic)

This agent is used for the treatment of malaria, systemic erythematosus, and rheumatoid arthritis. For antimalarial prophylaxis, 400 mg/week appears to be low risk for embryo-fetal harm. Doses used to treat malaria have been 200-400 mg/day.

Because very low concentrations of the drug have been found in breast milk, breastfeeding is probably compatible.

Mefloquine (generic)

This agent is a quinoline-methanol agent that does not appear to cause embryo-fetal harm based on a large number of pregnancy exposures.

There are no reports of its use while breastfeeding.

 

Primaquine (generic)

This agent is best avoided in pregnancy. There is no human pregnancy data, but it may cause hemolytic anemia in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD). Because the fetus is relatively G6PD deficient, it is best avoided in pregnancy regardless of the mother’s status.

There are no reports describing the use of the drug during lactation. Both the mother and baby should be tested for G6PD deficiency before the drug is used during breastfeeding.

Pyrimethamine (generic)

This agent has been used for the treatment or prophylaxis of malaria. Most studies have found this agent to be relatively safe and effective.

It is excreted into breast milk and has been effective in eliminating malaria parasites from breastfeeding infants.

Quinidine (generic)

Reports linking the use of this agent with congenital defects have not been found. Although the drug has data on its use as an antiarrhythmic, its published use to treat malaria is limited.

The drug is excreted into breast milk, but there are no reports of its during breastfeeding.

Quinine (generic)

This agent has a large amount of human pregnancy data (more than 1,000 exposures) that found no increased risk of birth defects. The drug has been replaced by newer agents but still may be used for chloroquine-resistant malaria.

The drug appears to be compatible during breastfeeding.

Mr. Briggs is clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at obnews@mdedge.com.

 

Question: Dr. X incorrectly informs his patient Y that he is HIV negative, when in fact he had tested positive. As a result, treatment was delayed for a year. In the meantime, Y infects his sexual partner Z, who is not Dr. X’s patient, and whom the doctor has never met. In a negligence lawsuit by Z against Dr. X, which of the following is best?

A. Legal duty is used as a filter to control the tide of litigation and to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

B. Duty of care arises from the doctor-patient relationship and is usually owed to the patient and no one else.

C. Even if Dr. X were negligent, Z must first establish that the doctor owes her a duty of due care.

D. As a nonpatient “third party,” Z has the burden of convincing the court that she was a known, foreseeable victim of a serious condition and was in a special relationship.

E. All correct.

Answer: E. The law requires that a professional acts reasonably with the knowledge, skill, and judgment ordinarily possessed by fellow members in good standing. For the medical profession, this duty of due care springs from the doctor-patient relationship, and is generally owed to the patient and to no one else. Allowing individuals outside the relationship, i.e., nonpatient third parties, a cause of action against the provider will unwisely expand the sphere of medical liability. Besides, an expansive view of legal duty may lead the provider to breach confidentiality or invite intrusive and/or irrelevant inquiries into a patient’s personal matters. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries. Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class” as famously articulated in the 1928 Plasgraf case.¹

Still, a health care provider can sometimes be found liable to one other than his or her immediate patient, notwithstanding the absence of a provider-patient relationship with that person. One such class of claims deals with communicable diseases. In Bradshaw v. Daniel,² the Supreme Court of Tennessee held that a physician has a duty to inform a patient’s immediate family of the risk of an infectious disease such as Rocky Mountain spotted fever, although the condition itself is not contagious without a vector. In Shepard v. Redford Community Hospital,³ a lower court found no physician-patient relationship between the doctor and the patient’s son who died after contracting meningitis from his mother, who had the disease first, but was not warned of the risk of spreading it to family members. The appellate court reversed, finding liability and holding that the physician-mother relationship resulted in a special situation for imposing a duty of care for her son.

A nonpatient can sue providers who have failed to advise their patients of the sexual transmissibility of conditions such as AIDS or hepatitis B. In DiMarco v. Lynch Homes-Chester County Inc.,⁴ the Supreme Court of Pennsylvania found liability where the physician’s failure to advise his patient to abstain from sexual activity for an appropriate period of time led to the sexual partner acquiring hepatitis B. The Court used a “foreseeable orbit of risk of harm” argument, stating: “If a third person is in that class of persons whose health is likely to be threatened by the patient … [she] has a cause of action … because the physician should recognize that the services rendered to the patient are necessary for the protection of the third person.” And in Reisner v. Regents of the University of California,⁵ a 12-year-old girl became infected with HIV after receiving tainted blood, but the defendant did not disclose the information in a timely manner. She died of AIDS at age seventeen, but not before infecting her sexual partner, who was the plaintiff in the case. The court held that a physician fulfills his duty only after he warns the patient of the risk to others, and that the lack of knowledge of the third party’s identity was immaterial.

Liability may be more likely in jurisdictions that impose a statutory duty on physicians to inform, counsel, or warn their patients or inform health authorities of conditions such as AIDS. California allows the attending physician to disclose to “a person reasonably believed to be the spouse … a sexual partner or a person with whom the patient has shared the use of hypodermic needles, or to the local health officer.”⁶ Although this statutory disclosure is permissive rather than mandatory, it may prove persuasive in any court’s deliberation over the “no-duty” defense argument.

A recent case⁷ presents an interesting fact-situation on the duty issue. Dr. CC incorrectly told his patient that he tested negative for a sexually transmissible disease (herpes), when in fact he had tested positive. His girlfriend, who was not Dr. CC’s patient, became infected and filed suit. The trial court dismissed, ruling that the doctor owed no duty to the girlfriend, because she was not his patient and therefore she had no “legally cognizable claim.” Connecticut’s highest court has recently heard oral arguments on appeal, and its decision is pending.

The AMA has filed an amicus brief in support of Dr. CC.⁸ It argues that Connecticut’s precedent mitigates against expansion of a provider’s duty to nonpatients and raises public policy concerns such as impact on malpractice insurance rates, patient care, and the ethics of patient confidentiality. The brief concluded that it was “… nearly impossible to articulate a bright-line rule of foreseeability … when, like here, the class of persons potentially exposed to injury from such care is so broad and cannot be readily identifiable at the time care is rendered.”

 

References

1. Palsgraf v. Long Island Railroad Co., 248 N.Y. 339, 162 N.E. 99 (1928).

2. Bradshaw v. Daniel, 854 S.W.2d 865 (Tenn. 1993).

3. Shepard v. Redford Community Hospital, 390 N.W.2d 239 (Mich. App. 1986).

4. DiMarco v. Lynch Homes-Chester County Inc., 583 A 2d 422 (Penn. 1990).

5. Reisner v. Regents of the University of California, 37 Cal Rptr 2d 518 (Cal App 2 Dist., 1995).

6. California Health & Safety Code §121015 (a).

7. Doe v. Cochran, 62 Conn L Rptr 33, 2016 (S.C. #19879).

8. What duties do physicians owe to non-patients? AMA News. 2018 Jul 13.
 

Dr. Tan is Emeritus Professor of Medicine and former Adjunct Professor of Law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

 

Question: Dr. X incorrectly informs his patient Y that he is HIV negative, when in fact he had tested positive. As a result, treatment was delayed for a year. In the meantime, Y infects his sexual partner Z, who is not Dr. X’s patient, and whom the doctor has never met. In a negligence lawsuit by Z against Dr. X, which of the following is best?

A. Legal duty is used as a filter to control the tide of litigation and to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

B. Duty of care arises from the doctor-patient relationship and is usually owed to the patient and no one else.

C. Even if Dr. X were negligent, Z must first establish that the doctor owes her a duty of due care.

D. As a nonpatient “third party,” Z has the burden of convincing the court that she was a known, foreseeable victim of a serious condition and was in a special relationship.

E. All correct.

Answer: E. The law requires that a professional acts reasonably with the knowledge, skill, and judgment ordinarily possessed by fellow members in good standing. For the medical profession, this duty of due care springs from the doctor-patient relationship, and is generally owed to the patient and to no one else. Allowing individuals outside the relationship, i.e., nonpatient third parties, a cause of action against the provider will unwisely expand the sphere of medical liability. Besides, an expansive view of legal duty may lead the provider to breach confidentiality or invite intrusive and/or irrelevant inquiries into a patient’s personal matters. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries. Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class” as famously articulated in the 1928 Plasgraf case.¹

Still, a health care provider can sometimes be found liable to one other than his or her immediate patient, notwithstanding the absence of a provider-patient relationship with that person. One such class of claims deals with communicable diseases. In Bradshaw v. Daniel,² the Supreme Court of Tennessee held that a physician has a duty to inform a patient’s immediate family of the risk of an infectious disease such as Rocky Mountain spotted fever, although the condition itself is not contagious without a vector. In Shepard v. Redford Community Hospital,³ a lower court found no physician-patient relationship between the doctor and the patient’s son who died after contracting meningitis from his mother, who had the disease first, but was not warned of the risk of spreading it to family members. The appellate court reversed, finding liability and holding that the physician-mother relationship resulted in a special situation for imposing a duty of care for her son.

A nonpatient can sue providers who have failed to advise their patients of the sexual transmissibility of conditions such as AIDS or hepatitis B. In DiMarco v. Lynch Homes-Chester County Inc.,⁴ the Supreme Court of Pennsylvania found liability where the physician’s failure to advise his patient to abstain from sexual activity for an appropriate period of time led to the sexual partner acquiring hepatitis B. The Court used a “foreseeable orbit of risk of harm” argument, stating: “If a third person is in that class of persons whose health is likely to be threatened by the patient … [she] has a cause of action … because the physician should recognize that the services rendered to the patient are necessary for the protection of the third person.” And in Reisner v. Regents of the University of California,⁵ a 12-year-old girl became infected with HIV after receiving tainted blood, but the defendant did not disclose the information in a timely manner. She died of AIDS at age seventeen, but not before infecting her sexual partner, who was the plaintiff in the case. The court held that a physician fulfills his duty only after he warns the patient of the risk to others, and that the lack of knowledge of the third party’s identity was immaterial.

Liability may be more likely in jurisdictions that impose a statutory duty on physicians to inform, counsel, or warn their patients or inform health authorities of conditions such as AIDS. California allows the attending physician to disclose to “a person reasonably believed to be the spouse … a sexual partner or a person with whom the patient has shared the use of hypodermic needles, or to the local health officer.”⁶ Although this statutory disclosure is permissive rather than mandatory, it may prove persuasive in any court’s deliberation over the “no-duty” defense argument.

A recent case⁷ presents an interesting fact-situation on the duty issue. Dr. CC incorrectly told his patient that he tested negative for a sexually transmissible disease (herpes), when in fact he had tested positive. His girlfriend, who was not Dr. CC’s patient, became infected and filed suit. The trial court dismissed, ruling that the doctor owed no duty to the girlfriend, because she was not his patient and therefore she had no “legally cognizable claim.” Connecticut’s highest court has recently heard oral arguments on appeal, and its decision is pending.

The AMA has filed an amicus brief in support of Dr. CC.⁸ It argues that Connecticut’s precedent mitigates against expansion of a provider’s duty to nonpatients and raises public policy concerns such as impact on malpractice insurance rates, patient care, and the ethics of patient confidentiality. The brief concluded that it was “… nearly impossible to articulate a bright-line rule of foreseeability … when, like here, the class of persons potentially exposed to injury from such care is so broad and cannot be readily identifiable at the time care is rendered.”

 

References

1. Palsgraf v. Long Island Railroad Co., 248 N.Y. 339, 162 N.E. 99 (1928).

2. Bradshaw v. Daniel, 854 S.W.2d 865 (Tenn. 1993).

3. Shepard v. Redford Community Hospital, 390 N.W.2d 239 (Mich. App. 1986).

4. DiMarco v. Lynch Homes-Chester County Inc., 583 A 2d 422 (Penn. 1990).

5. Reisner v. Regents of the University of California, 37 Cal Rptr 2d 518 (Cal App 2 Dist., 1995).

6. California Health & Safety Code §121015 (a).

7. Doe v. Cochran, 62 Conn L Rptr 33, 2016 (S.C. #19879).

8. What duties do physicians owe to non-patients? AMA News. 2018 Jul 13.
 

Dr. Tan is Emeritus Professor of Medicine and former Adjunct Professor of Law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

 

Question: Dr. X incorrectly informs his patient Y that he is HIV negative, when in fact he had tested positive. As a result, treatment was delayed for a year. In the meantime, Y infects his sexual partner Z, who is not Dr. X’s patient, and whom the doctor has never met. In a negligence lawsuit by Z against Dr. X, which of the following is best?

A. Legal duty is used as a filter to control the tide of litigation and to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

B. Duty of care arises from the doctor-patient relationship and is usually owed to the patient and no one else.

C. Even if Dr. X were negligent, Z must first establish that the doctor owes her a duty of due care.

D. As a nonpatient “third party,” Z has the burden of convincing the court that she was a known, foreseeable victim of a serious condition and was in a special relationship.

E. All correct.

Answer: E. The law requires that a professional acts reasonably with the knowledge, skill, and judgment ordinarily possessed by fellow members in good standing. For the medical profession, this duty of due care springs from the doctor-patient relationship, and is generally owed to the patient and to no one else. Allowing individuals outside the relationship, i.e., nonpatient third parties, a cause of action against the provider will unwisely expand the sphere of medical liability. Besides, an expansive view of legal duty may lead the provider to breach confidentiality or invite intrusive and/or irrelevant inquiries into a patient’s personal matters. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries. Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class” as famously articulated in the 1928 Plasgraf case.¹

Still, a health care provider can sometimes be found liable to one other than his or her immediate patient, notwithstanding the absence of a provider-patient relationship with that person. One such class of claims deals with communicable diseases. In Bradshaw v. Daniel,² the Supreme Court of Tennessee held that a physician has a duty to inform a patient’s immediate family of the risk of an infectious disease such as Rocky Mountain spotted fever, although the condition itself is not contagious without a vector. In Shepard v. Redford Community Hospital,³ a lower court found no physician-patient relationship between the doctor and the patient’s son who died after contracting meningitis from his mother, who had the disease first, but was not warned of the risk of spreading it to family members. The appellate court reversed, finding liability and holding that the physician-mother relationship resulted in a special situation for imposing a duty of care for her son.

A nonpatient can sue providers who have failed to advise their patients of the sexual transmissibility of conditions such as AIDS or hepatitis B. In DiMarco v. Lynch Homes-Chester County Inc.,⁴ the Supreme Court of Pennsylvania found liability where the physician’s failure to advise his patient to abstain from sexual activity for an appropriate period of time led to the sexual partner acquiring hepatitis B. The Court used a “foreseeable orbit of risk of harm” argument, stating: “If a third person is in that class of persons whose health is likely to be threatened by the patient … [she] has a cause of action … because the physician should recognize that the services rendered to the patient are necessary for the protection of the third person.” And in Reisner v. Regents of the University of California,⁵ a 12-year-old girl became infected with HIV after receiving tainted blood, but the defendant did not disclose the information in a timely manner. She died of AIDS at age seventeen, but not before infecting her sexual partner, who was the plaintiff in the case. The court held that a physician fulfills his duty only after he warns the patient of the risk to others, and that the lack of knowledge of the third party’s identity was immaterial.

Liability may be more likely in jurisdictions that impose a statutory duty on physicians to inform, counsel, or warn their patients or inform health authorities of conditions such as AIDS. California allows the attending physician to disclose to “a person reasonably believed to be the spouse … a sexual partner or a person with whom the patient has shared the use of hypodermic needles, or to the local health officer.”⁶ Although this statutory disclosure is permissive rather than mandatory, it may prove persuasive in any court’s deliberation over the “no-duty” defense argument.

A recent case⁷ presents an interesting fact-situation on the duty issue. Dr. CC incorrectly told his patient that he tested negative for a sexually transmissible disease (herpes), when in fact he had tested positive. His girlfriend, who was not Dr. CC’s patient, became infected and filed suit. The trial court dismissed, ruling that the doctor owed no duty to the girlfriend, because she was not his patient and therefore she had no “legally cognizable claim.” Connecticut’s highest court has recently heard oral arguments on appeal, and its decision is pending.

The AMA has filed an amicus brief in support of Dr. CC.⁸ It argues that Connecticut’s precedent mitigates against expansion of a provider’s duty to nonpatients and raises public policy concerns such as impact on malpractice insurance rates, patient care, and the ethics of patient confidentiality. The brief concluded that it was “… nearly impossible to articulate a bright-line rule of foreseeability … when, like here, the class of persons potentially exposed to injury from such care is so broad and cannot be readily identifiable at the time care is rendered.”

 

References

1. Palsgraf v. Long Island Railroad Co., 248 N.Y. 339, 162 N.E. 99 (1928).

2. Bradshaw v. Daniel, 854 S.W.2d 865 (Tenn. 1993).

3. Shepard v. Redford Community Hospital, 390 N.W.2d 239 (Mich. App. 1986).

4. DiMarco v. Lynch Homes-Chester County Inc., 583 A 2d 422 (Penn. 1990).

5. Reisner v. Regents of the University of California, 37 Cal Rptr 2d 518 (Cal App 2 Dist., 1995).

6. California Health & Safety Code §121015 (a).

7. Doe v. Cochran, 62 Conn L Rptr 33, 2016 (S.C. #19879).

8. What duties do physicians owe to non-patients? AMA News. 2018 Jul 13.
 

Dr. Tan is Emeritus Professor of Medicine and former Adjunct Professor of Law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

Almost 30 years ago a young woman made an appointment to see me. I had just started my internal medicine practice and almost all the patients who saw me were new to me. I assumed she was establishing care with me. Her first words to me were “Hello Dr. Paauw, I would like to interview you to see if you will be a good fit as my doctor.” We talked for the 40-minute appointment time. I asked her about her health, her life, and what she wanted out of both. We shared with each other that we both were parents of young children. When the appointment was over, she said she would really like for me to be her doctor. She told me that the main thing she appreciated about me was that I listened, and that her previous physician never sat down at her appointments and often had his hand on the door handle for much of the visit. Physicians and patients both agree that compassionate care is essential for good patient care, yet about half of patients and 60% of doctors believe it is lacking in our medical system.¹

 

Here are some suggestions on how to help provide patient-centered care.

Remember the golden first minutes

When you step in the room and greet the patient, make sure the first few minutes are about connecting with a new patient or reconnecting with a patient who has visited your office in the past. I often start by asking the patient to give me an update on how they are doing. This lets me know what is important to them. I do not touch the computer until after this initial check-in.

Use the computer as a bond to strengthen your patient relationship

Many studies have shown patients find the computer gets between the doctor and patient. It is especially problematic if it breaks eye contact with the patient. People are less likely to share scary, sensitive, or embarrassing information if someone is looking at a computer and typing. As you look up tests, radiology reports, or consultant notes, let the patient in on what you are doing. Explain why you are searching in the record, and if it helps make an important point, show your findings to the patient. Offer to print out results, so they have something to carry with them.

Explain what you are looking for and what you find on the physical exam

Being a patient is scary. We all want reassurance that our fears are not true. When you find normal findings on exam, share those with the patient. Hearing “your heart sounds good, your pulses are strong” really helps patients. Explaining what we are doing when we examine is also helpful. Explain why you are feeling for lymph nodes in the neck, why we percuss the abdomen. Patients are often fascinated by getting a window into how we are thinking. I usually have medical students with me, which offers another avenue to explaining the how and why behind the exam. In asking and explaining to students, the patient is also taught why we do what we do.

 

Make sure that we cover what they are afraid of, not just what their symptom is

Patients come in not just to get symptom relief but to rest their mind from their fears of what it could be. I find it helpful to ask the patient what they think is the cause of the problem, or if they are worried about any specific diagnosis. With certain symptoms this is particularly important (for example, headaches, fatigue, or abdominal pain).

None of these suggestions are easy to do in busy, time-pressured clinic visits. I have found though that when patients feel cared about, listened to and can have their fears addressed they value our advice more, and less time is needed to negotiate the plan, as it has been developed together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at fpnews@mdedge.com.

Reference

Lown BA et al. Health Aff (Millwood). 2011 Sep;30(9):1772-8.

Almost 30 years ago a young woman made an appointment to see me. I had just started my internal medicine practice and almost all the patients who saw me were new to me. I assumed she was establishing care with me. Her first words to me were “Hello Dr. Paauw, I would like to interview you to see if you will be a good fit as my doctor.” We talked for the 40-minute appointment time. I asked her about her health, her life, and what she wanted out of both. We shared with each other that we both were parents of young children. When the appointment was over, she said she would really like for me to be her doctor. She told me that the main thing she appreciated about me was that I listened, and that her previous physician never sat down at her appointments and often had his hand on the door handle for much of the visit. Physicians and patients both agree that compassionate care is essential for good patient care, yet about half of patients and 60% of doctors believe it is lacking in our medical system.¹

 

Here are some suggestions on how to help provide patient-centered care.

Remember the golden first minutes

When you step in the room and greet the patient, make sure the first few minutes are about connecting with a new patient or reconnecting with a patient who has visited your office in the past. I often start by asking the patient to give me an update on how they are doing. This lets me know what is important to them. I do not touch the computer until after this initial check-in.

Use the computer as a bond to strengthen your patient relationship

Many studies have shown patients find the computer gets between the doctor and patient. It is especially problematic if it breaks eye contact with the patient. People are less likely to share scary, sensitive, or embarrassing information if someone is looking at a computer and typing. As you look up tests, radiology reports, or consultant notes, let the patient in on what you are doing. Explain why you are searching in the record, and if it helps make an important point, show your findings to the patient. Offer to print out results, so they have something to carry with them.

Explain what you are looking for and what you find on the physical exam

Being a patient is scary. We all want reassurance that our fears are not true. When you find normal findings on exam, share those with the patient. Hearing “your heart sounds good, your pulses are strong” really helps patients. Explaining what we are doing when we examine is also helpful. Explain why you are feeling for lymph nodes in the neck, why we percuss the abdomen. Patients are often fascinated by getting a window into how we are thinking. I usually have medical students with me, which offers another avenue to explaining the how and why behind the exam. In asking and explaining to students, the patient is also taught why we do what we do.

 

Make sure that we cover what they are afraid of, not just what their symptom is

Patients come in not just to get symptom relief but to rest their mind from their fears of what it could be. I find it helpful to ask the patient what they think is the cause of the problem, or if they are worried about any specific diagnosis. With certain symptoms this is particularly important (for example, headaches, fatigue, or abdominal pain).

None of these suggestions are easy to do in busy, time-pressured clinic visits. I have found though that when patients feel cared about, listened to and can have their fears addressed they value our advice more, and less time is needed to negotiate the plan, as it has been developed together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at fpnews@mdedge.com.

Reference

Lown BA et al. Health Aff (Millwood). 2011 Sep;30(9):1772-8.

Almost 30 years ago a young woman made an appointment to see me. I had just started my internal medicine practice and almost all the patients who saw me were new to me. I assumed she was establishing care with me. Her first words to me were “Hello Dr. Paauw, I would like to interview you to see if you will be a good fit as my doctor.” We talked for the 40-minute appointment time. I asked her about her health, her life, and what she wanted out of both. We shared with each other that we both were parents of young children. When the appointment was over, she said she would really like for me to be her doctor. She told me that the main thing she appreciated about me was that I listened, and that her previous physician never sat down at her appointments and often had his hand on the door handle for much of the visit. Physicians and patients both agree that compassionate care is essential for good patient care, yet about half of patients and 60% of doctors believe it is lacking in our medical system.¹

 

Here are some suggestions on how to help provide patient-centered care.

Remember the golden first minutes

When you step in the room and greet the patient, make sure the first few minutes are about connecting with a new patient or reconnecting with a patient who has visited your office in the past. I often start by asking the patient to give me an update on how they are doing. This lets me know what is important to them. I do not touch the computer until after this initial check-in.

Use the computer as a bond to strengthen your patient relationship

Many studies have shown patients find the computer gets between the doctor and patient. It is especially problematic if it breaks eye contact with the patient. People are less likely to share scary, sensitive, or embarrassing information if someone is looking at a computer and typing. As you look up tests, radiology reports, or consultant notes, let the patient in on what you are doing. Explain why you are searching in the record, and if it helps make an important point, show your findings to the patient. Offer to print out results, so they have something to carry with them.

Explain what you are looking for and what you find on the physical exam

Being a patient is scary. We all want reassurance that our fears are not true. When you find normal findings on exam, share those with the patient. Hearing “your heart sounds good, your pulses are strong” really helps patients. Explaining what we are doing when we examine is also helpful. Explain why you are feeling for lymph nodes in the neck, why we percuss the abdomen. Patients are often fascinated by getting a window into how we are thinking. I usually have medical students with me, which offers another avenue to explaining the how and why behind the exam. In asking and explaining to students, the patient is also taught why we do what we do.

 

Make sure that we cover what they are afraid of, not just what their symptom is

Patients come in not just to get symptom relief but to rest their mind from their fears of what it could be. I find it helpful to ask the patient what they think is the cause of the problem, or if they are worried about any specific diagnosis. With certain symptoms this is particularly important (for example, headaches, fatigue, or abdominal pain).

None of these suggestions are easy to do in busy, time-pressured clinic visits. I have found though that when patients feel cared about, listened to and can have their fears addressed they value our advice more, and less time is needed to negotiate the plan, as it has been developed together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at fpnews@mdedge.com.

Reference

Lown BA et al. Health Aff (Millwood). 2011 Sep;30(9):1772-8.